Failure to Meet Minimum Staffing Requirements
Penalty
Summary
The facility failed to meet the minimum staffing requirements for nursing and certified nursing assistants (CNAs) on five out of twenty-eight days reviewed. Specifically, the facility did not meet the nursing minimum daily requirement of 1.0 hours of direct care on two days and failed to meet the CNA minimum daily requirement of 2.0 hours of direct care on three days. The daily averages for nursing and CNA care on these days were below the required thresholds, with nursing care averaging as low as 0.8787 hours and CNA care averaging as low as 1.8823 hours per resident per day. Interviews with the Business Office Manager (BOM) and the Nursing Home Administrator (NHA) confirmed the accuracy of the staffing numbers provided on the Long Term Care (LTC) sheets. The BOM stated that the Director of Nursing (DON) is responsible for the staffing schedule, and she inputs the numbers into the payroll system. The NHA acknowledged awareness of the days when staffing numbers did not meet the minimum requirements. The facility's policy and procedure for staffing indicate that the administrator and DON are responsible for ensuring sufficient nursing staff to meet federal and state law requirements, with staffing plans re-evaluated on an ongoing basis.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. N-063, Minimum Nursing Staff Element #1. A review of the State Minimum Nursing Staff for four (4) weeks (28 days) was conducted on __ of __, and the facility was identified to have failed to achieve minimum staffing requirements for Nursing on __ and __ and for Certified Nursing Assistants (CNA) on __ and __. The facility ensured that appropriate minimum staffing levels were achieved on the dates between those and from __ forward. Element #2. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit on __ of __ resident grievances and/or incidents to ensure that there were no concerns identified which correlated with the day/dates when the facility failed to ensure that minimum staffing requirements were met. No concerns were identified. Element #3. Policy regarding State Minimum Staffing Requirements were reviewed by the Interdisciplinary Team (IDT) and deemed appropriate. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan is developed and implemented to enhance the hiring of registered and licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Nurse and CNA's were called for interviews. Waiting for orientation are four (5) CNA's and one (1) Nurse. Other interviews are scheduled and pending. Element #5: Facility's Allegation of Compliance Date is __.