Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
William Penn Nursing and Rehab was found to be non-compliant with the Commonwealth of Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to maintain the required nurse aide-to-resident ratios during various shifts over a 21-day review period. On one day, the day shift did not meet the required ratio of one nurse aide per 10 residents. The evening shift failed to meet the required ratio of one nurse aide per 11 residents on three separate days. Additionally, the night shift did not meet the required ratio of one nurse aide per 15 residents on seven different days. The deficiency was identified through a review of nursing staffing hours and confirmed during an interview with the Nursing Home Administrator and Director of Nursing. The facility's staffing records for specific weeks in December 2024 and January 2025 showed that the number of nurse aides scheduled was insufficient to meet the regulatory requirements based on the resident census. This failure to comply with staffing regulations was acknowledged by the facility's administration during the survey process.
Plan Of Correction
1. Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. 2. The Director of Nursing or designee will provide re-education on minimum staffing ratios to RN Supervisors, Human Resources and Scheduling Coordinator who are responsible to maintain adequate staffing and staffing ratios. 3. The Director of Nursing or designee will audit the daily schedules to ensure the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed if a call off occurred. 4. Audits will be completed weekly, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved. 5. Compliance Date: 1/27/2025