Hospital Name HARLEM HOSPITAL CENTER

PFI # 1445

June 2003

Complaints:

Complaint Information: 2002
Complaint Investigations Completed: 8
Complaints with Statements of Deficiencies (SOD) issued: 6
% of Complaints with SODs Issued 75%
Regional % of Complaints with SODs issued: 44.9%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
04/22/02 405.19 Emergency Services Organization 06/13/02
05/01/02 405.05 Nursing Services - Organization 08/08/02
05/01/02 405.10 Medical Records 08/08/02
05/01/02 405.23 Food and Dietetic Services 08/08/02
05/01/02 405.04 Medical Staff – Medical Staff Accountability 07/02/02
05/01/02 405.05 Nursing Services – Delivery of Services 07/02/02
05/01/02 405.06 Quality Assurance Program 07/02/02
05/01/02 405.09 Admission/ Discharge 07/02/02
05/01/02 405.23 Food and Dietetic Services - General 07/02/02
06/27/02 405.02 Governing Body – Care of Patients 08/07/02
06/27/02 405.04 Medical Staff – Medical Staff Accountability 08/07/02
06/27/02 405.04 Medical Staff – Medical Staff Accountability 08/28/02
06/27/02 405.05 Nursing Services – Organization and Staffing 08/07/02
06/27/02 405.05 Nursing Services – Delivery of Services 08/28/02
06/27/02 405.07 Patient Rights – Hospital Responsibilities 08/07/02
06/27/02 405.07 Patients’ Rights – Hospital Responsibilities 08/28/02
10/28/02 405.07 Patients’ Rights – Hospital Responsibilities 11/27/02
11/12/02 405.05 Nursing Services – Delivery of Services 01/14/03
11/12/02 405.07 Patients’ Rights – Hospital Responsibilities 01/14/03

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
10/08/02 A-28 405.02 Governing Body 02/26/03
10/08/02 A-28 711.02 Pertinent Technical Standards 02/26/03

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
02/14/02 405.07 Patients' Rights 02/14/02
02/25/02 405.08 Incident Reporting - Investigative Report 03/27/02
03/14/02 405.05 Nursing Services - Delivery of Services 03/14/02
05/22/02 405.02 Governing Body  
05/22/02 405.04 Medical Staff  
05/22/02 405.05 Nursing Services  
05/22/02 405.06 Quality Assurance  
05/22/02 405.07 Patients' Rights