The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|ASCENSION ST JOHN MEDICAL CENTER||1923 SOUTH UTICA AVENUE TULSA, OK 74104||March 1, 2011|
|VIOLATION: INTEGRATION OF OUTPATIENT SERVICES||Tag No: A1077|
|Based on a review of policies and procedures, quality assurance/performance (QAPI) improvement meeting minutes and staff interviews, the facility failed to ensure the QAPI reviews were implemented into the housewide QAPI program.
1. In the review of the QAPI meeting minutes for the last six months there was no evidence the Department (The Breast Care Center) participated in the hospital"s (St. John Medical Center) house wide QAPI, process, or findings.
2. During an interview with the Radiology Director on 03/01/11 at approximately 1125, the director confirmed that the Breast Care Center is not included in the hospital's QAPI process.