Name    Anne M. Barrins, CSW - Founder/TJC Consultant for Barrins & Associates
E-mail   
Facility Name:   Barrins Psychiatric Hospital-LA_1Ad*
Facility COO: 
Facility Address:  Louisiana

Jt Com Org ID#     XXXX !

# Beds - Adult: 18
# Beds - Child & Adol:
# Beds - Forensic:
# Beds - Geriatric: 18
# Beds - MR/DD: 0
# Beds - Sex Offender: 0
# Beds - Sub Abuse: 0
# Beds - Total: 36
# Beds - CMS Distinct: ???
# Units - Total: 2
# Staff - Total: ???

Survey Type    Initial
Surveying Agency    JCAHO
Survey Dates (inclusive)    12/8-11/09
Survey Days (e.g., Mon - Weds)    Tues - Thurs
Number of Surveyors   2
Priority Focus Areas   
Last Survey Ending Date  NA

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)  Dyana Troester, MSN, EdS, ARNP - Very nice. Main focus is patient care. Welcomes questions and works with you to fix any problems before final report is submitted.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  James C. Woodson, Jr., Engineer, LS inspector - Is very thorough in tour and examination of building.

# of Non-Compliant Standards    9 (HAP: 2 Direct/ 7 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites

• NPSG.02.02.01/EP3/ during tracer activities, it was observed on four different occasions that organizational "do not use" abbreviations were used. These abbreviations included qd, u, and the lack of a leading 0 / Direct / Srvyr #1

MM/PC  Cites

• PC.01.02.03/EP4/ During tracer activities two H&P's had not been completed within the 24 hour time frame./Indirect/Srvyr#1
• PC01.03.01/EP22/During tracer activities it was observed that four patients did not have progress of short term goals in the weekly treatment plan update. All had the review identified whether to continue a focus on the problem, however had not documented the progress or lack thereof toward the short term goals./Indirect/Srvyr#1
• PC01.03.01/EP23/ It was observed during tracer activities that the treatment plan had not been revised to address the most immediate short term goals and so some goals we not reasonable to achieve in a short length of stay./Indirect/Srvyr#1
• PC.4.10/EP3/At both inpatient and outpatient facilities, it was noted that there was no documented evaluation of progress of the short term goals of the treatment plan. In both cases there were general statements of progress but no specific progress identified in relation to short term goals./Indirect/Srvyr#1
  

RC/RI  Cites

• RC01.01.01/EP11/during tracer activity, several Psychiatric Evaluations had been authenticated with signatures, however they had not been dated or timed./Indirect/Srvyr#1
  
  RC.01.01.01/EP19/There were several H&Ps that were signed and dated by the physician but they had not been signed./Indirect/Srvyr#1

IC/WT Cites

HR/LD Cites

IM/PI Cites

• IM.4.10./EP2/During a tracer activity, it was observed that a chart had contained information from 2007 and 2008 integrated into the current assessment data and progress notes. Information had not been organized or readily accessible to support decision making regarding care and treatment./Indirect/Srvyr#1

EC/EM//LS Cites 

• LS.02.01.20/EP8 - during building tour it was observed that the dining room exit to the outside has to pass through a flower bed with shrubs to reach the public way./Direct/Srvyr#2
  
• LS.02.01.10/EP5 - during the building tour it was observed that a number of stairwell doors did not close and latch/Indirect/Srvyr#2
• EC.04.01.01/EP14 - during the building tour it was observed that the mechanical room and maintenance shop had excessive clutter./ Indirect/Srvyr#2

 

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 on being organized with documentation (reports, etc.). Complimentary on nurses progress notes - very thorough. Complimentary of emergency management plan & restraint policy and procedures.
  
• Complimentary of Human Resource practices - specific to ongoing education with Health Streams online.

Preliminary Survey Result    Some Requirements for Improvement

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

•  Note: The hospital provided this PSQ through its consultant, Ms.Barins but has requested that its name and TJC ID be withheld.

EP Related to Direct Impact Findings:
1- NPSG.02.02.01/EP3
2- LS.02.01.20/EP8

EP Related to Inirect Impact Findings:
1- PC.01.02.03/EP4/
2- PC01.03.01/EP22 &23
3- PC.4.10/EP3
4- RC01.01.01/EP11 & 19
5- IM.4.10./EP2
6- LS.02.01.10/EP5
7- EC.04.01.01/EP14

Anonymous (Barrins)