Name   Sta'Cee Crawford, Director of Quality Management   [CPN]
E-mail    scrawfo1@dhh.la.gov
Facility Name:   Central Louisiana State Hospital (CLSH)__2Ad1Ca2Fr*S&R
Facility COO:  Patrick Kelly
Facility Address:  242 West Shamrock, Pineville, La. 71360

Jt Com Org ID#    603 

# Beds - Adult: 60
# Beds - Child & Adol: 16
# Beds - Forensic: 56
# Beds - Geriatric: 0
# Beds - MR/DD: 0
# Beds - Sex Offender: 0
# Beds - Sub Abuse: 0
# Beds - Total: 132
# Beds - CMS Distinct: 76
# Units - Total: 5
# Staff - Total: 362

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    12/1-3/09
Survey Days (e.g., Mon - Weds)    Tues - Thurs
Number of Surveyors   3
Priority Focus Areas   
Last Survey Ending Date  8/31/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)  Virginia J. Jordan, MSN, RN -
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Martin R. Macklin, MD, PhD -
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)  James C. Woodson, Jr. -

# of Non-Compliant Standards    7 (HAP: 0 Direct/ 7 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites

MM/PC  Cites

• MM.05.01.13 EP5 (C/M) - The night medication supply is stored in one of the unit medication rooms. When a medication is ordered after pharmacy hours, an RN will call a pharmacist to approve the medication. The nurse will then obtain the medication from the night box and sign for it. There was not a second signature or other verification for a medication obtained from the night box. Indirect/Srvyr #1?
  

RC/RI  Cites

IC/WT Cites

HR/LD Cites

• HR.01.02.05 EP1 (A/D) - Observed in Competence Session at Central Louisiana State Hospital site: Review of the Personnel File of a dietitian revealed the registration of this clinician had expired 5 months ago. Primary source was verified at the time of the survey, 12/2/09. Review of the Personnel File of a Graduate Social Worker revealed that the primary source for the individual's registration had not been verified at the time/date of hiring.  Based upon documentation in the file at the time of the survey, it was  completed 1 week later. Indirect/Srvyr #1?

IM/PI Cites

EC/EM//LS Cites 

• EC.02.03.03 EP5 (A/D) - A number of staff members in the Kitchen and other units did not fully understand components of the RACE fire response procedure.- Indirect/Srvyr #1?
• EC.02.03.05 EP10  (A/D) - Observed in document review, fire department connection were not inspected quarterly in a number of buildings. - IndirectSrvyr /#1?
• EC.02.06.01 EP20 (C/M) - Observed in the building tour at Central Louisiana State Hospital site, several patient buildings had stained ceiling tiles in various areas. - Indirect/Srvyr #1?
• LS.02.01.10 EP10 (C) - Observed in the building tour at Central Louisiana State Hospital site: The building X occupancy separation (health care to business) did not have a 1-1/2 hour fire rated door assembly for the corridor doors nor for the medication room door or the room 102 door. Indirect/Srvyr #3?
• LS.02.01.30 EP2 (C) - Observed in the building tour at Central Louisiana State Hospital site: Building Y and Z laundries did not have a door closer installed (greater than 100 square feet); clean linen store room did not have a door closer installed (greater than 50 square feet). 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)

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

• Srvyr#2 was impressed with our Immunization Records

Preliminary Survey Result    Some Requirements for Improvement

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

EP Related to Direct Impact Findings:

EP Related to Inirect Impact Findings:
1- EC.02.03.03 EP5
2- EC.02.03.05 EP10
3- EC.02.06.01 EP20
4- HR.01.02.05 EP1
5- LS.02.01.10 EP10
6- LS.02.01.30 EP2
7- MM.05.01.13 EP5

Sta'Cee Crawford