Observations
During a supervisory review of your licensing packet, the reviewer determined that the facility failed to document a written letter of agreement with a licensed hospital or physician for 24-hour emergency medical coverage.Findings:Based on a supervisory review of the facility's licensing packet the facility failed to document a written letter of agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
|
Plan of Correction
Standard
709.24(d) TREATMENT/REHABILITATION MANAGEMENT
In an effort to maintain compliance with regulation 709.24(d) The Clinical Coordinator will make certain that letters of aggrements with licensed hospitals or physicians for 24-hour emergency medical coverage are current and covers a time period of 1 to 2 years indicating an effective and expiration date. In addition, the Clinical Coordinator will ensure that all letters of agreement with licensed hospitals or physicians for 24-hour emergency medical coverage are reviewed during the facility DAPL site visit to validate compliance of regulation 709.24 at time of annual site visit. This process will be audited by the Quality Assurance Department periodily for compliance.
At time of audit as listed above 2/1/2012 the following
24-hour medical services agreements were in place. Letter of agreement with Charter Fairmont Hospital effective 1/19/2012 expires 1/19/2014. The 24-hour medical emergency care agreement was available by Dr. Janet Young effective 3/5/2011 thru 3/5/2012 for emergency admission to the following hospitals: Pennsylvania Hospital, Hospital of the University of Pennsylvania, Hahneman Hospital, Thomas Jefferson University Hospital, Temple University Hospital, and ARIA/Frankford Hospital. Current 24- emergency care agreement is effective from 3/5/2012 to 3/5/2013.
Correction time-frame - Complete
Monitoring on-going
|