Observations
Based on a telephone conversation with the facility director, the facility failed to notify the Department of a change in the authorized maximum capacity.
The findings include:
The Division responded to a written request by the facility director to authorize a patient capacity increase; facilities that are operating at or near their stated capacities must submit to the Division in writing to request a capacity increase. The documentation submitted to the Division by the facility director on May 13, 2009 identified that the facility was already operating at fifty patients above their approved capacity. In a telephone conversation with the facility director on June 1, 2009 the facility director confirmed that the facility was operating above their capacity.
The licensee, using Department forms, shall within 90 days of the occurrence of any of the following conditions:
(5)
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Plan of Correction
The facility Director and Clinical Coordinator will monitor the authorized capacity and caseloads on a weekly and monthly basis. Specifically, during weekly supervision with the intake counselor, the Clinical Coordinator will review the active caseload to make sure we are not above the authorized capacity. The facility Director will review the active caseloads during the Quality Improvement meeting on a monthly basis. The QIP committee reviews all aspects of the program during this meeting. In the event the facility needs to increase the authorized capacity, a written request on DOH Licensing forms will be submitted within 90 days as required in 709.14 (b)(5). |