Observations:
Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours to each resident in a 24 hour period. Findings include:
A review of nursing time schedules from April 15, 2022, to April 21, 2022 and May 2, 2022, to May 8, 2022 revealed that the facility failed to maintain 2.7 hours of general nursing care to each resident in a 24 hour period on April 17, 2022. The facility's calculated general nursing care hours for April 17, 2022 was 2.52.
During a staff interview on May 13, 2022, at approximately 1:30 PM, Nursing Home Administrator confirmed that the facility's general nursing care hours was below 2.7 on April 17, 2022.
| | Plan of Correction - To be completed: 06/08/2022
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Laurel Lakes Rehabilitation & Wellness Center agrees with the allegations and citations listed on the statement of deficiencies.
Laurel Lakes Rehabilitation & Wellness Center maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Laurel Lakes Rehabilitation & Wellness Center's written credible allegation of compliance.
By submitting this plan of correction, Laurel Lakes Rehabilitation & Wellness Center does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Laurel Lakes Rehabilitation & Wellness Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding
1. The calculated direct care hours for April 17, 2022, as scheduled met the state requirements. The calculated actual worked hours for April 17, 2022, were below the state required ppd due to numerous staff callouts and inability to get other staff to work the hours vacated. There were no identified issues related to inability to meet the requirement of 28PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
2. Laurel Lakes will review the scheduled hours of direct care daily to assure adequate staffing is available to meet the minimum number of general nursing care hours for each 24-hour period, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
3. Laurel Lakes will review the scheduled hours of direct care staff to assure the hours are equivalent or above the minimum required hours. Laurel Lakes will maintain additional on call staff if scheduled staff are unavailable to come to work. The Director of Nursing will re-educate the Scheduler and RN Supervisors on the process for filling shifts in the event scheduled staff become unavailable.
4. The DON or designee will audit the schedule daily M-F, to include weekend/holidays with the Nursing Scheduler for 90 days to assure adequate staff are scheduled and contact information for back up staff is available. The results will be reviewed at the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.
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