ST. LUKE’S HOSPITAL OF NEWBURGH County: Orange
PFI #0694
Complaints:
| Complaint Information: | 1999 |
| Complaint Investigations Completed | 3 |
| Complaints with Statements of Deficiencies (SOD) Issued | 2 |
| % of Complaints with SODs Issued | 67% |
| Regional % of Complaints with SODs Issued: | 30.4% |
Areas Cited as a Result of Complaints:
| Date of Survey | Regulatory Citation | Areas Cited as a Result of Complaints: | Date of Plan of Correction |
| 4/05/99 | 400.3 | Inspection, Reproduction and Reports | 4/13/00 |
| 405.4(a)(1) | Medical Staff | ||
| 405.5(b),(c) | Nursing Services | ||
| 405.7(b)(3),(23) | Patients’ Rights | ||
| 405.11 | Infection Control | ||
| 405.20 | Outpatient Services | ||
| 11/01/99 | 405.19(d) | Emergency Services | 1/24/00 |
Areas Cited as a Result of Surveys:
| Date of Survey | Regulatory Citation | Areas Cited as a Result of Complaints: | Date of Plan of Correction |
| 10/5/99 | 405.2136 | CoP: Governing Body and Management | 11/30/99 |
| (T-18 ESRD | 405.2136 | Health and Safety | |
| validation | 405.2136(c) | CEO: Qualified and Responsible | |
| survey) | 405.2136(c)(3) | CEO: Staff Orientation | |
| 405.2136(f)(1) | Patient Care Policies: Admit and Discharge | ||
| 405.2136(f)(1) | Patient Care Policies: Long Term Program and Patient Care | ||
| 405.2136(f)(4) | Patient Care Policies | ||
| 405.2136(g)(1) | Medical Supervision: Orders | ||
| 405.2137 | CoP: Long Term Program and Care Plan | ||
| 405.2137(a) | Written Long Term Plan | ||
| 405.2137(a)(1) | Long Term Plan Team Members | ||
| 405.2137(a)(2) | Long Term Plan: Reviewed by Team | ||
| 405.2137(b) | Patient Care Plan: Written, Assessment Based | ||
| 405.2137(b)(1) | Patient Care Plan: Individualized | ||
| 405.2137(a)(3) | Patient Care Plan: Patient Involved | ||
| 405.2137(b)(6) | Patient Care Plan: Home Patients | ||
| 405.2137(b)(7) | Patient Care Plan: EPO at Home | ||
| 405.2139 | CoP: Medical Records | ||
| 405.2139(a) | Medical Records: Identify, Justify, Document | ||
| 405.2139(a) | Medical Records: Medical and Nursing History | ||
| 405.2139(a) | Medical Records: Progress Notes | ||
| 405.2139(c) | Medical Records Supervisor | ||
| 405.2139(d) | Medical Records: Complete, Prompt, Information Central | ||
| 405.2139(d) | Medical Records: Self Care/Home Patients | ||
| 410.2140(a) | Physical Environment: Constructed and Maintained for Safety | ||
| 410.2140(a)(5) | AAMI – H2O Bacteriology | ||
| 410.2140(b)(4) | Comfortable Temperature | ||
| 410.2140(d)(5) | ER: Patients Informed | ||
| 410.2163(e)(1) | Self Dialysis Support Services | ||
| 410.2163(e)(5) | Self Dialysis: Water Treatment | ||
| 11/22/99 | 405.2136(c) | CEO: Qualified and Responsible | 3/09/00 |
| (T-18 ESRD | 405.2136(g)(1) | Medical Supervision: Orders | |
| follow-up | 405.2137(a)(1) | Long Term Plan Team Members | |
| survey) | 405.2137(b)(6) | Patient Care Plan: Home Patients | |
| 405.2139(d) | Medical Records: Self Care/Home Patients | ||
Areas Cited as a Result of Incident Investigations:
| Date of Survey | Regulatory Citation | Areas Cited as a Result of Complaints: | Date of Plan of Correction |