This report is a result of a complaint investigation conducted on June 1-16, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Pennsylvania Adult & Teen Challenge, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation, therefore a plan of correction is required.
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Plan of Correction
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Observations
Based on a review of the primary care staff hours, conducted on June 12, 2020, the facility failed to provide one primary care staff for every seven patients in the detoxification activity.
A schedule was submitted that indicated the hours worked for the detox nursing and primary care staff for the period from May 1, 2020 through June 12, 2020. The facility was not in compliance for the following time-frames:
May 25, 2020: census 8; 1 primary care staff from 2:30 pm to 10 pm & 10:30 pm to 12 am.
May 26, 2020: census 9; 1 primary care staff from 12 am to 6 am & 2:30 pm to 10 pm.
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Plan of Correction
On 7/10/2020 clinical leadership team will conduct training on appropriate staffing ratios for the detoxification program. Starting on 7/10/2020 The Clinical and Medical Director will review the staffing schedule each week to ensure up to date staffing information is accurate. Starting on 7/10/2020 the medical team will update the admissions team by 10 am on a daily basis regarding the current bed availability ensuring that we remain in compliance with the DDAP detox staffing regulations found in code 704.12. |