Pennsylvania Department of Health
CHAPEL POINTE AT CARLISLE
Patient Care Inspection Results

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CHAPEL POINTE AT CARLISLE
Inspection Results For:

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CHAPEL POINTE AT CARLISLE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights survey completed on April 4, 2024, it was determined that Chapel Pointe at Carlisle was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of staffing information furnished by the facility and staff interview, it was determined that the facility failed to ensure a required minimum of one Licensed Practical Nurse (LPN) per 40 residents during the night shift for 13 of 21 days reviewed (October 26 and 28-31, 2023; November 1, 2023; February 29, 2024; March 1, 2, 5, 28, and 31, 2024; April 1, 2024).

Findings include:

Review of facility provided staffing ratio information for October 26, 2023, through November 1, 2023; February 29, 2024, through March 6, 2024; and March 28, 2024, through April 3, 2024, on night shift, revealed a resident census of 55-59 residents. The information also revealed the facility did not meet the minimum LPN ratio required for the facility census of residents on the following shifts: October 26 and 28-31, 2023; November 1, 2023; February 29, 2024; March 1, 2, 5, 28, and 31, 2024; April 1, 2024.

However, during a staff interview on April 4, 2024, at 9:24 AM, NHA revealed that due to a resident census of 59 and below, one LPN was used as a substitute for the required Registered Nurse FTE for that shift. The substitution of the LPN for an RN for the shift resulted in an LPN FTE below the required 1.0 FTE.

During an interview with the NHA on April 3, 2024, at 1:58 PM, she expressed understanding that the facility did not meet the required ratios.



 Plan of Correction - To be completed: 05/06/2024

Upon discovery and completing further analysis of the night shift staffing hours, it was determined by the facility a need to create and advertise two new LPN positions to address the shortfall and meet the required LPN ratio.

The additional licensed nurse positions for night shift were each defined and advertised through the facility website, internet search engines such as Indeed, on social media platforms and within the local community using signage on the facility's campus.

The administrator will work urgently with the Director of Nursing, reviewing prospective applicants during the weekly staffing meeting, to identify appropriate candidates who can fulfill the duties and be hired to meet the ratio requirement.

Education about the staffing ratio was provided on April 8, 2024, and subsequent actions to meet the night shift LPN ratio requirement by using the current staff to fulfil shortfalls until the new positions can complete the on-boarding process.

The Director of Nursing will proactively monitor the staffing levels and secure coverage as needed to meet the required staffing levels. The Administrator will review the daily staffing logs on a weekly basis to ensure that the staffing requirements continue to be met consistently.

The Director of Nursing will provide staffing updates at the facility's monthly Quality Assurance and Performance meetings for review and approval for a minimum of 6 months or as determined by the QA Committee to ensure that the solutions are sustained.


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