Pennsylvania Department of Health
NORTH HILLS SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NORTH HILLS SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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NORTH HILLS SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on March 20, 2024, it was determined that North Hills Skilled Nursing and Rehabilitation Center corrected the deficiencies identified during the survey of January 12, 2024, as related to the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, however, has continued non-compliance with three regulations as related to the requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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 time schedules and staff interview, it was determined that the facility administrative staff failed to provide a minimum of one nursing assistant per twelve residents during the day shift for two of 11 days (3/9/24 and 3/16/24), and on the evening shift on two of 11 days (3/9/24 and 3/10/24), and failed to provide a minimum of one nursing assistant per twenty residents on night shift on one of 11 days (3/16/24).

Findings include:

Day shift:
3/9/24census 18188.30 actual hours120.67 hours required.
3/10/24census 17097.70 actual hours113.33 hours required.

Evening shift:
3/9/24census 181111.00 actual hours120.67 hours required.
3/16/24census 17081.20 actual hours113.33 hours required.

Night shift:
3/16/24census 18168.00 actual hours59.23 hours required.

During an interview on 3/19/24, at 2:30 p.m. the Nursing Home Administrator confirmed the facility administrative staff failed to provide the required minimum nursing assistant ratios on the above listed dates.

Plan of Correction - To be completed: 04/04/2024

Nursing Home Administrator will re-educate the Director of Nursing and Scheduler on staffing ratios regulations. Nursing Home Administrator /designee will audit staffing sheets weekly for four weeks to identify CNA ratio is met. Nursing Home Administrator/designee is reviewing all current staffing contracts to ensure most up to date rates are in place and has posted open positions on multiple employment platforms. Shift differentials for 3-11pm, and 11-7am already in place. Incentives offered as needed to ensure adequate staffing levels. Staffing meetings scheduled daily to ensure adequate staffing. Findings will be reported to QAPI.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 nursing time schedules and staff interview, it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 40 residents during the night shift on one of 11 days (3/9/24).

Findings include:

Review of the facility census data and nursing time schedules revealed the following LPN staffing shortages:

11-7 shift:

3/9/24census 18131.60 actual hours36.20 hours required.

During an interview on 3/19/24, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide LPN's on the night shift as required.

Plan of Correction - To be completed: 04/04/2024

Nursing Home Administrator will re-educate the Director of Nursing and Scheduler on staffing ratios regulations. Nursing Home Administrator /designee will audit staffing sheets weekly for four weeks to identify LPN ratio is met. Nursing Home Administrator/designee is reviewing all current staffing contracts to ensure most up to date rates are in place and has posted open positions on multiple employment platforms. Shift differentials for 3-11pm, and 11-7am already in place. Incentives offered as needed to ensure adequate staffing levels. Staffing meetings scheduled daily to ensure adequate staffing. Findings will be reported to QAPI.

§ 211.12(i)(1) LICENSURE Nursing services.:

(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.

Observations:

Based on review of facility provided staffing documents, it was determined that the facility failed to maintain the State minimum requirement of 2.87 hours of direct nursing care staff for two out of 11 days (3/9/24 and 3/10/24).

Findings include:

Review of the facility staffing from 3/6/24 through 3/16/24, identified the following days when the 2.87 PPD (staff per patient daily) was below the State requirement:

3/9/24-2.66 PPD.
3/10/24-2.84 PPD.

During an interview on 3/19/24, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain the State minimum requirement of 2.87 hours of direct nursing care staff on 3/9/24 and 3/10/24 as required.

Plan of Correction - To be completed: 04/04/2024

12/23/24, 12/24/23, 12/25/23, and 1/6/24 was below 2.87. The Administrator, Director of Nursing, Scheduler and Human Resource Director will be re-educated on the state requirement for nursing hours including the nurse to resident ratios by the Quality Clinical Consultant/designee. Staffing meetings will be held 5 days a week to review HPPD from the previous day and the projected HPPD for the current day, as well as the upcoming week to ensure appropriate staffing levels by the Nursing Home Administrator/ designee. If projected staffing levels are below the 2.87 minimum then the facility will reach out to current staff and local staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms. Results of these audits will be taken to the monthly Quality Assurance meeting and will be reviewed for quality and accuracy

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