University Hospital SUNY Health Science Center

PFI # 0635

Revised: 10/03

Complaints:

Complaint Information: 2002
Complaint Investigations Completed: 10
Complaints with Statements of Deficiencies (SOD) issued: 4
% of Complaints with SODs Issued 40%
Regional % of Complaints with SODs issued: 33.8%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
01/17/2002 405.6 Quality Assurance 2/26/2002
  405.6(a) Quality Assurance  
01/31/2002 405.2(b) Governing Body - Organization & Operation 6/27/2002
  405.5(e) Nursing Services - Quality Assurance  
  405.6(a) Quality Assurance  
  405.7(b) Patients' Rights - Hospital Responsibilities  
  405.9(b) Admission/Discharge - Admission  
  405.11(b) Infection Control - Nosocomial Surveillance, Prevention and Control  
07/11/2002 405.2(f) Governing Body - Care of Patients 3/17/2003
  405.6(a) Quality Assurance  
  405.9(f) Admission/Discharge - Discharge  
  405.10(a) Medical Records - General Requirements  
  405.10(b) Medical Records - Content  
09/25/2002 405.6(a) Quality Assurance 1/14/2003
  405.7 Patients' Rights  
  405.10(a) Medical Records - General Requirements  
  405.22(g) Critical Care and Special Care Services  
  63.6(a) Confidentiality & Disclosure  
  63.7(a) Documentation of HIV-Related Info & Disclosures  
  63.9(a) Health Care Provider & Health Facility Policy & Procedures  
  63.9(d) Health Care Provider & Health Facility Policy & Procedures  
  63.9(e) Health Care Provider & Health Facility Policy & Procedures  
       

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
1/2 - 11/2002 Annual Compliance Review - Resident Work Hours 405.4(b) - Medical Staff - Organization 4/18/2002
10/23 - 31/2002 Annual Compliance Review - Resident Work Hours 405.5(b) - Medical Staff - Organization 2/24/2003
12/12/2002 Article 28 Focus None  
       

Areas Cited as a Result of Incident Investigations:

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