Observations
Based on observations on May 15, 2012, the Staffing Requirements Facility Summary Report (SRFSR) form, and the client's census, the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized maximum capacity of beds to the number of clients.
The findings include:
A physical plant inspection was conducted on May 15, 2012. The facility's authorized maximum capacity for Inpatient Non-Hospital Detoxification beds to the number of clients is 28 and the facility's authorized maximum capacity for Inpatient Non-Hospital Drug-Free beds to the number of clients is 52.
Based on the client census and the SRFSR form, completed by the facility, the total number of clients in the Inpatient Non-Hospital Detoxification was 14 and the total number of clients in the Inpatient Non-Hospital Drug-Free was 65. The facility exceeded their authorized maximum capacity for the Inpatient Non-Hospital Drug-Free licensed activity by 13 clients.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager on August 10, 2012 at approximately 9:00 A.M.
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Plan of Correction
Malvern Institute submitted a letter to licensure on 8/20/12 requesting to decrease our licensed number of detoxification beds and increase our number of licensed rehabilitation beds. Malvern Institute also submitted a letter on 8/20/12 requesting an exception for the use of our detoxification beds for those situations when a rehabilitation bed is not available. Malvern will monitor admissions and "step-downs" to ensure Malvern does not exceed our licensed capacity. The Director of Admissions will monitor will monitor the non-hospital detoxification census on a daily basis to ensure we do not exceed capacity. The Director of Admissions will report this monitoring daily to the Executive Director. |