Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on two of 21 days (12/14/19, and 12/26/19).
Nursing time schedules for the period 12/9/19, through 12/29/19, revealed that the facility failed to maintain 2.7 hours of general nursing care to each resident in a 24 hour period on the following dates:
12/14/19 - 2.36
12/26/19 - 2.56
During interviews on 2/3/20, at 10:15 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the nursing hour requirements for those two days.
| ||Plan of Correction - To be completed: 02/18/2020|
"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."
Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction.
P2020 Nursing Services
1. The facility cannot correct that on 12/14/2020 an 12/26/2020 the facility did not meet the minimum direct care hours of 2.7. Quality care to residents was maintained and there were no negative outcomes to the residents related to not meeting the 2.7 direct care hours.
2. The facility will maintain a minimum of 2.7 hours of direct resident care. The facility will utilize certified/licensed professionals from other departments as direct care providers in the event PPD is found to be below 2.7.
3. Staffing hours will be reviewed by the Nursing Home Administrator and Director of Nursing daily and prior to next day schedule posting. The Nursing Home Administrator/designee will re-educate RN supervisors, director of nursing and scheduler on calculating and maintaining required 2.7 nursing hours, Act 102, Mandatory Overtime Protocol and notifying Nursing Home Administrator if hours are not being maintained.
4. The Nursing Home Administrator/designee will complete an audit 5 times a week for 4 weeks then weekly for 4 weeks, then monthly for 3 months to validate required nursing hours are met. The results of these audits will be reported to the monthly Quality Performance Improvement Committee for review.