Name   John A. Deegan, Chief Performance Improvement & Risk Management Executive   [CPN]
E-mail    jdeegan@state.pa.us
Facility Name   Wernersville State Hospital (WeSH)_5Ad*HBIPS
Facility CEO    Andrea Kepler
Facility Address:  P.O. Box 300 Wernersville, Pa. 19565-0300   

Jt Com Org ID#    1008  

# Beds - Adult    220
# Beds - Child & Adol   
# Beds - Sub Abuse   
# Beds - Forensic   0
# Beds - MR/DD    0
# Beds - TotaL   220
# Beds - CMS Distinct Part    220

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    March 31- April 2, 2009
Survey Days (e.g., Mon - Weds)    Tues - Thurs
Number of Surveyors    3
Priority Focus Areas   
Last Survey Ending Date   4/21/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Edward K Katz, M.D., M.P.H. – Survey Leader - Worked to set a customer service based survey environment/culture.  Took time to explain his reasoning on a subject, and as well, provided time for you too as well.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)    Kathleen P. Krone, MS, RN - Team member -  - Kathy was with us for our 2006 survey.  Very knowledgable and fair. 
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)   Roger L. Cagle, CHFM, 3/31/2009 only for Life Safety.
 

# of Non-Compliant Standards    12 (2 Direct/10 Indirect)

APR/NPSG Cites 

• NPSG.03.03.01 - EP 3 – Two LASA medications were not labeled in Tall Man lettering. Direct/ Svyr # 1
• NPSG.03.05.01 - EP 9 - Although data collected on anticoagulation medication use, there was no evidence (documented) of this data being used to evaluate medication safety practices. Indirect/Svyr #1
• NPSG.02.03.01 - EPs (1-5) Critical lab results and values not defined.  Turnaround time for such results not defined. Indirect/Svyr #2

MM/PC  Cites

RC/RI  Cites

IC/WT Cites

• IC.01.04.01 - EPs (1-4)  Although IC Risk Assessment had been done, the IC Plan did not contain clearly defined goals addressing these risks. Indirect/Svyr #2

HR/LD Cites

• HR.01.05.03 - EP 1:  No documentation for contract physical therapist & contract interpreter that they completed yearly annual training requirement (ART Program). Indirect/Svyr #2
• HR.01.06.01- EP 1:  HR folder of contract physical therapist & VASW worker did not have job specific competencies. Indirect/Svyr #2
• LD.04.03.09 - EP 4,5,6:  Issues of contract management of our Mobile X-ray services.  Monitoring of the quality of services provided. Indirect/Svyr #1

IM/PI Cites

EC/EM//LS Cites 

• EC.02.05.07 - EP 6: There was no documentation showing that all automatic switches were transferred 12 times a year at intervals of not less than 20 days and not more than 40 days apart. Direct/Svyr #3
• EC.02.03.05 - EP 7:  Our water storage tank high/low alarm had not been tested. Indirect/Svyr #3
• LS.02.01.20 - EP 15:  The patio & smoking areas attached to two of our buildings did not have an exit sign for further egress from that area. Indirect/Svyr #3
• LS.20.01.50 - EP 9:  Linen chute and discharge service door in two buildings was self closing but did not latch. Indirect/Svyr #3

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.06.01.07 - EP 8: -Issue of not distinguishing consultative services from treatment services of community providers.  These providers are not credentialed and privileged by our hospital.Svyr #1

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

• +Surveyors were complimentary of our staff & treatment provided to our consumers. 
  

Preliminary Survey Result    JC: Accreditted, Pending RFI

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

Wernersville State Hospital (WeSH) had a total of 2 Direct Impact Findings:
1- NPSG.03.03.01 - EP 3  Svyr #1
2- EC.02.05.07 - EP 6  Svyr #3
3-

WeSH also had 10 Indirect Impact Findings.
1- NPSG.03.05.01 - EP 9   Svyr #1
2- NPSG.02.03.01 - EPs (1-5)  Svyr #2
3- IC.01.04.01 - EPs (1-4)  Svyr #2
4- HR.01.05.03 - EP 1  Svyr #2
5- HR.01.06.01- EP 1  Svyr #2
6- LD.04.03.09 - EP 4,5,6:  Svyr #1
7- EC.02.03.05 - EP 7  Svyr #3
8- LS.02.01.20 - EP 15  Svyr #3
9- LS.20.01.50 - EP 9   Svyr #3
10- MS.06.01.07 - EP 8  Svyr #1

John A. Deegan