Name    Rhonda Wilson, Quality Manager
E-mail    Rhonda.Wilson@illinois.gov
Facility Name:   Chester Mental Health Center
Facility CEO:  Patricia Kelley
Facility Address:  1315 Lehman Drive, Chester, Illinois  62233

Jt Com Org ID#     1505

# Beds - Adult:
# Beds - Child & Adol:
# Beds - Forensic: 280
# Beds - Geriatric:
# Beds - MR/DD:
# Beds - Sex Offender:
# Beds - Sub Abuse:
# Beds - Total: 280
# Beds - CMS Distinct:
# Units - Total: 5
# Staff - Total: 533

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    3/22-24/2010
Survey Days (e.g., Mon - Weds)    Mon - Weds
Number of Surveyors   4
Priority Focus Areas   
Last Survey Ending Date  3/27-29/07

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)  Gracie Bumpass RN, MPA – Nurse Surveyor/ Gracie Bumpass is currently a resident of North Carolina.  Ms. Bumpass has been a Joint Commission surveyor since 2005, and is trained under the Accreditation Manual for Hospitals. Ms. Bumpass is presently a surveyor in the Hospital accreditation program. Ms. Bumpass is the Quality Manager at the Federal Medical Center in Butner, N. C.   Ms. Bumpass is currently licensed in North Carolina as a Registered Nurse. Focused on Infection Control, Direct Care Staffing, Falls, Competencies, Medication, Critical Radiology Tests.  Tips-Quiet at first, does quick tracers and fires off questions quickly.  If answer intelligently and quickly will quickly change directions.  Warmed up to staff by third day.  Very thorough and fair.

Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)   Jay S. Flocks, MD/Psychiatrist -  Jay Flocks, MD  is currently a resident of California. Dr. Flocks has been a Joint Commission surveyor since 2005, and is trained under the Accreditation Manual for Hospital. Dr. Flocks is presently a surveyor in the Hospital Accreditation Program.  Dr. Flocks is currently Clinical Professor of Psychiatry at the University of California, San Diego.  Prior to joining the Joint Commission, Dr. Flocks was a partner physician with Southern  California Permanente Medical Group, Kaiser Permanente Medical Care Plan. Dr. Flocks is board certified in Adult Psychiatry, and is currently licensed in California as an (MD.).  Dr. Flocks is also a Distinguished Life Fellow of the American Psychiatric Association. As indicated by the SPHCC advice a stickler for the hand hygiene between each patient on medication pass,  He focused on Medical Staff and the OPPE and FPPE practices and meet with treatment teams and medical staff.  Overall friendly and helpful.

Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)   Joan Kateiva, RN, Administrator Surveyor and Survey Team Leader/ Joan Kateiva is currently a resident of Louisiana. Mrs. Kateiva surveys the standards in the Comprehensive Accreditation Manual for Hospitals. Mrs. Kateiva is presently a surveyor in the Hospital Accreditation Program. Prior to joining the Joint Commission, Mrs. Kateiva had been the vice president of Quality and Care Management, Ochsner Clinic Foundation, New Orleans, Louisiana; Vice President Operations, Ochsner Foundation Hospital, New Orleans, Louisiana. Joan’s 12 years of military nursing experience involved critical care and medical surgical patients.Mrs. Kateiva is currently licensed in Louisiana as an RN.   Mrs. Kateiva also maintains membership in the American College of Health Care Executives. Focused on primarily medical issues and Leadership role.  Focused on the role of governing body and how the organization chart is designed.  Overall friendly, very professional, somewhat military style in approach, direct but fair. 

