Observations
Based on a complaint investigation conducted on March 5, 2020, the facility failed to provide one full time equivalent primary care staff person available for every seven clients during primary care hours in the reviewed staff schedules from December 22, 2019 through February 29, 2020.
December 23, 2019 with a client census of eight, the primary care staff hours were:
12:00 am-6:12 am- 1 primary care staff when 2 are required.
6:12 am-11:04 am- 1 primary care staff when 2 are required
6 pm-12 am- 1 primary care staff when 2 are required
December 25, 2019 with a client census of 7, the primary care staff hours out of compliance were:
9:30 am- 10 pm- 0 primary care staff
December 27, 2019 with a client census of 6, the primary care staff hours out of compliance were:
11:00 pm 12/26-6:00 am 12/27- 0 primary care staff
December 28, 2019 with a client census of 3, the primary care staff hours out of compliance were:
10:12 am- 6:00 pm - 0 primary care staff
December 29, 2019 with a client census of 4, the primary care staff hours out of compliance were:
6:15AM- 6:00 pm - 0 primary care staff
December 30, 2019 with a client census of 4, the primary care staff hours out of compliance were:
6:00 am-7:39 am- 0 primary care staff
4:40 pm-6:14 pm - 0 primary care staff
December 31, 2019 with a client census of 2, the primary care staff hours out of compliance were:
3:18 am- 12/31- 6AM 1/1/20- 0 primary care staff
January 2, 2020 with a client census of 9, the primary care staff hours out of compliance were:
12:00 am-6:11 am-1 primary care staff
6:15 am-6 pm- 1 primary care staff
6:34 pm-12:00 am-1 primary care staff
January 3, 2020 with a client census of 10, the primary care staff hours out of compliance were:
12:00 am-6:15 am-1 primary care staff
6:15 am-7:50AM- 1 primary car staff
7:00pm-12:00 am-0 primary care staff
January 4, 2020 with a client census of 10, the primary care staff hours out of compliance were:
12:00 am-6:13 am-0 primary care staff
6:13 am-8:30PM- 1 primary care staff
8:30PM-12:00 am-0 primary care staff
January 5, 2020 with a client census of 8, the primary care staff hours out of compliance were:
12:00 am-6:11 am-0 primary care staff
6:11 am-5:25 pm- 1 primary care staff
8:06 pm-12:00 am-1 primary care staff
January 6, 2020 with a client census of 10, the primary care staff hours out of compliance were:
12:00 am-6:11 am-1 primary care staff
9:18 am-6:00 pm- 1 primary care staff
6:00 pm-12:00 am-1 primary care staff
January 8, 2020 with a client census of 9, the primary care staff hours out of compliance were:
12:00 am-6:02 am-1 primary care staff
6:15 am-5:32 pm- 1 primary care staff
7:33 pm-12:00 am-1 primary care staff
January 9, 2020 with a client census of 10, the primary care staff hours out of compliance were:
12:00 am-6:03 am-1 primary care staff
6:03 am-10:46 am- 1 primary care staff
7:30 pm-12:00 am-1 primary care staff
January 10, 2020 with a client census of 11, the primary care staff hours out of compliance were:
12:00 am-5:36 pm-1 primary care staff
January 11, 2020 with a client census of 11, the primary care staff hours out of compliance were:
8:00 am-6:00 pm-1 primary care staff
6:03 am-10:46 am- 1 primary care staff
6:00 pm-12:00 am-1 primary care staff
January 12, 2020 with a client census of 12, the primary care staff hours out of compliance were:
12:00 am-6:06 am-1 primary care staff
6:30 am-6:00 pm- 1 primary care staff
6:25 pm-12:00 am-1 primary care staff
January 13, 2020 with a client census of 10, the primary care staff hours out of compliance were:
12:00 am-6:08 am-1 primary care staff
6:15 am-5:19 pm-1 primary care staff
7:20 pm- 12:00 am-1 primary care staff
January 20, 2020 with a client census of 5, the primary care staff hours out of compliance were:
6:34 pm-6:07 am-0 primary care staff
January 21, 2020 with a client census of 8, the primary care staff hours out of compliance were:
6:07 am-11:08 am-1 primary care staff
2:37 pm-6:28 pm-1 primary care staff
7:06 pm-12:00 am-1 primary care staff
January 22, 2020 with a client census of 8, the primary care staff hours out of compliance were:
12:00 am-6:52 am-0 primary care staff
6:52 am-11:32 am- 1 primary care staff
7:03 pm-12:00 am-1 primary care staff
January 23, 2020 with a client census of 8, the primary care staff hours out of compliance were:
12:00 am-6:11 am-1 primary care staff
7:17 am-5:37 pm- 1 primary care staff
5:37 pm-12:00 am-1 primary care staff
