INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 20-21, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Snug Harbor Rehabilitation and Recovery LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of facility policy, staff schedules and staff interview, the facility failed to provide one primary care staff during primary care hours. Licensing alert 3-02 defines primary care staff as the group of individuals, including clinical supervisors, counselors,physicians, physician ' s assistants, psychologists, registered nurses and licensed practical nurses who provide primary care services and those individuals who are responsible for developing and implementing the treatment plan. In addition, for the detoxification activity, primary care hours are 24 hours a day, seven days a week. Staffing levels of primary care staff must be maintained for each shift, 24 hours each day. These designated staff may not have any duties other than in the detoxification unit. It was determined that non-primary care staff, such as house monitors, intake staff and security guards are providing coverage for the detoxification unit while the nurse leaves the unit to administer medications to the rehabilitation clients.These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
The staff was educated on the "Primary care staff" requirement when moving from detox unit to residential unit for medication passed.
A counselor will be sent from residential to detox to cover detox while nurse is dispensing medications in residential unit, non primary staff will not be utilized during this procedure.
This has been effective since 3/21/24. The Nurse Manager and Program Director will monitor to ensure procedure is adhered to. |
709.62(a)(3) LICENSURE Completion Requirements
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
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Observations
Based on a review of client records, the facility failed to follow their detoxification requirements for the completion of treatment.Facility policy states that prior to discharge from the detoxification unit, clients will be assessed to ensure their symptoms have subsided and their vital signs are stable. A physician consult and order is obtained for the discharge from detoxification.There was no physican order or consult documented in client records # 1, 2, 3, 4 and 5. Client #1 was admitted to detox on February 2, 2024 and discharged from detox on February 7, 2024. There was no physician order or consult documented for client #1.Client #2 was admitted to detox on January 31, 2024 and discharged from detox on February 4, 2024. There was no physician order or consult documented for client #2.Client #3 was admitted to detox on August 2, 2023 and discharged from detox on August 6, 2023. There was no physician order or consult documented for client #3.Client #4 was admitted to detox on September 18, 2023 and discharged from detox on September 22, 2023. There was no physician order or consult documented for client #4.Client #5 was admitted to detox on August 14, 2023 and discharged from detox on August 18, 2023.. There was no physician order or consult documented for client #5.These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Nursing staff was re-educated om the policy of physician orders being obtained for all actions. Orders must be signed by our physician or Nurse Practitioner and kept within the client medical record.
Orders must be obtained for any change in level of care from detox to residential and detox completion and discharge.
This is will be in place by 4/15/24 and will be monitored by Nurse Manager and Program Director.
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