Observations:
Based on a a review of staffing documents provided by the facility and staff interviews it was determined that the facility failed to provide one nursing assistant (NA) per 10 residents on the daylight shift for one of five days (8/18/24) and one NA per 11 residents on the evening shift for one of five days (8/17/24) as required.
Findings include:
A review of facility staffing documents provided by the facility from 8/16/24 through 8/20/24, revealed the facility failed to provide the required NA's as follows:
Daylight shift:
DateCensusActual provided Minimum required
8/18/2410885.5086.40
Evening shift:
8/17/2410974.0079.27
During an interview on 8/21/24 at 2:55 pm, the Nursing Home Administrator confirmed that the facility failed to provide NA's as required in the facility and failed to meet the required staffing ratios.
| | Plan of Correction - To be completed: 08/23/2024
1)The facility was unable to take corrective action for the nurse aide staffing on the identified days that have already passed. No residents were affected by the nurse aide staffing on the identified scheduled days.
2) NHA, DON and/or designee will re-educate the labor manager and RN supervisors on the nurse aide ratio regulation for the state of PA including the revised staff ratio effective July 1, 2024.
3) The facility will conduct daily staffing meetings Monday through Friday to review all ratios are met throughout the day, the following day and the weekend staffing, in the event staffing ratio is not met staff assignments will be adjusted. In the event of factors affecting staffing ratio, DON or designee will be contacted to determine staffing adjustments needed to make best attempt to reach ratio requirement.
4) Audits of all steps taken to fill any vacancies that could affect the ratio will be completed by the DON and/designee the day following for the previous day staffing. Audits will be completed 5 days a week x 1 week, weekly x 2 weeks to review compliance with staffing ratios.
5) Results of the audits will be reviewed and recorded in the monthly QAPI meeting.
Compliance date Aug 23, 2024
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