Name   John Stolz, Chief Performance Improvement Executive   [CPN]
E-mail    jostolz@state.pa.us
Facility Name  Norristown State Hospital (NSH)
Facility CEO:  Gerald Kent
Facility Address:  1001 Sterigere Street, Building 19 Administration, Norristown, PA  19401

Jt Com Org ID#    1706

# Beds - Adult (Civil only)    324
# Beds - Child & Adol (Civil only)   
# Beds - Forensic    118
# Beds - Geriatric   
# Beds - MR/DD   
# Beds - Sex Offender   
# Beds - Sub Abuse  
# Beds - Total (all Civil & For)    442
# Beds - CMS Distinct    324
# Units - Total    14

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    February 9-13, 2009
Survey Days (e.g., Mon - Weds)    Mon - Fri
Number of Surveyors   2
Priority Focus Areas   
Last Survey Ending Date  2/11/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Edward K Katz, M.D., M.P.H., Lead Surveyor - (no comment provided)
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks) Barbara J. Hansen, R.N., M.A. - (no comment provided)
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)  George L. Thomas, CHFM - (no comment provided)
Profile - Surveyor #4

 

# of Non-Compliant Standards    16 (HAP: 5 Direct/ 11 Indirect) {BHC: Direct/ Indirect} [Clarified]

APR/NPSG Cites 

• NPSG.16.01.01-  The hospital selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual (s) when the patient's condition appears to be worsening.  / Direct / Srvyr# 2

MM/PC  Cites

• MM.06.01.01- The hospital safely administers medications / Direct / Srvyr# 1
• PC.02.02.03-  The hospital makes food and nutrition products available to its patients./ Direct / Srvyr# 1
  

RC/RI  Cites

• RC.02.01.01- The medical record contains information that reflects the patient's care, treatment, and services.  / Direct / Srvyr# 1

IC/WT Cites

• IC.01.02.01- Hospital leaders allocate needed resources for the infection prevention and control program. / Indirect/ Srvyr# 2
• IC.01.04.01- The hospital offers vaccination against influenza to licensed independent practitioners and staff / Indirect/ Srvyr# 2
• IC.02.04.01- The hospital offers vaccination against influenza to licensed independent practitioners and staff / Indirect/ Srvyr# 2t
  
  

HR/LD Cites

• HR.01.02.05- The hospital verifies staff qualifications indirect  / Indirect/ Srvyr# 1
• HR.01.05.03- Staff participate in ongoing education and training / Indirect/ Srvyr# 1
• LD.03.05.01- Leaders implement changes in existing processes to improve the performance of the hospital. / Indirect/ Srvyr# 1
• LD.04.03.11- The hospital manages the flow of patients through the hospital. / Indirect/ Srvyr# 2

IM/PI Cites

• PI.02.01.01- The hospital compiles and analyzes data / Indirect/ Srvyr# 2

EC/EM//LS Cites 

•  EC.02.05.07- The hospital inspects, tests, and maintains emergency power systems.  Note:  This standard does not require hospitals to have the types of emergency power equipment discussed below.  However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply. / Direct / Srvyr# 1
• EM.02.02.07- As part of its Emergency Operations Plan, the hospital prepares for how it will manage staff during an emergency. / Indirect/ Srvyr# 1
• EM.02.02.15- During disasters, the hospital may assign disaster responsibilities to volunteer practitioners who are not licensed independent practitioners, but who are required by la and regulation to have a license, certification, or registration.  Note:  While this standard allows for a method to streamline the process for verifying identification and licensure, certification, or registration, the elements of performance are intended to safeguard against inadequate care in an emergency situation./ Indirect/ Srvyr# 1

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.06.01.03- The hospital collects information regarding each practitioner's current license status, training, experience, competence, and ability to perform the requested privilege./ Indirect/ Srvyr# 1

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

• Compliments
  

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.16.01.01
2- MM.06.01.01
3- PC.02.02.03
4- RC.02.01.01
5- EC.02.05.07

EP Related to Inirect Impact Findings:
1- IC.01.02.01
2- IC.01.04.01
3- HR.01.02.05
4- HR.01.05.03
5- LD.03.05.01
6- LD.04.03.11
7- PI.02.01.01
8- EM.02.02.07
9- EM.02.02.15
10- MS.06.01.03


 

John Stolz