Observations
Based on a review of the licensure packet on May 17, 2011, including a full review of the Staffing Requirements Facility Summary Report and the Department of Health Data Collection Report, it was determined that at the time of the licensing inspection on November 22, 2010 and on December 1, 2010, the facility exceeded the maximum authorized capacity for the outpatient activity.
The findings included:
A supplemental review of the licensure packet for the December 1, 2010 inspection was conducted on May 17, 2010. During the review of the licensure material, specifically the Data Collection Report and the Staffing Requirements Facility Summary Report (both of which were signed by the Executive director) it was clear that the census of the outpatient treatment activity was at 43 clients. The authorized maximum capacity approved by the Department was at 27. The facility failed to notify the Department that it had exceeded the maximum approved capacity and failed to request approval from the Department to increase the outpatient capacity.
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Plan of Correction
A Better Today will formally request an increase in authorized capacity from the Hazelton Facility increasing to 70 clients. Formal request forwarded to licensure May 25, 2011. |