Name    Jerry Doss, Director of Performance Improvement
E-mail    jerry.doss@harper.mh.alabama.gov
Facility Name    Mary Starke Harper Geriatric Psychiatry Center
Facility CEO    Beverly White
Facility Address    200 University Blvd, PO Box 2131, Tuscaloosa, AL 35401
Facility Description (Brief)    Geri-psych, free-standing hospital

# Beds - Adult    96
# Beds - Child & Adol   
# Beds - Sub Abuse   
# Beds - Forensic   
# Beds - MR/DD  
# Beds - TotaL    96
# Beds - CMS Distinct Part    96

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    8/19-21/08
Survey Days (e.g., Mon - Weds)    Tue, Wed, Thu
Number of Surveyors    3
Priority Focus Areas    Medication Management, Physical Environment, Patient Safety, Psychiatry
Last Survey Ending Date    8/21/08
 

Profile - Surveyor #1  Janet Schindler, RN
• Very direct, no nonsense, always on point with standards

Profile - Surveyor #2     Martin R.Macklin, MD, PhD
• Brief, to the point

Profile - Surveyor #3    Richard A. Smith, CHFM
• Very thorough, lots of good suggestions

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

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

# of Non-Compliant Standards    5

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

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

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

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

IF an emergency management tracer was conducted using a mass casualty simulation, please indicate which scenario was used.    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:  Findings: During the review of medical staff credentials it was determined that none of the radiologists providing interpretive services for the patients in the hospital had had their credentials verified from primary sources.  Services are provided under a contract with a professional group which is not itself a Joint Commission accredited organization.  During the review of the credentials for medical staff member S.S. it was found that his license expired on 12/31/05; however it was not determined that he was still licensed until 1/9/06.

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

Preliminary Survey Result    JC: Some Requirements for Improvement

**Misc Comments, Suggestions, Etc  

Jerry Doss, Director of Performance Improvement