Pennsylvania Department of Health
DALLASTOWN NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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DALLASTOWN NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a State Licensure and Civil Rights survey completed on May 31, 2024, it was determined that Dallastown Nursing Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Observations:

Based on observation, policy review, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of one medication carts.

Findings include:

A review of facility policy titled, "HIPAA," (Health Insurance Portability and Accountability Act), not dated, indicates staff must cover or conceal all protected health information in all public areas after use.

During medication pass observations on April 21, 2024, Employee 11 (Licensed Practical Nurse) administered medications to four residents, each time leaving the medication screen, and medication log visible in the hallway for anyone to view. Employee 11 did comment that she was aware that she should have closed her computer screen and medication log closed between medication passes.

During an interview with the Director of Nursing (DON) on May 23, 2024, at 12:10 PM, the DON agreed that the policy should be followed, and that resident's health information should always be protected.

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code: 211.5(b) Clinical records.

Plan of Correction - To be completed: 06/21/2024

Corrective Action:
The nurse in question was inserviced on HIPAA and appropriate safeguarding of such. The resident's information was safeguarded immediately upon management notification.
All staff were educated on HIPPA and safeguarding of resident health information of all forms.

Identification of Those Affected:
One resident was affected by this deficient practice, and all have the potential to be affected.

Systematic Change to Prevent Recurrence:
The Administrator, or designee, will complete random walking-round audits on HIPPA compliance, 4 times per week for 4-weeks, and document the results. Findings will be resolved appropriately and discussed in QAPI Meeting. Concerns found during Audits will be addressed immediately and documented within the audit.

Monitoring to Ensure Compliance:
The results of audits, whether concerns are discovered or not, will be reviewed in QAPI meeting to ensure compliance and confirm that it is a sustained solution. If concerns continue, then QAPI Committee will determine a performance plan with updated audits or plans of correction to reach compliance.
During Morning Meeting for the next 4-weeks, the leadership team will be allowed input on any findings or concerns related to HIPAA non-compliance, which will be addressed immediately.
The subject of this deficiency will be discussed in QAPI Meetings x3 months or until substantial compliance is met.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on policy review, personnel file review and staff interview it was determined that the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for three of five new hire documents review (Employees 12, 13 and 14).

Findings Include:

Review of the facility's policy titled "Abuse Prohibition," recently reviewed May 2023, reads "When hiring or acquiring new staff, appropriate checks will be made." "Criminal background checks will be completed on all new hires. "

Review of Employee 12's personnel file revealed a hire date of March 28, 2024.

Continued review of the personnel file revealed the facility had not submitted a request for a criminal background check to the State Police until April 17, 2024.

Review of Employee 13's personnel file revealed a hire date March 8, 2024.

Continued review of the personnel file revealed the facility had not submitted a request for a criminal background check to the State Police until May 21, 2024, the date the information was requested by the survey team.

Review of Employee 14's personnel file revealed a hire date of April 15, 2024.

Continued review of the personnel file revealed the facility had not submitted a request for a criminal background check to the State Police until May 21, 2024, the date the information was requested by the survey team.

An interview with the Nursing Home Administrator, on May 21, 2024, at 1:54 PM revealed the facility had not submitted a request for the criminal background of those staff members due to the facility not having the funds to pay for the background checks at the time of the new hires.

28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.19 (8) Personnel policies and procedures

Plan of Correction - To be completed: 06/21/2024

Corrective Action:
The facility's abuse & neglect policy was reviewed and revised by the Board of Directors and the QAPI Committee.
Human Resources staff and the Administrator provided inservice on the requirement of background screening prior to hire.
Funds were immediately made available by the Board of Directors for this requirement.
An audit of all current HR files was completed to ensure that all background screening has been completed and documented appropriately.

Identification of Those Affected: All residents have the potential to be affected by this deficient practice.

Systematic Change to Prevent Recurrence:
A file audit of all newly hired employees will be completed by the Administrator for a period of 60 days. The results of audit will be reviewed in QAPI Meeting.

Monitoring to Ensure Compliance:
The subject of this deficiency will be discussed in QAPI Meetings x3 months or until substantial compliance is met.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding neurological assessments (neuro checks - an evaluation of a nervous system) after two unwitnessed falls for one resident (Resident 8).

Findings include:

A review of the facility's policy titled, Neurological Checks, last revised January 2018, states, "any resident who experiences a possible head injury due to a fall, accident, or acute neurological condition will be started on neurological checks for a 24-hour period after the incident occurred or was noted. Record findings on the neurological flow sheet every 15 minutes x 4, then every hour x3, then every four hours x5.

