Hospital Information 2004
Faxton - St. Luke's Healthcare – St. Luke's Division
PFI # 0599
Revised: 8/05
Complaints:
| Complaint Information: | 2004 |
|---|---|
| Complaint Investigations Completed: | 3 |
| Complaints with Statements of Deficiencies (SOD) issued: | 2 |
| % of Complaints with SODs Issued | 67% |
| Regional % of Complaints with SODs issued: | 52.6% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 8/4/2004 | 405.7(b) | Patients' Rights - Hospital Responsibilities | 9/20/2004 |
| 405.12(b) | Surgical Services - Operation & Service Delivery | ||
| 11/16/2004 | 405.5(b) | Nursing Services - Delivery of Services | 12/7/2004 |
| 405.6(a) | Quality Assurance | ||
| 405.10(b) | Medical Records - Content |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 1/21 - 22/2004 | Article 28 Compliance & Medicare ESRD Recertification - SLM Herkimer County Dialysis Site | 405.2136(d) - Personnel P/P - Safe and Sanitary Environment | 4/7/2004 |
| 405.2136(f) - Pt Care Policies - RX Services | |||
| 405.2136(g) - Medical Supervision - Orders | |||
| 405.2137 - LTP & PCP with Transfer | |||
| 405.2138(e) - Grievance Mechanism | |||
| 405.2140(b) - PE - Functional, Sanitary and Comfortable | |||
| 405.2140(b) - PE - Infection Control | |||
| 410.2140(a) - PE - Constr & Maintain for Safety | |||
| 757.1(a) - Chronic Renal Dialysis Services - Chronic Renal Dialysis Services |
Most Recent Survey Date: 1/21 - 22/2004 - Article 28 Compliance & Medicare ESRD Recertification - SLM Herkimer County Dialysis Site
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 8/10/2004 | 405.8(a) | Incident Reporting | 8/31/2004 |
| 9/3/2004 | 405.8(d) | Incident Reporting | 9/20/2004 |
| 11/05/2004 | 405.8(d) | Incident Reporting | No POC Required |
