Hospital Name: Strong Health-Highland
PFI # 0409
Complaints:
| Complaint Information: | 2001 |
| Complaint Investigations Completed | 12 |
| Complaints with Statements of Deficiencies (SOD) Issued | 6 |
| % of Complaints with SODs Issued | 50% |
| Regional % of Complaints with SODs Issued | 39.3% |
Areas:
| SOD Date | Regulatory Citation | Areas Cited | Date Plan of Correction Accepted |
| 10/22/01 | 405.6 | QUALITY ASSURANCE PROGRAM QUALITY ASSURANCE COMMITTEE | 11/9/01 |
| 10/22/01 | 405.4 | MEDICAL STAFF REG PHYSICIANS ASSTS & REG SPEC ASSTS | 11/9/01 |
| 10/22/01 | 405.19 | EMERGENCY SERVICES STAFFING | 11/9/01 |
| 10/22/01 | 405.19 | EMERGENCY SERVICES PATIENT CARE | 11/9/01 |
| 10/5/01 | 405.9 | ADMISSION & DISCHARGE DISCHARGE | 11/5/01 |
| 10/5/01 | 405.18 | REHABILITATION SERVICES DELIVERY OF SERVICES | 11/5/01 |
| 9/26/01 | 405.7 | PATIENT RIGHTS | NO POC REQUIRED |
| 6/8/01 | 711.4 | GEN'L STRUCTURES,EQUIP & SAFETY STANDARDS EXISTING HOSPITALS | 8/2/01 |
| 6/8/01 | 711.2 | PERTINENT TECH STANDARDS LIFE SAFETY CODE | 8/2/01 |
| 6/8/01 | 405.24 | ENV HEALTH HOUSEKEEPING | 8/2/01 |
| 6/8/01 | 405.17 | PHARMACY SERVICES PHYSICAL FACILTIES | 8/2/01 |
| 5/16/01 | 405.7 | PATIENT'S RIGHTS HOSPITAL RESPONSIBILITIES | NO POC REQUIRED |
| 1/22/01 | 711.4 | PERTINENT TECHNICAL STANDARDS GENERAL STRUCTURAL | 3/19/01 |
| 1/22/01 | 711.2 | PERTINENT TECHNICAL STANDARD CORRIDORS | 3/19/01 |
| 1/22/01 | 5-10.4.1.2 | LIFE SAFETY CODE EXITS | 3/19/01 |
| 1/22/01 | 405.24 | ENV HEALTH HOUSEKEEPING | 3/19/01 |
| 1/22/01 | 405.24 | ENV HEALTH BUILDING & GROUNDS | 3/19/01 |
| 1/22/01 | 27-3.2.1 | LIFE SAFETY CODE FURNACE & UTILITY ROOM | 3/19/01 |
Areas Cited as a Result of Surveys:
| Date Of Survey | Type | Areas Cited: | Date Plan of Correction Accepted |
| 6/1/01 - 6/1/01 | ED | 405.19 - EMERGENCY SERVICES PATIENT CARE | 8/9/01 |
| 6/1/01 - 6/1/01 | ARTICLE 28 | 405.19 - EMERGENCY SERVICES PATIENT CARE | 8/9/01 |
| 6/15/01 – 6/15/01 | ARTICLE 28 | 711.4 - GENL STRUCTURE, EQUIP AND SAFETY STANDARDS NURSING UNITS | 9/14/01 |
| 6/15/01 – 6/15/01 | ARTICLE 28 | - HOUSEKEEPING | 9/14/01 |
| 6/15/01 – 6/15/01 | ARTICLE 28 | - PREVENTATIVE MAINTENANCE | 9/14/01 |
| 6/15/01 – 6/15/01 | ARTICLE 28 | 405.24 - ENVIRONMENTAL HEALTH LIFE SAFETY FROM FIRE | 9/14/01 |
| 6/15/01 – 6/15/01 | ARTICLE 28 | 405.11 - INFECTION CONTROL | 9/14/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V310 - TRNG CURRICULUM | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V273 - WASTE STORAGE & DISPOSAL | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V280 - EMERGENCY RESPONSE PERIODIC DRILLS | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V325 - PERSONNEL PROTECTION | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V332 - LABEL INFORMATION | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V334 - TRANSPORTATION & HANDLING | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V359 - PATIENT ID CHECK | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V384 - QUALITY ASSURANCE AUDIT PRACTICE REUSE | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V385 - QA AUDIT SETUP FOR TX | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V263 - AAMI DIALYSATE BACTERIOLOGY | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V265 - PE FUNCTIONAL, SANITARY & COMFORTABLE | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V323 - STORAGE AREA | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V232 - MEDICAL RECORD PATIENT ASSESSMENTS | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V326 - GERMICIDES ENVIRONMENTAL SAFETY | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V336 - RINSING | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V267 - PHYSICAL ENVIRONMENT SUFFICIENT SPACE | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V189 - LONG TERM PROGRAM REVIEWED BY TEAM | 10/18/01 |
