Name   Stephanie Hetherington, Quality Assurance Specialist   [CPN]
E-mail    stephanie.hetherington@dmh.mo.gov
Facility Name:   Center for Behavioral Medicine (CBM)
Facility COO:  Scott Carter
Facility Address:  1000 E. 24th Street, Kansas City, MO 64108

Jt Com Org ID#    3043 !

# Beds - Adult (Civil only)    50
# Beds - Child & Adol (Civil only) 
# Beds - Forensic   
# Beds - Geriatric 
# Beds - MR/DD
# Beds - Sex Offender  
# Beds - Sub Abuse 
# Beds - Total (all Civil & For)   50
# Beds - CMS Distinct   ????
# Units - Total    2 Inpatient and 6 Residential
# Staff - Total    339

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. - Friendly, easy going but sharp. Keyed in on credentialing and contracted services.  Very consultative in the survey process, listen and learn. Have coffee available upon arrival.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Virginia Jordan, MSN, RN - Sharp & thorough. Keyed in on competencies and data-driven decision making.  Consultative throughout the process, very open about observations made (some were cited, many were not). 
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)   McCully_William (Bill) H. McCully, CHFM - Thorough tour of the facility, did not key in on one specific area of the LSC, rather covered all aspects.  Educational and consultative regarding issues surrounding the LSC.

# of Non-Compliant Standards    33 (HAP: 8 Direct/ 25 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites

• NPSG.02.03.01/EP1/The medical staff have defined expectations of 15 minutes for reporting critical lab values to the medical staff, but have not defined critical test turnaround times for 'stat' or mandated physician test reporting./Indirect/Srvyr#1
  
• NPSG.02.03.01/EP5/The hospital has not collected data on the timeliness of reporting critical test results. Also, it has not collected data for xray or CT tests performed for patient's sent out from the facility for these services./Indirect/Srvyr#1,2
  
• NPSG.09.02.01/EP6/At the time of the survey, the hospital had not evaluated the Fall Reduction Program to determine the effectiveness of the Program./Indirect/Srvyr#1,2
  
• NPSG.16.01.01/EP1/The hospital has not yet initiated a process to emphasize an early recognition and response method most suitable for its needs and resources. The facility recently created a policy to be taken to the medical staff next month for review and approval./Indirect/Srvyr#1

MM/PC  Cites

• PC.01.03.01/EP1/The hospital initial treatment plan did not specifically define interventions nor identified personnel to address the patient's medical disorders./Indirect/Srvyr#1.
  

• PC.16.30/EP5/At the time of the survey, a process for assessment of current competency with use of two methods per person for glucometer point of care testing had been implemented as of 4/09. Prior to this date, competency assessment for glucometer point of care testing was limited to laboratory monitoring of each user's quality control performance./Direct/Srvyr#2
• PC.7.10 EP2/Surveyor observation included review of the Temperature Log for the refrigerator and freezer. There was no documentation that the temperatures for the refrigerator and freezer had been noted for some dates and other dates were identified out of range with no action documented./Direct/Srvyr#2
  
• MM.4.10 EP5/Review of the medical record revealed duplicate orders for pain medication. The organization had not implemented a process for review of physician order for therapeutic duplication. Nor had the organization defined in policy the guidelines to be used by nurses to determine the circumstances under which to administer one or the other of the ordered pain medications./Indirect/Srvyr#2.
  

RC/RI  Cites

• RC.01.01.01/EP5/Multiple restraint debriefing reassessments did not have the name of the debriefing staff member, a disclosure of any history of abuse, and the staff involved in the restraint episode, per facility policy./Indirect/Srvyr#1
  
• RC.01.01.01/EP19/The physician authentication of documentation was dated, but not timed on multiple documents, one missing authentication completely./Indirect/Srvyr#1

IC/WT Cites

• IC.02.01.01/EP1/ The Infection Control Coordinator uses a "Hand Hygiene Monitoring Tool" which she distributes to various staff members each month to measure staff compliance with hand-hygiene. There was no documented evidence to reflect analysis of this data in regards to attempts to reduce the risk of infections to patients and staff.  This monitoring process appears to be inconsistent in staff completing the Tool. The ability of staff to minimize, reduce, or eliminate the risk of infection is difficult to evaluate based on limited and inconsistent data./Indirect/Srvyr#2
• IC.03.01.01/EP1/Observed in Infection Control Session, the Annual Evaluation of the Infection Control Plan for FY 2009 was limited to the following documentation: "The Infection Control Coordinator will educate staff and patients on a variety of issues including hand hygiene, influenza, MRSA, and other communicable diseases. Education of staff and patients will assist in preventing the spread of communicable diseases in our facility". This "evaluation" did not include a review of EP's 2-4./Indirect/Srvyr#2
• IC.03.01.01/EP2/The Annual Evaluation of the Infection Control Plan did not include a review of the infection prevention and control plan's prioritized risks./Indirect/Srvyr#2
• IC.03.01.01/EP3/The Annual Evaluation of the Infection Control Plan did not include a review of the infection prevention and control plan's goals./Indirect/Srvyr#2
• IC.03.01.01/EP4/The Annual Review of the Infection Control Plan did not include a review of implementation of the infection prevention and control plan's activities./Indirect/Srvyr#2
• IC.02.04.01/EP4/Minutes of the W.I.S.E. Committee reflected mention of the number of staff who had received the influenza vaccine during 2008. However, there was no evidence that the vaccination rates had been evaluated. Additionally, there was no documentation related to the reasons given by staff who declined the influenza vaccine/Indirect/Srvyr#2
• IC.02.04.01/EP5/Review of the minutes for the W.I.S.E. Committee did not reflect the fact that the hospital had taken any steps to increase influenza vaccination rates./Indirect/Srvyr#2
• WT.03.01.01/EP5/At the time of the survey, a process for assessment of waived testing for point of care glucometer testing was limited to one method per person per test, i.e. laboratory monitoring of each user's quality control performance. As of 4/09, the organization had implemented a process for competency assessment of staff with use of two methods per person per glucometer test./Direct/Srvyr#2
  