Profile - Surveyor #4 (Name/Disc/Tm Role/Traits/Quirks) Charles "Bill" Wensyel, P.E., C.E.M., Life Safety Code Specialist/Engineer/ Charles W. “Bill” Wensyel is currently a resident of the Commonwealth of Pennsylvania. Mr. Wensyel has been a Joint Commission Life Safety Code Specialist since 2009, and is trained under the Comprehensive Accreditation Manual for Hospitals and the Comprehensive Accreditation Manual for Critical Access Hospitals. Prior to joining The Joint Commission, Mr. Wensyel was the System Director, Engineering at Heritage Valley Health System located outside Pittsburgh, PA.  Mr. Wensyel is a Registered Professional Engineer in the Commonwealth of Pennsylvania and the State of West Virginia.  He is also certified with the Association of Energy Engineers as a Certified Energy Manager.  Focused on transfer switch logs, fire extinguisher checks having a date and went up into almost every ceiling space he could see.  Very thorough and friendly.

# of Non-Compliant Standards    22 (HAP: 9Direct/ 13 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites

• NPSG.07.07.01/EP1/CDC Hand washing/Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.  Five consecutive patients were seen receiving medication.  In no instance did the nursing administering the medication decontaminate he hands between patients/Direct Impact 45 Days/Srvyr #2
• NPSG.15.01.01/EP1/Suicide Assessment/Identify patients at risk for suicide.  The suicide risk Assessment tool was not specific to enable the staff to identify specific patient characteristics and environmental features that may increase or decrease the risk for suicide. Surveyor felt the tool didn’t identify the most important predictors of suicide. These were not weighed by importance. Then, the clinician was asked to use his/her judgement concerning suicidality with no data- driven way of attaching this judgement to the questions. This disconnect results in an incomplete suicide assessment.  The suicide assessment as above did not produce a data-driven way of connecting major contributing predictors of suicide with the clinician's appraisal of suicide, resulting in a weak, subjective appraisal.  Need to find a tool that is data driven and objective./Direct Impact - 45 Days/Srvyr #2
• NPSG.02.03.01/EP 1/ Critical Diagnostic Tests/Report critical results of tests and diagnostic procedures on a timely basis. The organization had not developed written procedures for managing critical results from diagnostic radiology procedures. They had not defined critical radiology results nor the acceptable length of time between the availability and reporting of these results.  Felt that our policy was weak in not defining in advance the radiology tests and results we felt would be critical./ Indirect 60 Days /Srvyrs #2, #3

MM/PC  Cites

• MM.01.02.01/EP 2/ LASA Medication/The hospital addresses the safe use of look-alike/sound-alike medications.  EP 2 It was noted that a yellow plastic box which signifies look alike, sound alike medication was labeled Metoprolol. Although there were some tablets of Metoprolol in the container, there was also a large box of Metronidazole. Confusion of these two drugs could result in a sentinel event./Indirect 60 Days/Srvyr #2
• PC.01.02.03/EP 3/ Annual Nursing Psychiatric Assessment/The hospital assesses and reassesses the patient and his or her condition according to defined time frames. During an individual tracer it was observed the patient did not have an annual psychiatric nursing assessment per organization policy. Our policy did not require an annual psychiatric nursing assessment so we are fighting this finding. Direct 45 Days/Survyr # 1
• PC.01.02.07/EP 1/Pain Assessment/The hospital assesses and manages the patient's pain. Observed in Unit A at Chester Mental Health Center site. During patient tracer activity, it was noted that no pain scale was used in the evaluation of pain on admission as suggested in hospital policy. Patient is asked merely whether they are currently in pain. No evaluation or data gathering of other pain syndromes was done, even though pain is alluded to in the chief complaint. Surveyor wanted an assessment for chronic pain issues on admission./Direct 45 Days/Survyr # 3
• PC.01.02.08/EP 2/Fall Follow up/The hospital assesses and manages the patient's risks for falls.  Observed in C Unit Module 1 at Chester Mental Health Center site. During an individual tracer it was observed that the patient was evaluated for fall risk and was classified as a "moderate risk". There were no documented interventions to reduce patient falls. We now changed policy to ensure evaluated after each fall and to document the follow up plan./ Direct 45 Days/Survyr # 1
  