| 7/25/01 – 8/7/01 | ARTICLE 28 ED | 405.19 - EMERGENCY SERVICES PATIENT CARE | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V112 - GOVERNING BODY HEALTH & SAFETY | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V159 - PATIENT CARE DEVELOPMENT & REVIEW | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V166 - PT CARE POLICIES RX SERVICES | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V185 - CONDITION OF PARTICIPATION LONG TERM PRGM & CARE PLAN | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V186 - LTP & PCP WITH TRANSFER | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V256 - PHYSICAL ENVIRONMENT CONSTR & MAINTAIN FOR SAFETY | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V188 - LTP TEAM MEMBERS | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V264 - AAMI CHEM CONTAMINATION | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V190 - LTP PATIENT INVOLVED | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V191 - LTP COPY WITH TRANSFER | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V194 - PATIENT CARE PLAN TEAM | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V195 - PCP PATIENT INVOLVED | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V166 - PT CARE POLICIES RX SERVICES | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V240 - MEDICAL RECORD ORDERS | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V347 - EXTERIOR CLEANING | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V187 - WRITTEN LONG TERM PLAN | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V323 - STORAGE AREA | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V325 - PERSONNEL PROTECTION | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V332 - LABEL INFORMATION | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V334 - TRANSPORTATION & HANDLING | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V359 - PATIENT ID CHECK | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V384 - QUALITY ASSURANCE AUDIT PRACTICE REUSE | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V385 - QA AUDIT SETUP FOR TX | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V112 - GOVERNING BODY HEALTH & SAFETY | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V267 - PHYSICAL ENVIRONMENT SUFFICIENT SPACE | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V265 - PE FUNCTIONAL, SANITARY & COMFORTABLE | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V310 - TRNG CURRICULUM | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V326 - GERMICIDES ENVIRONMENTAL SAFETY | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V336 - RINSING | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V347 - EXTERIOR CLEANING | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V259 - PE FREE OF HAZARDS | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V281 - EMERGENCY RESPONSE DRUGS & SUPPLIES | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V263 - AAMI DIALYSATE BACTERIOLOGY | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V191 - LTP COPY WITH TRANSFER | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V281 - EMERGENCY RESPONSE DRUGS & SUPPLIES | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V159 - PATIENT CARE DEVELOPMENT & REVIEW | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V185 - CONDITION OF PARTICIPATION LONG TERM PRGM & CARE PLAN | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V186 - LTP & PCP WITH TRANSFER | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V187 - WRITTEN LONG TERM PLAN | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V188 - LTP TEAM MEMBERS | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V280 - EMERGENCY RESPONSE PERIODIC DRILLS | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V190 - LTP PATIENT INVOLVED | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V273 - WASTE STORAGE & DISPOSAL | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V194 - PATIENT CARE PLAN TEAM | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V195 - PCP PATIENT INVOLVED | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V232 - MEDICAL RECORD PATIENT ASSESSMENTS | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V240 - MEDICAL RECORD ORDERS | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V256 - PHYSICAL ENVIRONMENT CONSTR & MAINTAIN FOR SAFETY | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V264 - AAMI CHEM CONTAMINATION | 10/18/01 |
| 7/25/01 - 8/7/01 | ARTICLE 28 | V259 - PHYSICAL ENVIRONMENT FREE OF HAZARDS | 10/18/01 |
| 7/25/01 - 8/7/01 | TITLE 18 | V189 - LONG TERM PROGRAM REVIEWED BY TEAM | 10/18/01 |