Name    Lynn Goldman

E-mail    customerservice@fieldsinc.com

Facility Name    Tinley Park Mental Health Center

Facility CEO    Ms. Brenda Hampton

Facility Address    Tinley Park, IL 60477

7400 West 183rd Street

Tinley Park Mental Health Center

Facility Description (Brief)    Facility Description (Brief)

# Beds - Adult    100

# Beds - Child & Adol    # Beds - Child & Adol

# Beds - Sub Abuse    # Beds - Sub Abuse

# Beds - Forensic    # Beds - Forensic

# Beds - MR/DD    100

# Beds - TotaL    # Beds - TotaL

# Beds - CMS Distinct Part    # Beds - CMS Distinct Part

Survey Type    Unannounced

Surveying Agency    CMS

Survey Dates (inclusive)    3/19-21/07

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

Number of Surveyors    2

Priority Focus Areas    IDK

Last Survey Ending Date    3/21/07

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)    Jay S. Flocks, MD

Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)    Virginia J. Jordan, MSN, RN

Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)    Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)

Profile - Surveyor #4 (Name/Disc/Tm Role/Traits/Quirks)    Profile - Surveyor #4 (Name/Disc/Tm Role/Traits/Quirks)

Profile - Surveyor #5 (Name/Disc/Tm Role/Traits/Quirks)    Profile - Surveyor #5 (Name/Disc/Tm Role/Traits/Quirks)

# of Non-Compliant Standards    12

APR/NPSG Cites (Tag#/EP#/Brief Descrip/Surveyor) 

• Requirement 2C, EP 1-6:Nowhere in the TPMHC policy was there an attempt to define or reference to critical tests or results/values.

• Requirement 8A, EP 2: Tracer activity and staff discussions indicated that a process for medication reconciliation was not in place.

RI/PC/MM/IC Cites (Stnd#/EP#/Brief Descrip/Surveyor)

• IC.4.10,EP 1: Observed in Dietary Department, a large floor fan which was in operation. The blades of the fan were coated with a thick black residue of dust and was blowing in the direction of food preparation tables and several clean trays used for patient food. Observed in Laboratory, test tubes with 7/06 expiration dates.  During tracer activity, the surveyor observed  barber cutting a male patient's hair in the Visitors Room. When the barber completed the hair cut, he began cutting another patient's hair. The barber used the same clippers and comb without cleaning or sanitizing them.

• MM.4.50,EP 3: During a patient tracer, medications were examined in the medication refrigerator. There was one vial of Tbc Antigen and two vials of Novolin Insulin not labelled with the date of opening.

*PC.2.130,EP1: PC.8.10, EP1

*IC.2.10, EP1: IC.4.15, EP4:

PI/LD/HR/IM Cites (Stnd#/EP#/Brief Descrip/Surveyor)

• IM.6.10,EP 5/11: During a patient tracer, it was noted that a patient physical assessment was signed by the MD in a completely unreadable fashion and no other identifier, e.g., a printed name or identifying number was appended to identify the author./The medical record delinquency rate averaged from the last four quarter was greater than 50% of the average monthly discharge rate.

• LD.3.20,EP 1: As of the day of survey, 3/19/07, the patient had not had her blood drawn, nor was there documentation in the medical record to indicate additional attempts by the phlebotomist to obtain a blood specimen.

Patients who are admitted during the regular work days of the phlebotomist have their blood drawn by

the next day. Patients admitted on the weekends or holidays with orders for routine blood tests need to

wait until the next regular scheduled work day of the phlebotomist.

• LD.4.60,EP 4: During the Data Tracer, it was noted that there was not the skill set in leadership to perform meaningful,yet simple data analysis. A number of PI projects were presented which, although well thought out,lacked any plan for analysis to show that they worked, did not work, or made things worse.

* IC.4.15, EP6:

* HR.2.20, EP4:

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

• EC.9.10,EP 4: Lack of annual evaluations of the environment of care plans

•

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

• MS.4.60,EP 3: A physician was noted to have a credentialing expire in 2005. The MD was never recredentialed after that, although active on the staff.

• MS.4.10,EP 6: In a review of three MD active staff charts, in no cases were there ANY credentialing activities as listed in this standard from 2003 o the present. In each case, the credentialing expired 1n 2005 and there was no attempt to recredential any of these quite active staff MD's after the expiration in 2005.

• MS.4.15,EP 1: In essence, then, none of the duties of credentialing have been performed by the Medical Staff since 2003.

• MS.4.20, EP 3,8  (esentially same as above)

**Surveyor Compliments (Policies, Procedures, etc noted by which surveyor)    **Surveyor Compliments (Policies, Procedures, etc noted by which surveyor)

Check if you would be willing to record some helpful tips from your survey experience in a 10-15 min interview.    no

Preliminary Survey Result    JC: Conditional Accreditation

Will you send us a copy of your survey report?    Blank

Will you send us a copy of your ESC?    Blank

If you said 'No' to either of the last 2 questions, please tell us why.    If you said 'No' to either of the last 2 questions, please tell us why.

**Misc Comments, Suggestions, Etc    **Misc Comments, Suggestions, Etc

Lynn Goldman