Observations
Based on a review of the Staffing Requirements Facility Summary Report and staff schedules for July 2024, the facility failed to keep client/primary care staff ratios regulatory requirements. This facility submitted documentation of intent to invoke Act 66 on January 11, 2024, with a 1:10 ratio.
Licensing Alert 2002-03 indicates designated primary care staff may not have any duties other than in the detoxification unit.
Per the Facility Director, every floor has a medication cart and a nursing station. One nursing staff working in the detoxification services unit will go to the men's floor and the women's floor to pass out medication and then come back to the detoxification unit. Also, intakes can occur at any time and one nursing staff working in the detoxification services will leave the unit to conduct the nursing assessment on new admissions.
On 7/4/24 there were two primary care staff working from 9pm to midnight, with 12 detoxification clients. This would leave one primary care staff working in the detoxification unit while the other primary care staff passed out medications and conducted intake assessments.
On 7/5/24 there were two primary care staff working from midnight-7am, with 12 detoxification clients. This would leave one primary care staff working in the detoxification unit while the other primary care staff passed out medications and conducted intake assessments.
On 7/6/24 there were two primary care staff working from 7pm to midnight, with 14 detoxification clients. This would leave one primary care staff working in the detoxification unit while the other primary care staff passed out medications and conducted intake assessments.
On 7/7/24 there were two primary care staff working from midnight to 7pm, with 14 detoxification clients. This would leave one primary care staff working in the detoxification unit while the other primary care staff passed out medications and conducted intake assessments.
On 7/12/24 there were two primary care staff working from 2 am to 7am, with 11 detoxification clients. This would leave one primary care staff working in the detoxification unit while the other primary care staff passed out medications and conducted intake assessments.
On 7/18/24 there were two primary care staff working from 8pm-11pm, with 12 detoxification clients. This would leave one primary care staff working in the detoxification unit while the other primary care staff passed out medications and conducted intake assessments.
On 7/19/24 there were two primary care staff working from 12 am - 7am, with 12 detoxification clients. This would leave one primary care staff working in the detoxification unit while the other primary care staff passed out medications and conducted intake assessments.
On 7/26/24 there were two primary care staff working from 8pm-11pm, with 12 detoxification clients. This would leave one primary care staff working in the detoxification unit while the other primary care staff passed out medications and conducted intake assessments.
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Plan of Correction
We will have one full-time equivalent primary care staff person for every 10 clients in detox, solely for detox clients, moving forward. Residential clients and duties will be assigned to residential staff members exclusively. The program director will audit the schedules monthly to ensure that this is happening consistently in comparison with the census.
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