Name  Margie Wofford, PI Director   [CPN]
E-mail    linda.wofford@arkansas.gov
Facility Name  Arkansas State Hospital (ArSH)
Facility COO:  Charles Smith
Facility Address:  305 S. Palm Street, Little Rock,AR  72205

Jt Com Org ID#    1536  !BHC

# Beds - Adult: 60
# Beds - Child & Adol: 10
# Beds - Forensic: 10 
# Beds - Geriatric: 0
# Beds - MR/DD: 0
# Beds - Sex Offender: 0
# Beds - Sub Abuse: 0
# Beds - Total: 80
# Beds - CMS Distinct: 80
# Units - Total: 5
# Staff - Total: 280

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    Jan 26-30, 2009
Survey Days (e.g., Mon - Weds)    Weds - Fri
Number of Surveyors   3
Priority Focus Areas   
Last Survey Ending Date   3/7/07

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Edward K Katz, M.D., M.P.H., Lead Surveyor - (no comments provided)
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks) Dyana Troester, MSN, EdS, ARNP -focused on Adolescents and Developmentally Disabled/Mentally Retarded
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)    William (Bill) H. McCully, CHFM, Engineer - (no comments provided)
Profile - Surveyor #4
 

# of Non-Compliant Standards    21 (HAP: 5 Direct/ 16 Indirect) {BHC: 0 Direct/ 3 Indirect} [Clarified]

APR/NPSG Cites 

• NPSG.02.03.01, EP 4, 5, 6, 7.  The hospital measures, assesses,  and, if needed, takes action to improve the timeliness of reporting and the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver.
• NPSG.02.03.01, EP 4, 5, 6, 7. The organization measures, assesses, and if needed, takes action to improve the timeliness of reporting and the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver. / Srvyr#2

MM/PC  Cites

• PC.01.02.03, EP 3 - The hospital assesses and reassesses the patient and his or her condition according to defined time frames.  Direct
• PC.01.03.01, EP 1 & 23 - The hospital plans the patient's care.  Direct
• PC.03.03.09, EP 1 - The hospital obtains information about the patient that could help minimize the need to use restraint or seclusion for behavioral health purposes with the patient.
• PC.03.03.29, EP 2  - Patients are debriefed after the use of restraint or seclusion for behavioral health purposes.
• PC.4.40, EP 2 -  The organization develops a plan for care, treatment, and services that reflects the assessed needs, strengths, and limitations. / Srvyr#2

RC/RI  Cites

• RC.01.04.01, EP 3 - The hospital audits its medical records

IC/WT Cites

• IC.02.01.01, EP 1 - The hospital implements its infection prevention and control plan.
  
  

HR/LD Cites

• HR.01.02.05, EP 1 - The hospital verifies staff qualifications.
  
• HR.1.20, EP 3 - Staff qualifications are consistent with his or her job responsibilities.

IM/PI Cites

EC/EM//LS Cites 

• EM.01.01.01, EP 3 - The hospital engages in planning activities prior to develop its written Emergency Operations Plan.
• EM.02.02.03, EP 1 - As part of its Emergency Operations Plan, the hospital prepares for how it will manage resources and assets during emergencies.
• EC.02.03.01, EP 1 - The hospital manages fire risks.  Direct
  
• EC.02.03.05, EP 5 - The hospital maintains fire safety equipment and fire safety building features.  Direct
• EC.02.04.03, EP 2 & 3 - The hospital inspects, tests, and maintains medical equipment.
• EC.02.06.01, EP 1 - The hospital establishes and maintains a safe, functional environment.
• EC.04.01.01, EP 15 - The hospital collects information to monitor conditions in the environment.
• LS.02.01.10, EP 9 -  Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. / Srvyr#3
• LS.02.01.20, EP 13 - The hospital maintains the integrity of the means of egress. / Srvyr#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.06.01.05, EP 2 - The decision to grant or deny a privilege (s), and/or to renew an existing privilege (s), is an objective, evidence-based process. / Srvyr#1

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

• The staff were complimented on their caring attitude towards the patients.
  

Preliminary Survey Result    JC: Accreditted, No RFI

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

EP Related to Direct Impact Findings:
1- PC.01.02.03, EP 3
2- PC.01.03.01, EP 1 & 23
3- EC.02.03.01, EP 1
4- EC.02.03.05, EP 5
5- EC.02.04.03, EP 2 & 3

EP Related to Inirect Impact Findings:
1- NPSG.02.03.01, EP 4, 5, 6, 7
2- NPSG.02.03.01, EP 4, 5, 6, 7
3- PC.03.03.09, EP 1
4- PC.03.03.29, EP 2
5- PC.4.40, EP 2
6- RC.01.04.01, EP 3
7- IC.02.01.01, EP 1
8- HR.01.02.05, EP 1
9- HR.1.20, EP 3
10- EM.01.01.01, EP 3
11- EM.02.02.03, EP 1
12- EC.02.06.01, EP 1
13- EC.04.01.01, EP 15
14- LS.02.01.10, EP 9
15- LS.02.01.20, EP 13
16- MS.06.01.05, EP 2

 

Margie Wofford