Hospital Information 2004
Hospital Name: St. James Mercy*
PFI # 0870
Revised: 7/2005
Complaints:
| Complaint Information: | 2004 |
|---|---|
| Complaint Investigations Completed | 1 |
| Complaints with Statements of Deficiencies (SOD) Issued | 0 |
| % of Complaints with SODs Issued | 0% |
| Regional % of Complaints with SODs Issued | 35.9% |
Areas Cited:
| Date of Survey | Type | 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 |
|---|---|---|---|
| 5/11-19/04 | TITLE 18 | V166 - PT CARE POLICIES- RX SERVICES | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V110 - GOVERNING BODY & MGMT | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V262 - AAMI-H20 BACTERIOLOGY | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V261 - PHYSICAL ENVIRONMENT WATER TREATMENT | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V258 - PHYSICAL ENVIRONMENT- EQUIPMENT PM | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V257 - PHYSICAL ENVIRONMENT FIRE EXT AND EVAC PLANS | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V256 - PHYSICAL ENVIRONMENT CONSTR & MAINTAIN FOR SAFETY | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V255 - PHYSICAL ENVIRONMENT | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V265 - PHYSICAL ENVIRONMENT FUNCTIONAL, SANITARY AND COMFORTABLE | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V181 - MEDICAL STAFF APPTS | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V266 - PHYSICAL ENVIRONMENT INFECTION CONTROL | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V159 - PT CARE POLICIES- DEVELOPMENT AND REVIEW | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V158 - PATIENT CARE POLICIES -REVIEWED | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V157 - PATIENT CARE POLICIES- WRITTEN | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V147 - PERSONNEL P/P -HEALTH EXAMS | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V141 - CHIEF EXECUTIVE OFFICER STAFF- TRAIN | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V137 - CHIEF EXECUTIVE OFFICER STAFF- ORIENTATION | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V124 - GOVERNING BODY -RESPONSIBILITY FOR REUSE | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V112 - GOVERNING BODY HEALTH AND SAFETY | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V241 - MEDICAL RECORD PROGRESS NOTES | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V323 - STORAGE AREA | 6/30/2004 |
| 5/11-19/04 | ARTICLE 28 | 751.6 - ORGANIZATION & ADMINISTRATION -PERSONNEL | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V369 - WRITTEN GUIDE FOR TESTS | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V365 - SAMPLE FOR PRESENCE | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V347 - EXTERIOR CLEANING | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V344 - FILLING WITH GERMICIDE, CAP CLEANING | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V338 - PERFORMANCE TEST AFTER EACH USE | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V337 - CLEANING | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V264 - AAMI-CHEM CONTAM | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V325 - PERSONNEL PROTECTION | 6/30/2004 |
| 5/11-19/04 | ARTICLE 28 | 757.1 - CHRONIC RENAL DIALYSIS SERVICES | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V319 - PROCESS CONTROL TESTING | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V318 - UTILITY REQUIREMENTS | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V312 - REUSE MEDICAL ISSUES | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V310 - TRAINING CURRICULUM | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V309 - PERSONNEL QUALIFICATIONS | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V303 - DIALYZER REPROCESSING MANUAL | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V300 - CONDITION OF PARTICIPATION- REUSE | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V280 - EMERGENCY RESPONSE PERIODIC DRILLS | 6/30/2004 |
| 5/11-19/04 | TITLE 18 | V332 - LABEL INFORMATION | 6/30/2004 |
Most Recent Survey Date: 5/11/2004
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| none | |||
