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TEQUESTATERRACIE

11301 SP

TEQUESTA, 5L 33469

SANDY plhlES

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CCR#2012011963
One of the fOUr

shall
to child ratio
care staff
asleep, the direct

I

allegations

wos

Contlrmed

I be

Treatrnel)t Facility far
i sandy Pines Residential
had a deficlencp [OUnd.
A+
d
Olescentg
Children and
reviewed at the time Of

12/!)~
iJ2012.

on

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irect
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r.
are

stdff

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1I9WQke

and on

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child
stafftninaintained:

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proyided
1. During

and

direct Care staff Shall 17e
t11C
at all timo6 In Qddltil„i,
r8605 EhaU be

cars

l,
ur5
r,
when children are

f

I

fi

in the

I
I

the faciiit y.the
3.While residents
he t10 less
Sn211
y
rCtAents
those
9tatfing ratio for
will +
be

1

i

itltensive „tatfing

cal

es

staff

3. The nursing
to

12

hours

their
sllatl not divide line on
of
located in other areas

from 8
shifts have been changed
the risk of not
tes
which mitiga
shifts to
e
fewer
there

finding coverage
cover.

since

Additionally, several

hired and
our website
shortage

in

our

comple_tion
Person

to
our

ensure

per

ability

RNs have been

we

to cover

not

pdo

that

ool

30,
Date_December
Interim DO

OR
L.
4'
NBOR. rikY DIRECTOR'S
S

RM

2013

JAN
I

Y;

the~_

PROOUIDER~sUrNLIR

would

f>

Responsible_

Cif residential
tranaparting rggldents
homPS, Olts
other
than
group
I trootrnent cente
care stars
direct
as
Lhe
c{,
leer shall not be counters
or supervision of
I
a5sistanoe
rHre,
roviding
dOp~
HCA HOrm 342 o-

have

all shift

shift between prograrTIS
the facility or other buildings,

I >~

on

job requisition

diem

5.W OR

TAl t FC

new

there is an open

j eopardize

l
detArmineti by the child'E pnyslelZ++

d, ClirpCt

DON
Interim
!

Person Re sponsible_

I

are away lram

mai a

appropriately

is

Completes=-

I

normr714Y

the criildran
2,Enuring hours when
shall lie
ve staff to child ratio
a sleep, ne
+ direct car
no le54 than 1 8;and

for
tilers 1:4,The need

and Director of
The staffing coordinator
for reviewing census
Nursing will be responsible

each shift

no leis

ire

Responsible:

daily and ensuring
and
will attend Admissions
staffed. They both
daily.
Discharge Meeting
i
December 6, 2012

i

staff
awake, the direct cars
facility and normally
than 1,4, and
be
tD Chii+j ratio Shall

10, 2012

DateL'_December
Interim DON

Completion
Person

to

with

2•

i

present

accordance

in

changes in census.

I

4

updated

have been

kept

are

ratios

ensure

t
t t,

btaMng -staff Composition
i

6.
less than 1:

rids
The staffing g

1.

I

i
0

no

Plan
on°
of~
eCt!
n

i relakl-d to the ailCgaitCns
the visit

are

children

when
2. During hours

normally

W~
Nn?
REPRCGCNTP~
Uw
AE;YITL1=
eMFX11

CEO

I

ixe>DAYS

13

 y.

Carp.Adfrlllll

enc for Hsalth
tIY

7ATEtASNI
Awe PLAN

OF

DEFIGIEI~cIES

La

on

s)
DATE 3VPVCY

RoVADtFVSUPPLIEPJCLkA
flit) a~
IDENTIFICATION

GDRRGDTIoN

COMr`Lt

X2SMULTIPLCCbN£TRUCTION

MlJtIAHhW

A. BUILDIN©

1210612012

8,NANta

R~
S7000060
NAME OF PROVIoLk

SANDY

w

i

Z1}

L'a'LIAT,
UlTI

PENEL

XA)Ifa
PRtHX

TKG

C 121

5
SUM IMRY STAT0VFNT OF UtFICIEN=
BE PRE00LD aY FULL
EhGFI DFFICIENCV MIfST
INFORMATION)
Y2NG
RE,W AWAY OR L3C IDENTIf

I

Continued From gagR

3 3459
9

C 121

1

IANDARD
on

11AIt

DLFIGIENCYI

i

T

t
4. The

evidenced by:

I

Pie RICA
record roview and interview.

CQ

Mo£
s RRFERENGI-II

I

This, S
rd

iS IIt11 t11et as

I alt!

A(TIC)N SHUULD
tACN CORRECTIVE IYJTHEAl RCPRIArE

I

TAG

1

F,
C.
n.
0){
i38.
507(
0
e),
F-

& 0`CORRECTION
PROVIDGn' +PL N
Be

ID

PREFIX

child.

