Hospital Information 2004

Hospital Name: Arnot-Ogden Medical Center*

PFI # 0116

Revised: 7/2005

Complaints:

Complaint Information: 2004
Complaint Investigations Completed 4
Complaints with Statements of Deficiencies (SOD) Issued 0
% of Complaints with SODs Issued 0%
Regional % of Complaints with SODs Issued 35.9%

Areas Cited:

SOD Date Regulatory Citation 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
11/2-5/04 TITLE 18 V258 - PHYSICAL ENVIRONMENT -EQUIPMENT PM 1/7/2005
11/2-5/04 TITLE 18 V135 - CEO: ADMIN FUNCTIONS 1/7/2005
11/2-5/04 TITLE 18 V141 - CEO: STAFF TRAIN 1/7/2005
11/2-5/04 TITLE 18 V145 - PERSONNEL P/P: SAFE AND SANITARY ENVIRO 1/7/2005
11/2-5/04 TITLE 18 V152 - PERSONNEL RECORDS: JOB DESCRIPTIONS 1/7/2005
11/2-5/04 TITLE 18 V154 - PERSONNEL P/P: STAFF EDUCATION 1/7/2005
11/2-5/04 TITLE 18 V158 - PT CARE POLICIES: REVIEWED 1/7/2005
11/2-5/04 TITLE 18 V166 - PT CARE POLICIES: RX SERVICES 1/7/2005
11/2-5/04 TITLE 18 V177 - MEDICAL SUPERVISION: ORDERS 1/7/2005
11/2-5/04 TITLE 18 V187 - WRITTEN LONG TERM PLAN 1/7/2005
11/2-5/04 TITLE 18 V188 - LONG TERM PLAN TEAM MEMBERS 1/7/2005
11/2-5/04 TITLE 18 V220 - PT R/R: PT INFORMED REUSE 1/7/2005
11/2-5/04 TITLE 18 V237 - MED REC: CONSENTS 1/7/2005
11/2/2004 - 11/5/2004 TITLE 18 V128 - RULES AND REGS REVIEWED ANNUALLY 1/7/2005
11/2-5/04 TITLE 18 V247 - MED REC: COMPLETED PROMPT; INFO CENTRAL 1/7/2005
11/2-5/04 ARTICLE 28 757.1 - CHRONIC RENAL DIALYSIS SERVICES 1/7/2005
11/2-5/04 TITLE 18 V261 - PHYSICAL ENVIRONMENT WATER TREATMENT 1/7/2005
11/2-5/04 TITLE 18 V263 - AAMI-DIALYSATE BACTERIOLOGY 1/7/2005
11/2-5/04 TITLE 18 V264 - AAMI-CHEM CONTAM 1/7/2005
11/2-5/04 TITLE 18 V266 - PHYSICAL ENVIRONMENT INFECTION CONTROL 1/7/2005
11/2-5/04 TITLE 18 V273 - WASTE STORAGE AND DISPOSAL 1/7/2005
11/2-5/04 TITLE 18 V278 - EMERGENCY ROOM PERSONNEL TRAINED 1/7/2005
11/2-5/04 TITLE 18 V304 - REPROCESSING RECORD 1/7/2005
11/2-5/04 TITLE 18 V305 - EQUIPMENT MAINTENANCE RECORD 1/7/2005
11/2-5/04 TITLE 18 V313 - INFORMED CONSENT 1/7/2005
11/2-5/04 TITLE 18 V320 - MAINTENANCE OF EQUIPMENT 1/7/2005
11/2-5/04 TITLE 18 V334 - TRANSPORTATION AND HANDLING 1/7/2005
11/2-5/04 TITLE 18 V347 - EXTERIOR CLEANING 1/7/2005
11/2-5/04 TITLE 18 V238 - MED REC: MED & NRSG HISTORY 1/7/2005

Most Recent Survey Date: 11/2/2004

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
2/2/2004 405.6 QUALITY ASSURANCE -QA COMMITTEE 2/24/2004
2/2/2004 405.2 GOVERNING BODY -CARE OF PATIENTS 2/24/2004