St. Joseph's Hospital health Center
PFI # 0630
Revised: 2/02
Complaints:
| Complaint Information: | 2001 |
| Complaint Investigations Completed: | 11 |
| Complaints with Statements of Deficiencies (SOD) issued: | 2 |
| % of Complaints with SODs Issued | 18% |
| Regional % of Complaints with SODs issued: | 21.9% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 3/29/01 | 405.5(b) | Nursing Services - Delivery of Services | 5/14/01 |
| 405.13(b) | Anesthesia Services - Operation/Service Delivery | ||
| 7/30/01 | 400.21(d) | Advance Directives - Policies & Procedures | 8/6/02 |
| 405.2(b) | Governing Body - Organization & Operation | ||
| 405.3(b) | Administration - Personnel | ||
| 405.5(b) | Nursing Services - Delivery of Services | ||
| 405.5(e) | Nursing Services - Quality Assurance | ||
| 405.6(a) | Quality Assurance | ||
| 405.6(b) | Quality Assurance | ||
| 405.7(b) | Patients' Rights - Hospital Responsibilities | ||
| 405.15(a) | Radiology/Nuclear Medicine - General Provisions | ||
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
| 1/24-25/01 | ESRD Recertification Extension Clinic | 405.2136(c) - Governing Body & Management - CEO: Staff Train | 3/26/01 |
| 405.2136(d) - Governing Body & Management - Personnel P/P: Incidents Reviewed | |||
| 405.2136(d) - Governing Body & Management - Personnel P/P: Staff Education | |||
| 405.2139(a) - Medical Records - Orders | |||
| 405.2139(b) - Medical Records - Protection of Medical Record Information | |||
| 405.2140(a) - Physical Environment - AAMI - Chem Contamination | |||
| 405.2140(b) - Physical Environment - Functional, Sanitary and Comfortable | |||
| 405.2140(d) - Physical Environment - ER: Written Plan | |||
| 10/22-24/01 | ESRD Recertification Extension Clinic & Article 28 | 405.2136(c) - Governing Body & Management - CEO Staff Train | 4/4/02 |
| 405.2136(d) - Governing Body & Management - Personnel P/P Staff Education | |||
| 405.2136(d) - Governing Body & Management - Personnel P/P Staff Qualified | |||
| 405.2137(a) - Long Term Program & Care Plan - Long-Term Plan: Reviewed by Team | |||
| 405.2137(b) - Long Term Program & Care Plan - PCP: Individualized | |||
| 405.2139(b) - Medical Records - Protection of Medical Record Information | |||
| 405.2140(a) - Physical Environment - AAMI - Chem Contam | |||
| 405.2140(b) - Physical Environment - Infection Control | |||
| 405.2140(d) - Physical Environment - ER: Periodic Drills | |||
| 405.2140(d) - Physical Environment - ER: Patients Informed | |||
| 405.2163(c) - Minimal Service Requirements - Social Worker Responsibilities | |||
| 715.2 - Renal Dialysis Centers | |||
| 12/17-20/01 | Article 28 Resident Work Hours | None |
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |