Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the required minimum of 3.2 hours of direct resident care per resident per day, as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, effective July 1, 2024. A review of the facility's staffing levels revealed deficiencies on specific dates in January 2025, where the facility provided only 3.13, 3.00, and 3.06 direct care nursing hours per resident, respectively. This shortfall in nursing care hours was confirmed during an interview with the Nursing Home Administrator on January 28, 2025.
Plan Of Correction
The facility cannot retroactively correct the per patient hours on previous days. The NHA/Designee educated the Nursing Staff Scheduler and Director of Nursing on minimum 3.20 per patient hours per day, ensuring continued proactive planning and follow up to address issues identified. Daily staffing meetings will be held with the NHA, Staff Scheduler, DON, and other team members as necessary to review per patient hours 5 days per week to review projected staffing, reconcile prior days staffing, and follow up as needed for continued improvement and comprehensive team approach. The facility utilizes contracted nursing staff, incentives, and flexible schedules etc. for current staff, focuses on recruitment of direct hire staff for continuity of care as well as employee engagement, feedback through town hall meetings, and individualized support to decrease absences. A call-in list is used to attempt to fill unexpected absences. Resident occupancy is reviewed and revised as needed with IDT during staffing meetings. The NHA/Designee will quality monitor per patient hours 5 days per week for 4 weeks, then one per week for 3 weeks, then monthly for 2 months to ensure minimum 2.87 per patient hours are met. The NHA/Designee will quality monitor daily staffing meetings 5 days per week for 4 weeks, weekly for 3 weeks, then monthly for 2 months to ensure staffing meetings are occurring with required attendees.