Observations
The facility failed to comply with the required client/staff ratios in the detoxification unit on September 9, 2024 as evidenced by client and staff interviews, a review of primary care staff schedules and client census documentation. On September 9, 2024, there was only one primary care staff person working with 12 clients in the detoxification unit on September 9, 2024 from 12:00 AM through 8:00 AM and from 11:00 PM to 12:00 AM. The facility has opted to utilize Act 66 of 2023 regulatory flexibility for 704.12(a)(1) replacing the client to staff ratio of 7:1 with a ratio of 10:1. However, the client to staff ratio was 12:1 on September 9, 2024.
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Plan of Correction
EH will update the bed board system - reinstalling the previous version as it allows us to monitor levels of care and gender.
Initiate a communication process to alert nursing and counseling leaders when the census is getting tight and bed availability is low.
Before using Oak 2B as the Non-hospital detox unit leaders will be notified to ensure there is adequate staffing. If there is staffing for <=10 patients, Non-hospital detox patients will be admitted to the hospital unit or assessed and provided alternative placement options.
Human Resources will immediately work on recruiting counseling staff for the Oak 2 units. |