Name   Amanda Maretoli, Quality Assurance Specialist   [CPN]
E-mail    Amanda.Maretoli@dmh.mo.gov
Facility Name:   Northwest Missouri Psychiatric Rehabilitation Center (NMPRC)
Facility COO: 
Facility Address:  3505 Frederick Ave. . St. Joseph, Missouri  64505

Jt Com Org ID#    1790 

# 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)   108??
# Beds - CMS Distinct   ????
# Units - Total    ????
# Staff - Total    ???

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    9/21-23/09
Survey Days (e.g., Mon - Weds)    Mon - Thurs
Number of Surveyors   3
Priority Focus Areas   
Last Survey Ending Date  6/23/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Race - George W. (Bill) Race M.D. -
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Schindler_Janet Schindler, RN, MEd -
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)   Emmett Wier/Life Safety Code specialist -

# of Non-Compliant Standards    12 (HAP: 5 Direct/ 7 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites

MM/PC  Cites

• PC.01.03.01 EP1 Axis III diagnosis not on treatment plans: pain, hearing loss, etc. 

RC/RI  Cites

IC/WT Cites

• IC.02.01.01 EP1 Shower curtains in the cottages, Dust on Med room cabinet doors

HR/LD Cites

IM/PI Cites

EC/EM//LS Cites 

• EC.02.01.01  EP3 Ligature points, trash bags, VA assessment
• EC.02.03.01 EP1 Electrical Junction boxes, Oxygen tanks, plastic door wedges
• EC.04.01.01 EP15 EOC management plans having a clear objective, scope, performance and effectiveness of each plan
• EC.02.02.01 EP1 List of Hazardous Materials in the hospital
• EC.02.03.05 EP12 Water flow tests for the standpipe system
• EM.02.02.13 EP5 Bylaws to include information regarding Government issued ID
• LS.01.0101 EP1 Assigned individual for the SOC, compliance with Life Safety Codes
• LS.02.01.30 EP2 Smoke Barriers extend from the floor to roof
• LS.02.01.30 EP18 Penetrations are properly sealed
• LS.02.01.35 EP6 Linen room , kitchen storage room items stored closer than 18 inches to sprinkler head

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 EP6 Verification of contracted radiology service provider, Primary source verification of podiatrist

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

• Both surveyors commended staff, and appreciate their time and working with them. They noted that there are no patient care issues – no poor patient care. Environment of care drove a lot of the findings. They were very impressed with the facility, the severity of our patients’ illness, and the direction leadership is going. Fix what you can this week, and start discussion on the ligature issues.
  
• Dr. Race commented that this is a short report, less than half the length of some of your colleagues. He acknowledged that we had gotten different opinions on some issues in our previous surveys, three and six years ago. TJC is working to reduce this experience. He recommended that we watch TJC publications and send people to TJC training whenever possible.  Ms. Schindler praised the physical plan, commenting that she has not seen a psychiatric hospital this nice in many moons, with private rooms and baths. She remarked that there is little incentive to go home!

Preliminary Survey Result    Some Requirements for Improvement

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

EP Related to Direct Impact Findings:
1- NPSG.01.01.01, EP 2

EP Related to Inirect Impact Findings:
1- MM.01.01.03, EP 2
2- HR 01.02.05,EP 1
3- EC 02.06.01/ EP 1
4- EC.02.06.01, EP 20
5- LS.02.01.10, EP 5
6- LS.02.01.10, EP 9
7- LS.02.01.30, EP 18

Amanda Maretoli