Non-Compliance with Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.20 hours of direct resident care per resident per 24-hour period on 13 specific days across three different months. The deficiency was identified through a review of facility staffing documentation and confirmed during an interview with the Nursing Home Administrator. On the specified dates, the facility provided between 3.01 and 3.18 hours of care, falling short of the mandated minimum. This shortfall was documented for several days in July and October 2024, as well as January 2025, indicating a pattern of non-compliance with the required staffing levels.
Plan Of Correction
There has been no negative effect on residents due to nursing hours <3.20. Staffing hours have been evaluated for future schedules to ensure compliance with State Regulation of a minimum of 3.20 hours of direct care for each resident daily. RN Nursing Supervisors have been educated on staffing requirements. A policy has been developed to ensure minimum staffing requirements are met to the best of the facilities ability via communication with current staff and staffing agencies in the event of terminations, resignations, call-offs and failure of staff to report to work, resulting in staffing levels below minimum requirements. Nursing hours will be evaluated daily by RN nursing supervisors to ensure compliance. A QA tool has been developed to review 10% of nursing hours weekly to ensure minimum staffing levels are met to the best of the facilities ability per policy. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.