Name    Clayton Shealy, PhD - Director of Clinical Services
E-mail    clayton.shealy@hardin.mh.alabama.gov
Facility Name:   Taylor Hardin Secure Medical Facility
Facility COO:  James F. Reddoch, Jr.
Facility Address:  1301 Jack Warner Parkway NE - Tuscaloosa, Alabama

Jt Com Org ID#     1143

# Beds - Adult (Civil only)    # Beds - Adult (Civil only)
# Beds - Child & Adol (Civil only)    # Beds - Child & Adol (Civil only)
# Beds - Forensic    115
# Beds - Geriatric    0
# Beds - MR/DD    0
# Beds - Sex Offender    0
# Beds - Sub Abuse    0
# Beds - Total (all Civil & For)    115
# Beds - CMS Distinct    24
# Units - Total    3
# Staff - Total

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    1/6-7/10
Survey Days (e.g., Mon - Weds)    Weds - Thurs
Number of Surveyors   3
Priority Focus Areas   
Last Survey Ending Date  1/19/07

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks) - Carol Larimore, MS,RN /Team Leader - Very personable; interacted and joked with all levels of staff.  She was very efficient and moved along quickly.  On the programs, she was very focused on (and impressed with) the knowledge base of mental health workers and nurses regarding the treatment plan and diagnoses for each patient.  During individual tracers, she focused on how we 1) collect, document quality control and reference range information for glucometers; 2) document "Read Back done" on phone orders; and 3) transcribe physician orders.  Checked the medication rooms (looked at expiration dates on vials, whether orderly and clean) and asked some medication questions while observing two LPN's during medication pass with attention to the two patient identifiers.  Focused on hand hygiene.   Actually asked mental health workers to show their individual hand sanitizer.  Looked at hand hygiene PI data.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Margaret D. Kordylewska, MD/Physician, Friendly, but somewhat reserved and soft spoken.  Broad experience, from private practice to state forensic hospital.  Thorough in her individual tracers.  Interested in seeing if patient plan of care was updated when changes occurred in patient's condition or patient moved to another program/level of care.  Typically satisfied with what she saw in our records.  During individual tracers, she asked very specific questions aimed at addressing processes (e.g., - how are labs ordered, drawn, and results accounted for?, how do we use high risk medications and clozapine; how are medical staff involved in assessment of the environment (safety, suicide risks, razors, patient accountability; how we used Standing Orders).  Strong focus on the role of the Medical Staff/MSEC in providing direction to the hospital and its PI program.  Conscientious in reviewing credentialing  and privileging files.  Closely examined, and asked questions about, OPPE and FPPE processes.

Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks) Cagle_Roger L. Cagle, CHFM/ Life Safety Code Specialist - Thorough in checking records but not picky.  Gave good advice while going through the building.

# of Non-Compliant Standards    3 (HAP: 1 Direct/ 2 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites

MM/PC  Cites

RC/RI  Cites

IC/WT Cites

HR/LD Cites

• HR.01.02.05/EP1 -  During a review of the employee record for the dietician, documentation revealed the primary verification was for a license which expired 12/31/09.  There was a copy of the current license due to expire 12/31/11; however there was no support primary verification.  The primary verification was obtained from the Alabama State Board of Dietetics License Search upon completion of the competency session.  Indirect/Surveyor #1

IM/PI Cites

EC/EM//LS Cites 

• EC.02.03.01/EP1 - Observed in building tour open electrical junction boxes located above the ceiling.  Direct/Surveyor #1
  
• LS.02.01.35/EP4 - Observed in building tour there were electrical metal conduit attached to the approved sprinkler systems. Indirect/Surveyor #1

 

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)

• Team Leader was impressed with our Medication Reconciliation process and said we could probably "bench mark" it.  All surveyors  impressed with the cleanliness of the facility.  Psychiatrist liked our process for critical test results.  Both the Nurse (Team Leader) and Psychiatrist were very complementary of staff to staff interaction.

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- EC.02.03.01/EP1

EP Related to Inirect Impact Findings:
1- HR.01.02.05/EP1
2- LS.02.01.35/EP4