Professional Documents
Culture Documents
Yorkville Endoscopy Sod 09 05 2014 PDF
Yorkville Endoscopy Sod 09 05 2014 PDF
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
COMPLAINT # NY00152029
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 1 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 4 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Findings include:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 5 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Findings include:
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 9 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 13 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Findings include:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 14 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Findings include:
See Q -0060
Q 162 416.47(b) FORM AND CONTENT OF RECORD Q 162
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 15 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Findings include:
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 17 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 18 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Findings include:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 19 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Findings include:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 21 of 22
PRINTED: 10/06/2014
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
C
33C0001136 B. WING _____________________________
09/05/2014
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KI8R11 Facility ID: HP1396S If continuation sheet Page 22 of 22