(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.
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Observations:
Based on a review of facility staffing data, it was determined that the failed failed to meet the required Per Patient Day (PPD) of 2.87 for one day for the period from June 24, 2024 through June 30, 2024, and failed to meet the required PPD of 3.20 for two days during the period from July 1, 2024 through July 3, 2024.
Findings include:
A review of the facility staffing data from June 24 through June 30, 2024, revealed that on the following days the facility had a PPD below 2.87.
6/24/2024 - 2.81
A review of the facility staffing data from July 1 through July 3, 2024 revealed that on the following days the facility had a PPD below 3.2.
7/1/2024 - 3/17
7/2/2024 - 2.96
The aforementioned data was conveyed to the Nursing Home Administrator in a telephone interview on July 15, 2024.
| | Plan of Correction - To be completed: 08/22/2024
1. No residents or staff were harmed by not meeting the minimum HPPD.
2. Staffing sheets will be reviewed for previous two weeks to ensure overall PPD was met.
3. The facility will take the further steps to ensure the problem does not reoccur by in-servicing the DON, Unit Managers,HRD, and scheduler on the PA State Regulation 5630.
4.The DON/designee, NHA, Unit Managers and Staffing Coordinator will meet twice daily to review staffing.
4.Compliance will be monitored by the Director of Nursing/designee through audits daily x4 weeks to ensure the facility is meeting the minimum HPPD requirement of 3.2, with audit results being reported to the QAA committee to determine the need for further additional follow up / monitoring.
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