The facility added a note to the neuro check policy that states, "unwitnessed falls with no obvious head trauma or change in mental status; neuro checks every 15 minutes x4, then every hour x3, and then discontinue.

The Agency for Healthcare Research and Quality (AHRQ) recommends vital signs (temperature, pulse, respirations, blood pressure) and neuro checks observations (pupil check, alertness, arm and leg strength, speech, and orientation) at least hourly for four hours, and then to continue vital signs and neuro check observations every four hours for 24-hours.

The clinical record review for Resident 8 revealed the resident has diagnoses that include hypertension (high blood pressure) and congestive obstructive pulmonary disease (progressive lung disease) a physician's order dated July 17, 2023, that staff were to complete vital signs (blood pressure, pulse, respirations, and temperature) every shift.

Further review of Resident 8 ' s clinical record revealed the resident had two unwitnessed falls. The first fall occurred on May 6, 2024. A review of the neurological flow sheet revealed neuro checks were only completed every 15 minutes x4, then every hour x3.

Resident 8 ' s second fall occurred on May 8, 2024. A review of the neurological flow sheet revealed neuro checks were completed every 15 minutes x4, then the resident was sleeping for the next four hours, and no neuro checks were completed, one neuro check was completed 12 hours after the fall, and then neuro checks were discontinued. Staff documented on the flow sheet " stable ". The resident only had five neuro checks over 12 hours and then they were discontinued.

During an interview with the Director of Nursing (DON) on May 23, 2024, the neuro check flow sheet was reviewed, and the DON confirmed the policy was not being followed. The DON also agreed that the policy should be revised to include a minimal vital sign and neuro check assessment for 24-hours post fall, and the frequency of neuro checks should include residents with an unwitnessed fall.

28 Pa. Code 211.10(b) Resident care policies.
28 Pa. Code 211.12(d)(1)(2) Nursing services.

Plan of Correction - To be completed: 06/28/2024

Corrective Action:
Resident #8 will be provided a clinical assessment by nurse and Medical Director. A progress note will be updated to confirm the current clinical status of the resident in relation to their recent incident/fall. Any concerns will be addressed immediately.
All nurses were inserviced on facility policy related to Neurological checks after an incident and appropriate documentation of such.
The prior 30-days of incident reports for falls were reviewed. A nurse assessment was completed for each and a progress note entered on the resident's condition.

Identification of Those Affected:
All residents have the potential to be affected.

Systematic Change to Prevent Recurrence:
Incident reports will be reviewed daily in morning meeting to capture any concerns and resolve as necessary.
Fall Incident Reports will be audited during Morning Meeting for the next 30-days, to ensure that neurological checks were completed per policy.

Monitoring to Ensure Compliance:
The subject of this deficiency will be discussed in QAPI Meetings x3 months or until substantial compliance is met.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on document review and staff interview it was determined that the facility failed to complete a performance review once every 12 months for nurse aide staff for five of five nurse aide documents reviewed (Employees 6, 7, 8, 9 and 10).

Findings Include:

Review of the facility's handbook, under a section titled "Performance Review," revealed "Your on-the-job performance will be reviewed by your supervisor before the completion of your probationary period, and at least annually thereafter."

Review of personnel documentation revealed Employee 6 with a hire date of October 7, 1980. Review of Employee 6's personnel record revealed no performance evaluation in the past 12 months.

Reivew of personnel documentation revealed Employee 7 with a hire date of October 17, 1995. Review of Employee 7's personnel record revealed no performance evaluation in the past 12 months.

Review of personnel documentation revealed Employee 8 with a hire date of September 21, 2011. Review of Employee 8's personnel record revealed no performance evaluation in the past 12 months.

Review of personnel documentation revealed Employee 9 with a hire date of June 3, 1995. Review of Employee 9's personnel record revealed no performance evaluation in the past 12 months.

Review of personnel documentation revealed Employee 10 with a hire date of June 16, 2014. Review of Employee 14's personnel record revealed no performance evaluation in the past 12 months.

An interview with the Nursing Home Administrator, on May 22, 2024, at 10:34 AM revealed the nurse aide staff had no annual performance evaluation completed.

28 Pa. Code 201.19 (2) Personnel policies and procedures

Plan of Correction - To be completed: 06/28/2024

Corrective Action:
A file audit was performed for all currently employed Nurse Aides. Performance Evaluations were completed per this requirement for all Nurse Aides who did not have a current evaluation on file.
The Director of Nursing and Human Resource Director were inserviced on the importance of this requirement.

