Failure to Maintain Minimum Staffing Requirements
Penalty
Summary
The facility failed to maintain the minimum staffing requirements as mandated by state regulations. Specifically, the facility did not meet the required 2.0 direct care hours by certified nursing assistants (CNAs) on two occasions out of ninety-two days. Additionally, the facility failed to maintain a weekly average of 3.6 direct care hours per resident for eight out of fourteen weeks during the survey period. The discrepancies were identified through a review of the facility's staffing records, which showed incorrect calculations and inconsistencies in the reported staffing hours. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) provided multiple copies of staffing records, which contained errors and corrections. The initial records did not include weekly averages, and subsequent records showed incorrect calculations of CNA and nursing hours. Interviews with the staffing coordinator revealed that the facility did not use the state form for recording staffing hours but relied on a corporate Key Factor form, which did not accurately reflect the weekly averages required by state regulations. The staffing coordinator admitted to learning the role without formal training and acknowledged issues with call-offs affecting staffing levels. Further interviews with the Assistant Business Office Manager (ABOM) and the staffing coordinator highlighted a lack of clarity and consistency in recording and reporting staffing hours. The ABOM, new to payroll, relied on instructions from the NHA and the staffing coordinator to adjust hours to meet state requirements. The facility's assessment indicated a reliance on a formula to determine staffing needs, but the actual staffing levels fluctuated and occasionally fell below the state minimum requirements. The facility's failure to maintain accurate and compliant staffing records contributed to the deficiency identified during the survey.
Plan Of Correction
The Certified Nursing Assistant's (CNA) Per Patient Day for the specific dates were reviewed. No actions warranted due to the time has passed. The weekly direct care staffing hours for the specific weeks of /24, /24, /24 and for the quarter of through for meeting the weekly direct care average of 3.6 per patient day staffing requirement were reviewed. No actions are warranted due to the time has passed. An audit was conducted on the other 6 weeks which are /24, and for the Quarter through for meeting the minimum staffing requirements of 2.0 per patient day daily for Certified Nursing Assistants and the weekly average of direct care staffing of 3.60 per patient day. The results of the audit found that there were no other days during that specific quarter that the daily Certified Nursing Assistant staffing or the weekly average of direct care staffing did not meet the minimum staffing requirement of 2.0 per patient day and 3.6 per patient day respectively. On the Administrator initiated education for the Director of Nursing, Staffing Coordinator, Business Office Manager, Assistant Business Office Manager/Payroll, Rehab Director and the Activity Director related to meeting the daily minimum staffing for Certified Nursing Assistants of 2.0 per patient day and the definition of direct care staffing and meeting the required minimum weekly average of the 3.6 per patient day for direct care staff. Education was completed by The Director of Nursing/designee will audit the Certified Nursing Assistant staffing and direct care staffing 5 times per week for 12 weeks to ensure that the facility is meeting the Certified Nursing Assistant and direct care staffing requirements. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement Committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.