Name   Brandi Kennedy, QA/RM Director   [CPN]
E-mail    brkennedy@state.pa.us
Facility Name   Allentown State Hospital (ALSH)_4Ad*HBIPS
Facility CEO    Gregory Smith
Facility Address:  1600 Hanover Ave. Allentown, PA

Jt Com Org ID#    1560   

# Beds - Adult    175
# Beds - Child & Adol   
# Beds - Sub Abuse   
# Beds - Forensic   0
# Beds - MR/DD    0
# Beds - TotaL   175
# Beds - CMS Distinct Part   175

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    Feb 17-20, 2009
Survey Days (e.g., Mon - Weds)    Tues - Fri
Number of Surveyors    3
Priority Focus Areas   
Last Survey Ending Date   3/17/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Edward K Katz, M.D., M.P.H. – Survey Leader - Tips: He's reasonable and you can convince him to see your side of things.  His best advice (and I held him to this) was:  "you only need to show me you meet the standard at a 'D' level, not an 'A+' level."  He gave us lots of ideas on how to improve but didn't hold us to the A+ measure in the end.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)    Carol Johnson, RN - Team member - Tips: Much harder to convince but could be convinced on some level.  VERY knowledgeable about the standards: you won't get much by her.  She focused on NPSGs, Infection Control and the medical care of patients- not much psychiatric focus (unfortunately since that's our specialty).  She was easy on Staffing Effectiveness, Data and Human Resources.  Many of our RFIs came from her observations.  She was a great consultant.
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)   Richard Smith, CHFM - Life Safety Code Specialist, Most of our RFIs came from the LSC specialist.  He didn't miss a thing.  Very knowledgeable about the standards and spent time giving us lots of tips, but in the end, he cited us for everything he found.  Focus: penetrations, ILSM.

# of Non-Compliant Standards    13 (3 Direct/10 Indirect)

APR/NPSG Cites

• NPSG.02.03.01 - EPs (3-6) Indirect: we hadn't defined a specific acceptable length of time between reporting and availability of CT/CR and receipt by LIP; we didn't collect data on the time it took; we didn't assess the data to determine if improvements needed to be made.  Nurse surveyor. 

MM/PC  Cites

RC/RI  Cites

• RC.01.01.01 EP6: Indirect: legibility (they found 3 examples).  Nurse and lead surveyor.

IC/WT Cites

• IC.01.05.01 EP6:  Indirect: the IC specialist was not informed of possible mold in a non-patient area leading surveyor to believe our IC program was not fully integrated across all departments.  Nurse surveyor.

HR/LD Cites

IM/PI Cites

• PI.02.01.01 EP7: Indirect: we didn't have a letter from the OPO stating we had 0 opportunities for donation.  Lead surveyor.

EC/EM//LS Cites 

• EC.02.03.05/EPs 11 and 13: Direct: did not test our fire pump under flow every 12 months; did not inspect the main kitchen automatic fire extinguishing system every 6 months.  LSC specialist.
• EC.02.06.01 EP 26:  (MOS)/Indirect: (3) bathroom patient safety alarms found malfunctioning.  LSC specialist.
• EM.01.01.01 EP8:  Indirect: there was no inventory of resources in our EOP.  Nurse surveyor.
• EM.02.01.01 EP3:  Indirect: we did not identify our capabilities to sustain operations in an emergency lasting >96 hours. Nurse surveyor.
• EM.03.01.03 EP2:  Indirect: we did not drill on an influx of patients that might come from another state hospital during an emergency.  Nurse surveyor.
  
• LS.01.02.01 EP3: Direct: did not implement ILSM for part of our e-SOC (some doors' fire ratings were not labeled).  LSC specialist.
• LS.02.01.34 EP2: Direct: the master fire alarm panel is not monitored.  LSC Specialist.
• LS.02.01.30 EP 18:  Indirect: 3 penetrations found.  LSC specialist.

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: -Indirect: the physician who reads the X-rays performed by the mobile X-ray company that comes to our campus was not credentialed by our medical staff.  Lead surveyor.

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

• +They liked the suicide risk awareness training we did for our staff- we took pictures from our hospital environment of risks and put them in a powerpoint; it saved us an RFI that many of our sister hospitals got (how do you mitigate suicide risk in your hospital). 
  
• +Elimination of the use of PRN medications for psychiatric reasons and the reduction in use of seclusion and restraint.

Preliminary Survey Result    JC: Accreditted, no RFI

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

Allentown State Hospital (ASH) had a total of 3 Direct Impact Findings:
1- EC.02.03.05/EPs 11 and 13 -   Svyr #3
2- LS.01.02.01 EP3 -  Svyr #3
3- LS.02.01.34 EP2 - Svyr #3

ASH also had 10 Indirect Impact Findings.
1- NPSG.02.03.01 - EPs (3-6) - Svyr #2
2- RC.01.01.01 EP6 - Svyr #2/1
3- IC.01.05.01 EP6 - Svyr #2
4- PI.02.01.01 EP7 - Svyr #1
5- EC.02.06.01 EP 26. - Svyr #3
6- EM.01.01.01 EP8. - Svyr #2
7- EM.02.01.01 EP3. - Svyr #2
8- EM.03.01.03 EP2. - Svyr #2
9- LS.02.01.30 EP 18.  - Svyr #3
10- MS.06.01.07 - EP 8. - Svyr #1

Brandi Kennedy