Name   Angela R. Harris, Acting Chief Performance Improvement Executive   [CPN]
E-mail    angharris@state.pa.us
Facility Name  Torrance State Hospital
Facility COO:  Edna McCutcheon
Facility Address:  State Route 1014, Torrance PA  15779

Jt Com Org ID#    1507 

# Beds - Adult (Civil only)    218
# Beds - Child & Adol (Civil only)  
# Beds - Forensic
# Beds - Geriatric   
# Beds - MR/DD   
# Beds - Sex Offender   21
# Beds - Sub Abuse  
# Beds - Total (all Civil & For)    239
# Beds - CMS Distinct    212
# Units - Total    10
# Staff - Total    500

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    June 17-19, 2009
Survey Days (e.g., Mon - Weds)    Weds - Fri
Number of Surveyors   4
Priority Focus Areas   
Last Survey Ending Date   8/18/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Edward K Katz, M.D., M.P.H., Lead Surveyor - he focused on national patient safety goals and credentialing
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks) Walter Diggs, FACHE, Administrator - he focused on measuring outcomes through the use of the GAF score; he also focused on patient safety and culture of safety within the entire hospital system.
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)    Carol Johnson, RN, Nurse Surveyor - she focused on medication administration, and documentation in the record to support needs identified in assessments (continuity of care).
Profile - Surveyor #4 (Name/Disc/Tm Role/Traits/Quirks)    Richard Smith, CHFM, Life Safety Engineer - he was thorough in his review of the physical plant.

 

# of Non-Compliant Standards    9 (HAP: 3 Direct/ 6 Indirect) {BHC: Direct/ Indirect} [Clarified]

APR/NPSG Cites 

• NPSG.02.03.01, EP 5 - data for critical values on time to physician and time to nurse must be aggregated and analyzed.  Indirect; Surveyor #1,2
• NPSG.0.05.01, EP 2 - hand off communication must occur between the on call/covering physician and treating physician; and the nursing changing shift hand off report must include a review of all patients.  Direct; Surveyor #3

MM/PC  Cites

• PC.02.01.01, EP 1 - treatment provided must be reflected in the individualized plan of care.  Direct -  Surveyor #3

RC/RI  Cites

• RC.02.01.01, EP 2 - the medical record must contain information relevant to medication administration.  Direct - Surveyor #3

IC/WT Cites

• xxIC.02.02.01, EP 2 - sterilized equipment should be transported in a non-permeable container. - Direct; Surveyor #1
  
  

HR/LD Cites

IM/PI Cites

EC/EM//LS Cites 

• EC.04.01.01, EP 15 - annual management reports must include staff competency measures including user errors.  Indirect; Surveyor #2
• LS.02.01.10, EP 5 - fire exit doors did not close and latch properly.  Indirect - Surveyor #4
• LS.02.01.20, EP 31 - exit signs not adequately lit.  Indirect; Surveyor #4
• LS.02.01.30, EP's 18, 19, 23 - building features to protect individuals from the hazards of fire and smoke - specifically smoke barriers.  Indirect; Surveyor #4

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 - all physicians providing treatment to patients must be credentialed and privileged as a member of the medical staff.  - Credentialing – The cardiologist (outside hospital)  who reads and interprets the EKG’s had an extensive file of credentialing information, however he was not credentialed and privileged as part of the TSH medical staff./  Indirect; Surveyor #1

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

• Compliments were received regarding the discharge checklist used within the Social Service Department, as it was comprehensive and user friendly.
  
• One of the surveyors remarked that it is evident that the individuals served by Torrance display the symptoms of serious and persistent mental illness but he noted something was different here.  He later concluded that it is the manner in which he observed staff taking care of the needs of the individuals even when under the stress of surveyors observing.
• One of the surveyors complimented a treatment team as being consultative and collaborative.

Preliminary Survey Result    JC: Accreditted, No RFI

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

7/23/09:Joint Commission is removing the IC standard from the list of RFI’s, as we submitted a 10-day clarification which was accepted

EP Related to Direct Impact Findings:
1- NPSG.0.05.01, EP 2
2- PC.02.01.01, EP 1, 2
4- xxIC.02.02.01, EP 2

EP Related to Inirect Impact Findings:
1- NPSG.02.03.01, EP 5
2- EC.04.01.01, EP 15
3- LS.02.01.10, EP 5
4- LS.02.01.20, EP 31
5- LS.02.01.30, EP's 18, 19, 23
6- MS.06.01.07,EP 8
 

Angela R. Harris, Acting Chief Performance Improvement Executive