Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on five out of six days, specifically on 2/25/25, 2/27/25, 2/28/25, 3/1/25, and 3/2/25. The nursing time schedules and staffing documents reviewed indicated that the PPD hours were 2.56, 2.96, 2.90, 2.82, and 2.50, respectively, on these dates. This deficiency was confirmed during an interview with the Nursing Home Administrator on 3/5/25, who acknowledged the failure to provide the required minimum PPD hours of direct care on the specified dates.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing agency as needed to ensure sufficient nursing staff meets PA Regulation. The RDO re-educated NHA/DON on ensuring sufficient nursing staff and a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x per week for x4 weeks; then Weekly x2 Months and then Monthly X 2 months; to ensure required PPD and ratios are met. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.