Failure to Maintain Minimum Staffing Requirements
Summary
The facility failed to maintain the minimum staffing requirements as mandated by state regulations. Specifically, the facility did not meet the required 2.0 direct care hours by certified nursing assistants (CNAs) on two occasions out of ninety-two days. Additionally, the facility failed to maintain a weekly average of 3.6 direct care hours per resident for eight out of fourteen weeks during the survey period. The discrepancies were identified through a review of the facility's staffing records, which showed incorrect calculations and inconsistencies in the reported staffing hours. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) provided multiple copies of staffing records, which contained errors and corrections. The initial records did not include weekly averages, and subsequent records showed incorrect calculations of CNA and nursing hours. Interviews with the staffing coordinator revealed that the facility did not use the state form for recording staffing hours but relied on a corporate Key Factor form, which did not accurately reflect the weekly averages required by state regulations. The staffing coordinator admitted to learning the role without formal training and acknowledged issues with call-offs affecting staffing levels. Further interviews with the Assistant Business Office Manager (ABOM) and the staffing coordinator highlighted a lack of clarity and consistency in recording and reporting staffing hours. The ABOM, new to payroll, relied on instructions from the NHA and the staffing coordinator to adjust hours to meet state requirements. The facility's assessment indicated a reliance on a formula to determine staffing needs, but the actual staffing levels fluctuated and occasionally fell below the state minimum requirements. The facility's failure to maintain accurate and compliant staffing records contributed to the deficiency identified during the survey.
Plan Of Correction
The Certified Nursing Assistant's (CNA) Per Patient Day for the specific dates were reviewed. No actions warranted due to the time has passed. The weekly direct care staffing hours for the specific weeks of /24, /24, /24 and for the quarter of through for meeting the weekly direct care average of 3.6 per patient day staffing requirement were reviewed. No actions are warranted due to the time has passed. An audit was conducted on the other 6 weeks which are /24, and for the Quarter through for meeting the minimum staffing requirements of 2.0 per patient day daily for Certified Nursing Assistants and the weekly average of direct care staffing of 3.60 per patient day. The results of the audit found that there were no other days during that specific quarter that the daily Certified Nursing Assistant staffing or the weekly average of direct care staffing did not meet the minimum staffing requirement of 2.0 per patient day and 3.6 per patient day respectively. On the Administrator initiated education for the Director of Nursing, Staffing Coordinator, Business Office Manager, Assistant Business Office Manager/Payroll, Rehab Director and the Activity Director related to meeting the daily minimum staffing for Certified Nursing Assistants of 2.0 per patient day and the definition of direct care staffing and meeting the required minimum weekly average of the 3.6 per patient day for direct care staff. Education was completed by The Director of Nursing/designee will audit the Certified Nursing Assistant staffing and direct care staffing 5 times per week for 12 weeks to ensure that the facility is meeting the Certified Nursing Assistant and direct care staffing requirements. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement Committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Penalty
The facility did not meet the required daily average of 2.0 CNA hours per resident on multiple days during the first quarter of FY 2025, with daily averages falling below the standard. The DON acknowledged these findings during the survey. This constitutes a Class III deficiency.
The facility did not meet the minimum staffing requirements for nursing and CNAs on five out of twenty-eight days. Nursing care fell below the required 1.0 hours on two days, and CNA care was below the 2.0 hours requirement on three days. The BOM and NHA confirmed the staffing numbers, and the facility's policy holds the administrator and DON responsible for ensuring sufficient staff.
Failure to Meet Minimum CNA Staffing Requirements
Penalty
Summary
The facility failed to meet the daily average minimum staffing requirement for Certified Nurse Assistants (CNAs) during the first quarter of Fiscal Year 2025. A review of the State Minimum Nursing Staff for Long Term Care Facilities showed that on several days, the facility's daily average CNA hours fell below the required 2.0 hours per resident per day. Specifically, the daily average CNA hours recorded were 1.9411, 1.9316, 1.9837, and 1.8799 on different days within the quarter. This deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged the findings. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The deficiency is classified as a Class III violation.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. N63- What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The staffing coordinator and Nurse Managers have been re-educated on ensuring that Certified Nursing Assistant minimum daily hour of direct care is at least 2.0 per resident per day. No residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Audit completed for the past 30 days, and no deficient practice identified. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Nursing Home Administrator educated the Director of Nursing and those responsible for staffing on the requirements of meeting the daily per patient day direct care hours.
Failure to Meet Minimum Staffing Requirements
Penalty
Summary
The facility failed to meet the minimum staffing requirements for nursing and certified nursing assistants (CNAs) on five out of twenty-eight days reviewed. Specifically, the facility did not meet the nursing minimum daily requirement of 1.0 hours of direct care on two days and failed to meet the CNA minimum daily requirement of 2.0 hours of direct care on three days. The daily averages for nursing and CNA care on these days were below the required thresholds, with nursing care averaging as low as 0.8787 hours and CNA care averaging as low as 1.8823 hours per resident per day. Interviews with the Business Office Manager (BOM) and the Nursing Home Administrator (NHA) confirmed the accuracy of the staffing numbers provided on the Long Term Care (LTC) sheets. The BOM stated that the Director of Nursing (DON) is responsible for the staffing schedule, and she inputs the numbers into the payroll system. The NHA acknowledged awareness of the days when staffing numbers did not meet the minimum requirements. The facility's policy and procedure for staffing indicate that the administrator and DON are responsible for ensuring sufficient nursing staff to meet federal and state law requirements, with staffing plans re-evaluated on an ongoing basis.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. N-063, Minimum Nursing Staff Element #1. A review of the State Minimum Nursing Staff for four (4) weeks (28 days) was conducted on __ of __, and the facility was identified to have failed to achieve minimum staffing requirements for Nursing on __ and __ and for Certified Nursing Assistants (CNA) on __ and __. The facility ensured that appropriate minimum staffing levels were achieved on the dates between those and from __ forward. Element #2. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit on __ of __ resident grievances and/or incidents to ensure that there were no concerns identified which correlated with the day/dates when the facility failed to ensure that minimum staffing requirements were met. No concerns were identified. Element #3. Policy regarding State Minimum Staffing Requirements were reviewed by the Interdisciplinary Team (IDT) and deemed appropriate. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan is developed and implemented to enhance the hiring of registered and licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Nurse and CNA's were called for interviews. Waiting for orientation are four (5) CNA's and one (1) Nurse. Other interviews are scheduled and pending. Element #5: Facility's Allegation of Compliance Date is __.
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