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Gov't audit insider: Nursing home staffing requirements

Healthcare Auditing Weekly, December 9, 2003

The OIG's objective for this review was to determine whether WillowBrooke Court at Southampton Estates (WillowBrooke Court) was in compliance with federal and state staffing laws and regulations for nursing homes.

The OIG performed the following steps:

1.       Obtained background, staffing, and deficiency data for WillowBrooke Court from the Centers for Medicare and Medicaid Services' Online Survey Certification and Reporting System database through CMS' Nursing Home Compare Web site.

2.       Reviewed federal and Pennsylvania state laws and regulations for nursing homes to determine what staffing standards WillowBrooke Court was required to adhere to.

3.       Obtained staffing schedules, time and attendance records, and payroll records to determine the home's direct care hours per resident per day, as well as the employee-to-resident ratio for three two-week periods.

4.       Obtained and analyzed background checks for all direct care employees to assure they adhere to the state requirements.

5.       Conducted inquiries through Pennsylvania's online license and certification systems to determine whether all direct care employees were in good standing.

6.       Reviewed the survey and certification process at the Pennsylvania State Survey Agency and analyzed the rest of the two most recent standard surveys conducted at WillowBrooke Court.

7.       Learned about WillowBrooke Courts' procedures for recruiting, retaining, and scheduling staff through meetings and discussions with personnel at the home.

       Click here to read this audit report

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