Name    Donna L. Murray, Interim Hospital Administrator
Facility Name:   Clyde L. Choate Mental Health Center
Facility CEO:  Elaine Ray, Facility Director
Facility Address:  765 Little Creek Loop, Dongola, IL, 62926

Jt Com Org ID#     622

# Beds - Adult: 70
# Beds - Child & Adol: 9
# Beds - Forensic: 0
# Beds - Geriatric: 0
# Beds - MR/DD: 0
# Beds - Sex Offender: 0
# Beds - Sub Abuse: 0
# Beds - Total: 79
# Beds - CMS Distinct: 0
# Units - Total: 3
# Staff - Total: 167

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates  12/7-8/09 
Survey Days ( Mon - Tues) 
Number of Surveyors   3
Priority Focus Areas   
Last Survey Ending Date  12/15/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)  Vishal K. Adma, MD,MS/Leader: He was focused on C&P information, medical staff by-laws, leadership, review of scripts (range orders, verbal orders, do not use), review of MSO policy and brief validation we followed them, and review of initial assessments upon admission to ensure we IMMEDIATELY assessed suicide risk and put plan in action. VERY easy to deal with and helpful. He took more of an educator role.

Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Roger L. Cagle, CHFM  /Architech/Engineer.  VERY easy to deal with and helpful. He took more of an educator role. From TN and stated there are minimal architech/engineers in this region so we surmise he may be visiting several of our state hospitals .

Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks) Rosie L. Stanfield, EdD, MSN, RN Surveyor.  She focused on data and how we use it, employee evaluations and competencies, weight documentation and the policy on fluctuation and notification, primary cource verification for NON-physician licensed staff (particularly system at license renewal time), disasters drills, med errors, and if ALL documents in record were signed, dated amd TIMED.  She did not take as much of an educator role and her strong military background was very evident.

# of Non-Compliant Standards    7(HAP: 3Direct/ 4 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites 

MM/PC  Cites

• PC.01.02.03, EP 3 - Orders written for weight lacked documentation of follow through as the ordered required or follow up when a weight had fluctuated - Direct - #3

RC/RI  Cites

• RC.01.01.01, EP19-  Documentation in clinical record did not always have date and time after signature. Time was the issue overall.- Indirect- #1 and #3
• RC.02.03.07, EP4- Telephone orders not authenticated within 24 hours per hospital policy.- Indirect- #1

IC/WT Cites   

HR/LD Cites

• HR.01.02.05, EP 1 - No documentation that a primary source verification was done with any licensed personnel at the exact time of the renewal of license.- Indirect- #3
  
  
• LD.04.03.07, EP 1 - Patient's who are admitted during after hours are seen by MOD (who is usually an internist or a family practice doctor). These physicians generally continue only medications that are required for the patient's medical issues (i.e. synthyroid for hypothyroidism) and generally do not continue the psychotropic medications (i.e zyprexa). This leads to patients not receiving psychotropic medications for up to 24 hours of stay. Also, a patient who is prescribed a stimulant medication later in the day, the nurse will not be able to access it in the Documed (not available) for the next day, and probably through the weekend as there is no pharmacy
  open during the weekend.- Indirect- #1
  

IM/PI Cites

EC/EM//LS Cites 

• EC.02.03.01, EP 1 - Electrical junction boxes without covers. - Direct- #2

• EC.02.05.07, EP 6 - No documentation showing that all automatic transfer switches were tested twelve times a year, at intervals of not less than 20 days and not more than 40 days apart. The staff also said that this was not being done.- Direct- #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)

• Was very impressed with our C&P process, forms, policy, etc.  Took a few of our forms.
  

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.01.02.03, EP 3
2- EC.02.03.01, EP 1
3- EC.02.05.07, EP 6

EP Related to Inirect Impact Findings:
1- RC.01.01.01, EP19
2- RC.02.03.07, EP4
3- HR.01.02.05, EP 1
4- LD.04.03.07, EP 1

Donna L. Murray