Name   Kim Sivak, RN, Chief Nurse Executive   [CPN] & Carol S. Barnickel, Chief Exec PI  [CPN]
E-mail    ksivak@state.pa.us
Facility Name   Warren State Hospital (WaSH)_5Ad1FR*HBIPS
Facility CEO    David Kucherawy
Facility Address    33 Main Drive, Warren, PA 16365

Jt Com Org ID#    1668

# Beds - Adult    223
# Beds - Child & Adol   
# Beds - Sub Abuse   
# Beds - Forensic    27
# Beds - MR/DD    0
# Beds - TotaL    250
# Beds - CMS Distinct Part    250

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    March 9-12, 2009
Survey Days (e.g., Mon - Weds)    Mon- Thurs.
Number of Surveyors    3
Priority Focus Areas   
Last Survey Ending Date    5/11/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Michael T. Chisholm, CPE - 3/10 only/environmental -thorough but fair, focus: Environmental Review  Emergency power / lighting / generators
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)   Edward K Katz, M.D., M.P.H. - Leader -3/9-3/12/main surveyor/tracers/med man-fair, took time to explain his reasoning and accepted our explanations, focused on Patient safety, Privacy
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)    Nancy Paterson, MS,RN - 3/9-3/12-nurse surveyor/tracers/IC/table top exercise/competency review of personnel records-very gracious and fair, really put staff at ease so they could tell and show what they knew, focused on Infection Control  Disaster Planning
 

# of Non-Compliant Standards    13 (1 Direct/12 Indirect)

APR/NPSG Cites 

MM/PC  Cites

RC/RI  Cites

• RI.01.01.01 EP7: partial compliance with pts' right to privacy in that pt phones in hallway without privacy panels (Need sound proof panels at patient phones to prevent others from hearing their conversations.) -indirect-Svyr # 2

IC/WT Cites

HR/LD Cites

• HR.01.06.01 EP1: Insufficient compliance of one staff with job description not containing specific competences  required for the position (Speech, Language and Hearing Specialist)  -indirect-Svyr # 3
• LD.04.04.05 EP10: Insufficient compliance with choice of proactive risk assessment-indirect-Svyr # 3

IM/PI Cites

EC/EM//LS Cites 

• EC.02.01.01 EP3: Partial compliance in taking action to minimize or eliminate safety risks (Suicide prevention issues.  Identified area where patients could fit items thru to harm themselves.  i.e.,  space between the top and bottom mesh screens, hinges of a metal storage closet, plumbing fixtures (faucets and flush valves))  -direct-Svyr # 2
• EC.02.01.03 EP6:  partial compliance in compliance with smoking policy-evidence of smoking found in 2 areas-indirect-Svyr # 1
• EC.02.03.05 EP3 and EP11: insufficient compliance as during annual 2008 fire alarm review evidence and documentation not done on test of electric releasing devices and no annual flow test of fire pump-indirect-Svyr # 1
• EC.02.04.03: Partial compliance as 2 refrigerators did not have completed temp logs-indirect-Svyr # 2
• EC.02.05.01 EP7: Insufficient compliance with labeling of some electrical panels-indirect-Svyr # 1
• EC.02.05.07: insufficient compliance and partial-EP1-only showed documentation of every other month for a monthly test for first 3 quarters in 2008 and EP2-same plus no annual 90 minute test completed-indirect-Svyr # 1
• EC.02.06.01: insufficient compliance with interior spaces safe and suitable for the pt population unsafe cul-de-sac, hanging lamp cords by pt beds in special needs unit, exposed toilet plumbing, brackets on toilet stalls-indirect-Svyr # 2 and 3
• LS.02.01.20 EP31: -insufficient compliance 3 exit signs either inoperable or one bulb out-indirect-Svyr # 1
  

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 EP8: insufficient compliance with credentialing of local hospital practitioners-indirect-Svyr # 2
• MS.06.01.07 EP8: -insufficient compliance with a mobile X-ray company-indirect  Svyr #2

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

• +Liked our program plan for patient therapeutic activities.  WSH has a daily schedule.
  
• +Liked our fall prevention procedures AND effectiveness of the outcome   

Preliminary Survey Result    JC: Accreditted, No RFI

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

Warren State Hospital (WaSH) had a total of 1 Direct Impact Findings:
1- EC.02.01.01 EP3  Svyr #2

WaSH also had 12 Indirect Impact Findings.
1- RI.01.01.01 EP7  Svyr #2
2- HR.01.06.01 EP1  Svyr #3
3- LD.04.04.05 EP10  Svyr #3
4- EC.02.01.03 EP6  Svyr #1
5- EC.02.03.05 EP3 and EP11  Svyr #1
6- EC.02.04.03  Svyr #2
7- EC.02.05.01 EP7  Svyr #1
8- EC.02.05.07  Svyr #1
9- EC.02.06.01  Svyr #2/3
10- LS.02.01.20 EP31  Svyr #1
11- MS.06.01.05 EP8  Svyr #2
12- MS.06.01.07 EP8  Svyr #2

Kim Sivak