Claxton-Hepburn Medical Center
PFI # 0798
Revised: 3/03
Complaints:
| Complaint Information: | 2002 |
| Complaint Investigations Completed: | 0 |
| Complaints with Statements of Deficiencies (SOD) issued: | 0 |
| % of Complaints with SODs Issued | 0% |
| Regional % of Complaints with SODs issued: | 33.8% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
| 5/14 - 15/2002 | Validation | 482.13(a) - Patients' Rights - Notice of Rights | Optional |
| 482.21(a) - Quality Assurance - Clinical Plan | |||
| 482.24(a) - Medical Records - Content of Record | |||
| 482.25(a) - Pharmaceutical Services - Pharmacy Management & Administration | |||
| 482.25(b) - Pharmaceutical Services - Delivery of Services | |||
| 482.41(b) - Physical Environment - Life Safety from Fire | |||
| 482.41(c) - Physical Environment - Facilities | |||
| 482.42(a) - Infection Control - Organization & Policies | |||
| 482.45 - Organ Procurement - Organ Procurement Responsibilities | |||
| 482.45 - Organ Procurement - Survey Procedures & Probes | |||
| 482.51(b) - Surgical Services - Delivery of Services | |||
| 482.52(b) - Anesthesia Services - Delivery of Services | |||
| 482.55(a) - Emergency Services - Organization & Direction | |||
| 482.57(b) - Respiratory Care Services - Delivery of Services | |||
| NFPA 101 - Life Safety Code Standard | |||
| 10/1 - 3/2002 | Article 28 Compliance & Medicare ESRD Recert | 405.5(b) - Nursing Services - Delivery of Services | 3/6/2003 |
| 405.6(a) - Quality Assurance | |||
| 405.11 - Infection Control | |||
| 405.17(c) - Pharmaceutical Services - Physical Facilities | |||
| 405.2136 - Governing Body & Management | |||
| 405.2136(c) - Governing Body & Management - CEO: Staff Train | |||
| 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 | |||
| 405.2137(b) - Long Term Program & Care Plan - PCP: Patient Involved | |||
| 405.2139(a) - Medical Records - Med & Nursing History | |||
| 405.2140(a) - Physical Environment - AAMI: Dialysate Bacteriology | |||
| 402.2140(a) - Physical Environment - AAMI: H20 Bacteriology | |||
| 405.2140(a) - Physical Environment - PE: Equipment PM | |||
| 410.2140(a) - Physical Environment - PE: Constr & Maintain for Safety | |||
| 405.2140(b) - Physical Environment - PE: Infection Control | |||
| 405.2140(d) - Physical Environment - ER: Patients Informed | |||
| 405.2140(d) - Physical Environment - ER: Periodic Drills | |||
| 405.2163(c) - Minimal Service Requirements - Social Worker Responsibilities | |||
| 405.2163(c) - Minimal Service Requirements - Social Worker Qualified | |||
| 12/31/2002 | Initial Medicare Certification – Rehabilitation Unit | None | |
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |