St. Joseph's Hospital Health Center
PFI # 0630
Revised: 3/03
Complaints:
| Complaint Information: | 2002 |
| Complaint Investigations Completed: | 8 |
| Complaints with Statements of Deficiencies (SOD) issued: | 3 |
| % of Complaints with SODs Issued | 38% |
| Regional % of Complaints with SODs issued: | 33.8% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
| 02/20/2002 | 405.6(a) | Quality Assurance | 5/2/2002 |
| 405.19(e) | Emergency Services - Patient Care | ||
| 405.20(d) | Outpatient Services - Ambulatory Surgery Service | ||
| 05/31/2002 | 405.2(b) | Governing Body - Organization & Operation | 6/25/2002 |
| 405.4(a) | Medical Staff - Medical Staff Accountability | ||
| 405.10(b) | Medical Records - Content | ||
| 07/24/2002 | 405.2(f) | Governing Body - Care of Patients | 9/3/2002 |
| 405.6(a) | Quality Assurance | ||
| 405.10(b) | Medical Records - Content | ||
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
| 4/17/2002 | Article 28 Focus | None | |
| 4/23 - 25/2002 | Article 28 Compliance & Medicare ESRD Recert at Regional Dialysis Center | 405.2136(d) - Governing Body & Management - Personnel P/P: Incidents Reviewed | 8/22/2002 |
| 405.2137(b) - Long Term Program & Care Plan - PCP: Individualized | |||
| 405.2137(b) - Long Term Program & Care Plan - PCP: Home Patients | |||
| 405.2140(a) - Physical Environment - AAMI: Dialysate Bacteriology | |||
| 405.2140(a) - Physical Environment - AAMI: Chem Contamination | |||
| 402.2140(a) - Physical Environment - AAMI: H20 Bacteriology | |||
| 405.2140(a) - Physical Environment - PE: Water Treatment | |||
| 410.2140(a) - Physical Environment - Constr & Maintain for Safety | |||
| 405.2140(b) - Physical Environment - PE: Infection Control | |||
| 405.2140(d) - Physical Environment - ER: Personnel Trained | |||
| 405.2163(d) - Minimal Service Requirements - RD Responsibilities | |||
| 11/20/2002 | Annual Compliance Review - Resident Work Hours | 405.5(b) - Medical Staff - Organization | 2/4/2003 |
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |