Name    Paul Ortner, Quality Improvement Coordinator
E-mail    paul.ortner@alaska.gov
Facility Name:   Alaska Psychiatric Institute
Facility CEO:  Ronald Adler
Facility Address:  3700 Piper Street, Anchorage Alaska 99508

Jt Com Org ID#     1526

# Beds - Adult: 60
# Beds - Child & Adol: 10
# Beds - Forensic: 10 
# Beds - Geriatric: 0
# Beds - MR/DD: 0
# Beds - Sex Offender: 0
# Beds - Sub Abuse: 0
# Beds - Total: 80
# Beds - CMS Distinct: 80
# Units - Total: 5
# Staff - Total: 280

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    3/11-12/2010
Survey Days (e.g., Mon - Weds)    Thurs-Fri
Number of Surveyors   3
Priority Focus Areas    Medication Management Physical Environment   Organizational Structure   Communication      Information Management    Patient Safety
Last Survey Ending Date  3/7/07

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)  Jay S. Flocks, MD/Psychiatrist - Conducted tracer or survey activities in patient care, Performance Improvement, Contracts, Credentialing, Medical Staff, record of care, medication management, rights of individuals and NPSG.     This is not our first visit from Dr. Flocks, he also surveyed our hospital in 2007, so there was familiarity between senior management and this surveyor. He does have a focus on moving performance improvement out of bar charts and graphs to statistically evaluated information, which he mentioned in 07 and fortunately he was able to find in this survey. Did provide a educational presentation on medical staff credentialing that was helpful to staff managing that process. Generally very willing to talk through findings and expectations. Was a bit pressured to work through what is now a 2 day survey (three day in 2007).

Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Eileen H. Fraser, MA, RN  /Nurse, conducted tracer or survey activities in patient care, infection control, human resources, information management, leadership, medication management, waived testing, and NPSGs  Very positive in her interactions, educational and willing to talk through findings and expectations. Very engaging in a pleasant and non threatening way.

Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)  Byron Kitagawa  /Environment of Care/Emergency Management.  Conducted tracer and survey activities in environment of care, life safety and emergency management.  Mr. Kitagawa had a very brief amount of time to run through his area of expertise as he had only one day for his part of the survey, part of which is spent working up the report. He moved very quickly through his task, but was also very thorough. He was very pleasant, had a easy going jokey demeanor. He was able to spot relevant problems in our environment quickly. He also was easy to engage and was open to questions outside of his findings.

# of Non-Compliant Standards    12 (HAP: 4Direct/ 8 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites

• NPSG.15.01.01, EP 1  - During patient tracer activity, it was noted that the suicide assessment listed a number of factors that contribute to suicidality. None of them were weighted as to seriousness. After checking these off the clinician was then asked for a suicide assessment, which was in no way connected to the check boxes, and was totally subjective and not data driven in any way. • During tracer activity and record review… it was noted that the "Suicide Risk Assessment" conducted on a forty two year old male patient admitted with a diagnosis of Psychosis NOS, suicidal and homicidal thinking and assaultive behavior, had been rated as high risk for suicidal behavior, however the risk assessment tool does not contain a complete list of either potentiating factors, or protective factors. The tool is subjective and does not contain weighted indicators, or allow clinicians to arrive at an empirically based risk determination. • While conducting the Data Management Systems Tracer it was noted that the Suicide Risk Assessment tool utilized and related information obtained from the tool, were not sufficient to meet the evidence based objective elements that would be able to inform the Performance Improvement Process, identify needs or guide the process of testing both validity and reliability. The data is not useful, and is unable to lead to a change process - Direct Impact, Surveyor #1 
• NPSG.02.03.01 EP 1 - During data session, it was seen that there was no policy that defined critical values or critical tests in either lab or Imaging. Without these definitions and requirements for timing there is no possibility to assess the effectiveness of handling critical values and tests safely. - Indirect Impact, Surveyor #1
• NPSG.02.03.01 EP 3(?) - During Data Session, it was noted that there was no assessment of adherence to a standard of timing for the reporting of critical lab and imaging data. (see EP 1). Without a policy, there is nothing to measure - Indirect Impact, Surveyor #1
• NPSG.07.01.01 EP 1  - During Data and Infection control data sessions it was noted that the data re: Hand Hygiene Surveillance for all four quarters of the year 2009, were not completed . The absence of the data rendered the follow up processes of aggregation and analysis, and potential interventions incomplete for the year. The API Infection Control Plan identifies this as a requirement - Indirect Impact, Surveyor #2

MM/PC  Cites

RC/RI  Cites

• RC.01.02.01, EP 4 - During patient tracer activity, it was noted that there were three separate signatures that were not timed on a Master Treatment Plan. • During record review, it was noted that there were three separate signatures that were not timed on a Master Treatment Plan. • During patient tracer activity, it was noted that a part of the Master Treatment Plan was moderately unreadable due to illegibility. Even after being reviewed by two staff members there was never a complete translation provided. - Indirect, Surveyor #2

