Observations
Based on a review of the facility's detoxification service schedule and census reports, the facility failed to ensure that the client to primary care staff ratio did not exceed 7:1.
The findings include:
The facility's schedules were reviewed during the follow-up inspection on November 24, 2009. As a result of the review of employee schedule, the facility was determined to exceed the the 7:1 client to primary care staff ratio on the following days:
November 5, 2009 - There was a 8:1 ratio during the 3rd shift.
November 13, 2009- There was a 9:1 ratio during the third shift.
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Plan of Correction
The Nurse Manager will assure that the staff to client ratio does not exceed one to seven in detox. Should census rise above seven, the Program Director will authorize overtime as requested by the Nurse Manager. The Nurse Manager will assume responsibility for coordinating additional staff coverage using staff nurses, temp nurses, or counselors as approved. Ongoing conformance will be monitored and reported by the Nurse Manager in her monthly Quality Improvement report.
Target Date for Resolution:12/14/09
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