Observations
Based on a review of the staff schedules and the daily census from May 8, 2011 through June 4, 2011 inclusive, the facility failed to maintain a ratio of one primary care staff person for every seven clients in detox.
The findings include:
The facility reported a census of greater than seven client on the following dates as follows:
May 8, 9, 20, 21 and 23, 2011 - eight clients.
May 12, 14 and 22, 2011 - nine clients.
May 13, 2011 - 10 clients.
The facility does list additional staff members on the days when the census went above seven; however when cross referencing the work schedule, it was discovered that facility had been using House Managers to fill the voids. The staff must be primary care staff.
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Plan of Correction
The Program Director reviewed the staffing ratio regulations and qualifications for primary care staff in detox with the Program Supervisor, Intake Counselor, and Nurses, all of whom share responsibility for monitoring detox program census and staffing and reporting any related issues.
In order to ensure adequate available coverage of qualified primary care staff in detox a new nurse was hired, a contract with Medical Staffing Network was established, and the program is actively interviewing to hire an additional Counselor.
When exceeding seven clients in detox, a second primary care staff will be scheduled to work in addition to the regularly assigned primary care staff.
The Program Director and Program Supervisor will share responsibility for ongoing monitoring of conformance and reporting via the monthy Performance Improvement system.
Targeted Resolution Date: 9/19/11 |