Pennsylvania Department of Health
EMBASSY OF HILLSDALE PARK
Patient Care Inspection Results

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EMBASSY OF HILLSDALE PARK
Inspection Results For:

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EMBASSY OF HILLSDALE PARK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Findings of an abbreviated complaint survey completed on February 6, 2024, at Embassy of Hillsdale Park identified no deficient practice under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities as it relates to the Health portion of the survey process; however, deficient practice was identified under 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on review of nursing schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to meet the required nurse aide-to-resident staffing ratio on daylight shift for five of 21 days (24-hour periods), on the afternoon shift for four of 21 days, and on the overnight shift for 11 of 21 days reviewed.

Finding include:

Nursing time schedules provided by the facility for the days of January 16, 2024, through February 5, 2024, revealed that the facility provided one nurse aide per 13 residents on January 16, 23, 24, 25, and February 3, 2024, during the day shift; provided one nurse aide per 13 residents on January 16, 17, 18, and February 1, 2024, during the afternoon shift; and provided one nurse aide per 21 residents on January 27 and 28, 2024, one nurse aide per 22 residents on January 18, 22, 24, 31, and February 1, 2, 4 and 5, 2024, and one nurse aide per 23 residents on January 21, 2024, on the overnight shift.

Interview with the Nursing Home Administrator on February 6, 2024, at 2:03 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.



 Plan of Correction - To be completed: 03/15/2024

The facility did not ensure a minimum of one nurse aide to resident ratio on day shift for 5 of 21 days, on the afternoon shift for 4 of 21 days, and overnight shifts for 11 of 21 days. The facility cannot retroactively correct the identified days the facility did not ensure the correct staffing ratio.

No evidence exists of any residents having any potential to be affected by this deficient practice.

Upon review of the facilty's current process for staffing review, the following steps and system changes have been implemented to ensure all steps are being taken to meet the current ratio requirements.

During the current "Daily Labor Meeting" with attendance of the Nursing Home Administrator, Director of Nursing, Human Resource Director and Scheduler, will focus on the following:

Focus on Daily PPD, ratio requirements, daily needs, future needs for clinical coverage and the safety of the residents.

Review of daily/weekly schedules

Daily completion of the newly revised DOH Nursing Staff Ratio form. Form will be completed during meeting and decisions on staffing ratio will be made.

The facility continue to explore all avenues for staff needs, i.e., active recruitment efforts, and bonus program have been exhausted.

A regional recruiter has been hired to assist in the recruitment of all clinical staff in an effort to both hire and retain staff to ensure the safety and well-being of our residents.

Nursing Home Administrator and Director of Nursing will evaluate admissions based on the staffing needs of the facility.

Daily actions will be monitored by the Director of Nursing and Nursing Home Administrator during our ongoing daily labor meetings and make decisions of the corrective actions to be taken. Trending and monitoring data/information will be reported daily at the morning leadership team meeting and at the monthly Quality Assurance and Performance Improvement Committee Meeting for further discussion and recommendations by all in attendance.

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