St Francis Hospital

PFI # 0563

Revised: 3/21/03

Complaints:

Complaint Information: 2002
Complaint Investigations Completed: 15
Complaints with Statements of Deficiencies (SOD) issued: 6
% of Complaints with SODs Issued 40%
Regional % of Complaints with SODs issued: 53.9%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
3/04/02 405.2 Governing body (c) Compliance with federal, state and local laws 5/6/02
  405.6 Quality assurance program (a) Governing body  
  405.7 Patients’ rights (b) Hospital responsibilities  
  405.11 Infection control (b) Nosocomial surveillance, prevention and control  
  711.2 General standards (b) Pertinent technical standards  
1/30/02 405.5 Nursing services (b) Delivery of services NO POC REQUIRED
7/16/02 405.4 Medical staff (a) Medical staff accountability 12/10/02

405.6 Quality assurance program (a) Governing body

405.7 Patients rights (b) Hospital responsibilities

405.9 Admission/discharge (f) Discharge

6/10/02 405.4 Medical staff (a) Medical staff accountability 11/15/02
7/15/02 405.15 Radiologic and nuclear medicine services (5) Records 8/05/02
1/30/02 405.6 Quality assurance program (b) Activities of the quality assurance committee 4/5/02

405.8 Incident reporting (a) Incident required to be reported

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
       

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted