Observations:
Based on a review of facility staffing data, it was determined that the facility failed to meet the required Per Patient Day (PPD) for seven days for the period from December 23, 2025 through December 29, 2025.
Findings include:
A review of facility staffing data from December 23 through December 29, 2025, revealed that on the following days the facility had a PPD below the required 3.20.
12/23/2025 - 3.05
12/24/2025 - 3.05
12/25/2025 - 3/05
12/26/2025 - 2.91
12/27/2025 - 3.14
12/28/2025 - 2.94
12/29/2025 - 2.91
The aforementioned data was conveyed to the Nursing Home Administrator in a telephone interview on January 5, 2026.
| | Plan of Correction - To be completed: 03/13/2026
1. Corrective Action for the Resident(s) Affected
The facility acknowledges that staffing levels fell below the required 3.20 PPD during the identified period.
An immediate review was conducted to ensure resident care needs were met during the affected dates.
No adverse outcomes or unmet care needs were identified as a result of the staffing shortfall.
Nursing leadership provided additional supervisory oversight to ensure resident safety and continuity of care.
2. Identification of Other Residents Who May Be Affected
All residents had the potential to be affected by reduced staffing levels.
A retrospective review of incident reports, call light response times, skin integrity reports, and grievance logs for the period of December 23–29, 2025 was completed.
The review revealed no evidence of compromised resident care or safety concerns related to staffing levels.
3. Systemic Changes to Prevent Recurrence
The facility has implemented the following corrective actions to ensure compliance with required PPD levels:
a. Staffing Plan Review & Adjustment
On January 6, 2026, the Nursing Home Administrator (NHA) and Director of Nursing (DON) conducted a review of the facility's staffing model.
Baseline staffing schedules were adjusted upward to maintain staffing above the 3.20 PPD requirement, accounting for weekends, holidays, and census fluctuations.
b. Contingency & Coverage Measures
The facility established a staffing contingency plan that includes:
Mandatory use of overtime when necessary.
Expanded use of agency staff during staffing shortages.
On-call staffing coverage for unexpected absences.
c. Management Oversight
Nursing management is now required to review daily PPD calculations to ensure compliance.
Any projected staffing shortfall triggers immediate corrective action prior to the start of the shift.
4. Monitoring and Quality Assurance
To ensure sustained compliance:
a. Daily Monitoring
The DON or designee will review daily staffing reports and PPD calculations for 90 days.
Any day trending below required PPD will be corrected immediately.
b. QAPI Review
Staffing compliance and PPD data will be reviewed monthly by the Quality Assurance & Performance Improvement (QAPI) Committee for six months.
Trends, corrective actions, and outcomes will be documented in QAPI meeting minutes.
5. Person(s) Responsible
Nursing Home Administrator (NHA)
Director of Nursing (DON)
|