January 24, 2020 with a client census of 7, the primary care staff hours out of compliance were:
6:29 pm-12:00 am- 0 primary care staff
January 25, 2020 with a client census of 5, the primary care staff hours out of compliance were:
12:00 am-6:05 am-0 primary care staff
6:28 pm-6:56 pm- 0 primary care staff
January 26, 2020 with a client census of 3, the primary care staff hours out of compliance were:
12:41 am-6:05 am-0 primary care staff
6:35 pm-12:00 am-0 primary care staff
January 27, 2020 with a client census of 1, the primary care staff hours out of compliance were:
12:00 am-6:10 am-0 primary care staff
January 29, 2020 with a client census of 4, the primary care staff hours out of compliance were:
6:33 pm-12:00 am-0 primary care staff
January 30, 2020 with a client census of 6, the primary care staff hours out of compliance were:
12:00 am-6:08 am- 0 primary care staff
6:47 pm-12:00 am- 0 primary care staff
January 31, 2020 with a client census of 9, the primary care staff hours out of compliance were:
12:00 am-6:19 am-0 primary care staff
6:19 am-5:11 pm-1 primary care staff
February 1, 2020 with a client census of 10, the primary care staff hours out of compliance were:
1:18 am-6:16 am-1 primary care staff
7:41 am-5:34 pm-1 primary care staff
6:54 pm-12:00 am-1 primary care staff
February 7, 2020 with a client census of 8, the primary care staff hours out of compliance were:
12:00 am-9:10 am- 1 primary care staff
9:10 am-6:00 pm- 0 primary care staff
6:00 pm- 12:00 am- 1 primary care staff
February 9, 2020 with a client census of 8, the primary care staff hours out of compliance were:
1:11 am-6:00 am-1 primary care staff
7:35 pm-12:00 am- 1 primary care staff
February 11, 2020 with a client census of 8, the primary care staff hours out of compliance were:
12:00 am- 6:13 am- 1 primary care staff
7:30 am-5:43 pm- 1 primary care staff
5:43 pm- 12:00 am- 1 primary care staff
February 12, 2020 with a client census of 8, the primary care staff hours out of compliance were:
12:00 am- 6:09 am- 1 primary care staff
9:04 am- 6:00 pm- 1 primary care staff
6:00 pm- 12:00 am-1 primary care staff
February 13, 2020 with a client census of 8, the primary care staff hours out of compliance were:
12:00 am-6:00 am-1 primary care staff
6:00 am- 6:09 am- 0 primary care staff
6:09 am- 12:08 pm- 1 primary care staff
5:42 pm-6:00 pm-1 primary care staff
6:52 pm- 12:00 am- 1 primary care staff
February 14, 2020 with a client census of 8, the primary care staff hours out of compliance were:
12:00 am-6:00 am- 1 primary care staff
6:00 am-6:55 am- 0 primary care staff
6:55 am-11:41 am- 1 primary care staff
6:49 pm-12:00 am- 1 primary care staff
February 19, 2020 with a client census of 8, the primary care staff hours out of compliance were:
7:42 pm-12:00 am 1 primary care staff
February 20, 2020 with a client census of 8, the primary care staff hours out of compliance were:
12:00 am-6:00 am- 1 primary care staff
10:30 pm-12:00 am- 1 primary care staff
February 22, 2020 with a client census of 8, the primary care staff hours out of compliance were:
12:00 am-6:07 am- 1 primary care staff
6:15 am- 6:00 pm- 1 primary care staff
7:26 pm-12:00 am- 1 primary care staff
February 26, 2020 with a client census of 8, the primary care staff hours out of compliance were:
5:00 am- 6:00 am-1 primary care staff
11:00 pm-12:00 am- 1 primary care staff
February 27, 2020 with a client census of 9, the primary care staff hours out of compliance were:
12:00 am- 6:00 am- 1 primary care staff
7:15 pm-7:27 pm-1 primary care staff
February 28, 2020 with a client census of 10, the primary care staff hours out of compliance were:
2:22 am-6:00 am- 1 primary care staff
6:50 pm-12:00 am- 1 primary care staff
February 29, 2020 with a client census of 9, the primary care staff hours out of compliance were:
12:00 am-6:00 am- 1 primary care staff
10:00 pm-12:00 am-1 primary care staff
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Plan of Correction
The RN supervisor will be responsible for overseeing that at least one primary care staff is present on every shift The Program Director has ensured that the number of detox residents being accepted presently has been reduced to seven detox residents beginning 4/14/20 until adequate nursing is hired to ensure 2 primary care staff are present during operating hours. The RN supervisor will continue to address vacancies for primary care staff to increase the maximum allowed capacity to 14 detox patients. |