Hospital Name: WOMAN'S CHRISTIAN ASSOCIATION
PFI # 0103
Complaints:
| Complaint Information | 2000 |
| Complaint Investigations Completed | 5 |
| Complaints with Statements of Deficiencies (SOD) Issued | 2 |
| % of Complaints with SODs Issued | 40% |
| Regional % of Complaints with SODs Issued | 40.6% |
Areas
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
| 7/11/00 | 405.6 | Quality Assurance Program QA Committee | 7/31/00 |
| 7/11/00 | 405.20 | Outpatient Services General Requirements | 7/31/00 |
| 7/11/00 | 405.2 | Governing Body Care of Patients | 7/31/00 |
| 4/3/00 | 405.9 | Admission/Discharge Discharge | 5/5/00 |
Areas Cited as a Result of
Surveys:
| Date of Survey | TYPE | Areas Cited | Date Plan of Correction Accepted |
| 1/12/00 - | Validation | 482.28 - Food and dietetic services Diets | 2/18/00 |
| 1/12/00 - | Validation | 482.41 - Physical environment Facilities | 2/18/00 |
| 1/12/00 - | Validation | 482.24 - Medical Record Services Content | 2/18/00 |
| 1/12/00 - | Validation | 482.22 - Medical Staff Composition of Medical Staff | 2/18/00 |
| 1/12/00 - | Validation | 482.21 - Quality Assurance Clinical Plan | 2/18/00 |
| 1/12/00 - | Validation | 482.41 - Physical Environment Facilities | 2/18/00 |
| 1/12/00 - | Validation | 482.24 (b) - Medical Record Services | 2/18/00 |
| 1/12/00 - | Validation | 482.22 - Medical Staff Composition | 2/18/00 |
| 1/12/00 - | Validation | 482.21 - Quality Assurance Clinical Plan | 2/18/00 |
| 1/12/00 - | Validation | 482.28 - Food and Dietetic Services Diets | 2/18/00 |
INCIDENTS
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
| 7/11/00 | 405.6 | Quality Assurance QA Committee | 7/31/00 |
| 7/11/00 | 405.20 | Outpatient Services General Requirements | 7/31/00 |
| 7/11/00 | 405.20 | Outpatient Services General Requirements | 7/31/00 |
| 7/11/00 | 405.2 | Governing Body Care of Patients | 7/31/00 |