Name    Laura K. Godinez, Quality Manager
E-mail    laura.godinez@illinois.gov
Facility Name:   Tinley Park Mental Health Center
Facility CEO:  Brenda Hampton
Facility Address:  7400 W. 183rd Street, Tinley Park, IL  60477

Jt Com Org ID#     1577

# Beds - Adult: 100
# Beds - Child & Adol: 0
# Beds - Forensic: 0
# Beds - Geriatric:
# Beds - MR/DD: 100
# Beds - Sex Offender:
# Beds - Sub Abuse:
# Beds - Total:
# Beds - CMS Distinct:
# Units - Total:
# Staff - Total:

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    2/8-9/2010
Survey Days (e.g., Mon - Weds)    Mon - Tues
Number of Surveyors   3
Priority Focus Areas   
Last Survey Ending Date  3/21/07

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)  Edward K. Katz, M. D. -
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Kurt P. Streit, CHFM/Engineer,

Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks) Karen A. Szymanski, RN/Team Leader

# of Non-Compliant Standards    13 (HAP: 4Direct/ 9 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites

MM/PC  Cites

• PC.02.01.01, ep1 - Groups that patients were scheduled for did not match groups that they attended./Direct - Surveyor #3,
  
• PC.01.03.01, ep5 - Treatment objectives were too generic, did not contain specific behaviors, and were not measurable.  Target dates were too far out based on our average length of stay.    Indirect - Surveyor #1 and #3
  
• PC.01.03.01,ep23 - Goals and services were not revised based on the patient's needs. Indirect - Surveyor #1 and #3

RC/RI  Cites

• RC01.01.01/EP6/There was contradictory information in one social assessment regarding substance abuse without any explanation, there were blank forms found in the charts, there were blank elements of some forms without any explanation of why the element was left blank and a physician order was illegible./Indirect/Srvyr#1+#3
  
  RC.01.01.01/EP19/Date and time were missing on one suicide risk assessment and one H&P which documented 11 follow-up attempts to complete the evaluation - 10/11 follow-up attempts were dated but not timed../Indirect/Srvyr#1+#3

IC/WT Cites

HR/LD Cites

• HR.01.02.05,ep1 - Primary source verification of the renewed licenses for two social workers were received after the expiration of the old license.  - Indirect - Surveyor #3
  
• HR.01.06.01, ep6 - There was no documentation that the RN's and Technicians who ran groups were competent to do so. - Indirect Surveyor #3
  
• LD.04.03.07, ep1 -Surveyors found a number of unusual occurrences which disrupted the outcome of care - a fire during the survey which led to a slight delay in SW assignment, an unusual discharge and readmission which caused for the misplacement of an H&P which was found later.
  
• LD.04.03.07,ep2- the facility did not have a back-up to provide nutritional assessments when our dietician calls off causing one assessment  to be done a day late./ Indirect - Surveyor #1 and #3
  

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 

• EC.02.03.05, ep1 - Did not document testing of the supervisory signals related to the fire pump - direct - Surveyor #2
  
• EC.02.03.05, ep5 - Had not documented the notification of the fire department when fire alarm is activated - direct - Surveyor #2
  
• EC.02.03.05, ep10 - Did not conduct the FDC inspection - direct - Surveyor #2
  
• EC.02.03.05, ep11 - Had not performed the annual flow testing of the fire pump - direct - Surveyor #2
  
• EC.02.05.07, ep5 - Had not conducted a generator load test in 2008 ( had conducted it in 2006, 2007 and 2009) - direct - Surveyor #2
  
• LS.01.02.01, ep3 - Did not perform the ILSM assessment when defective dampers had been found.  ILSM policy did not include criteria. - direct - Surveyor #2
  
• EC.02.02.01,ep1 - Did not have a current written inventory of hazardous materials which included quantities and locations. - Indirect - Surveyor #2
  
• EM.02.02.07, ep8 - Had not communicated in writing with our LIPs regarding their roles and to whom to report in an emergency. - Indirect - Surveyor #2
  
• LS.02.01.20, ep13 - One pallet of 8 boxes of paper and two fans were found in an exit egress corridor. - Indirect - Surveyor #2
  
• LS.02.01.20, ep19 - Stairwells did not have proper signage.  It is a 4-story building, but the surveyor counted the basement as a fifth floor. - Indirect - Surveyor #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)

• The surveyors noted that it was clear that the staff knew our patients very well and that there was a lot of treatment being provided, but that treatment and progress could be better documented. 
  
• They also complimented us on our collection and use of data which had been an issue in previous surveys.

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- PC.02.01.01, ep1
2- EC.02.03.05, ep 1.5.10,11
3- EC.02.05.07, ep5
4- LS.01.02.01, ep3

EP Related to Inirect Impact Findings:
1- PC.01.03.01, ep5, 23
2- RC01.01.01/EP6, 19,
3- HR.01.02.05,ep1, 6,
4- HR.01.06.01, ep6
5- LD.04.03.07, ep1,2
6- IM.4.10./EP2
7- EC.02.02.01,ep1
8- EM.02.02.07, ep8
9- LS.02.01.20, ep13, 19

Laura K. Godinez, Quality Manager