Name   Cary Drennen, Regional QM Director   [CPN]
E-mail    cary.drennen@dmh.mo.gov
Facility Name  2009/02-tjc-St. Louis Psychiatric Rehabilitation Center (SLPRC)
Facility COO:  Curt Trager   
Facility Address:  5300 Arsenal Street, Saint Louis, MO 63139   

Jt Com Org ID#    895 !

# Beds - Adult    ??????
# Beds - Child & Adol    ??????
# Beds - Sub Abuse    ??????
# Beds - Forensic ??????
# Beds - MR/DD    ??????
# Beds - TotaL    196
# Beds - CMS Distinct Part    ??????

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    May 18 - 21,, 2009
Survey Days (e.g., Mon - Weds)    Mon- Thurs.
Number of Surveyors    3
Priority Focus Areas   
Last Survey Ending Date   3/31/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   George W. (Bill) Race M.D./Psychiatrist/Team Leader/Focused a lot on the environment/Kind of "all over the place" - didn't do tracers the way we expected him to.  Lots of emphasis on details sometimes at the expense of the big picture.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Linda Sellers, RN/ nurse surveyor/ thorough but fair/ Couldn't say what her primary focus was, covered a lot of ground/ knowledgeable and experienced
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)    Vincent L. Melton /Engineer/Life Safety Code Specialist/ Rushed not at all thorough/ several of his cites were not clear and others were reduced by TJC in final report.
 

# of Non-Compliant Standards    35 (HAP: 11 Direct/ 24 Indirect) {BHC: Direct/ Indirect} [1? Clarified]

APR/NPSG Cites 

• NPSG.02.02.01/ EP4  During tracer activities, observations were made that a” do not use” abbreviation QD was used in a preprinted order form  /Direct/ Srvr#1-2
• NPSG.16.01.01 EP2,EP7  The organization had not developed criteria for calling additional assistance to respond to a change in the patient's condition or perception of change by the staff, patient, and/or family; The performance improvement committee has not measured or evaluated their early intervention efforts for effectiveness /Direct/ Srvr#1-2
• NPSG.02.03.01 EP1,EP2,EP5  Policy does not define critical tests and values for radiology; The organization has not defined timelines for reporting; The facility only collected data on the timeliness of reporting critical tests, critical results & values for the 3rd Qtr./Indirect/ Srvr#1-2
• UP.01.03.01 EP1 The organization did not have a process in place for time outs to be done for tooth extractions until 2/1/09 consequently there was no time out completed for these three (3) separate extractions /Direct/ Srvr#1-2

MM/PC  Cites

• PC.01.02.07 EP3  Observations were made that pain was not reassessed after intervention of pain medication on several separate occasions for a variety of patients /Direc t/ Srvr#1-2
•  PC.8.10 EP4 Multiple instances of no reassessment after treatment for pain in cottages/ Indirect/Behavioral Health Standard/ Srvr#1-2
• PC.01.02.15 EP1 During tracer activities, observations were made that Lithium levels were not obtained as ordered /Direct/ Srvr#1-2
• PC.02.02.03 EP11 Patient and staff food were observed to be stored in the unit kitchen refrigerator mixed together on numerous shelves. Facility policy requires separation of these two groups food materials to reduce risk of contamination. /Direct/ Srvr#1-2
• PC.02.03.01 EP1 No evidence that we assessed learning needs per standard on admission and reassessment./Indirect/ Srvr#1-2
• PC.6.10 EP2  No evidence that we assessed learning needs per standard on admission and reassessment./Indirect /Behavioral Health Standard/ Srvr#1-2
• PC.03.03.09 EP5   No evidence that we asked if client had and a behavioral advance directive./Indirect/ Srvr#1-2
• PC.12.40 EP10  No evidence that we asked if client had and a behavioral advance directive./Indirect/Behavioral Health Standard/ Srvr#1-2
• PC.03.03.29 EP1 On one ward, 2 instances of no debriefing after a restraint./ Indirect/ Srvr#1-2
• MM.03.01.01 EP2 Medication Refrigerator temperatures were not checked on several occasions/ Indirect/ Srvr#1-2
• MM.2.20 EP2 Medication Refrigerator temperatures were not checked on several occasions/ Indirect Behavioral Health Standard/ Srvr#1-2

RC/RI  Cites

IC/WT Cites

• WT.04.01.01 EP4,EP5 Glucometer testing was not done every day the glucometer was in use for two separate clients ; Two levels of control for quality assurance were not obtained for the unit glucometer on two occasions /Direct/ Srvr#2
• IC.4.10 EP4 The hospital policy indicated that nursing was responsible for checking the dishwasher temperatures daily. The temperatures were not checked during the month of May /Direct/ Srvr#2
• IC.02.02.01 EP4 Various pieces of equipment were stored under sinks in treatment areas /Indirect/ Srvr#1-2
  
  

HR/LD Cites

• LD.04.01.05 EP4  Staff were not held accountable for following policies and procedures as described in the EOC Management Plans. Policies state that inspections and tests must be performed according to standards. /Indirect Srvr#1
• HR.01.02.05 EP1  3 agency nurses, Infection Control nurse, a Dietitian contract Pharmacists and a Social Worker did not have primary source verification of credentials./Indirect/ Srvr#2
• HR.1.20 EP3  3 agency nurses, Infection Control nurse, a Dietitian contract Pharmacists and a Social Worker did not have primary source verification of credentials./Indirect/Behavioral Health Standard/ Srvr#2

