Pennsylvania Department of Health
HAVEN CONVALESCENT HOME INC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HAVEN CONVALESCENT HOME INC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on January 11, 2024, it was determined that Haven Convalescent Home Inc., 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)(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 failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the overnight shift for one of 21 days reviewed (11/23/23); and one LPN per 25 residents during the day shift for one of 21 days reviewed (1/6/24).

Findings include:

Review of facility census data revealed that on 11/23/23, the facility census was 91 which required a minimum of 2.28 LPNs during the day shift. Review of the nursing time schedules revealed that only 2.0 LPNs worked during the overnight shift for that date, therefore not meeting the required LPN ratio.

Review of facility census data revealed that on 1/6/24, the facility census was 90 which required a minimum of 3.6 LPNs during the day shift. Review of the nursing time schedules revealed that only 3.25 LPNs worked during the day shift for that date, therefore not meeting the required LPN ratio.

During an interview on 1/11/24, at 10:19 a.m. the Facility Staffing Coordinator confirmed that the facility did not meet the LPN ratios for the above identified dates and shifts.

Plan of Correction - To be completed: 02/19/2024

Facility Staffing Coordinator was reeducated on current LPN staffing ratios according to current census and shifts. Facility will attempt to utilize facility staff and temporaty staffing agencies as needed.
Facility weekly Schedule will be made in accordance with current Pennsylvania DOH Staffing guidelines and facility census.
Nurses will be educated by Director of Nursing on current Pennsylvania DOH Staffing Guidelines on 1/12/2024.
Schedule and census will be monitored daily per shift by RN Nursing Supervisor for call offs and changes in census. Adjustments will be made as needed by Director of Nursing or RN Nursing Supervisor. Facility will utilize facility staff and or temporary Staffing Agencies to fill in shifts as needed according to type of nursing service personal that is needed.
Assistant Administrator will monitor schedules at least weekly x 4 weeks and then every 2 weeks until deemed in compliance by facility QAPI Committee

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