Name   Renee H. Presley, Director of Planning/Quality Improvement   [CPN]
E-mail    renee.presley@searcy.mh.alabama.gov
Facility Name:   Searcy Hospital (SH)
Facility COO:  Beatrice McLean
Facility Address:  P. O. Box 1090 - Mt. Vernon, Alabama  36560

Jt Com Org ID#    1403 

# Beds - Adult (Civil only)    285
# Beds - Child & Adol (Civil only)    0
# Beds - Forensic    40
# Beds - Geriatric   0
# Beds - MR/DD   0
# Beds - Sex Offender    0
# Beds - Sub Abuse   0
# Beds - Total (all Civil & For)    325
# Beds - CMS Distinct    140
# Units - Total    3
# Staff - Total    565

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    11/16-20/09
Survey Days (e.g., Mon - Weds)    Tues - Fri
Number of Surveyors   3
Priority Focus Areas   
Last Survey Ending Date  1/25/07

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)  Eileen H. Fraser, MA, RN - Friendly, easy going but very knowledgeable.  Focuses on issues pertinent to nursing - will allow leadership to provide additional information if something needs clarifying even during interactions with line staff.  Many years experience in the behavioral health system.  A dedicated history buff.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Jay S. Flocks, MD - Team Leader.  Friendly but very focused.  A high emphasis on risk assessment; especially as related to suicide, both from an environmental and clinical aspect.  Loves to teach and is very knowledgeable.  A true statistician who loves data presentation in the form of graphics, charts, etc. as related to any area being discussed.  Very focused on the credentialing process and  legibility within the medical record.  Believes it is disrespectful for someone to be late to a given meeting, etc.
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)  Richard Smith, CHFM - Focused on the task at hand - cuts no slack on issues.

# of Non-Compliant Standards    13 (HAP: 6 Direct/ 7 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites

• NPSG 15.01.01/EP1/During tracer activities it was noticed that the suicide assessment was not scored in any quantitative way and the final determination was a subjective decision made by the psychiatrist. / Direct Impact - Surveyor #2

MM/PC  Cites

• MM.03.01.01/EP6/During tracer activities it was observed that the storage cabinet utilized for the patient's daily medications was not secured and locked within the medication room.  The hospital's policy requires the medication room door, as well as the medication cabinet to be locked when the nurse is not present/ Indirect Impact - Surveyor #1.
  
• MM.04.01.01/EP13/During tracer activities it was noted that there was an order for medication which took two staff members to decipher with a signature that was illegible and despite the fact that this is counter to hospital policy, the medication was dispensed and administered without clarification either by nursing or pharmacy./Direct Impact - Surveyor #2
  
• MM.07.01.01/EP1/During tracer activities it was noted that prn medications were not always followed up within the two hour period allowed by hospital policy or were not followed up at all/Indirect Impact - Surveyor #2
  
• PC.01.02.01/EP 23/During tracer activity it was noted that the psychiatric assessment did not justify the diagnosis on multiple records. In addition one psychiatric evaluation was not performed within 24 hours as is dictated by hospital policy./Direct Impact - Surveyor #2
  
• PC..01.03.01/EP1/During tracer activities it was noted that a treatment plan was developed for a patient who was in an acute care setting at the time.  In addition, goals and interventions on treatment plans reviewed were not in a form that could be quantitatively measured.  Terms utilized were subjective and not objective and data driven evidence based goals./Direct Impact - Surveyor #2

RC/RI  Cites

• RC.01.01.01/EP5/During tracer activities it was noted that there was a consult that was unreadable due to illegibility and did not convey sufficient information, therefore, to document the patient's care and diagnosis.  In addition, a history and physical done by an internist was essentially unreadable when text was used, as opposed to check boxes, and did not susbstantiate the medical diagnosis./Indirect Impact - Surveyor #2
  
• RC.01.02.01/EP3/During tracer activities it was noted that there was a progress note in which the signature was illegible and unqualified by a unique number, printing, stamp or other means of identification./Indirect Impact - Surveyor #2

IC/WT Cites

HR/LD Cites

IM/PI Cites

EC/EM//LS Cites 

• EC.02.01.01/EP3/During a tour of the units hospital-wide, it was noted that there were horizontal grab bars which would easily support a ligature. Additionally, the shower faucets and sink faucets on the unit could support a ligature for hanging.  There were also hasps on each closet, with a lock suspended by a chain, which could easily be used quickly for hanging and/or the edges of the hasp were sharp metal which could be used for self mutilation./Direct Impact - Surveyor #2
• EC.02.05.07/EP4,5,6/During tour it was noted that the generator was tested at intervals less than 20 days; emergency generator tests are conducted with a dynamic load that is at least 30% of the nameplate rating of the generator and the hospital did not conduct an annual load bank test as required which met the NPPA requirement.   Test of automatic transfer switches must be done at intervals of not less than 20 days and not more than 40 days./Direct Impact - Surveyor #3
• LS.02.01.10/EP9/During building tour it was observed that the fire wall above the ceiling in multiple areas had a penetration that was not properly sealed./Indirect Impact - Surveyor #3
• LS.02.01.30/EP2, 11, 18/During building tour it was noted that several soiled utility room doors did not close and latch properly; it was noted that several corridor doors did not positive latch; it was observed on tour that the smoke wall above the ceiling in two areas had a penetration that was not properly sealed./Indirect Impact - Surveyor #3
• LS.02.01.35/EP4,9/During the building tour it was observed that the piping for approved automatic sprinkler systems was used to support a duct above the ceiling in multiple locations; it was further observed that in a staff lounge, there was a grease -producing device (George Foreman grill) and there was no type K fire extinqiusher within 30 feet./Indirect Impact - 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)

• Surveyor #1 was extremely impressed with our fall risk assessment/risk reduction protocols/reassessment following a fall - took a blank copy of our forms to enter into the data base at TJC for sharing with others.
  
• Both Surveyor #1 and Surveyor #2 were highly complementary regarding our therapeutic milieu, the fact that our clients are afforded ground privileges unless contra-indicated.  Also highly complimentary of the fact that clients knew by name not only line staff but administrative staff as well.

Preliminary Survey Result    Some Requirements for Improvement

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

EP Related to Direct Impact Findings:
1- NPSG 15.01.01/EP1
2- MM.04.01.01/EP13
3- PC.01.02.01/EP 23
4- PC..01.03.01/EP1
5- EC.02.01.01/EP3
6- EC.02.05.07/EP4,5,6

EP Related to Inirect Impact Findings:
1- MM.03.01.01/EP6
2- MM.07.01.01/EP1
3- RC.01.01.01/EP5
4- RC.01.02.01/EP3
5- LS.02.01.10/EP9
6- LS.02.01.30/EP2, 11, 18
7- LS.02.01.35/EP4,9

Renee H. Presley