Pennsylvania Department of Health
HANOVER HALL FOR NURSING AND REHABILITATION
Patient Care Inspection Results

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HANOVER HALL FOR NURSING AND REHABILITATION
Inspection Results For:

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HANOVER HALL FOR NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Revisit Survey completed on February 16, 2024, it was determined that Hanover Hall for Nursing and Rehabilitation did not correct the deficiency cited during the survey of January 19, 2024, under the 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 staffing information furnished by the facility and staff interview, it was determined that the facility failed to ensure a required minimum of one nurse aide per 12 residents on the day shift for three of seven days reviewed for staffing ratio (February 7, 11, and 13, 2024); a minimum of one nurse aide per 12 residents on the evening shift for five of seven days reviewed for staffing ratio (February 7, 8, 10, 11, and 13, 2024); and a minimum of one nurse aide per 20 residents on the night shift for two of seven days reviewed for staffing ratio (February 9 and 10, 2024).

Findings include:

Review of the facility provided staffing ratio information for the day shift on February 7, 11, and 13, 2024, revealed a census ranging from 110-113. The information also revealed the facility was not meeting the required nurse aide ratio of 9.17 to 9.42 required for the facility census of residents on those shifts.

Review of the facility provided staffing ratio information for the evening shift February 7, 8, 10, 11, and 13, 2024, revealed a census ranging from 111-113. The information also revealed the facility was not meeting the required nurse aide ratio of 9.25 to 9.42 required for the facility census of residents on this shift.

Review of the facility provided staffing ratio information for the night shift on February 9 and 10, 2024, revealed a census ranging from 113-114. The information also revealed the facility was not meeting the required nurse aide ratio of 5.65-5.70 required for the facility census of residents on those shifts.

In an email received from the Nursing Home Administrator on February 16, 2024, at 11: 33 AM, she indicated that she had no additional information to offer.


 Plan of Correction - To be completed: 03/05/2024

1. Facility cannot retroactively correct staffing concern.
2. All residents have the potential to be at risk for care concerns related to low staffing and CNA ratios.
3. The facility will continue to utilize recruiting services for hiring new staff and holds weekly meetings for ongoing recruitment/retention efforts. The facility has contracted with a company who provides NA training classes, to which facility is hiring people directly into these classes, with success in onboarding new employees. Monetary incentives continue to be offered to staff on days when anticipated ratios are below minimum. DON/Administrator will monitor PPD and staffing ratios via daily meeting with scheduler to ensure compliance with regulations. Facility has previously provided education to staff on Act 102 and mandating policy, in addition to education to supervisors and schedulers to contact staff and agencies in the event of call out's or absences at the start of a shift. Agency rates have recently been reviewed and increased.
4. Facility will monitor ratios daily x4 weeks. Audits will be reviewed at QAPI to ensure compliance and quality improvement.


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