HR/LD Cites

• LD.04.03.09/EP4/ At the time of the survey, organization leaders had not established expectations for the performance of the contracted pharmacy and laboratory services./Indirect/Srvyr#1
  
• LD.04.03.09/EP5/At the time of the survey, the organization leaders had not implemented a process to monitor the contracted pharmacy and laboratory services by communicating the expectations in writing to the providers./Indirect/Srvyr#1
  
• LD.04.03.09/EP6/At the time of the survey, the organization leaders had not implemented a process to evaluate the contracted pharmacy and laboratory services in relation to the hospital's expectations./Indirect/Srvyr#1
  
• LD.04.03.09/EP7/At the time of the survey, organization leaders had not taken any steps to improve the contracted pharmacy and laboratory services as monitoring data had not been collected in relation to the hospital's expectations./Indirect/Srvyr#1

IM/PI Cites

EC/EM//LS Cites 

• EC.02.01.01/EP3/Three trash cans were observed in the corridor with a plastic bag liner and replacement bags underneath the liner. There was no documentation that failed smoke dampers had been repaired./Direct/Srvyr#1,3
  
• EC.02.03.01/EP1/During the building tour it was observed that combustible items were stored in mechanical areas./Direct/Srvyr#3
  
• EC.02.05.07/EP6/During the document review it was noted that the automatic transfer switches on the emergency generator were not documented as having been tested monthly as required/Direct/Srvyr#3
  
• EM.02.02.13/EP5/The medical staff Bylaws have a disaster credentialing process that does not require a governmental photo identification. It only requires one source of verification of medical credentials as outlined in this standard/Direct/Srvyr#3
  
• EC.02.03.05/EP3/The electronic door locks throughout the facility were not documented as having been tested/Indirect/Srvyr#3
  
• EC.02.03.05/EP10/During the document review it was noted that the quarterly inspection of the fire department connections were not documented for the 3rd and 4th quarters of 2008./Indirect/Srvyr#3
  
• LS.02.01.10/EP9/Observed in Building Tour, there were multiple conduits penetrating the barrier that were not sealed properly./Indirect/Srvyr#3
  
• LS.02.01.20/ EP29/During the building tour it was observed the stair signage in the north and south stair of area E that the signage did not include the direction to and story of exit./Indirect/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.08.01.01/EP1/The medical staff have criteria for reappointment in an ongoing evaluation process manner, but have not developed or defined a FPPE process/Indirect/Srvyr#1
  
• MS.08.01.01/EP2/The medical staff do not have have criteria developed or defined for a FPPE process for new staff members, members requesting new privileges, or triggers from quality of care concerns./Indirect/Srvyr#1
  
• MS.08.01.01/EP7/They have not addressed the process of this monitoring, triggers for monitoring, or criteria for assessment of the professional's practice (FPPE)./Indirect/Srvyr#1
  

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

Preliminary Survey Result    Accreditation Pending RFI

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

EP Related to Direct Impact Findings:
1- PC.16.30/EP5
2- PC.7.10 EP2
1- WT.03.01.01/EP5
2- EC.02.01.01/EP3
3- EC.02.03.01/EP1
4- EC.02.05.07/EP6
5- EM.02.02.13/EP5
 

EP Related to Inirect Impact Findings:
1- MM.4.10 EP5

1- NPSG.02.03.01/EP1
2- NPSG.02.03.01/EP5
3- NPSG.09.02.01/EP6
4- NPSG.16.01.01/EP1
5- PC.01.03.01/EP1
6- RC.01.01.01/EP5
7- RC.01.01.01/EP19
8- IC.02.01.01/EP1
9- IC.03.01.01/EP1
10- IC.03.01.01/EP2
11- IC.03.01.01/EP3
12- IC.03.01.01/EP4
13- IC.02.04.01/EP4
14- IC.02.04.01/EP5
15- LD.04.03.09/EP4
16- LD.04.03.09/EP5
17- LD.04.03.09/EP6
18- LD.04.03.09/EP7
19- EC.02.03.05/EP3
20- EC.02.03.05/EP10
21- LS.02.01.10/EP9
22- LS.02.01.20/ EP29
23- MS.08.01.01/EP1
24- MS.08.01.01/EP2
25- MS.08.01.01/EP7

Stephanie Hetherington