Name:   Pamela Lynn Wagaman, RN, Chief Performance Improvement   [CPN]
E-mail:    pwagaman@state.pa.us
Facility Name:  South Mountain Restoration Center (SMRC)_4Ge*Demtia,SNF
Facility CEO:    J Michael Hogarth, NHA
Facility Address:    10058 South Mountain Road South Mountain, PA 17261

Jt Com Org ID#     4643  SNF

# Beds - Adult (Civil only)    # Beds - Adult (Civil only)
# Beds - Child & Adol (Civil only)    # Beds - Child & Adol (Civil only)
# Beds - Forensic    # Beds - Forensic
# Beds - Geriatric    159
# Beds - MR/DD  
# Beds - Sex Offender  
# Beds - Sub Abuse   
# Beds - Total (all Civil & For)    159
# Beds - CMS Distinct  

Survey Type    Unannounced
Surveying Agency    JCAHO (LTC)
Survey Dates (inclusive)    March 20, 2009
Survey Days (e.g., Mon - Weds)    Fri
Number of Surveyors    1
Priority Focus Areas   
Last Survey Ending Date    5/16/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Hattie L. Courtney, RN / Because H Courtney only had one day to survey the Center she was data driven.  She expected that all the information that she reviewed be assembled in a manner that she could review it efficiently.  Her main focus was the Patient Safety Goals and tracer reviews focused on them.
Profile - Surveyor #2
Profile - Surveyor #3 

# of Non-Compliant Standards    7 (5 Direct/2 Indirect)

APR/NPSG Cites 

• NPSG.09.02.01, EP#2 / A resident noted to have fallen prior to admission had not written summary of assessments to determine her risk for falls upon admission. No documented criteria for what actually made a resident at risk for falls. A 2nd resident with multiple falls and risk factors not identified as a fall risk nor did record confirm fall education./ Dir /Srvry1
• NPSG.14.01.01, EP#2 / Medical record lacked evidence that initial assessment for risk of pressure ulcers/  Dir /Srvry1
• NPSG.14.01.01, EP#3 / Medical record lacked evidence that a validated risk assessment tool was being used to assess risk of pressure ulcers/  Dir /Srvry1
• NPSG.14.01.01, EP#4 / Medical record lacked evidence that  pressure ulcers were being reassessed at  periodic intervals/  Dir /Srvry1

MM/PC  Cites

RC/RI  Cites

IC/WT Cites

HR/LD Cites

• HR.4.20, EP#2 / The medical director was not evaluating for voluntary and involuntary termination of medical staff membership at other organizations or voluntary and involuntary limitation, reduction or loss of clinical privileges./  Indir /Srvry1

IM/PI Cites

• IM.6.130, EP#1 / Resident's response to education not being documented/  Dir /Srvry1
• PI.1.10,EP#3 / Organization was not collecting data on the resident's perception of care, treatment and services, including the specifics required by standard / Indir /Srvry1

EC/EM//LS Cites 

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)

Preliminary Survey Result    JC: Accreditted, Pending RFI

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

South Mountain Restoration Center (SMRC) had a total of ??? Direct Impact Findings:
1- NPSG.09.02.01, EP#2
2- NPSG.14.01.01, EP#2
3- NPSG.14.01.01, EP#3
4- NPSG.14.01.01, EP#4
5- IM.6.130, EP#1
SMRC ultimately had???? Indirect Impact Findings (see also Misc Comments above).
1- HR.4.20, EP#2
2- PI.1.10,EP#3

Pamela Lynn Wagaman, RN, Chief Performance Improvement