IM/PI Cites

EC/EM//LS Cites 

• EC.02.03.05 /EP2,EP4,EP6,EP10/There was no documentation that valve tamper switches were tested. There was no documentation that water-flow devices were tested; The annual fire alarm test and inspection was completed in April, 2009. There were 21 devices not tested. There was no documentation that the 21 devices had been tested in the past 12 months; The 21 devices that had not been tested included audio/visible devices. Staff did not know why the devices were not tested; There was no documentation that the fire pump had been tested on a weekly basis for the last year and one half; There was no documentation that fire department water supply connections had been inspected./Direct
• EC.02.04.03 EP3 The supplemental oxygen tank was not inspected once and the emergency equipment package for patient emergency care was not inspected once;/ Indirect
• EC.02.05.07 EP1,EP2  There was no documentation that battery operated lights were tested on a monthly basis or an annual basis for a year and a half; /Indirect
• EC.7.40 EP3 There was no documentation that battery operated lights were tested monthly or annually/Indirect./ Behavioral Health Standards
• EC.04.01.01 EP15 The facility assesses activities for EOC activities for safety each year, but does not evaluate all environment of care management plans annually, to include a review of each plans objectives, scope, performance, and effectiveness.  /Indirect
• EC.9.10 EP4,EP5 The facility assesses activities for EOC activities for safety each year, but does not evaluate all environment of care management plans annually, to include a review of each plans objectives, scope, performance, and effectiveness. / Indirect /Behavioral Health Standards
• EC.02.02.01 EP3,EP11  The lab area has an eye wash for use by clinic staff. However there has been no regular examination or checking it for temperature of functionality; MSDS Sheets not found for several chemical in use./ Indirect
• EC.1.20 EP1 The AED on the unit had not been checked daily for battery charged status per facility policy over the last 3 months/ Indirect/Behavioral Health Standards
• LS.01.02.01 /EP3/ The last fire alarm inspection report lists 4 devices that failed (smoke detectors that did not report to fire alarm panel. The hospital did not assess the failed devices and determine if interim life safety measures were needed/ Direct/ Srvr#3
• LS.02.01.34/ EP1,EP2 The hospital did not utilize a central monitoring station to transmit the fire alarm signal The master fire alarm panel was located in an open area at the main desk in the lobby and not in an enclosed protected environment/Direct/Srvr#3
• LS.02.01.10 EP5,EP9 In several areas the fire doors did not latch when the doors were closed; In several areas of the facility  the material sealing penetrations was not approved fire resistant rated material. /Indirect / Srvr#3
• LS.02.01.20 EP13,EP31 lockers were stored in the egress corridor. There was furniture stored in the exit way. There was a chair in the exit way; Several exit signs did not have directional arrows to show exiting path out of area to exterior of building.  One exit sign had an arrow pointing in the wrong direction for exiting to exterior of building./Indirect/ Srvr#3
• LS.01.01.01 EP2 14?? cottages should be listed as “residential”, not as healthcare occupancy./Indirect (we are trying to clarify this with TJC as of July 15, 2009/ Srvr#3

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)

• Liked handoff communication process (shift report) but we're not sure why.  They were particularly impressed with the Infection Control annual plan and report.  They also liked the management plans (although we had not evaluated them) and Emergency Preparedness Plan
• Complimented us on treatment in general and particularly our Transitional Rehab program's work with Hope scales.

Preliminary Survey Result    JC: Accreditted, No RFI

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

EP Related to Direct Impact Findings:
1- NPSG.02.02.01/ EP4
2- NPSG.16.01.01 EP2
3- NPSG.16.01.01 EP7
4- UP.01.03.01 EP1
5- PC.01.02.07 EP3
6- PC.01.02.15 EP1
7- PC.02.02.03 EP11
8- WT.04.01.01 EP4
9- WT.04.01.01 EP5
10- IC.4.10 EP4
11- EC.02.03.05 /EP2, 4, 6, 10

EP Related to Inirect Impact Findings:
1- NPSG.02.03.01 EP1, 2, 5
2- PC.8.10 EP4
3- PC.02.03.01 EP1
4- PC.03.03.09 EP5
5- PC.12.40 EP10
6- PC.03.03.29 EP1
7- MM.03.01.01 EP2
8- MM.2.20 EP2
9- IC.02.02.01 EP4
10- LD.04.01.05 EP4
11- HR.01.02.05 EP1
12- HR.1.20 EP3
13-EC.02.04.03 EP3
14- EC.02.05.07 EP1, 2
15- EC.7.40 EP3
16- EC.04.01.01 EP15
17- EC.9.10 EP4, 5
18- EC.02.02.01 EP3, 11
19- EC.1.20 EP1
20- LS.02.01.34/ EP1, 2
21- LS.02.01.10 EP5, 9
22- LS.02.01.20 EP13
23- LS.02.01.20 EP31
24- LS.01.01.01 EP2 ??, EP14??

Cary Drennen, Regional QM Director