Observations
The facility failed to notify the Department of a change in activity based on staff interviews and a physical plant inspection conducted on March 16, 2017 at approximately 2:00 PM.The facility is licensed to provide outpatient services. The facility has ten beds located in the basement. Per the clinical supervisor, five individuals reside in the building and the facility provides onsite weekly drug and alcohol counseling to these individuals. The facility is not licensed to provide this residential activity.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Clinic will relocate to the TAC building. The Facility Director will submit a request for permission to relocate the outpatient facility and will include certificate of occupancy, zoning approval and floor plan for new outpatient location. Facility Director will ensure the new location is in compliance with all regulations by May 31,2017. |