RC/RI  Cites

• RC.01.01.01/EP 7/ The hospital maintains complete and accurate medical records for each individual patient. The physician had ordered a test (2/27) to determine if the patient was malingering. The results were not on the record at the time of the survey. After investigation by the staff it was determined that the test had not been sent out to be interpreted. The pending test results were considered important for discharging the patient. During a patient tracer it was noted that the patient had a valproic acid level of 111, which was considered high by the reference lab. Further review of the record could not support that the result had been noted by the physician./ Indirect 60 Days/Survyrs # 2, 3
• RC.01.02.01/EP 3/ Physician Signatures/ Entries in the medical record are authenticated. Three orders were signed illegibly and none were qualified by a stamp, number, or other unique identifier which would clearly identify the author.  We have a physician signature page, but they didn’t accept the posted signature page./ Indirect 60 Days/Survyr #2
  

IC/WT Cites

• WT.01.01.01/EP 6/ Glucose Bottle Open Dates/ Policies and procedures for waived tests are established, current, approved, and readily available. Observed in Unit A at Chester Mental Health Center site. During a tour of glucometer bottles of test solutions were found with relatively unreadable dating and appeared to have been opened six months before and should have been considered expired. Plan to attach expiration date and open dates on a label attached to zip tie around waive test bottles./ Direct 45 Days/Survyr # 1
• WT.05.01.01/EP 3/ Accu Check Form/The hospital maintains records for waived testing.  Patient on an insulin sliding scale regime it was noted that the form used to record the results of the accu- Check did not include reference intervals specific to this testing method. Reference ranges form had ranges, but page 2 didn’t./ Indirect 60 Days/Survyr #3
  

HR/LD Cites

• HR.01.02.05/EP 1/ Primary Source Verification/The hospital verifies staff qualifications.   During the competency system tracer it was observed that there were two dieticians and one radiology technician whose license or certification had not been primary source verified until 03-23-10./ Indirect 60 Days/Survyr # 3
• HR.01.05.03/EP 1/ Contract - education and training /Staff participate in ongoing education and training. During the competency system tracer it was observed that the two dieticians had no documentation of ongoing education and training to increase their competency.  Indirect 60 Days/Survyr #1
• HR.01.06.01/EP 3/ Competencies/ Staff are competent to perform their responsibilities.   The dental hygienist annual competence are evaluated by the organization's medical director who is a psychiatrist. The medical director does not have the educational background, experience, or knowledge to effectively evaluate this employee. The organization had a contracted dentist who works with this employee and would be able to provide an evaluation of the employee.  The contracted radiology technologist annual competence assessment was performed by the organization's medical director who is a psychiatrist. The films are sent to a contacted radiologist who would be more appropriate to evaluate the technical competence of this contracted service./ Indirect 60 Days/Survyr # 1
• LD.03.06.01/EP 3/ Staffing/ Those who work in the hospital are focused on improving safety and quality. During individual tracers on the C unit it was observed that there were three separate modules each containing 21 patients for a total of 63 patients. The was staff with only one RN and one LPN to care for these patients.  The other staff on the modules were security therapy associates who report to the security department with no evidence in the organization chart of a direct or indirect reporting responsibilities to nursing. The security associates were being counted in the numbers for direct FTE patient staff ratio's. The use of Restraint and Seclusion over the last six months averaged 22% . In addition the incident rate of staff injuries over the same time period averaged 17 per month The organization has closed one unit which did result in a decrease in their ADC. However observations reveals their are no nursing coverage for each modules. The organization's Nursing Staffing plans only requires one RN or one LPN for each unit, this coverage was inadequate for the total number of patients on the unit. Concern over staffing reoccurred from previous surveys./ Direct 45 Days/Survyr #1
• LD.04.03.09/EP 6/Contract   Leaders evaluate services/ Care, treatment, and services provided through contractual agreement are provided safely and effectively. During the review of Human Resources and training files it was observed that two contract dieticians and one radiology technician contracted services had not been evaluated.  Facility did not have any formal system in place for contract staff./ Indirect 60 Days/Survyr #3
  
  

