Hospital Complaint and Survey Information - 2003

ELLENVILLE REGIONAL HOSPITAL

PFI # 1002

Revised: September 2004

Complaint Information:

Calendar Year: 2003
Complaint Investigations Completed: 3
Complaints with Statements of Deficiencies (SOD) issued: 1
% of Complaints with SODs Issued 33%
Regional % of Complaints with SODs issued: 24.5%

Areas Cited as a Result of Complaint Investigations:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
10/27/03 405.2(a) Governing Body Pending
10/27/03 405.4(a)(1)(i) Medical Staff Pending
10/27/03 405.4(b)(4) Medical Staff - Organization Pending
10/27/03 405.5(a) Nursing Services-Organization and staffing Pending
10/27/03 405.6(a)(2)(i) Quality Assurance Program Pending
10/27/03 405.10(c)(1) Medical Records - Authentication Pending
10/27/03 405.15(a)(2)(4)(iv) Radiologic and Nuclear Medicine Services Pending
10/27/03 405.19(d)(1)(i) Emergency Services - Staffing Pending

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
12/17/03 Title 18 485.616(a)(2) Agreements 5/7/04
12/17/03 Title 18 485.618 Emergency Services 5/7/04
12/17/03 Title 18 485.623(a) Construction 5/7/04
12/17/03 Title 18 485.623(b)(1) Maintenance 5/7/04
12/17/03 Title 18 485.623(c)(1) emergency Procedures 5/7/04
12/17/03 Title 18 485.627(a) Governing Body 5/7/04
12/17/03 Title 18 485.635 Provision of Services 5/7/04
12/17/03 Title 18 485.635(a)(3)(1)(iv)(vi) Patient Care Policies 5/7/04
12/17/03 Title 18 485.635(b)(3) Radiology Services 5/7/04
12/17/03 Title 18 485.635(c)(1)(I)(3) Services Provided through agreement OR 5/7/04
12/17/03 Title 18 485.635(d)(1)(4) Nursing Services 5/7/04
12/17/03 Title 18 485.638(a)(2)(4)(I)(II) Records System 5/7/04
12/17/03 Title 18 485.638(b)(1) Protection of Record Information 5/7/04
12/17/03 Title 18 485.639 Surgical Services 5/7/04
12/17/03 Title 18 485.641(a)(1)(I) Periodic Evaluation & Quality Assuranc3 5/7/04
12/17/03 Title 18 485.641(b)(5)(II) Quality Assurance 5/7/04
12/17/03 Article 28 405.2(b)(2) Governing Body Pending
12/17/03 Article 28 405.3(b)(10)(i) Administration: Personnel Pending
12/17/03 Article 28 405.4(b)(2)(4) Medical Staff: Organization Pending
12/17/03 Article 28 405.5(A)(5)(II)(b)(1)(i)(2)(ii)(3)(4) Nursing Services Pending
12/17/03 Article 28 405.5(c) Nursing Services Pending
12/17/03 Article 28 405.6 quality Assurance Program Pending
12/17/03 Article 28 405.7(b)(9) Patients' Rights Pending
12/17/03 Article 28 405.8(a) Incident Reporting Pending
12/17/03 Article 28 405.9(b)(12) Admission/Discharge-Admission Pending
12/17/03 Article 28 405.9(f)(7) Admission/Discharge-Discharge Pending
12/17/03 Article 28 405.10(a)(1)(2)(4) Medical Records - General Requirements Pending
12/17/03 Arielle 28 405.11(b) Infection Control Pending
12/17/03 Article 28 405.12(a)(b) Surgical Services Pending
12/17/03 Article 28 405.13(a)(b)(2)(iii)(b) Anesthesia Services Pending
12/17/03 Article 28 405.15(a)(3)(4)(ii) Radiologic and Nuclear Medicine Services Pending
12/17/03 Article 28 405.17(a) Pharmaceutical Services Pending
12/17/03 Article 28 405.19(d)(1)(i) Emergency Services - Staffing Pending
12/17/03 Article 28 405.19(e)(2) Emergency Services - Patient Care Pending
12/17/03 Article 28 405.20 Outpatient Services Pending
12/17/03 Article 28 405.24(a)(1) Environmental Health - Buildings and Grounds Pending
12/17/03 Article 28 405.24(b)(2)(c)(2)(i) Environmental Health Pending
12/17/03 Article 28 405.24(e)(1) Environmental Health-Housekeeping Pending

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
none