Faxton - St. Luke's Healthcare – St. Luke’s Division
PFI # 0599
Revised: 4/03
Complaints:
| Complaint Information: | 2002 |
| Complaint Investigations Completed: | 1 |
| Complaints with Statements of Deficiencies (SOD) issued: | 1 |
| % of Complaints with SODs Issued | 100% |
| Regional % of Complaints with SODs issued: | 33.8% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 01/14/2002 | 405.2(b) | Governing Body - Organization & Operation | 4/23/2002 |
| 405.2(f) | Governing Body - Care of Patients | ||
| 405.6 | Quality Assurance | ||
| 405.6(a) | Quality Assurance | ||
| 405.7(b) | Patients' Rights - Hospital Responsibilities | ||
| 405.21(c) | Maternity & Newborn Services - General Requirements | ||
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
| 3/11 - 13/2002 | Article 28 Compliance & Medicare ESRD Recert – Hospital | 405.5(b) - Nursing Services - Delivery of Services | 9/3/2002 |
| 405.6 - Quality Assurance | |||
| 405.11 - Infection Control | |||
| 711.2(a) - Pertinent Technical Standards - Life Safety Code | |||
| 711.2(c) - Pertinent Technical Standards | |||
| 757.2(f) - General Requirements | |||
| 405.2136 - Governing Body & Management - Health and Safety | |||
| 405.2136(c) - Governing Body & Management - CEO: Staff Train | |||
| 405.2136(d) - Governing Body & Management - Personnel Records - Health | |||
| 405.2136(f) - Governing Body & Management - Patient Care Policies - Development & Review | |||
| 405.2137(a) - Long Term Program & Care Plan - Long-Term Plan: Reviewed by Team | |||
| 405.2137(b) - Long Term Program & Care Plan - PCP: Patient Involved | |||
| 405.2137(b) - Long Term Program & Care Plan - PCP: Individualized | |||
| 405.2139(a) - Medical Records - Orders | |||
| 405.2139(a) - Medical Records - Med & Nursing History | |||
| 405.2139(b) - Medical Records - Protection of Medical Record Information | |||
| 405.2140(a) - Physical Environment - Constr & Maintain for Safety | |||
| 405.2140(a) - Physical Environment - AAMI: Chem Contamination | |||
| 405.2140(b) - Physical Environment - Infection Control | |||
| 405.2140(d) - Physical Environment - ER: Patients Informed | |||
| 11/27/2002 | Article 28 Focus | None | |
| 12/10/2002 | Article 28 Compliance & Medicare ESRD Recert – Rome Unit | 405.6(a) - Quality Assurance | 4/10/2003 |
| 405.11 - Infection Control | |||
| 405.2136 - Governing Body & Management - Health and Safety | |||
| 405.2136(d) - Governing Body & Management – Personnel P/P: Safe and Sanitary Environment | |||
| 405.2136(f) - Governing Body & Management - Patient Care Policies - Development & Review | |||
| 405.2136(f) - Governing Body & Management - Patient Care Policies – Physical Plant | |||
| 405.2137(a) - Long Term Program & Care Plan - Long-Term Plan: Reviewed by Team | |||
| 410.2140(a) - Physical Environment - Constr & Maintain for Safety | |||
| 405.2140(a) - Physical Environment - PE: Fire Ext & Evac Plans | |||
| 402.2140(a) - Physical Environment - AAMI: H20 Bacteriology | |||
| 405.2140(a) - Physical Environment - AAMI: Dialysate Bacteriology | |||
| 405.2140(b) - Physical Environment – Functional, Sanitary and Comfortable | |||
| 405.2140(d) - Physical Environment - ER: Patients Informed | |||
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |