Hospital Complaint and Survey Information - 2003
St. Joseph's Hospital Health Center
PFI # 0630
Revised: 2/04
Complaint Information:
| Calendar Year: | 2003 |
|---|---|
| Complaint Investigations Completed: | 5 |
| Complaints with Statements of Deficiencies (SOD) issued: | 2 |
| % of Complaints with SODs Issued | 40% |
| Regional % of Complaints with SODs issued: | 38.9% |
Areas Cited
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| 3/5/2003 | 405.5(b) | Nursing Services - Delivery of Services | 4/30/2003 |
| 405.6(a) | Quality Assurance | ||
| 405.9(f) | Admission/Discharge - Discharge | ||
| 405.10(b) | Medical Records - Content | ||
| 405.19(b) | Emergency Services - Organization | ||
| 405.19(e) | Emergency Services - Patient Care | ||
| 4/9/2003 | 405.2(e) | Governing Body - Medical Staff | 4/22/2003 |
| 405.6(b) | Quality Assurance |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| 5/20 — 21/2003 | EMTALA | SOD Issued by the Centers for Medicare & Medicaid Services | |
| 10/23/2003 | EMTALA 1ST Followup | None | |
| 11/4 - 12/2003 | Article 28 Compliance & Medicare ESRD Recert — Camillus Site | 405.2136(f) - Governing Body & Management - Patient Care Policies - RX Services | 1/27/2004 |
| 405.2137(b) - Long Term Program & Care Plan - PCP: Individualized | |||
| 405.2137(b) - Long Term Program & Care Plan - PCP: Frequency | |||
| 405.2139(a) - Medical Records — PT Assessments | |||
| 405.2139(d) - Medical Records — Completed Prompt; Info Central | |||
| 410.2140(a) - Physical Environment - Constr & Maintain for Safety | |||
| 405.2140(a) - Physical Environment - PE: Water Treatment | |||
| 405.2140(b) - Physical Environment - Infection Control | |||
| 400.21(d) - Advance Directives - Policies & Procedures | |||
| 405.11 - Infection Control | |||
| 757.1(a) - Chronic Renal Dialysis Services - Chronic Renal Dialysis Services |
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
|---|---|---|---|
| none | |||