Identification of Those Affected:
All Nurse Aides have the potential to be affected.

Systematic Change to Prevent Recurrence:
The Administrator will monitor for completion of Performance Evaluations for all newly-hired or currently employed Nurse Aides for the next 3 months to help ensure ongoing compliance.
A tracking spreadsheet will be completed to aid in monitoring compliance with performance evaluations

Monitoring to Ensure Compliance:
Tracking spreadsheet/results of audit will be reviewed in QAPI to confirm that compliance is sustained.
The subject of this deficiency and results of audit will be discussed in QAPI Meetings for 3 months or until substantial compliance is met.

483.70(d)(1)(2) REQUIREMENT Governing Body:

§483.70(d) Governing body.
§483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and

§483.70(d)(2) The governing body appoints the administrator who is-
(i) Licensed by the State, where licensing is required;
(ii) Responsible for management of the facility; and
(iii) Reports to and is accountable to the governing body.

Observations:

Based on document review and staff interview it was determined that the facility failed to establish a governing body responsible for establishing and implementing polices regarding the management and operation of the facility and failed to appoint a licensed administrator who is responible for the building.

Findings Include:

Review of policies and documents provided by the facility during its annual survey revealed no documentation regarding its Board of Directors and/or its members.

An interview with the Nursing Home Administrator (NHA), on May 21, 2024, at 1:49 PM revealed the facility has no Board of Directors or governing body responsible for implementing polices, management and operations of the facility.

Verbal notification from the NHA on May 20, 2024, at approximately 9:45 AM revealed his last day of employment at the facility, and as the NHA, would be Friday, May 24, 2024. Written notification was received on May 24, 2024 that the NHA would no longer be serving as the administrator as of that day. The facility reported that the Director of Nursing had applied for a temporary/emergency NHA license but as of May 31, 2024, has not received approval for the license. An out of state Nursing Home Administrator applied for the state license by endorsement. As of May 31, 2024, the facility does not have a state required licensed Nursing Home Adminstrator.

28 Pa. Code 201.14 (a) Responsibility of licensee

Plan of Correction - To be completed: 06/11/2024

Corrective Action: F837
Effective immediately, a Governing Body has been made available to the facility.
A Licensed Nursing Home Administrator is now performing such duties as appointed by the Governing Body.
The QAPI Committee has discussed and signed understanding that a Governing Board/Board of Directors is available.

Identification of Those Affected: All residents have the potential to be affected.

Systematic Change to Prevent Recurrence:
The Governing Board will monitor 483.70(d)(2) related to compliance of policies for management and operation of the facility.

Monitoring to Ensure Compliance:
The subject of this deficiency will be discussed in QAPI Meetings x3 months or until substantial compliance is met.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on document review, policy review and staff interview it was determined that the facility failed to ensure its quality assessment and assurance committee meeting consists of the Medical Director for one of three quarterly meeting documents reviewed (January 2024).

Findings Include:

Review of the facility's first quarter Quality Assessment and Assurance meeting sign in sheets revealed no signature by the facility's Medical Director dated January 15, 2024.

An interview with the Nursing Home Administrator, on May 21, 2024, at 11:20 AM confirmed the Medical Director was absent during that quarterly meeting.

28 Pa. Code 201.14 (a) Responsibility of licensee

Plan of Correction - To be completed: 06/11/2024

Corrective Action:
An urgent QAPI Meeting was held on 06/11/24 to discuss pertinent updates. The Medical Director was included in an inservice amongst QAPI committee members educating each on attendance requirements.

Identification of Those Affected:
All residents have the potential to be affected.

Systematic Change to Prevent Recurrence:
An updated tracking system for QAPI has been created by the Administrator to aid in monitoring for attendance compliance. If any specific QAPI committee members are unable to be present, they must review and sign meeting minutes asap, or on their next scheduled work day, within a reasonable amount of time, and offer any additional input as necessary. The Administrator is responsible to ensure compliance.

Monitoring to Ensure Compliance:
The subject of this deficiency will be discussed in QAPI Meetings for 3 months or until substantial compliance is met.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on interview and review of the facility's Infection Control Committee attendance records, the facility failed to ensure that the required nine multidisciplinary members were present at the Infection Control meetings. Based on interview and data utilization reports (reports of central line) submitted to PA-PSRS (Pennsylvania Patient Safety Reporting System), it was determined that the facility failed to report monthly data accurately for two months (March 2024 and April 2024).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the Medical Care Availability and Reduction of Error (Mcare) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include...a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members includes Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, community member, laboratory personnel, pharmacy staff, and infection control team members.

