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    Other

Surveying Agency    JCAHO

Survey Dates (inclusive)    6/13/07

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

Number of Surveyors    1

Priority Focus Areas    NA

Last Survey Ending Date    6/13/07

Profile - Surveyor #1   Debra F. Payne, MBA, RN

Profile - Surveyor #2

Profile - Surveyor #3

Profile - Surveyor #4

Profile - Surveyor #5

# of Non-Compliant Standards    11

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

• Requirement 2B, ep3: Multiple findings of 'qd' in physician orders

• Requirement 8A, EP1: reviewed 8 medical records. There was no medication reconciliation on admission on any of these records.

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

• PC.4.10, EP2: The patient attempted suicide by using the string in his pants. The treatment plan did not include anything related to the suicide attempt./The patient was being treated for the following during the hospitalization: 1) asthma, 2) dental caries, 3) infected IV site, and 4) rash on both legs. None of these issues were included on the treatment plan.

• There is a lack of coordination from leadership in securing the appropriate services, in this case, laboratory, to ensure the patients receive the care, treatment and services they require in [a timely manner]

• MM.2.20, EP9: A vial of NPH insulin and A vial of Novolin insulin was opened and still in use past the 28 day limit.

* PC.2.130,EP2:

PC.8.10, EP1:

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

• LD.3.20, EP1: The patient had the following labs ordered on 03/29/07 at 0745: CBC/diff, fasting CMP, RPR, UA, fasting lipid profile, and TSH. The blood for these labs was not drawn until 03/30/07.

• LD.2.20,EP1/5: additional findings of lab not drawn on time

• LD.3.90, EP2: There was no narrative information in the discharge summary relating to these five areas [required by standard]./2 Discharge Summary was not completed [on time]

• HR.1.20, EP3: Primary source verification of license was not found for several nurses

* IM.6.10, EP4:

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

• EC.6.20,EP3:  AED was not checked as required by hospital policy.

• EC.8.10, EP4: [A significant number of EC risks] had not been identified on the risk assessment.

• EC.5.40,EP12: Several fire extinguishers lacked monthly inspections

MS/NR Cites (Stnd#/EP#/Brief Descrip/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?    Yes

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   

Lynn Goldman