Name   Linda Lesher, Chief Performance Improvement Exec. [CPN]
E-mail    lilesher@state.pa.us
Facility Name   Danville State Hospital (DSH)_4Ad
Facility CEO    Donna M. Ashbridge, RN, MS
Facility Address    200 State Hospital Drive, Danville, PA 17821

Jt Com Org ID#    3107 

# Beds - Adult    170
# Beds - Child & Adol   
# Beds - Sub Abuse   
# Beds - Forensic    0
# Beds - MR/DD    0
# Beds - TotaL    170
# Beds - CMS Distinct Part    170

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    May 19-22, 2009
Survey Days (e.g., Mon - Weds)    Tues - Fri
Number of Surveyors    3
Priority Focus Areas   
Last Survey Ending Date    6/23/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Edward K Katz, M.D., M.P.H.. - Leader -Very detail oriented particularly in the area of Environmental Risks within a Psychiatric facility.  Steadfast in meeting each aspect of all standards.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)    Nancy Paterson, MS,RN - Very familiar with the challenges associated with psychiatric treatment. She has a background of working is a state operated psychiatric facility.  Personable, reasonable, and realistic.
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)   Mark A. Trudzinski, CHFM- Life Safety Code Specialist - Proficient and knowledgeable in all aspects of his area of expertise.  Demonstrates an understanding of the intent of the standards and practical application.

# of Non-Compliant Standards    6 (2 Direct/4 Indirect)

APR/NPSG Cites 

• NPSG.02.03.01  EP5- INDIRECT hospital measures, assesses, and takes action to improve the timeliness of reporting and receipt of critical tests, values, results by the caregiver. Although the information is collected regarding the timeframes from ordering until notification of findings, there is no data collection on the timeliness of the report  to the responsible physician.
• NPSG.16.01.01 EP6, EP7-  INDIRECT- hospital measures cardiopulmonary arrest, respiratory arrest, and mortality rates before and after implementation of the early intervention plan. Our hospital measured each area before the onset of policy and training however since we had no deaths, cardiopulmonary arrests, or respiratory arrests, demonstrating a zero as data for the months post implementation was not acceptable

MM/PC  Cites

RC/RI  Cites

IC/WT Cites

• IC.02.01.01-EP3-the hospital implements its infection prevention and control plan in response to the pathogens that are suspected or identified within the hospital's service setting and community. A cabinet door was labeled "isolation mask third shelf." No masks were found in the room.  Upon surveyor request, management immediately went to a storage room to replace this equipment.  The surveyor indicated that a system that did not have the isolation masks available as per planning, did not support infection prevention. No consumer on that unit during the survey, required isolation masks.  Also, in the patient dining room it was noted that hand washing facilities or supplies such as hand sanitizer gels are not made available to patients as they entered the room for lunch. The protocol of consumers washing their hands on the unit prior to going to the dining room did not meet the surveyors expectations.

HR/LD Cites

• HR.01.02.05 EP1: hospital verifies staff qualifications- The primary source verification of current licensure status had not been done for an Occupational Therapist and a Dietician. The licensure verification must occur at the time of licensure renewal.
  

IM/PI Cites

EC/EM//LS Cites 

• EC.02.01.01 EP3: A coiled telephone cord on a dietary wall phone was easily and quickly removable- this was fixed during the survey by enclosing the telephone in a locked box. Also, the serving line had automatic, constantly available multi-spigot coffee machine, and persons unaware could have the cup overflow with coffee, causing scalding. Coffee machine had previously been modified so that the coffee would not be hot enough to cause burns/scalding, but this was not acceptable. The surveyor was familiar with this brand of coffee machine and it's resulting law suits
• LS.02.01.30 EP2: - Hospital provides and maintains building features to protect individuals from hazards of fire and smoke.  Dietary dry storage rooms were not equipped with an automatic sprinkling system or automatic door closing devices. Also, medical records storage area did not have automatic door closing devices and had no sprinkler system.  The door also had a mail slot which was unacceptable
  

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)

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

• + Regarding early intervention program, they were agreeable to our policy and the supplemental measurement of consumer change in medical status as we didn't have life threatening events to measure post implementation.  However, we still didn't meet the full measure of the standard as we hadn't experienced a sufficient amount of deaths/arrests.
  
• + Our facility addresses fall prevention through a perception that all consumers due to the utilization of psychotropic medications are at risk for falls and therefore all consumers receive training / education as part of the orientation program to the hospital.  

Preliminary Survey Result    JC: Accreditted, No RFI

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

Danville State Hospital (DSH) had a total of 2 Direct Impact Findings:
1- EC.02.01.01 EP3
2- IC.02.01.01-EP3

DSH also had 4 Indirect Impact Findings.
1- NPSG.02.03.01  EP5
2- NPSG.16.01.01 EP6, EP7
3- HR.01.02.05 EP1
4- LS.02.01.30 EP2

Linda Lesher