Review of the facility's Infection Control Committee Attendee signature page for October 23, 2023, revealed attendees only included the Nursing Home Administrator, Director of Nursing, Maintenance, and the Medical Director.

Review of the facility's Infection Control Committee Attendee signature page for January 15, 2024, revealed attendees only included the Nursing Home Administrator, Pharmacy, Director of Nursing, Pharmacy, Infection Control, and a community member.

Review of the facility's Infection Control Committee Attendee signature page for April 26, 2024, revealed attendees only included the Pharmacy, Director of Nursing, Laboratory, and the Medical Director.

An interview with the Director of Nursing and Nursing Home Administrator on May 23, 2024, at 12:10 PM, confirmed that all nine interdisciplinary members should attend their quarterly scheduled infection control meetings.

Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the Medical Care Availability and Reduction of Error (Mcare), requires facilities as part of their infection control surveillance, to submit data monthly that includes the number of resident days in the facility and the number of days a central line (a central venous catheter that is inserted under the skin and threaded into a large vein near or just inside the heart to deliver medication) was utilized by a resident.

A review of Resident 4 ' s clinical record revealed the resident was admitted on March 18, 2024, with an implanted port (type of central line), and the implanted port remained in Resident 4 as of May 23, 2024, as ordered by her oncologist (a doctor who treats cancer).

A review of the March 2024, and April 2024, Utilization Reports to PA-PSRS failed to reveal any resident had a central line for those months.

Written correspondence from Employee 3 (Infection Prevention and Control Professional) on May 23, 2024, at 10:30 AM, confirmed that she failed to report the data to PA-PSRS for March and April, stating that she wasn't aware that the Resident had an implanted port until orders were sent to send the resident monthly to oncology to have the central line flushed in April 2024.

During an interview with the Director of Nursing (DON) on May 23, 2024, at 12:10 PM, the DON confirmed the expectation that all central lines should be reported to PA-PSRS monthly per Act 52.

Plan of Correction - To be completed: 06/28/2024

Corrective Action: P1020
An urgent Infection Control Committee Meeting will be held by 6/28/24 with all appropriate multidisciplinary members present. All will be inserviced on required attendance. If any member is not present for a meeting, they should be dialed in or must review QAPI minutes within a reasonable amount of time for any additional input or changes.
October 2023, January and April 2024 meetings were reviewed with all members present to ensure appropriate communication, follow up, or new recommendations.
Central Line reports for March and April were reviewed during an urgent QAPI meeting on 06/11/24 to assess for accuracy and submission to Pennsylvania Patient Safety Reporting System.

Identifiation of Those Affected:
All residents have potential to be affected by this deficient practice.
Residents with a Central Line are specifically at risk in relation to Pennsylvania Patient Safety Reporting System.

Systematic Change to Prevent Recurrence:
A binder was created and resides with the Director of Nursing with a copy of all date-stamped Central Line submissions to Pennsylvania Patient Safety Reporting System. A tracking cover-sheet is also included with initials to confirm submission for each month.
Infection Control Committee meeting minutes will be reviewed in QAPI, to include attendance records, to ensure accuracy and appropriateness.
The Director of Nursing, or designee, will sign-off/initial that Central Line submissions to Pennsylvania Patient Safety Reporting System was completed timely in the new tracking binder.

Monitoring to Ensure Compliance:
Follow-up of this deficiency will be reviewed in QAPI for the next 3 months to ensure ongoing compliance.

§ 201.23(c.1) LICENSURE Closure of facility.:

(c.1) The facility shall develop a closure plan that includes all of the following:

Observations:

Based on policy review and staff interview it was determined that the facility failed to develop a closure plan if the facility would close and terminate all services.

Findings Include:

A review of policies provided by the facility revealed none developed detailing its processes in the event of its closure.

An interview with the Nursing Home Administrator, on May 21, 2024, at 12:39 PM revealed the facility had not developed any policy detailing its plans in the event of its closure.

28 Pa. Code 201.23 Closure of facility

Plan of Correction - To be completed: 06/21/2024

Corrective Action:
A policy related to Business Closure, including the occurrence of terminating all services, has been created and reviewed by the Board of Directions and QAPI Committee.

Identification of Those Affected:
All residents have the potential to be affected by this deficient practice.

