Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. A review of nursing schedules over a 21-day period revealed that on 12 separate days, the total direct care hours per resident fell below the mandated threshold. Specific days were identified where the care hours ranged from 2.72 to 3.16 per resident, indicating that the facility did not consistently staff enough nursing personnel to meet the required standard during the reviewed timeframe. No information regarding the medical history or condition of individual residents at the time of the deficiency was provided in the report.
Plan Of Correction
1. Nursing hours noted in the survey cannot be corrected as this is a past event. 2. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility recently completed nurse aide training classes to fill vacant nurse aide positions. LPN school recruitment efforts continue with presentation scheduled this fall to graduating LPNs. Continue with collaboration with local Penn State campus to introduce graduating nurses to long term care in our facility. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements. 4. PPD hours will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months, or until substantial compliance is achieved. Results will be reviewed at QAPI meeting. 5. Date of compliance is 08/20/2025.