Name    Janice Lubeck

E-mail    janice.lubeck@lsh.ks.gov

Facility Name    Larned State Hospital

Facility CEO    Mark E. Schutter, Ph D

Facility Address    1301 KS Hwy 264

Larned, KS 67550

Facility Description (Brief)    State Psychiatric Hospital with 3 programs: Psychiatric Services, State Security, Sexual Predators.

# Beds - Adult    555-all beds listed are licensed, not budgeted beds.

# Beds - Child & Adol    25

# Beds - Sub Abuse    03

# Beds - Forensic    260

# Beds - MR/DD    0

# Beds - TotaL    580

# Beds - CMS Distinct Part    104

Survey Type    Unannounced

Surveying Agency    CMS

Survey Dates (inclusive)    March 24-26, 2008

Survey Days (e.g., Mon - Weds)    Mon, Tues, Wed.

Number of Surveyors    3

Priority Focus Areas: Treatment Plan, Patient Schedule, Therapeutic Activities, Interviews with department heads (Psy, SW, Activity Therapy, DON, Clinical Director).

Last Survey Ending Date    May 18, 2005

Profile - Surveyor #1   Norma Josef, MD: Had worked as a CEO of a large psychiatric hospital.

Profile - Surveyor #2   Renee Gobe, RN, MS:  Had worked as a DON of two psychiatric hospitals.

Profile - Surveyor #3   Michael Horwitz, ACSW, BCD   .

# of Non-Compliant Standards    1

APR/NPSG Cites (Tag#/EP#/Brief Descrip/Surveyor)    Had no deficiencies.



RI/PC/MM/IC Cites (Stnd#/EP#/Brief Descrip/Surveyor)    The CMS surveyors wanted these items ASAP but no later than 3 PM on first day of survey:

- S/R profiles for past year, S/R use reports for past 3 months/

- name/location of patients who have been in S/R in the past 30 days.

- sentinel event reports for past year.

- current state/federal investigation or activities.

- minutes for the past year of QM/PI, Medical Staff, and Nursing Management committees.

- medication variances/error profiles for past year, data for past 3 months.

- five discharge records.

- death records during the past year, hospital deaths  and deaths within 1 week of discharge, include autopsy reports, Case/Mortality Reviews, and time the attending physician(s) will be available for interviews.



PI/LD/HR/IM Cites (Stnd#/EP#/Brief Descrip/Surveyor)    Forms to be completed by the hospital included:

- Hospital/CAH Medicare Database Worksheet REv. 10/21/05 (pages 1-4).

- Medicare/Medicaid Psychiatric Hospital Survey Data Form CMS-724 (09/94) pages 1-2.

- Nursing Staffing forms.

- Medical Staffing forms.



EC Cites (Stnd#/EP#/Brief Descrip/Surveyor)    EC Cites (Stnd#/EP#/Brief Descrip/Surveyor)



MS/NR Cites (Stnd#/EP#/Brief Descrip/Surveyor)    MS/NR Cites (Stnd#/EP#/Brief Descrip/Surveyor)

**Surveyor Compliments

Treatment-related strengths that were noted:

- provision of active treatment.

- offering treatment opportunities seven days a week.

- adjusting treatment to meet patient needs.

- ensuring "special patient population" needs are met (interpretive services, medical conditions, developmental disabilities, substance abuse issues).

- collaborative interactions of Treatment Teams in planning and providing patient care.

Support Services-related strengths that were noted:

- flexibility and responsiveness of the Information Technology (IT) department.

- the collective planning and implementation of the Electronic Medical Record.

- the completeness of Medical Record documentation.

- dedication shown by Environmental Services, Dietary, and Grounds Department staff in providing a safe, clean, pleasant environment.

Check if you would be willing to record some helpful tips from your survey experience in a 10-15 min interview.    yes

Preliminary Survey Result    CMS: No Conditions of Participation Out

Will you send us a copy of your survey report?    No

Will you send us a copy of your ESC?    No

If you said 'No' to either of the last 2 questions, please tell us why.    There is no report to send,

just a letter stating that we meet the requirements for participation as a provider of psychiatric hospital services.

**Misc Comments, Suggestions, Etc

The CMS surveyors wanted these items immediately:

- list of patients (age, gender, diagnosis, date of admission, attending physician).

- description of programs, total number of beds, LOS for certified beds.

- names/locations of patients who do not speak English, and are deaf/blind.

- Treatment team meeting dates and program schedules for each unit.

- description of chart order for active and closed medical records.

- time frame for completion of assessments, treatment plans/reviews, treatment/ progress notes.

- polices/procedures for seclusion/restraint, manual holds, special observation, translator services, staffing, monitoring of patients.

- hospital organizational table and facility map.

- curriculum vitae for Clincial Director, DON, Director of Social Work.  

Janice Lubeck