(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.
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Observations:
Based on a review of facility staffing data, it was determined that the facility failed to meet the required PPD (Patient Per Day) of 2.87) for four days in a twelve day period.
Findings include:
A review of the facility's staffing from May 1, 2024 through May 12, 2024, revealed that on the following days the facility had a PPD below 2.87.
5/3/2024 - 2.64
5/6/2024 - 2.68
5/11/2024 - 2.80
5/12/2024 - 2.76
Telephone interview with the Nursing Home Administrator on May 16, 2024, confirmed that the facility did not meet the required PPD for the days mentioned above.
| | Plan of Correction - To be completed: 06/04/2024
1. Facility cannot retroactively correct staffing schedule to meet required PPD hours for 5/3, 5/6, 5/11,and 5/12.
2. NHA, DON, and staffing scheduler have weekday meetings twice daily to ensure daily PPD hours are above minimum requirement of 2.87 Facility will also utilize the services of agency staffing to help meet the 2.87 PPD hour requirements
3. NHA, or designee, will educate DON and nursing scheduler on daily PPD requirements. Scheduler will work with staffing agency to fulfill PPD requirements.
4. NHA, or designee, will perform audits of daily PPD requirements to ensure facility meets 2.87 hours. Audits will be performed twice a week for two weeks, then weekly for two weeks, then monthly for two months. Results will be submitted to monthly QAPI meetings for review and recommendations.
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