Pennsylvania Department of Health
PROVIDENCE HEALTH & REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PROVIDENCE HEALTH & REHAB CENTER
Inspection Results For:

There are 117 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


PROVIDENCE HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on May 30, 2024, it was determined that Providence Health and Rehab Center corrected the deficiencies identified during the survey of April 25, 2024, as related to the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however, continues to have one deficiency 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)(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 30 residents during the evening shift on two of seven days (5/25/24 and 5/26/24).

Findings include:

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

Evening shift:

5/25/24census 12226.00 actual hours32.53 hours required.
5/26/24census 12235.00 actual hours39.04 hours required.

During an interview on 5/30/24, at 2:45 p.m. the Nursing Home Administrator confirmed that the facility failed to provide LPN's on the evening shift on the above dates as required.

Plan of Correction - To be completed: 06/12/2024

Facility Administration will ensure a minimum of one license practical nurse per 25 residents during day shift and 30 residents during the evening shift.
The facility staffing schedule was reviewed to ensure that it provided the necessary coverage of License practical nurses per regulation.
To prevent this from happening again the facility Administrator, Director of Nursing and Scheduler will conduct a staffing meeting to review staffing ratios weekly times four weeks then monthly times two month.
Regional Director of Clinical Services will educate the facility Administrator, Director of Nursing and scheduler on the LPN staffing ratios implemented on 07/01/2023.
To monitor and maintain ongoing compliance the Director of Nursing/designee will audit staffing weekly times four weeks then monthly times two months.

Results will be taken to the QAPI for review and revision as needed.

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