IC/WT Cites

HR/LD Cites

• HR.01.07.01, EP 1 - During the Competence session it was noted that an RN had not had the annual performance Evaluation that was indicated as having been due in 2009.Policy for the organization requires this to be completed annually. • During the competence review of employees, it was noted tha a Recreational Therapist was overdue for the 2009 Performance Evaluation. State regulations and the organization policy require this to be completed on an annual basis. - Indirect, Surveyor #2
  

IM/PI Cites

EC/EM//LS Cites 

• EC.02.05.07, EP 4 - During the document review of the generator logs, it was noted that generator 2 was tested on June 10, 2009. Except, the organization substituted the annual load bank test for the June monthly test. The annual load bank was a static load and not a dynamic load. Therefore, generator 2 did not meet the requirement of EP5 for dynamic load. The previous test was conducted on May 20, 2009 and the next test was completed on July 8, 2009. - Direct, Surveyor #3
  
• EC.02.05.07, EP 6 -  - During the document review of the automatic transfer switches, it was noted that the organization had not documented the testing of the ATS prior to September 2009. In September 2009, the form was changed to reflect the testing of the
  ATS except that only two of the three ATS were being tested in each month. The testing of the two ATS per month were a result of the method used by the organization. The organization has two generators and each generator was being tested separately each month with only one ATS being exercised. Therefore, one ATS was not tested each month. - Direct, Surveyor #4(?)
  
• EC.02.06.01, EP 1 - During a tour … it was determined that the beds being used were fairly light and easily lifted and moved. This creates a safety hazard, in that the bed could be lifted and dropped on a vulnerable body part, causing serious injury or death. Secondly, the bed could be used to barricade a door, also an unsafe condition. • During a tour … it was noted that the shower faucets and sink faucets did not meet the minimum standard of protection from suicidality, in that these both cold easily support a ligature for hanging. • During tracer activity and unit tour … it was noted that the room occupied by a medically compromisedpatient with a history of Psychotic disorder NOS, chronic pain, paraplegia, and suicidal and homicidal ideation, had ahospital type bed, which was not secured to the floor, and which had long electric cords that could potentially bedisconnected from the main affixed cord, and manipulated as a ligature. There was no evidence that a High RiskAssessment of the environment had been completed, in which this might have been identified, and therefore there was no supportive evidence that additional measures were initiated in order to afford a level of mitigation until such time that a long term corrective measure could be implemented. - Indirect, Surveyor #3
  
• EC.02.01.01, EP 1 - While conducting the environment of care tour of the Denali unit, it was noted that the patient bathroom fixtures, shower flow adjustors , and sink faucets were not modified to correct for potential risk of ligature manipulation. There was no evidence that these risk factors had been identified in a Pro Active Risk Assessment, and no supportive evidence that there was a plan to attempt to mitigate the risk to the patients until such time that a long term correction could be obtained. • During tracer activity and unit tour of the Denali unit, it was noted that the patient's Day Room had a large trash container with a large plastic bag used as a can liner. The plastic bag poses a risk for self harm to at risk patients. There was no supportive evidence that the bag placement had been previously identified via a Risk Assessment and no evidence of a plan to remove the bag as a temporary or corrective measure. - Indirect, Surveyor #3
  
• EM.03.01.03, EP 13 - During the Emergency Management session, it was noted that the organization did not evaluate the six critical functions
  for the past two disaster drills.
  Indirect, 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)

• MS.06.01.05, EP 2 - During credentials tracer, there were no criteria for determining the performance of an individual practitioner over a two-year period using a consistent data driven system. There are no sets of uniform measurable criteria used to re-grant a privilege. - Indirect, Surveyor #1
• MS.08.01.01, EP 5 - During credentials, it was noted that there was no list of triggers which can place an LIP into FPPE, nor could one be produced using the current method of OPPE data analysis. - Indirect, Surveyor #1
• MS.08.01.03, EP 1 - There is no process in place to conduct OPPE. There is no consistent Data collected to enable comparison of staff members to each other or National norms. There is no evidence in the credentials charts reviewed that OPPE is being done. - Indirect, Survyor #1

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

• Surveyor complimented the facility and the progressiveness of care being provided (treatment mall, Recovery model of care). Openess of staff in survey process.
  
• Felt Medication Reconcilliation form used at time of admission was a good example of best practice. Surveyor #1
• Noted how staff could be found engaging patients even at the level of housekeeping. Surveyor #2

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.15.01.01, EP 1
2- NPSG.02.03.01 EP  1/3
3- NPSG.07.01.01 EP 1
4- EC.02.05.07, EP 4/6

EP Related to Inirect Impact Findings:
1- RC.01.02.01, EP 4
2- HR.01.07.01, EP 1
3- EC.02.01.01, EP 1
4- EC.02.06.01, EP 1
5- EM.03.01.03, EP 13
6- MS.06.01.05, EP 2
7- MS.08.01.01, EP 5
8- MS.08.01.03, EP 1

Paul Ortner