Hepburn Medical Center
PFI #0798
Complaints:
| Complaint Information: | 1999 |
| Complaint Investigations Completed | 3 |
| Complaints with Statements of Deficiencies (SOD) Issued | 1 |
| % of Complaints with SODs Issued | 33% |
| Regional % of Complaints with SODs Issued: | 36.5% |
Areas Cited as a Result of Complaints:
| SOD Date | Regulatory Citation | Areas Cited as a Result of Complaints: | Date Plan of Correction Accepted |
| 3/24/99 | 400.21(c) | All Facilities - Advance Directives – Facility Compliance | 4/16/99 |
| 400.21(d) | All Facilities - Advance Directives – Policies & Procedures | ||
| 405.4(c) | Medical Staff – Medical Staff Bylaws | ||
| 405.5(b) | Nursing Services – Delivery of Services | ||
| 405.6 | Quality Assurance | ||
| 405.7(c) | Patients’ Rights – Patient’s Bill of Rights | ||
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited as a Result of Complaints: | Date Plan of Correction Accepted |
| 6/15 -17/99 | ESRD – Recertification | 402.2140(a) - AAMI – H20 Bacteriology | 4/11/00 |
| 405.2137(a) - Patient Long Term Program & Patient Care Plan - Long-Term Plan – Reviewed by Team | |||
| 405.2140(a) - Physical Environment - Equipment PM | |||
| 405.2140(b) - Physical Environment – Infection Control | |||
| 405.2140(b) - Physical Environment – Sufficient Space | |||
| 405.2140(c) - Physical Enviroment – Prevent Cross Contamination | |||
| 405.2140(d) - ER – Written Plan | |||
| 405.2140(d) - ER – Patients Informed | |||
| 405.2163(d) - RD Responsibilities | |||
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited as a Result of Complaints: | Date Plan of Correction Accepted |