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 an Abbreviated Survey in response to five complaints completed on May 30, 2024, at North Hills Skilled Nursing and Rehabilitation Center it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 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 facility policy, nursing time schedule documents, and staff interview, it was determined that the facility failed to provide a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift for two out of 21 days (5/23/24 and 5/28/24) and failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the overnight shift six out of 21 days (5/11/24, 5/13/24, 5/20/24, 5/21/24, 5/23/24, and 5/28/24).

Findings include:

The facility "Staffing" policy dated 8/7/23, last reviewed 3/5/24, indicated that the facility will provide qualified and appropriate staffing levels to meet the needs of the patient population. The facility meets or exceeds the staffing levels mandated by the state and federal staffing requirements.

A review of 3-week nursing staffing documents (2/18/24-2/24/24; 3/30/24-4/5/24, 5/7/24-5/13/24) did not include a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift on the following dates: 5/23/24 and 5/28/24.

A review of 3-week nursing staffing documents (2/18/24-2/24/24; 3/30/24-4/5/24, 5/7/24-5/13/24) did not include a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the overnight shift on the following dates: 5/11/24, 5/13/24, 5/20/24, 5/21/24, 5/23/24, and 5/28/24.

During an interview on 5/29/24, at 2:15 p.m. the Director of Nursing (DON) confirmed that the failed to provide a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift for two out of 21 days and failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the overnight shift six out of 21 days.

Plan of Correction - To be completed: 06/17/2024

NHA will re-educate the DON and Scheduler on staffing ratio regulations.

NHA or designee will review all staffing contracts to ensure most up to date rates are in place and has posted open positions on multiple employment platforms. Shift differentials for evenings and nights are already in place. Incentives offered as needed to ensure adequate staffing levels.

Staffing meetings scheduled daily to ensure adequate staffing.

NHA or designee will audit staffing sheets daily for 2 weeks for LPN ratio met.Findings reported through Quality Assurance and Process Improvement for recommendation ongoing.

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