1 Jan 2000
Name XXXXXXXXX, Quality Improvement Coordinator
E-mail paul.ortner@alaska.gov
Facility Name: XXXXXXXXXXXXX
Facility CEO: XXXXXX
Facility Address: 123 Main Street, City, State, Zip
Jt Com Org ID# 1526
# Beds - Adult: XX
# Beds - Child & Adol: XX
# Beds - Forensic: XX
# Beds - Geriatric: 0
# Beds - MR/DD: 0
# Beds - Sex Offender: 0
# Beds - Sub Abuse: 0
# Beds - Total: XX
# Beds - CMS Distinct: XX
# Units - Total: X
# Staff - Total: XXX
Survey Type Unannounced
Surveying Agency JCAHO
Survey Dates (inclusive)
Survey Days (e.g., Mon - Weds)
Number of Surveyors 3
Priority Focus Areas
Last Survey Ending Date 3/7/07
Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks) Jay S. Flocks, MD/Psychiatrist - Conducted
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks) Eileen H. Fraser, MA, RN /Nurse,
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks) Byron Kitagawa /Environment
# of Non-Compliant Standards 12 (HAP: 4Direct/ 8 Indirect) {BHC: Direct/ Indirect} [1 Clarified]
APR/NPSG Cites
- NPSG.15.01.01, EP 1 - During - Indirect, Surveyor #2
MM/PC Cites
RC/RI Cites
- RC.01.02.01, EP 4 - During . - Indirect, Surveyor #2
IC/WT Cites
HR/LD Cites
- HR.01.07.01, EP 1 - During the . - Indirect, Surveyor #2
IM/PI Cites
EC/EM//LS Cites
- EC.02.05.07, EP 4 - During the 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 - Indirect, Surveyor #2
**Surveyor Compliments (Policies, Procedures, etc noted by which surveyor)
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-
2-
3-
4-
5-
6-
7-
8-
EP Related to Inirect Impact Findings:
1-
2-
3-
4-
5-
6-
7-
8-
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