Observations
Based on a review of letters of agreement and an interview with the facility director, the facility failed to provide documentation of a current written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.The findings include:The letters of agreement were reviewed on August 30, 2011. The letter of agreement regarding 24- hour emergency medical coverage was signed with a local hospital on April 30, 2010. The agreement had an expiration date of March 28, 2011. The facility director was interviewed on August 30, 2011. It was confirmed at that time that no additional documentation of 24- hour emergency medical coverage was available.
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Plan of Correction
Campus Director will hand deliver referral agreement to the Good Samaritan Hospital and await signature for 24-hour emergency agreement. This referral agreement will be signed within 14 days. Campus Director will ensure compliance with this referral agreement moving forward and ensure timeliness of all required signatures. |