Chapter

GODE

yTRCGTAODRESS, CITY, STATE.,
t iEST"t RRAG E

SUPPLIER

was

Staffing of Residential Units Policy 35-17
to ensure the verbiage coincided

revised

with the staffing ratio grid.
1 Completion Date: January4, 2013

for Children and
at

ResidAntlal Treatment Facility
Cale staff
Adolescents)failed to provide direct

Responsible: Interim DON and CEO

person

member to 6
minimum of 1 direct care staff
710 AM shift.
residents On the 11:0U PM to
October, Nbvemoor and

a

during Seitltrambcr,
Decembor 2012.

Monitoring Plan:
The

T! C

findings IIiCIUdI?'

DON

and

staffing

coordinator

are

maintaining a record of the
staffing by shift daily that includes current
census. Compliance with staffing mandates is
reported to the CEO weekly and to the Quality

child to staff

P.
CV19w, on 12106117, of lh6TCA'3
0W12 to 9130112
i ratio for eeoh day from 9/
more
revealed that the RTCAwa5 understatfed,
00
on the 11:
1
n1+
3
rrlhpr,
staff
to
residents
than G
through
0106/
1
2
13
days;
30 AM shirt for
to 7!

responsible

for

Council

monthly

on a

basis.

PM

0109/12,9112112 through IVI 8112.9120112,
9!
30/ less than the requirRri
912711 ] ttlluugh 12
mtln was on 9130112 when
the
highest
staffing;
12
the

I

RTCAhad 40 residents, out only

I

direct

staff motllper to
staff MemhPrs. a tatio of 1
7.5 child residents.
child to staff
RAView, on 12106112, of the RTCA's
to 10131112
10101112
from
ratio for each day
moIµ
revealed that the RTCAwa5 understaffed,
n,
r
mb
to
1
staff
than 6 residents
30 AM shift for 26 cloys;
PM to 7:
101091'12,101'11112 through
care

1D~~
e101217.,
i?

1014112 through
the highest
1(
N231i2, 10125112 through W129112,
fiI
staff
V1Q3 on 10126112
residents
ratio of child
but I mly 10
when the RTCA had 8d residents,
ratio of 1 staff
direct care st;irf -r embers, a
8.
1
4
residents.
member to
child to Aaff
Review(on 12106112 of the R 1 CA's
11/30112
11/
112
0
1,
to
I'
m
m
each
day
ratio for

CA

Form

3020 0001

TATE FARM

i
l

j
j

It
6040

6MFX 11

QVAIludtlPn

nhect a of 9

 A enc

for Health Gare Administration
m)PROVIDERISUPPLIER1CLtA
IDENTIFICATION NUMBER:

DEFICIENCIES '

OF

STATEMENT

DATE SURVEY
I=

AND PLAN OF CORRECTION

COMPLETED

XZ}MULTIPLE CONSTRUCTION
A. BUILDING

1210612012

B. WING

RCST00008D
NAME OF

PROVIDER

OR SUPPLIER

11301

PREFIX

SETEQUESTATERRACE

I

PROVIDER'S

ID

DEFICIENCIES
SUMMARY STATEMENT OF
FULL
MUST BE PRECEDED BY
DEFICIENCY
EACH
INFORMATION)
REGULATORY OR LSC IDENTIFYING

TAG

CODE

TEQUESTA, FL 33469

SANDY PINES
X4)ID

STATE. ZIP
STREET ADDRESS, CITY.

PREFIX
TAG

EACH

Ii

PLAN of

CROSS-REFERENCED

I

c0RRECTiON

COFRECTIVEACTION SHOULD

APL

BE

hTE
I DATE

TO THE APPROPRIATE

I

DEFICIENCY)

C 121

C 1211 Continued From page 2
the

understaffed
revealed that the RTCA was
11/1/
for
22 days; 12
shift
AM
30
11:00 PM to 7:
on

I through

11/
11/
through 12,
11/
68112
0
112,,

11/
16/11118/12,
11/
14112 through 12,

11/
12,
26/
12,
21/,
11/
1
212,
3112through
9/
1/
ratio was
the
on

30112;
highest
11/
29112 and 11/
RTCA had 89
11/16/and 11130/12 when the
12
staff members,
residents, but only 11 direct care
8.
0
9.
to
a ratio of 1 staff member
RTCA's child to staff
Review, on 12106/12 of the
12/
12
01/to 12104112
from
ratio for each day
the
was understaffed on
RTCA
the
that
revealed
4
30 AM shift for 3 of the days
11:00 PM to 7:
ratio was on
12/1112 through 1213/12;the highest
but
residents,
89
had
12/1112 when the RTCA
1
of
ratio
a
members,
11 direct care staff

