Observations
Based on the review of staff schedules, the facility failed to comply with the client/staff ratios on two days of a three month time frame.
The findings include:
Staffing schedules between November 9, 2008 and February 7, 2009 were reviewed on February 12, 2009. Primary hours are 24/7 for detoxification level of care and require one FTE primary care staff person for every seven clients during all shifts. Client census showed eight clients in detoxification on Novemeber 14, 2008. There was only one staff scheduled for each shift. Client census on January 9, 2009 showed nine clients in detoxification. There was only one staff person scheduled for each shift.
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Plan of Correction
Project director reviewed the applicable staffing standard with the governing body on 3/13/09 to ensure their understanding. Project director submitted a revised staffing roster for the Detox facility that would effectively address the staffing standard in question and secured governing body approval on 3/13/09. Facility director will ensure appropriate compliance with the staffing standard from this day forward and will hire additional staff for the facility to ensure consistent compliance by 3/31/09. Facility director will review the staffing pattern with the project director on a weekly basis beginning 3/13/09 to ensure continued compliance.
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