Hospital Information 2004
St. Luke's Cornwall Hospital-Newburgh
PFI # 0694
Revised: July 19, 2005
Complaints:
| Complaint Information: | 2004 |
|---|---|
| Complaint Investigations Completed: | 2 |
| Complaints with Statements of Deficiencies (SOD) issued: | 1 |
| % of Complaints with SODs Issued | 50% |
| Regional % of Complaints with SODs issued: | 25% |
Areas Cited:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 11/23/04 | 405.4(a)(1)(i) | Medical Staff-Medical Staff Accountability | 1/18/05 |
| 11/23/04 | 405.5(b)(1)(ii)(4) | Nursing Services-Delivery of Services | 1/18/05 |
| 11/23/04 | 405.8(b)(1)(d) | Incident Reporting | 1/18/05 |
| 11/23/04 | 405.8(c) | Incident Reporting | 1/18/05 |
Areas Cited as a Result of Surveys:
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 4/2/04 | Title 18 Recertification Survey | 405.2136(b) Revised Operational objectives | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2136(c)(3)(i) CEO: Implement/Coordinate | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2136(d)(2) Personnel P/P:Health Exams | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2136(d)(6) Personnel P/P: Staff Education | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2136(g)(1) Medical Supervision: Orders | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2137(a)(1) Long-Term Plan Team Members | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2137(b) PCP:Written, Assessment Based | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2137(b)(3) PCP: Patient Involved | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2139(a) Med Rec: Med & Nursing History | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2139(a) Med Rec: D/C/ Summary | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2139(b) Protection of Medical Record Information | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2140(a)(2) PE: Equipment PM | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 402.2140(a)(5) AAMI-H20 Bacteriology | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2140(a)(5)(ii) AAMI- Dialysate Bacteriology | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2140(a)(5)(ii) AAMI-Chem Contam | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2140(b) PE: Functional, Sanitary & Comfortable | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2140(b)(1) PE: Infection Control | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2140(b)(2) PE: Sufficient Space | 6/30/05 |
Areas Cited as a Result of Surveys (Continued):
| Date of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| 4/2/04 | 405.2140(b)(2) | 405.2140(b)(2) PE: Storage Self Dialysis Supplies | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2140(b)(3) PE: Nursing Station | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2410(b)(5) PE: Central Delivery | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2140(c) Prevent Cross Contamination | 6/30/05 |
| 4/2/04 | Title 18 Recertification Survey | 405.2140(c) Waste Storage and Disposal | 6/30/05 |
| 4/2/04 | 405.2140(d) | 405.2140(d) Emergency Preparedness | 6/30/05 |
Most Recent Survey Date:11/23/04
Areas Cited as a Result of Incident Investigations:
| SOD Date | Regulatory Citation | Areas Cited: | Date Plan of Correction Accepted |
|---|---|---|---|
| None | |||
