Observations
Based on a review of the client daily census for the week of January 21-January 27, 2024, the facility failed to notify the Department within 90 days of the occurrence of a change in authorized maximum capacity.
The DDAP license issued by the Department for11/1/23 through 4/30 24 included the approved a capacity of 50 for inpatient hospital services, 20 for inpatient hospital detoxification services, 10 for inpatient non-hospital services and 6 for inpatient non-hospital detoxification services.
The facility exceeded approved capacity on the following dates:
During the week of January 21-27, 2024: On 1/21 the census for hospital inpatient was 52. On 1/22 the census for hospital detox was 21. On 1/24 the census for hospital detox was 21. On 1/25 the census for hospital inpatient was 51. On 1/27 the census for hospital detox was 23 and the census for hon-hospital rehabilitation was 12.
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Plan of Correction
As of May 2, the hospital has filed and been approved for a change in authorized maximum capacity for hospital and non-hospital beds. The flex bed waiver is applicable for licensed activities for each (1) hospital and (2) non-hospital beds for the duration of the current licensure period. The hospital shall ensure that the flex bed waiver request is re-submitted timely, prior to the expiration of the current waiver prior to the end of the current licensure period utilizing appropriate Department forms. The Executive Director is ultimately responsible for ensuring compliance with this requirement. |