Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to provide the required minimum of 3.2 hours of direct nursing care per resident per day over a 24-hour period, as mandated effective July 1, 2024. A review of nursing staffing hours for selected dates in June, July, and August 2025 revealed that on 16 out of 21 days reviewed, the facility did not meet this minimum standard. Specific daily nursing care hours ranged from 2.70 to 3.20 hours per resident per day, with several days falling below the regulatory requirement. This deficiency was identified through a review of facility records and confirmed during an interview with the Nursing Home Administrator and Director of Nursing. The report does not mention any specific residents or their medical conditions, nor does it provide details about the impact on individual patient care. The findings are based solely on the documented nursing care hours provided during the reviewed periods.
Plan Of Correction
The facility cannot retroactively correct past PPD staffing levels. The facility will continue to take measures to adequately provide nursing staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff. These measures include, continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will educate RN Supervisors, HR, and the nursing scheduler about PPD staffing levels, who are responsible for maintaining adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5 times a week for 6 weeks to ensure that the minimum PPD staffing levels have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations. Jeanne Parici Jeanne Parisi Deputy Secretary for Quality Assurance Pennsylvania Debra L. Bogu MD Debra L. Bogen, MD, FAAP Secretary of Health Department of Health THIS IS A CERTIFICATION PAGE PLEASE DO NOT DETACH THIS PAGE IS NOW PART OF THIS SURVEY