QA Investigation Results

Pennsylvania Department of Health
CLARION HOSPITAL
Health Inspection Results
CLARION HOSPITAL
Health Inspection Results For:


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Initial Comments:

This report is the result of a full State Licensure survey conducted on February 8, 2021, at Clarion Hospital, with additional documentation review concluding on April 26, 2021. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 Pa Code, Part IV, Subparts A and B, November 1987, as amended June 1998.

The following offsite locations were included in this survey:

Cancer Center
Clarion Hospital
1 Hospital Drive
Clarion, PA 16214

Family Healthcare of Clarion
24 Doctors Lane Suite 202
Clarion, PA 16214

Wound Care Center
24 Doctors Lane Suite 101
Clarion, PA 16214



Plan of Correction:




51.3 (c) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(c) A health care facility shall provide similar notice at least 60 days prior to the effective date it intends to cease providing an existing health care service or reduce it licensed bed complement.

Observations:

Based on review of facility documentation and employee interviews (EMP), it was determined the facility failed to provide at least 60 days notice to the Department of Health, Division of Acute and Ambulatory Care (DAAC), that it had ceased to provide the service of Radiology at AC Valley Medical Center.

Findings Include:

1. When asked, at approximately 11:44 AM on March 11, 2021, when the services ceased at Radiology at AC Valley Medical Center, EMP3, stated, "... Still working on this. When this office closed, all services ended at this office at the same time. ..."

2. When asked, at approximately 9:31 AM on April 9, 2021, if there were any updates regarding a closure notification sent to DAAC, EMP3, stated, "... So far this is what I have found [Terminating Registration of Radiation Producing Machines, dated January 22, 2019]. ..."

3. On April 9, 2021, at approximately 2:11 PM, review of documentation provided by EMP3, dated January 22, 2019, revealed, "Date of Transfer/Sale/Disposal: 5-1-18." At the time of the review, the facility had provided no documentation of notification to DAAC, regarding the discontinuation of the service.






Plan of Correction:

- The Patient Safety Officer will be responsible for implementing the Plan of Correction.

- All service lines will be reviewed, 2018-current. Any, of the reviewed service lines, that have ceased providing an existing health care service will be reviewed for Department of Health notification. Department of Health will be immediately notified for any service line found to be non- compliant.

- Department of Health will be notified, by Director of Patient Safety and Quality, at least 60 days prior to the effective date it intends to cease providing and existing health service or reduce its licensed beds.

- Managers will be educated, on to notify Director of Patient Safety and Quality of any service lines that it intends to cease providing or reducing its licensed beds. This notification must happen to allow for Department of Health Notification, at least 60 days prior to cease date.

- Quarterly review of all changes to current beds and service lines at the Quality Committee. Compliance will be demonstrated with Quarterly updates x 1 year, reflected in the Quality Committee meeting minutes and/or notifications to the Department of Health regarding changes.

- This will become a standing agenda item for all Department Head meetings, beginning in July, 2021. This will prevent reoccurrence and provide ongoing education for managers, as evidence by meeting minutes.


Initial Comments:

This report is the result of a full State Licensure survey conducted on February 8, 2021, at Clarion Hospital, with additional documentation concluding on April 26, 2021. It was determined the facility was in compliance with the requirements of 35 P.S. 448.809 (b).

The following offsite locations were included in this survey:

Cancer Center
Clarion Hospital
1 Hospital Drive
Clarion, PA 16214

Family Healthcare of Clarion
24 Doctors Lane Suite 202
Clarion, PA 16214

Wound Care Center
24 Doctors Lane Suite 101
Clarion, PA 16214



Plan of Correction: