Initial Comments:
This report is for the new service,Tele-Psychiatry, beginning on April 13, 2023 at Encompass Health Rehabilitation Hospital of Harmarville. The facility attested to but 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.
Plan of Correction:
§ 51.3 (a) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(a) A health care facility shall
notify the Department in writing at
least 60 days prior to the intended
commencement of a health care service
which has not been previously provided
at that facility.
Observations:
Based on review of facility notification, and staff interview (EMP), it was determined that the facility failed to ensure that the Department received written notification of a new Telepsychiatry service at least 60 days prior to its implementation.
Findings include:
On April 15, 2023, a review of facility document "Hospital Attestation to Request the Addition of a New Service", revealed, "... Name of New Service: Telepsychiatry Date the New Service will begin: 04/13/2023 ... The Required 60-day notification for the new service was sent to the Department on 04/12/2023.
1. On August 23, 2023, EMP1 confirmed there was no 60 day notification for Tele-Psychiatry provided to the Department prior to the start of the service.
Plan of Correction:Findings of Observation #0003 will be presented at the leadership meeting (Leaders of all departments) on 12/15/23, as well as presented at MEC on 12/15/23, and Governing Body Meeting on 12/13/23. Requirements will be explained at these meetings that a 60 day notification is required to be submitted to the DOH prior to the start of any new services. The corrective action will also be discussed at the MEC and Governing Body meetings. The corrective action will be that the Director of Quality (DQR) must be informed immediately upon the discussion of the start of new services by any leadership. Once the services have been approved by MEC and the Governing Body (GB), the "Hospital Attestation to Request the Addition for a New Service" will be completed by the DQR and forwarded to the DOH. New services will not begin until 60 days after the date of notification.
Continuing Compliance will be maintained and monitored during the quarterly Quality meeting-next meeting January 15, 2024. Any new services will be presented at the Quality meetings quarterly, along with dates of approval of the new service by MEC and GB, and the date of the Attestation being forwarded to the DOH.
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