Pennsylvania Department of Health
QUALITY LIFE SERVICES - MARKLEYSBURG
Patient Care Inspection Results

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QUALITY LIFE SERVICES - MARKLEYSBURG
Inspection Results For:

There are  83 surveys for this facility. Please select a date to view the survey results.

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QUALITY LIFE SERVICES - MARKLEYSBURG - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a State Licensure Monitoring survey on April 16, 2024, it was determined that Quality Life Services - Markleysburg was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 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 nurse aide (NA) per twelve residents during the day and/or evening shift, and/or one nurse aid per 20 residents during the night shift for seven of 21 days (3/4/24, 3/6/24, 3/8/24, 3/9/24, 3/10/24, 3/15/24, and 3/16/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets revealed the following nurse aide staffing shortages:
On 3/4/24, Census 55. Evening shift short one NA.
On 3/6/24, Census 55. Evening shift short one NA.
On 3/8/24, Census 55. Evening shift short one NA.
On 3/9/24, Census 55. Evening shift short one NA.
On 3/10/24, Census 54. Day shift short one NA, evening shift short one NA.
On 3/15/24, Census 56. Evening shift short one NA.
On 3/16/24, Census 56. Evening shift short one NA.


During an interview on 4/16/24, at 11:15 a.m. the Director of Nursing confirmed that the facility failed to provide a minimum of one nurse aide per twelve residents during the day and evening shift, and/or one nurse aid per 20 residents during the night shift on seven of 21 days.


 Plan of Correction - To be completed: 05/15/2024

Director of nursing or designee will provide re-education to the labor manager and RN supervisors regarding the required daily staffing ratios on their next scheduled day of work. Education will be completed by 4/27/24.

Daily staffing meetings will be held with labor manger, DON, ADON, and NHA to assure proper staffing ratios are being met for the day. Meetings ongoing with no anticipated end date.

An audit of all steps taken at the meeting and throughout the day of the steps taken to assure proper ratios are met and to fill any vacancies related to call offs.

Labor Management meetings will be held daily and the DOH staffing tool will be completed weekly to ensure proper ratios. Updates ongoing with no anticipated end date.

All audits will be reviewed in QAPI to ensure ongoing compliance.

211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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 interviews it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, per 30 residents during the evening shift, and per 40 residents during the night shift on 11 of 21 days (3/4/24, 3/5/24, 3/6/24, 3/7/24, 3/9/24, 3/10/24, 3/11/24, 3/14/24, 3/15/24, 3/16/24, and 4/13/24).

Findings include:

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

On 3/4/24, Census 55. Day shift short one LPN.
On 3/5/24, Census 55. Day shift short one LPN.
On 3/6/24, Census 55. Day shift short one LPN.
On 3/7/24, Census 55. Day shift short one LPN.
On 3/9/24, Census 55. Day shift short one LPN.
On 3/10/24, Census 54. Day shift short one LPN.
On 3/11/24, Census 55. Day shift short one LPN.
On 3/14/24, Census 56. Day shift short one LPN.
On 3/15/24, Census 56. Day shift short one LPN.
On 3/16/24, Census 56. Day shift short one LPN.
On 4/13/24, Census 56. Day shift short one LPN.

During an interview on 4/14/24, at1 11:15 a.m. the Director of Nursing confirmed that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, per 30 residents during the evening shift, and per 40 residents during the night shift 11 of 21 days.


 Plan of Correction - To be completed: 05/15/2024

Director of nursing or designee will provide re-education to the labor manager and RN supervisors regarding the required daily staffing ratios on their next scheduled day of work. Education will be completed by 4/27/24.

Daily staffing meetings will be held with labor manger, DON, ADON, and NHA to assure proper staffing ratios are being met for the day. Meetings ongoing with no anticipated end date.

An audit of all steps taken at the meeting and throughout the day of the steps taken to assure proper ratios are met and to fill any vacancies related to call offs.

Labor Management meetings will be held daily and the DOH staffing tool will be completed weekly to ensure proper ratios. Updates ongoing with no anticipated end date.

All audits will be reviewed in QAPI to ensure ongoing compliance.


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