IM/PI Cites

EC/EM//LS Cites 

• EC.02.05.07/EP 1/ The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply. The organization could not provide documentation that the battery powered egress light in the vicinity of Room 2233 has been tested any month during the past 12 months./ Direct 45 Days/ Survyr # 4
• EC.02.05.07/EP 2/Test Battery egress light annual/ The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply. The organization could not provide documentation that the battery powered egress light in the vicinity of Room 2233 has been tested for 90 minutes during the past 12 months./ Direct 45 Days/Survyr # 4
• EC.02.05.07/EP 6/Documentation of Transfer Switches/ The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.  The organization could not provide documentation that any of the three automatic transfer switches had been tested during the month of July, 2009, October, 2009, December, 2009./ Direct 45 Days/ Survyr #4
• EC.04.01.01/EP 15/Annual EOC Report/The hospital collects information to monitor conditions in the environment. The organization could not provide evidence that each environment of care management plan had been evaluated./ Direct 45 Days/Survyr #4
• EC.02.03.05/EP 15/Fire Extinguishers/ The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply. The monthly inspection of the fire extinguisher was not properly documented.  The extinguisher card had month and initials, but no date./ Indirect 60 Days/Survyr #4
• EC.02.06.01/EP 1/ Electrical Junction Boxes/ The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community. Two open electrical junction boxs were found./ Indirect 60 Days/ Survyr #4
• LS.02.01.10/EP 5/ Fire Doors/ Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.   Three areas did not close tightly and thus could not prohibit the transfer of smoke./ Indirect 60 Days/Survyr #4
• LS.02.01.10/EP 9/ Penetrations/ Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. - During the building tour two unsealed penetration were found, one in the wall and one in the 2 hour ceiling./ Indirect 60 Days/ Survyr #4
  
   

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.08.01.01/EP 5/ FPPE/ The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance. Observed in Credentials Tracer it was noted that there did not exist a list of specific triggers for initiation of FPPE. The matter was left up to the medical director. Triggers added to policy./ Indirect 60 Days/Survyr # 2
  

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

• Zip ties for medication insulin vials.  Colored ties to easily identify long acting from short acting. (Borrowed idea from sister hospital).
• Liked our treatment planning process and reports - liked how it included all members of the treatment team.
• Excellent documentation on response to first dose to a medical medication.  (Often time psychiatric hospitals forget to document first dose on medical issues.
• Good follow up on giving pain medication.
• Very impressed with our Infection Control program and practices.
• Really liked our Failure Mode Effect (FMEA) Analysis on diets.  Great help from our Dietary manager and Assistant Business Administrator on doing this.
• Really liked our FMEA on medication.  Dr. Suneja originally did the first one and it has been improved by the Pharmacy Director and Quality Management and a PI project to train the FMEA was done with each discipline (Physician/Psychiatrist, Nursing, and Pharmacy) for potential areas that might effect them. 
• Great OPPE process (Ongoing Physician Practice Evaluation).  Kudos from the physician surveyor at exit as not many facilities in the country have a thorough process in place.  Great efforts from the Medical Director Executive Secretary to accomplish this.
  
  

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.07.07.01/EP1
2- NPSG.15.01.01/EP1
3- PC.01.02.03/EP 3
4- PC.01.02.07/EP 1

5- PC.01.02.08/EP 2
6- WT.01.01.01/EP 6
7- LD.03.06.01/EP 3/
8- EC.02.05.07/EP 1/6

9- EC.04.01.01/EP 15

EP Related to Inirect Impact Findings:
1- NPSG.02.03.01/EP 1
2- MM.01.02.01/EP 2
3- RC.01.01.01/EP 7
4- RC.01.02.01/EP 3
5- WT.05.01.01/EP 3
6- HR.01.02.05/EP 1
7- HR.01.05.03/EP 1
8- HR.01.06.01/EP 3
9- LD.04.03.09/EP 6
10 - EC.02.03.05/EP 15
11 - EC.02.06.01/EP 1
12 - LS.02.01.10/EP 5/9
13 - MS.08.01.01/EP 5

Rhonda Wilson, Quality Manager