Hospital Complaint and Survey Information - 2003

St. Joseph'S Hospital

PFI # 1098

Revised: April 2004

Complaint Information:

Calendar Year: 2003
Complaint Investigations Completed: 1
Complaints with Statements of Deficiencies (SOD) issued: 0
% of Complaints with SODs Issued 0%
Regional % of Complaints with SODs issued: 24.5%

Areas Cited

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

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited Date Plan of Correction Accepted
7/18/03 Title 18 405.2136 COP: Governing Body and Management 8/14/03
7/18/03 Title 18 405.2136 GB: Health and Safety 8/14/03
7/18/03 Title 18 405.2136 GB: Operation 8/14/03
7/18/03 Title 18 405.2136(b) Revised Operational Objectives 8/14/03
7/18/03 Title 18 405.2136(d)(2) Personnel P/P: Safe and sanitary enviro 8/14/03
7/18/03 Title 18 405.2136(f) Pt. Care Policies: Reviewed 8/14/03
7/18/03 Title 18 405.2138(c) Respect, Dignity & Privacy 8/14/03
7/18/03 Title 18 405.2138(e) Grievance Mechanism 8/14/03
7/18/03 Title 18 405.2139 COP: Medical Records 8/14/03
7/18/03 Title 18 405.2139(a) Med Rec: D/C Summary 8/14/03
7/18/03 Title 18 405.2139(f) Location and Facilities 8/14/03
7/18/03 Title 18 405.2140 COP: Physican Environment 8/14/03
7/18/03 Title 18 410.2140(a) PE: Const & Maintain for Safety 8/14/03
7/18/03 Title 18 405.2140(a)(1) PE: Fire Ext. & Evac Plans 8/14/03
7/18/03 Title 18 405.2140(a)(3) PE: Free of Hazards 8/14/03
7/18/03 Title 18 405.2140(a)(5)(ii) AAMI-chem Contam 8/14/03
7/18/03 Title 18 405.2140(b) PE: Functional, Sanitary and Comfortable 8/14/03
7/18/03 Title 18 405.2140(b)(1) PE: Infection Control 8/14/03
7/18/03 Title 18 405.2140(b)(2) PE: Sufficient Space 8/14/03
7/18/03 Title 18 405.2140(b)(3) PE: Nursing Station 8/14/03
7/18/03 Title 18 405.2140(c) Prevent Cross Contamination 8/14/03

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

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