Name   David Schmitt, Director of QM   [CPN]
E-mail    david.schmitt@dmh.mo.gov
Facility Name  Southeast Missouri Mental Health Center (SMMHC)
Facility COO:  
Facility Address:  1010 W. Columbia, Farmington, MO 63640

Jt Com Org ID#    1815

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

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    7/21-7/24/09
Survey Days (e.g., Mon - Weds)    Tues - Fri
Number of Surveyors   3
Priority Focus Areas   
Last Survey Ending Date   4/29/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   George W. (Bill) Race M.D., Physician, Lead Surveyor - Consultative, likes to tell stories, sharp, puts you at ease but is paying very close attention
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Inez A. Kennemore, RN, MN - Nurse, Sharp, accepts explanations
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)   William (Bill) H. McCully, CHFM - Engineer, Quiet, particular, stands his ground
Profile - Surveyor #4 (Name/Disc/Tm Role/Traits/Quirks)  

 

# of Non-Compliant Standards    11 (HAP: 4 Direct/ 7 Indirect) {BHC: Direct/ Indirect} [Clarified]

APR/NPSG Cites 

• NPSG 02.03.01/ EP 1/ did not have seperate list of critical tests or critical values for them - e.g. X-rays/ indirect

MM/PC  Cites

• PC 01.02.07/ EP 3/  no evaluation for effectiveness of pain  (migraine)/ Direct
• MM 03.01.01 EP 2 / found 2 insulin viles expired/ Indirect

RC/RI  Cites

• RC 01.01.01/ EP 5 and 19/  records without dated entries (especially assessments) and things left off the treatment plan/ indirect

IC/WT Cites

HR/LD Cites

• HR 01.02.05EP 1/ One nurse was hired, we got primary source, her license expired, she started, we got primary source of her renewal 14 days later/ indirect
• LD 04.03.09/EP 6/ insufficient "metrcs" for the evaluation of contracts/ indirect
  

IM/PI Cites

EC/EM//LS Cites 

• EC 02.05.07/ EP 6/ - We were doing and documenting the tests on the emergency generator including documenting the equipment on it came on, but did not document that the transfer switches had worked/ Direct/ Surveyor #3
• EC 02.06.01/ EP 1 - We have bathrooms inside the patient rooms. They did not like our bathroom doors and hardware that we installed.  Also we needed a PM on dryer vents/ Indirect/ Kennemore was the big pusher here/ Surveyor #2
• LS 01.01.01/ EP1 - No document assigning responsibility for SOC and eBBI/ Indirect/  Surveyor #3
• LS 02.01.10/ EP 3 - Barrier walls not sealed to deck above - corrugated deck causing small gaps/ indirect/ Surveyor #3
• LS 02.01.30/ EP 18/ holes in firewall.  Primarily an issue of the building being constructed with 2 hour firewalls when only 1 hour were needed.  We were maintaining as 1 hour walls but because they were constructed as 2 hour we were cited for this/ 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)

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

• Very complimentary of our staff interactions, of our readiness for survey, of the treatment we give clients etc.  Overall they were very positive about the organization
  

Preliminary Survey Result    Some Requirements for Improvement

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

EP Related to Direct Impact Findings:
1- PC 01.02.07/ EP 3
2- RC 01.01.01/ EP 5 and 19
3- EC 02.05.07/ EP 6
4- LS 02.01.30/ EP 18

EP Related to Inirect Impact Findings:
1- NPSG 02.03.01/ EP 1
2- MM 03.01.01 EP 2
3- HR 01.02.05EP 1
4- EC 02.06.01/ EP 1
5- LS 01.01.01/ EP1
6- LS 02.01.10/ EP 3
7- LD 04.03.09/EP 6
 
 

David Schmitt