only

09.
staff member to 8.
conducted
j In an interview,

j

12106/12 at 1:50
the
RTCA's Staffing Coordinator and
on

i

PM with the
the
Interim DON (Director of Nursing),

participants ackiic7wledgeu
i

a

I

i

I

understaf:in

7:
30 AM shifts. This
on
was also acknowledged by the Risk Manger
who
an
intQnview,
08 PM, during
12/
12
06/at 3:
the regular staff to
reported that the RTCA used
on

concern

provide
some

the 11:00 PM

one to one

to

supervision frequently

I

to

did not
of the residents, as needed, and

have staff available for overnight.
and
t Review of the RTCA's own policies

units
i procedures, regarding staffing of residential
and

12/
12
06/revealed that the policies
AM
PM-7:
for 11:00 30
procedures documented
MHT'
s
and
nurses
of
a staffing ratio
shift,
Technicians) combined is a 6;1

I on

Health
resident to staff ratio."

Mental

i

1
I

AHCA Form 3020-0001

F

If
ceoe

continuation sheet

3

or 3

6MFX11

STATE FORM

TnTAI

P. 1;

 Y

RICK SCOTT

JN
i:
AFt!~
C'1g. H AI 1Ft J)-'.,

ELIZABETH DUDEK
SECRETARY

Better Health Care for all Floridians

GOVERNOR

December 18, 2012

Administrator

Sandy

Pines

11301 Se Tequesta Terrace
Tequesta, FL. 33469

2012011963
Re: CCR #
Dear Administrator:

This letter reports the
December 6, 2012 by

findings of a Complaint Inspection
a representative of this office.

survey visit that

only

on

conducted

on

that

the

deficiency
provider's copy of the State (3020)Form, which indicates
You
* will not receive a copy of this report in the mail; you
the day of the visit.*

Attached is the

identified

was

receive this faxed

was

will

report.

of correction to this Field Office, in accordance with enclosed instructions, for
You will not
the identified deficiency within ten working days of receipt of this faxed report.
in the mail, you will only receive this faxed report. The deficiency shall
of this
receive a
Please

provide

a

copy

be corrected

no

plan

report

later than

January 5,2013.

obtain your feedback following
Quality Assurance Questionnaire has long been employed to
website at
survey activity. This form has been placed on the Agency's
based
as a first step in providing a webhttp://
myflorida.
Publications/
shtml
ahca.
c
F
orms.
om/
the
questionnaire through the link
interactive consumer satisfaction survey system. You may access
as our
under Health Facilities and Providers on this page. Your feedback is encouraged and valued,
the survey process.
goal is to ensure the professional and consistent application of

The

Thank you for the assistance provided to the
5840.
call this office at (561)381-

representative.

Should you have any

questions please

Sincerely,

Mayo-Davis
Field Office Manager

Arlene

AMD
TB132

Enclosure: State Form 3020
j

Headquarters
2727 Mahan Drive
Tallahassee, FL 32308

http://
myflorida.
ahca.
c
om

ay

Delray

Beach Field Office

5150 Linton Boulevard, Suite 500
Delray Beach, FL 33484
Phone (561)3815840; Fax (561)496-5924

 Pines

Sandy

December 18, 2012

Page

2

AGENCY FOR HEALTH CARE ADMINISTRATION

INSTRUCTIONS FOR PLAN OF CORRECTION

Please review the following Prior to completing the
Plan of Correction section of AHCA 3020-0001

1. Prepare your

reply by using

a

typewriter

or

computer to

ensure

legibility.

2. Note that each

repeated

deficiency is consecutively numbered with an ID Prefix tag. This tag number is
in column #
3,and your plan of correction (POC)should begin opposite the number.

3. The POC must be

during
simply

specific and realistic, have reasonable time frames based on dates discussed
the exit conference and state exactly how the
deficiency was (or will be)corrected. Stating
that "staff will be trained"is not
POC
acceptable. An
state that "

acceptable
might
regarding policy and procedure, before and after tests were given, daily
evaluated in one month, then
performed, staff will be requarterly."

trained
be

4. POC's should address the problem and be aimed at
correction in
opposed to correcting an example or an isolated

a

staff

staff

were

monitoring

will

systematic sense, as

problem.

5. The plan may not be argumentative
Generalized, unsubstantiated arguments are not
acceptable. A deficiency may be disputed provided it is supported by factual attached
documentation. For example, attached is the controlled substance verification
log which has the
date, time and signature of oncoming and outgoing nurses who have counted controlled

substances.
6. The

responsibility for correction
position to preclude recurrence.

7. You must

sign

and

the bottom of page 1 of the statement of

date.
After the
result in

completed POC is received, it
finding of noncompliance.

a

ongoing monitoring

should be

assigned

deficiencies, include

will be evaluated. Failure to submit

a

to

a

specific

your title and

timely report

may