Name   Anne Ecker, PI/RM Assistant Director   [CPN]
E-mail    anne.eckert@dmh.mo.gov
Facility Name  Metropolitan St. Louis Psychiatric Center (MSLPC)
Facility CEO:  Anthony Cuneo   
Facility Address: 5300 Delmar Blvd., St. Louis, MO  63112

Jt Com Org ID#    3045

# Beds - Adult    ??????
# Beds - Child & Adol    ??????
# Beds - Sub Abuse    ??????
# Beds - Forensic ??????
# Beds - MR/DD    ??????
# Beds - TotaL    112
# Beds - CMS Distinct Part    ??????

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    April 20 - 21, 2009
Survey Days (e.g., Mon - Weds)    Mon- Thus.
Number of Surveyors    3
Priority Focus Areas   
Last Survey Ending Date   2/8/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   George W. (Bill) Race M.D./Psychiatrist/Team Leader/Focused on  NPSG, Medical Staff Credentialing and Privileging, Leadership, Waived Testing, Medication Management / Be aware that Dr. Race may expect some documents for the Preliminary Planning Session that are not typically on the TJC suggested list. ( e.g., the Emergency Management Plan, EOC Management Plans, various policies).   If he couldn’t find a document quickly, he assumed it wasn’t there.  Dr. Race approached tracers in a manner different from what we expected in that he did not follow a system all the way through to the end.  When something else caught his attention, he chased it down immediately.  He was also noted to use his experience and practice in his own hospital as a baseline for investigating practices at our facility. First impressions carried a lot of weight with him. For example, if the first nurse he met didn’t know something he asked, he assumed all nurses lacked the knowledge. We found the best way to manage this was to get him what he asked for quickly, listen respectfully and answer his questions without over explaining.   To his credit, he was quite willing to be consultative and we received useful information on topics related to National Patient Safety Goals. 
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Linda Sellers, RN/ nurse surveyor/ Focused on Environment of Care, Human Resources, Data Use Tracers: Infection Control, Emergency Management, Provision of Care / Ms. Sellers was organized, efficient, competent, thorough, and professional with no personal agendas that we could determine. 
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)    McCully_William (Bill) H. McCully, CHFM  Life Safety / Very thorough  - used the ladder and the flashlight
 

# of Non-Compliant Standards    18 (HAP: 9 Direct/ 9 Indirect) {BHC: Direct/ Indirect}

APR/NPSG Cites 

• NPSG.02.02.01  EP3. The hospital implements the 'do not use' list of abbreviations, acronyms, symbols, and dose designations and applies it to all orders and all medication-related documentation that is handwritten or entered as free text into a computer.  The pharmacy used 'QD' on a handwritten client “home meds and disposition form.” / Direct / Surveyor #1
• NPSG.16.01.01 EP1. The hospital selects an early recognition and response method most suitable for its needs and resources.
• NPSG.16.01.01 EP2. The hospital develops criteria for calling additional assistance to respond to a change in the patient’s condition or a perception of change by the staff, the patient, and/or family./  Direct / Surveyor #1
• NPSG.16.01.01 EP7. The hospital evaluates its early intervention program and any underlying organizational system issues, takes appropriate action to improve its intervention system, and measures the effectiveness of those actions on a regular basis.  Surveyor did not judge our choice of early intervention method to by sufficient, therefore criteria for enactment of early intervention system and evaluation of system were also insufficient./  Direct / Surveyor #1

MM/PC  Cites

• MM.04.01.01  EP13. The hospital implements its policies for medication orders.  During tracer activities, observations were made that Haldol 5 mg IM and Ativan 2 mg po were ordered for anxiety. The order did not specify the parameters as to when each of the medications were to be administered or that they could be administered at the same time. / Indirect / Surveyor #2
• PC.01.02.03  EP3. Each patient is reassessed as necessary based on his or her plan for care or changes in his or her condition. A patient had no reassessment of falling risks on several dates  / Direct / Surveyor #1
• PC.01.02.07  EP3. The hospital reassesses and responds to the patient’s pain, based on its reassessment criteria.  Several instances when a patient received a pain intervention with no reassessment per policy. / Direct / Surveyor #1
• PC.02.02.03  EP11. The hospital stores food and nutrition products, including those brought in by patients or their families, using proper sanitation, light, moisture, ventilation, and security.  During tracer activities, observations were made that the temperature logs for food and nutrition products were not recorded for two days during the current month of April. The organization's policy required that food refrigerators on the patient care units be recorded daily. Temperatures were documented out of range at 42 degrees once during the first twenty days of April without any action taken for correction. The guidelines indicated that safe temperatures were 40 degrees or below.
  / Direct / Surveyor #1

RC/RI  Cites

IC/WT Cites

• WT.03.01.01  EP5. Competency for waived testing is assessed using at least two of the following methods per person per test:
  - Performance of a test on a blind specimen
  - Periodic observation of routine work by the supervisor or qualified designee
  - Monitoring of each user's quality control performance
  - Use of a written test specific to the test assessed
  The organization did not have documentation to indicate that competency for waived testing was assessed by using two methods annually. The emergency room nurse is required to have an annual competency for pregnancy testing, urine drug screening, and finger stick blood glucose testing. There was only one method used for each of these competencies. Two of the competencies were by documented observation and one was by a written test. / Direct / Surveyor #2
  

