Failure to Meet Minimum 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 patient daily (PPD) for each resident. This deficiency was identified during a review of nursing time schedules and staff interviews, which revealed that on two specific days, the facility provided only 2.99 and 2.74 PPD hours of direct care, respectively. The Director of Nursing confirmed this shortfall during an interview, acknowledging that the facility did not meet the required PPD minimum hours for 2 out of the 21 days reviewed.
Plan Of Correction
DON/designee completed education with the scheduler to schedule the staffing for 3.20 and above to maintain required PPD. An off-shift scheduler was hired to perform scheduling duties after hours in an attempt to maintain PPD. Nursing supervisors will be educated to make phone calls to replace call offs and no shows. Employment ads will be placed in the local newspaper. To monitor and maintain ongoing compliance, the DON/designee will audit 5 schedules weekly x 2 weeks to ensure staffing PPD is 3.20 or above. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.