St. Joseph’s Hospital Health Center
PFI # 0630
Complaints:
| Complaint Information: | 2000 |
| Complaint Investigations Completed | 14 |
| Complaints with Statements of Deficiencies (SOD) Issued | 4 |
| % of Complaints with SODs Issued | 29% |
| Regional % of Complaints with SODs issued: | 30.6% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 4/24/00 | 405.5(b) | Nursing Services –Delivery of Services | 7/13/00 |
| 405.5(c) | Nursing Services – Administration of Drugs | ||
| 405.5(e) | Nursing Services – Quality Assurance | ||
| 405.24(i) | Environmental Health – Injury Control | ||
| 4/25/00 | 405.4 | Medical Staff | 9/27/00 |
| 405.5 | Nursing Services | ||
| 405.6 | Quality Assurance | ||
| 405.12 | Surgical Services | ||
| 6/19/00 | 400.21(c) | Advance Directives – Facility Compliance | 7/25/00 |
| 405.5(b) | Nursing Services – Delivery of Services | ||
| 405.6 | Quality Assurance | ||
| 405.7(b) | Patients’ Rights – Hospital Responsibilities | ||
| 12/12/00 | 400.21(d) | Advance Directives – Policies & Procedures | 1/30/01 |
| 405.2(b) | Governing Body – Organization & Operation | ||
| 405.4(a) | Medical Staff – Medical Staff Accountability | ||
| 405.5(c) | Nursing Services – Administration of Drugs | ||
| 405.6 | Quality Assurance | ||
| 405.7(b) | Patients’ Rights – Hospital Responsibilities | ||
| 405.10(c) | Medical Records – Authentication of Medical Records, Record Entries and Medical Orders | ||
Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
| 9/12/00 | Article 28 Focus | 755.6(c) - Patient Admission and Discharge | 2/16/2001 |
| 755.6(e) - Patient Admission and Discharge | |||
| 755.7(c) - Medical Record System | |||
| 755.7(f) - Medical Record System | |||
| 12/12/00 | ESRD Recert Ext Clinic | 405.2136(c) - CEO: Staff Train | 2/20/01 |
| 405.2136(d) - Personnel P/P – Staff Qualified | |||
| 405.2137(a) – Written Long-Term Plan | |||
| 405.2137(b) – PCP: Patient Involved | |||
| 405.2139(a) –Medical Records – Orders | |||
| 410.2140(a) – PE: Construction & Maintain for Safety | |||
| 405.2140(b) – Infection Control | |||
| 405.2140(d) – ER: Written Plan | |||
| 405.2163(c) – Social Services | |||
Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |