Deficiency in Meeting Required Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules and staff interviews, which revealed that for seven out of 21 days reviewed, the facility did not provide the required hours of care. Specifically, on January 19, 20, 25, 26, 28, 30, and February 8, 2025, the facility provided between 2.88 and 3.15 hours of direct care per resident, falling short of the mandated 3.2 hours. The Nursing Home Administrator confirmed the shortfall in care hours during an interview on February 12, 2025.
Plan Of Correction
Unable to retroactively correct the hours provided of direct resident care for dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1.) Generous Sign on Bonus 2.) Flexible Scheduling 3.) Benefits Package for full-time employees 4.) Competitive Wages 5.) "Kudos" employee recognition program 6.) Wage analysis completed 7.) The facility is near public transportation. 8.) Referral bonus 9.) Agency Contracts 10.) Administrative Coverage Monitoring will be captured through auditing PPD. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.