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Hospital Information 2004

St. Joseph's Hospital Health Center

PFI # 0630

Revised: 8/05

Complaints:

Complaint Information:	2004
Complaint Investigations Completed:	3
Complaints with Statements of Deficiencies (SOD) issued:	1
% of Complaints with SODs Issued	33%
Regional % of Complaints with SODs issued:	52.6%

Areas Cited:

SOD Date	Regulatory Citation	Areas Cited:	Date Plan of Correction Accepted
3/23/2004	405.11(b)	Infection Control - Nosocomial Surveillance, Prevention and Control	No POC Required

Areas Cited as a Result of Surveys:

Date of Survey	Type	Areas Cited:	Date Plan of Correction Accepted
3/22 – 24/2004	Article 28 Compliance & Medicare ESRD Recertification - Seneca Campus	405.11 - Infection Control	5/11/2004
		751.6(m) - Organization and Administration - Personnel
		757.1(a) - Chronic Renal Dialysis Services - Chronic Renal Dialysis Services
		405.2136(d) - Personnel P/P - Good Care
		405.2136(f) - Pt Care Policies - RX Services
		405.2137(b) - PCP - Individualized
		405.2140(a) - PE - Water Treatment
		405.2140(b) - PE - Infection Control
		405.2163(f) - Participation in Recipient Registry
		410.2140(a) - PE - Constr & Maintain for Safety
10/25 – 27/2004	Article 28 Compliance & Medicare ESRD Recertification – Northeast Dialysis Center	405.11 - Infection Control	12/13/2004
		711.2(b) - Pertinent Technical Standards
		757.1(a) - Chronic Renal Dialysis Services - Chronic Renal Dialysis Services
		405.2136(g) - Medical Supervision - Orders
		405.2137(a) - Written Long-Term Plan
		405.2140(b) - PE - Infection Control
		405.2163(c) - Social Worker Responsibilities
		410.2140(a) - PE - Constr & Maintain

Most Recent Survey Date: 12/9/2004 – EMTALA 4^th Followup

Areas Cited as a Result of Incident Investigations:

SOD Date	Regulatory Citation	Areas Cited:	Date Plan of Correction Accepted
9/3/2004	405.8(a)	Incident Reporting	10/1/2004
	405.8(d)	Incident Reporting
10/18/2004	405.8(a)	Incident Reporting	No POC Required