HR/LD Cites

• HR.01.02.05  EP1. When law or regulation requires care providers to be currently licensed, certified, or registered to practice their professions, the hospital both verifies these credentials with the primary source and documents this verification when a provider is hired and when his or her credentials are renewed.  The organization had not verified the license of the dietician or a pharmacist at the time of renewal with the licensing board./ Indirect / Surveyor #2
• LD.03.04.01  EP1. Communication processes foster the safety of the patient and the quality of care.
  A patient had a critically low blood sugar result on a fasting specimen. The nurse contacted the physician's telephone number and left a message on the answering machine. Current policy asks staff to contact physicians and document that contact. The answering machine presents a risk for communications delay in proper medical response./ Indirect / Surveyor #1
  
  

IM/PI Cites

EC/EM//LS Cites 

• EC.02.03.05  EP3. Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors. The completion date of the tests is documented.  The documentation for the annual testing of the electro-mechanical devices and the electronic door locks was not documented for 2008 or 2007./ Indirect / Surveyor #3
  
• EP10. For automatic sprinkler systems: Every quarter, the hospital inspects all fire department water supply connections. The completion dates of the inspections are documented.  There was no documentation that the fire department connections are being inspected quarterly/ Indirect / Surveyor #3
• EC.02.04.03  EP2. The hospital inspects, tests, and maintains all life support equipment. These activities are documented. The AED was checked for annual maintenance, but there was no documentation of daily checks for several dates./ Direct / Surveyor #3
• EC.02.05.07  EP 6. Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests all automatic transfer switches. The completion date of the tests is documented.  During the document review it was observed that the Automatic Transfer switches were not being documented as being tested every month. There was no documented evidence that every switch was exercised each month./ Direct / Surveyor #3
• EC.02.06.01  EP1. Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.  In two storage rooms there were light fixtures with exposed fluorescent tubes that need to have protective tubes installed./ Indirect / Surveyor #3
• EC.03.01.01  EP2. Staff and licensed independent practitioners can describe or demonstrate actions to take in the event of an environment of care incident.  A housekeeper did not know of fire safety actions other than to alert nursing leader on unit. She did not know that her key could open the locked fire extinguisher box or alarm. She was not familiar with the facility fire safety learning of "RACE".  A patient care staff was unable to identify the actions for a fire emergency other than gathering patients and alerting nurse leadership. She was aware of the facility "RACE" concept, but did not know to close doors ("C" contain) or to ("E") extinguish fires, when able. / Indirect / Surveyor #1
• EM.02.02.13  EP 5. Before a volunteer practitioner is considered eligible to function as a volunteer licensed independent practitioner, the hospital obtains his or her valid government-issued photo identification (for example, a driver’s license or passport) and at least one of the following… The Medical Staff Bylaws disaster privileging as currently written, does not require a governmental picture ID as well as another competency verification data evidence. / Direct / Surveyor #1
• LS.02.01.30  EP 11. Corridor doors are fitted with positive latching hardware, are arranged to restrict the movement of smoke, and are hinged so that they swing. The gap between meeting edges of door pairs is no wider than 1/8 inch, and undercuts are no larger than 1 inch. Roller latches are not acceptable.  In two areas the corridor smoke door did not close properly and was not smoke tight.
  The shell area being used for storage had the double doors leading into that area blocked open with a chain holding one door and an installed doorstop on the other. / Indirect / Surveyor #3
• LS.02.01.30  EP 18. Smoke barriers extend from the floor slab to the floor or roof slab above, through any concealed
  spaces (such as those above suspended ceilings and interstitial spaces), and extend continuously from
  exterior wall to exterior wall. All penetrations are properly sealed. The smoke wall above the ceiling was penetrated with several pipes that were not sealed properly. - There were several pipes that were sealed with insulation that is not approved for fire/smoke stop material.
  The smoke barrier above the smoke doors by one room  did not have sheetrock to the roof deck./ Indirect / Surveyor #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)

• MS.01.01.01  EP 17. The medical staff bylaws must also include the following: A description of the privileging process (including temporary and disaster privileging). - The current Medical Staff Bylaws allow for a 90 day appointment and another 90 day extension, which exceeds the 120 day maximum appointment period allowed./ Indirect / Surveyor #3
• MS.06.01.07  EP8. Privileges are granted for a period not to exceed two years. - A medical staff member credentials folder found them reappointed exceeding 2 years from previous appointment (12-13-06 to 12-19-08)./ Indirect / Surveyor #1
   

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

• Surveyor #1 liked our form for reporting critical lab values and tests.  He took a copy with him.
  
• Surveyor #2 complimented our Infection control Practitioner -  said that the Infection Control Plan, Reports and Evaluations were the best she had ever seen.

Preliminary Survey Result    JC: Accreditted, No RFI

**Misc Comments, Suggestions, Etc    **Misc Comments, Suggestions, Etc
Our 45 Day ESC was approved by TJC.  Our 60 Day ESC was submitted, but not approved yet

EP Related to Direct Impact Findings:
1- NPSG.02.02.01  EP3
2- NPSG.16.01.01 EP1, 2, 7
3- PC.01.02.03  EP3
4- PC.01.02.07  EP3
5- PC.02.02.03  EP11
6- WT.03.01.01  EP5
7- EC.02.04.03  EP2
8- EC.02.05.07  EP 6
9- EM.02.02.13  EP 5

EP Related to Inirect Impact Findings:
1- MM.04.01.01  EP13
2- HR.01.02.05  EP1
3- LD.03.04.01  EP1
4- EC.02.03.05  EP3, 10
5- EC.02.06.01  EP1
6- EC.03.01.01  EP2
7- LS.02.01.30  EP 11, 18
8- MS.01.01.01  EP 17
9- MS.06.01.07  EP8

Anne Eckert