Observations:
Based on review of facility documents, the Department of Health (Department) Database, and staff interview (EMP), it was determined the the facility failed to notify the Department in writing at least 60 days prior to the effective date the facility ceased to perform procedures.
Findings include:
Email communication dated April 2, 2024, from EMP1 revealed no procedures were performed at Evangelical Community Hospital Endoscopy Center (ECHEC) since August 24, 2023.
Review of the Department's database revealed no notification of cessation of procedures was received from ECHEC.
Review of facility documents on June 25, 2024, confirmed the last cases provided at ECHEC were on August 24, 2023.
Interview on June 25, 2024 at approximately 0900 with EMP1 confirmed the findings noted above.
Interview on June 28, 2024 at 1051 with EMP1 confirmed the two providers at ECHEC are operating at Evangelical Ambulatory Surgery Center or Evangelical Community Hospital. There are no plans to operate at ECHEC until more providers are hired.
| | Plan of Correction - To be completed: 07/10/2024
To ensure the missed notification does not reoccur the following measures will be taken.
1. The Administrator/Director, Medical Director, and Nursing Coordinator will review DOH regulation 51.3 (c)
2. An infrastructure failure report will be submitted to DOH via PSRS submission by 7/12/2024. Report submitted 7/10/2024.
3. The PSRS Report will include last date cases were performed in the facility.
4. To ensure communication of updates to DOH, the facility administrator will send a letter of notification to DOH at least quarterly to share updates on the status of the facility.
5. When cases are anticipated to resume in the facility, the Administrator/Director will notify DOH by letter of notification complying with 51.3 (c).
To ensure the measures are audited the following will occur:
1. The Administrator/Director or designee will monitor case scheduling to identify an anticipated interruption of service
2. Any interruption of service will be acknowledged by the Administrator and a letter of notification will be sent to DOH at least 60 days prior to the date the service will be interrupted.
3. A PSRS report will be filed as an infrastructure failure for any interruption of service.
4. Any infrastructure failure reports will be reviewed by the Administrator/Director or designee within 24hrs
The corrective action will be completed by 8/11/2024.
|
