Hospital Information 2004

Hospital Name: viaHealth-Rochester General

PFI # 0411

Revised: 6/2005

Complaints:

Complaint Information: 2004
Complaint Investigations Completed 7
Complaints with Statements of Deficiencies (SOD) Issued 3
% of Complaints with SODs Issued 43%
Regional % of Complaints with SODs Issued 35.9%

Areas Cited:

SOD Date Regulatory Citation Areas Cited Date Plan of Correction Accepted
12/29/2004 405.7 PATIENTS RIGHTS -PROCEDURAL REQUIREMENTS 1/21/2005
12/29/2004 405.5 NURSING SERVICES -DELIVERY OF SERVICES 1/21/2005
12/29/2004 405.28 SOCIAL SERVICES 1/21/2005
4/6/2004 405.5 MEDICAL STAFF -MEDICAL STAFF ACCOUNTABILITY 5/14/2004
4/6/2004 405.4 NURSING SERVICES -DELIVERY OF SERVICES 5/14/2004
2/19/2004 405.7 PATIENTS RIGHTS -HOSPITAL RESPONSIBILITIES 3/16/2004
2/19/2004 405.19 EMERGENCY SERVICES- PATIENT CARE 3/16/2004

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
2/23-26/04 TITLE 18 V194 - PATIENT CARE PLAN TEAM 4/23/2004
2/23-26/04 TITLE 18 V112 - GOVERNING BODY HEALTH & SAFETY 4/23/2004
2/23-26/04- TITLE 18 V262 - AAMI-H2O BACTERIOLOGY 4/23/2004
2/23-26/04 TITLE 18 V261 - PHYSICAL ENVIRONMENT- WATER TREATMENT 4/23/2004
2/23-26/04 TITLE 18 V258 - PHYSICIAL ENVIRONMENT- EQUIPMENT PM 4/23/2004
2/23-26/04 TITLE 18 V257 - PHYSICAL ENVIRONMENT- FIRE EXT & EVAC PLANS 4/23/2004
2/23-26/04 TITLE 18 V256 - PHYSICAL ENVIRONMENT CONSTR & MAINTAIN FOR SAFETY 4/23/2004
2/23-26/04 TITLE 18 V265 - PHYSICAL ENVIRONMENT- FUNCTIONAL, SANITARY AND COMFORTABLE 4/23/2004
2/23-26/04 TITLE 18 V195 - PATIENT CARE PLAN- PATIENT INVOLVED 4/23/2004
2/23-26/04 TITLE 18 V280 - EMERGENCY ROOM PERIODIC DRILLS 4/23/2004
2/23-26/04 TITLE 18 V190 - LONG TERM PROGRAM PT INVOLVED 4/23/2004
2/23-26/04 TITLE 18 V181 - MEDICAL STAFF APPOINTMENTS 4/23/2004
2/23-26/04 TITLE 18 V159 - PT CARE POLICIES -DEVELOPMENT AND REVIEW 4/23/2004
2/23-26/04 TITLE 18 V157 - PATIENT CARE POLICIES WRITTEN 4/23/2004
2/23-26/04 TITLE 18 V144 - PERSONNEL P/P STAFF QUALIFIED 4/23/2004
2/23-26/04 TITLE 18 V123 - REVISED OPERATIONAL OBJECTIVES 4/23/2004
2/23-26/04 TITLE 18 V241 - MEDICAL RECORD- PROGRESS NOTES 4/23/2004
2/23-26/04 TITLE 18 V334 - TRANSPORTATION AND HANDLING 4/23/2004
2/23-26/04 ARTICLE 28 751.8 - ORGANIZATION & ADMINISTRATION 4/23/2004
2/23-26/04 TITLE 18 V365 - SAMPLE FOR PRESENCE 4/23/2004
2/23-26/04 TITLE 18 V361 - GERMICIDE CONTACT TIME CHECK 4/23/2004
2/23-26/04 TITLE 18 V355 - DISPOSITION OF REJECTED DIALYZERS 4/23/2004
2/23-26/04 TITLE 18 V347 - EXTERIOR CLEANING 4/23/2004
2/23-26/04 TITLE 18 V346 - GERMICIDE CONCENTRATION -VERIFICATION 4/23/2004
2/23-26/04 TITLE 18 V264 - AAMI-CHEM CONTAM 4/23/2004
2/23-26/04 TITLE 18 V337 - CLEANING 4/23/2004
2/23-26/04 ARTICLE 28 757.1 - CHRONIC RENAL DIALYSIS SERVICES 4/23/2004
2/23-26/04 TITLE 18 V325 - PERSONNEL PROTECTION 4/23/2004
2/23-26/04 TITLE 18 V312 - REUSE MEDICAL ISSUES 4/23/2004
2/23-26/04 TITLE 18 V311 - TRAINING DOCUMENTED 4/23/2004
2/23-26/04 TITLE 18 V309 - PERSONNEL QUALIFICATIONS 4/23/2004
2/23-26/04 TITLE 18 V305 - EQUIPMENT MAINTENANCE RECORD 4/23/2004
2/23-26/04 TITLE 18 V304 - REPROCESSING RECORD 4/23/2004
2/23-26/04 TITLE 18 V344 - FILLING WITH GERMICIDE, CAP CLEANING 4/23/2004

Most Recent Survey Date: 12/21/04

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited Date Plan of Correction Accepted
10/28/2004 405.8 INCIDENT REPORTING- 24 HOUR REPORTING 12/24/2004
10/28/2004 405.8 INCIDENT REPORTING -24 HOUR REPORTING 12/24/2004
10/28/2004 405.8 INCIDENT REPORTING- 24 HOUR REPORTING 12/24/2004
10/28/2004 405.8 INCIDENT REPORTING -24 HOUR REPORTING 12/24/2004
10/28/2004 405.8 INCIDENT REPORTING- 24 HOUR REPORTING 12/24/2004
10/28/2004 405.8 INCIDENT REPORTING- 24 HOUR REPORTING 12/24/2004
10/28/2004 405.8 INCIDENT REPORTING -24 HOUR REPORTING 12/24/2004
10/28/2004 405.8 INCIDENT REPORTING- 24 HOUR REPORTING 12/24/2004
10/28/2004 405.8 INCIDENT REPORTING- 24 HOUR REPORTING 12/24/2004
9/28/2004 405.8 INCIDENT REPORTING -24 HOUR REPORTING 10/22/2004