Name   Monica Bradbury, Chief Performance Improvement Executive   [CPN]
E-mail    mobradbury@state.pa.us
Facility Name   Clarks Summit State Hospital (CSSH)_5Ad
Facility CEO    Thomas Comerford
Facility Address    1451 Hillside Drive, Clarks Summit PA  18411

Jt Com Org ID#   974

# Beds - Adult    242
# Beds - Child & Adol   
# Beds - Sub Abuse   
# Beds - Forensic   0
# Beds - MR/DD    0
# Beds - TotaL   242
# Beds - CMS Distinct Part    242

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    March 3-6, 2009
Survey Days (e.g., Mon - Weds)    Weds - Fri
Number of Surveyors    3
Priority Focus Areas   
Last Survey Ending Date    4/6/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Edward K Katz, M.D., M.P.H. – Tm Leader
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)    Schindler_Janet Schindler, RN, MEd - Team member - Has worked in QI/QC role, Emphasis on measurement of baseline and improvement
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)   Roger Cagle, Life Safety
 

# of Non-Compliant Standards    11 (3 Direct/8 Indirect)

APR/NPSG Cites 

• APR 09.01.01 EP 2 Information to public on how to contact TJC.  Was on Web site but not in patient handbook.  Needed prominent place for employee notice  (Indirect)

MM/PC  Cites

• PC 01.02.01  EP 23 Medical Treatment plan needs to be linked to specific goals in the psychiatric treatment plan where applicable.  Reassessments need to be linked to specific goals of the treatment plan.  (Direct)
  

• PC 01.02.09 EP 1 Current documentation needed to address ALL elements of abuse evaluation  (Indirect)

RC/RI  Cites

• RI.01.04.01 EP1: Data collected for the ongoing review of medical records from the preceding quarter needed to include legibility as an indicator.  (Indirect)

IC/WT Cites

• IC 02.02.01 EP 2  Biological indicator product needed to be used consistent with manufacturer's package insert instructions.  (Direct)
  

• IC 01.02.01 EP 3  Outdated pin worm test kit needed to be discarded.  Use of outdated supplies could lead to false negative or positive.  Supplies no longer used needed to be removed.  (Indirect)

HR/LD Cites

• HR.01.02.05 EP1:  Primary source verification of an RN was completed after the date of expiration on the license.  No evidence of primary source was documented on a contract radiology technician  (Indirect)

IM/PI Cites

EC/EM//LS Cites 

• EC.02.02.01 EP1: Radiology badge to measure exposure to radiation in the dental office needed to be tested for exposure.  (Direct) 
• EC.02.01.01 EP7:  Risk assessments needed to be tailored to identify risks for specific types of the patient population on each unit.  (Indirect)
• EC.02.06.01 EP3 and EP1: Beds in patient rooms not bolted to the floor; could be used as hanging risk or parts broken off and used for weapons or self injuries.  Water filter needed to be changed; past date on PM  (Indirect)

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 EP3: -Contract radiologists needed to be addressed in the credentials process for hospital privileges.  (Indirect)

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

• +Liked our Medical care and long term care being provided in addition to psychiatric care.
  

Preliminary Survey Result    JC: Accreditted, Pending RFI

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

Clarks Summit State Hospital (CSSH) had a total of 3 Direct Impact Findings:
1- PC 01.02.01  EP 23
2- IC 02.02.01 EP 2
3- EC.02.02.01 EP1

CSSH also had 8 Indirect Impact Findings.
1- APR 09.01.01 EP 2
2- PC 01.02.09 EP 1
3- RI.01.04.01 EP1
4- IC 01.02.01 EP 3
5- HR.01.02.05 EP1
6- EC.02.01.01 EP7
7- EC.02.06.01 EP3 and EP1
8- MS.06.01.07 EP3

Monica Bradbury