Systematic Change to Prevent Recurrence:
A review of this policy was completed by the Administrator and Governing Body to ensure appropriateness. An annual policy review was completed. Policies will be reviewed annually, and as needed.

Monitoring to Ensure Compliance:
This policy will be reviewed in QAPI Meeting for 3 months to ensure understanding.

§ 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 document review and staff interview, it was determined that the facility failed to ensure a required minimum of one licensed practical nurse per 25 residents during both evening and night shifts for 6 of 7 days reviewed (May 16, 2024- May 21, 2024).

Findings Include:

A review of facility-provided staffing ratio information for May 16, 2024-May 21, 2024, revealed a resident census of 16 residents. The information also revealed a Licensed Practical Nurse (LPN) ratio of 0 hours worked on the following evening shifts, May 16, 2024, May 17, 2024, May 18, 2024 May 20, 2024, and May 21, 2024; therefore, the facility did not meet the minimum LPN ratio of 8 hours required for the facility census of residents on those shifts.

A review of facility-provided staffing information for May 16, 2024- May 21, 2024, revealed a resident census of 16 residents. The information also revealed an LPN ratio of 4 hours worked on the evening shift on May 19, 2024; therefore, the facility did not meet the minimum LPN ratio of 8 hours required for the facility census of residents on that shift.

An interview with the Nursing Home Administrator, on May 22, 2024, at 9:45 AM revealed the facility had not met the minimum required LPN ratio on those dates.

Plan of Correction - To be completed: 07/12/2024

Corrective Action:
Review of this regulation was completed with Administrator, DON, and other pertinent staff with signature of understanding.

A waiver for this regulation is being requested which will still allow for appropriate care of our resident population.

If the waiver of this regulation is denied, then the facility will ensure compliance following a review of the staffing schedule. Revisions will be made to such schedule to ensure compliance with regulation.

Agency staffing availability and contract was reviewed to prepare for staffing emergencies. If agency staffing becomes unavailable, and no alternative option presents itself, the Administrator would communicate to the Department of Health and the Governing Body for guidance and immediate intervention or suggestions.

The Director of Nursing was inserviced on this requirement and to notify the Administrator for any discrepancies in planning the staff schedule.

Identification of Those Affected:
All residents have the potential to be affected by this deficient practice.

Systematic Change to Prevent Recurrence:
In similar situations, the facility has implemented a new bonus structure for picking up additional shifts to encourage staff to help cover open holes in schedule. If this fails, the DON would be responsible to ensure appropriate coverage or assign contract/agency staff.

A clinical staffing meeting has been implemented reoccurring on a weekly basis to assess for appropriate staffing levels, for the next 8-weeks, or until compliance is achieved.

During daily stand-up meeting, the nursing schedule will be reviewed for appropriateness in relation to compliance with regulation.

The staffing coordinator, or designated employee, will notify the Administrator for occurrences when staffing levels may be at risk for noncompliance.

An audit of staffing levels across will be completed weekly for 6-weeks, and then monthly for 2-months, by the Director of Nursing and provided to the Administrator for compliance review.

Updated postings for open positions have been created to encourage new applicants as we work to fill them as soon as possible.

Monitoring to Ensure Compliance:
The staffing schedules will be reviewed at QAPI Meeting for 3 months or until substantial compliance is met.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on document review and staff interview it was determined that the facility failed to ensure a required minimum of 1 Registered Nurse during all shifts for 6 of 7 dates reviewed (May 15, 2024, May 16, 2024, May 17, 2024, May 19, 2024, May 20, 2024, and May 21, 2024).

Findings Include:

A review of facility-provided staffing ratio information for May 19, 2024, on the day shift, revealed a census of 16 residents. Further review revealed a Registered Nurse (RN) ratio of 0 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on that shift.

A review of facility-provided staffing ratio information for May 19, 2024, on the evening shift, revealed a census of 16 residents. Further review revealed an RN ratio of 4 hours worked that shift; therefore, the facility did not meet the required minimum RN ratio of 8 hours for the facility census on that shift.

A review of the facility-provided information for May 15, 2024, May 16, 2024, May 17, 2024, May 20, 2024, and May 21, 2024, revealed a census of 16 residents. Further review revealed an RN ratio of 0 hours worked on those shifts; therefore, the facility did not meet the required minimum RN ratio of 8 hours for the facility census on those shifts.

An interview with the Nursing Home Administrator, on May 22, 2024, at 9:45 AM revealed the facility had not met the required RN ratio on those dates and those shifts.

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