Name    Ellen Otomo
E-mail    Ellen.Otomo@illinois.gov
Facility Name    Chicago Read Mental Health Center
Facility CEO    Elaine Novak
Facility Address    4200 N. Oak Park Ave
Chicago IL 60634
Facility Description (Brief)    On file
# Beds - Adult 130
# Beds - Child & Adol 
# Beds - Forensic
# Beds - Geriatric
# Beds - MR/DD
# Beds - Sex Offender
# Beds - Sub Abuse 
# Beds - Total # Beds - Total
# Beds - CMS Distinct 24

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    7/29/08
Survey Days (e.g., Mon - Weds)    Tuesday
Number of Surveyors    1
Priority Focus Areas    Validation survey
Last Survey Ending Date    7/29/08

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)    Donald Geeze MD  [DG]
Retired 5 years ago from the Air Force; has been a full time TJC surveyor since. Very regimented with military expectations and examples. He was supposed to survey previous RFI's and did not survey any.  He demonstrated how a sheet could be tied to a faucet and create a hanging hazard; he looked for illegible words in charts and conducted medication room inspections.  Wants a weighted suicide risk tool and gave military examples.  Wants very specific MD privileges - to include each and every possible kind of psychotherapy or patient education group, etc. to ensure that MD's do not practice outside of their privileges. Loves lunch.  Did not review any policies, procedures, minutes, PI plans or data.

Profile - Surveyor #2 (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 #5 (Name/Disc/Tm Role/Traits/Quirks)  

# of Non-Compliant Standards    4
APR/NPSG Cites
RI/PC/MM/IC Cites (Stnd#/EP#/Brief Descrip/Surveyor)   

• MM 1.10 EP3: indications for use not included in medication orders.  This was identified by our hospital previously as needing to be attended to; however, we had not had a Medical Director for over a year to implement this. [DG]
• MM 2.20 EP 7: found unlabeled medication cups with half tablets in the medication room; found five unit dose tablets without patient labels in a bin in a medication room.  He asked the nurses why it was there, and how long it had been there.  He asked if it could inadvertently be given to a patient and create a safety risk. [DG]

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

• IM 6.10 EP 6: searched for illegible words in orders and progress notes.  Covered up legible words around the offending illegible word so that it would be impossible to guess the word in its context "this is the true test of whether a word is illegible." Demonstrated this on each unit he visited. [DG]

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

• EC 8.10 EP 4: On the first unit visited, asked staff for sheet or PJ bottom and repeatedly attempted to tie same around faucet handle until he found one that held, and demonstrated a hanging hazard.  Did the same with patient bathroom interior door knobs.  Stressed the importance of hazard risk assessments with plans to change unsafe hardware and plumbing over time for affordability while placing patients most at risk in the rooms which had safety improvements already made. [DG]

IF an emergency management tracer was conducted using a mass casualty simulation, please indicate which scenario was used.   

MS/NR Cites

**Surveyor Compliments

Felt that the staff were caring about the patients and complimented the hospital as "being on the cusp of becoming a premier hospital."

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

Ellen Otomo