Name    Deborah L. Brandom

E-mail    dbrandom@dhh.la.gov

Facility Name    Eastern Louisiana Mental Health System (ELMHS)

Facility CEO    Mark Anders

Facility Address    P.O. Box 498

Jackson, La  70748

Facility Description (Brief)    !7Ad1Ca5Fr*HBIPS

# Beds - Adult    318

# Beds - Child & Adol    10 (Residential)

# Beds - Sub Abuse    # Beds - Sub Abuse

# Beds - Forensic    235

# Beds - MR/DD    # Beds - MR/DD

# Beds - TotaL    553

# Beds - CMS Distinct Part    43

Survey Type    Unannounced

Surveying Agency    JCAHO

Survey Dates (inclusive)    6/2-6/08

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

Number of Surveyors    4

Priority Focus Areas   

• Assessment and Care/Services
  
  


• Information Management
  
  


• Patient Safety
  
  


• Physical Environment

Last Survey Ending Date    3/3/05

Profile - Surveyor #1  Kirven - Leo Kirven, Jr., MD [LK]

•Team Leader

•Old school physician, full time/long-term surveyor who  is is fair. At times, may not seem thorough but can cut through "fluff" and is usually on target. Rarely gives/writes RFIs.

•Doesn't eat turkey.

•(More info in profile)

Profile - Surveyor #2  Kathleen Ostrowski RN, BSN, MPA, CNRN  [KO]

•Became a Joint Commission survey in 2005 and is trained under the Accreditation Manual for Hospitals.  Was Assistant Vice President for Nursing and Service Line Manager for Neuroscience at the Methodist Hospitals in Merrillville and Gary Indiana.

•Very safety minded, likes to teach

•(More info in profile)

Profile - Surveyor #3  Dyana Troester, MSN, EdS, ARNP  [DT]

•Joint Commission surveyor since 2007 in the Behavioral Health Care, accreditation program. Has a Clinical Specialty in Child and Adolescent Psychiatric Nursing and is currently licensed as an Advanced Registered Nurse Practitioner in the State of Florida 

•Vegetarian

•(More info in profile)

Profile - Surveyor #4  Michael T. Chisholm, CPE  [MC]

•Life Safety Code Specialist from South Carolina.  Also the Director of Safety and Security at Medical College of Georgia Health, Inc.  He says this was his 1st survey of a state hospital.

•Knowledgeable, thorough, fair

•(More info in profile)



# of Non-Compliant Standards    7

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

• NPSG 2C EP#3: Timeframe for internal notifications not adequately defined. (BHC and HAP)  [KO]

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

• PC.4.20 EP#1,4: Medical issues not integrated into TxPln  [DT]

• PC.4.10  EP#2: TxPln inadequately reflecting medical care [KO/DT]
  
  


• IC.2.10  EP#3: Mold problem in radiology dept room [KO]

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

• LD.3.90 EP 1,2: De-escalation Assessment not done in BHC programs as per policy  [DT]
  
  


• HR.1.20  EP#3: No PSV of beautician license.  Barber with no license. [KO]

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

• EC.5.20  EP#1,2:  Incomplete PFIs without approved extensions [MC]
  
  


• EC.5.40  EP#15: Annual test for shutdown devices (air-handling equipment) not conducted at one site.[MC]
  
  


• EC A.4D.1: Penetrations [MC]
  
  


• EC A.6J.6: Penetrations [MC]

MS/NR Cites

**Surveyor Compliments

• [KO] - Complimented our honesty in reporting less than 100% compliance with 7C

• [KO] - Liked our nurses monthly progress notes

• [DT] - Impressed that our IC was tracking Noravirus rates.

• [DT] - Like the txplns in our Evolutions program

• [LK] - Complemented staff morale and relationships with management

Preliminary Survey Result    JC: Some Requirements for Improvement

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

Will you send us a copy of your ESC?    Yes



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

Deborah L. Brandom