Name    Janice Lubeck
E-mail    janice.lubeck@lsh.ks.gov
Facility Name    Logansport State Hospital (LoSH)_!5Ad2Fr1Ge1Mr1Sx
Facility CEO    Mark E. Schutter, Ph.D
Facility Address    1301 KS Hwy 264, Larned, KS 67550

• Facility Description (Brief)    Psychiatric in patient state hospital with three programs:
• PSP- Psychiatric Services Program,
• SSP- State Security Program,
• SPTP- Sexual Predator Treatment Program.

Jt Com Org ID# 3186

# Beds - Adult    445
# Beds - Child & Adol    20
# Beds - Sub Abuse    3- included in the 445 above
# Beds - Forensic    200/SSP- included in the 445 above
# Beds - MR/DD    0
# Beds - TotaL    465
# Beds - CMS Distinct Part    99- inlcuded in the 445 above

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    Feb 10-13, 2009
Survey Days (e.g., Mon - Weds)    Mon- Thurs.
Number of Surveyors    3
Priority Focus Areas    Patient Safety, Infection Control, Physical Environment, Staffing, Assessment & Care/ Services, Equipment Use
Last Survey Ending Date  8/31/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)    H. D. Brown, FACHE
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)    Virginia J. Jordan, MSN, RN
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)    Dwight A. Owens, MD
 

# of Non-Compliant Standards    19 (9 Direct/10 Indirect)

APR/NPSG Cites 

• NPSG.01.01.01, EP 2- Need to use two user-friendly patient identifiers during a med pass.
• NPSG.02.03.01, EP 1- critical test results definition, and length of time between ordering and reporting
• NPSG.15.01.01, EP 1-needed a risk assessment for suicide to include environmental features.

MM/PC  Cites

• MM.03.01.01, EP 5- Storage cabinets for controlled substances were not locked, nor where there always two signatures on the controlled substance log.
• PC.01.02.03, EP 2: Certain assessments were not completed on one unit within 24 hours of admission- the H & P and the Psychiatric Assessment.
• PC.01.02.07, EP 1: Lack of comprehensive pain assessments. Three observations on two patients.
• PC.01.02.11, EP 1 (Clarified this one)- Lack of a substance abuse assessment on a female patient in a forensic evaluation unit. LSH does not do these assessments here, sends them out for referral if patient is here for treatment.
• PC.02.01.11, EP 2: One AED machine was not in the room noted on the AED list. It was observed and corrected at the time.
• PC.03.03.15, EP 4: After a S/R event, the psychiatrist did not see the patient (youth) within the one time time frame (saw him in 1 hr. 51 min. after the order).

IC/RC/RI  Cites

• RC.02.03.07, EP 4: Psychiatrists had not authenticated two phone orders on two units.
• RI.01.01.01, EP 8 (Clarified this one)- Lack of pain assessment on same female patient in a forensic unit; sent verification that she was receiving meds for pain and received other medical assessments.

HR/LD/PI Cites

• PI.01.01.01, EP 12: LSH had not collected Behavior Modification data on B.Mod. plans that were in place.
• HR.01.02.05, EP 3: No competency found for an Activity Therapist for teaching a forensics education class.

EC/EM//LS Cites 

• EC.02.05.07, EP 6: No documentation of automatic transfer switches being tested 12 times per year.
• LS.01.02.031, EP 3:  A number of items noted on the PFI on e-SOC were not scheduled for completion for 12 months or longer; needed interim life safety measures.
• EC.02.06.01, EP 1: Hazards found in a tub room on a PSP unit; needed a proactive risk assessment done.
• EC.04.01.01, EP 15: The annual evaluations of the EOC management plans had not been evaluated for the effectiveness of the plans.

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.06.01.05, EP 1: During the credentialig session, we did not have verification from the KS State Board of healing Arts in the file of two physicians. It was corrected on site.
• MS.06.01.03, EP 5: During credentialing session, the surveyors did not like the fact that we sent a picture of the physician to the verification sites.

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

Preliminary Survey Result    JC: Some Requirements for Improvement

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

Larned State Hospital (LSH) had a total of 9 Direct Impact Findings:
1- EC.02.05.07, EP 6.
2- LS.01.02.01, EP 3.
3- MS.06.01.05, EP 1.
4- NPSG.01.01.01, EP 2.
5- NPSG.15.01.01, EP 1.
6- PC.01.02.03, EP 2.
7- PC.01.02.07, EP 1.
8- PC.02.01.11, EP 2.
9- PC.03.03.15, EP 4.

LSH also had 10 Indirect Impact Findings.
1- EC.02.06.01, EP 1.
2- EC.04.01.01, EP 15.
3- HR.01.02.05, EP 3.
4- MM.03.01.01, EP 3.
5- MS.06.01.03, EP 5.
6- NPSG.02.03.01, EP 1,2,5.
7- PC.01.02.11, EP 1.
8- PI.01.01.01, EP 12.
9- RC.02.03.07, EP 4.
10- RI.01.01.01, EP 8.

Janice Lubeck