Name: Ann Boisclair

E-mail: ann.boisclair@illinois.gov

Facility Name: Elgin Mental Health Center

Facility CEO: Tajudeen Ibrahim

Facility Address: 750 S. State Street

Elgin, IL  60123

Facility Description (Brief): Largest forensic hospital in Illinois with a 75 bed civil program serving North east Illinois except Chicago.

# Beds - Adult: 75

# Beds - Child & Adol:

# Beds - Sub Abuse:

# Beds - Forensic: 315

# Beds - MR/DD:

# Beds - TotaL: 390

# Beds - CMS Distinct Part: 75

Survey Type: Unannounced

Surveying Agency: JCAHO

Survey Dates (inclusive): 8/19/08 - 8/22/08

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

Number of Surveyors: 4

Priority Focus Areas: Pt Safety, Rights & Ethics, Assessment & Care/Services, Physical Environment

Last Survey Ending Date: 9/23/2005

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks): Judith A. Lisa, RN, MSN, Team Leader.

Highly focused on medication management.  She had us make a case for a finding when she found 1 HR chart each not up to date on mandatory TB tesing or CPR training - she asked us to find 3 more records.  (We were able to get this finding removed.)

Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks): George W. Race, MD, Psychiatrist.  Very personable and reasonable, made staff feel at ease and seemed to understand State Hospital systems.  Although he, too, made a finding that we were able to remove with a clarification - he found patients with pain reassessments not completed within our required span by selecting patients who had multiple medical problems so they left the unit for medical appointments after receiving a pain med.

Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks): Steven E. Hart, DO, MPH, Administrator.  Did not know psychiatry very well, was very focused on data, its presentation & analysis.  Extremely rigid and apparently overmatched when asked to consider problems and responses differently from how he was accustomed to seeing them.

Profile - Surveyor #4 (Name/Disc/Tm Role/Traits/Quirks): Byron Kitagawa, Life Safety Specialist, was very educational in his approach, giving an explanation and a practical example, very congenial.  Helpful not only in Life Safety but all Environment of Care.

Profile - Surveyor #5 (Name/Disc/Tm Role/Traits/Quirks): Cynthia Leslie, trainee, who works in Standards Interpretation, accompanied various surveyors.

# of Non-Compliant Standards: 5

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

• NPRG 2E, EP 2 Hand-off Communications.  Ms. Lisa found that although we have an excellent system for hand-off communications for patients going to external providers for care, we do not provide current information for repeat visits (for a kidney dialysis or ECT patient, for example).

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

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

• HR.1.20 EP 3 - Staff qualifications are consistent with his or her job responsibilities.  During the Competency Session, Ms. Lisa found that the file of one Dietician had an expired license for part of the previous year.

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

• EC.5.40 EP's 1,8,14 & 15.  Mr. Kitagawa found our documentation inadequate for a series of Life Safety tests although the previous surveyor had praised our documentation.  He required us to document that our staff checks to ensure the contractor has completed the tests. 


• EC.7.40, EP's 5 and 7, both related to load bank testing - the annual test did not meet load testing requirement and one generator was not retested after a repair.
  
  

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

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

• MS.4.10, EP 6  Dr. Race found that one psychiatrist's file that he reviewed in the Credentialing Session did not have primary source verification.

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



Preliminary Survey Result: JC: Some Requirements for Improvement



**Misc Comments, Suggestions, Etc:

Ann Boisclair