Name    Stacey Werth-Sweeney
E-mail    Stacey.Werthsweeney@nebraska.gov
Facility Name    Lincoln Regional Center (LRC)_!3Ad1Ca3FR2Sx
Facility CEO    William Gibson, CEO
Facility Address    801 W. Prospector Place Lincoln, NE 68521
Facility Description (Brief)    On file
# Beds - Adult (Civil only)    131
# Beds - Child & Adol (Civil only)    24
# Beds - Forensic    119
# Beds - Geriatric    0
# Beds - MR/DD    0
# Beds - Sex Offender    88
# Beds - Sub Abuse    0
# Beds - Total (all Civil & For)    250
# Beds - CMS Distinct    131

Survey Type    Triennial Unannounced    
Surveying Agency    JCAHO
Survey Dates (inclusive)   1/10-14/11
Survey Days (e.g., Mon - Weds)    Mon-Fri
Number of Surveyors    3
Priority Focus Areas    
Last Survey Ending Date    1/18/08

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Edward K.Katz, MD - Psychiatrist/Team Leader – was very chatty, seem to be talking about everything but the tracer and then zing you at the end…it was bizarre… very friendly, seasoned surveyors… actually very helpful.  It was a good experience overall.

Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)   Barbara J.Hansen, MA, RN - Nurse Surveyor –  was very chatty… very concerned about infection control standards… very friendly… seasoned surveyor… actually very helpful… good experience overall.

Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks) Peter M.Jaroscak - Life Safety Code Specialist –

# of Non-Compliant Standards    17 (HAP: 7 Direct/ 10 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites

• NPSG.02.03.01/EP 2/ Observed    /Indirect/Surveyor #2
• NPSG.15.01.01/EP1/ Observed   /Direct Surveyor#1
•  

MM/PC  Cites

• PC.01.02.01/EP 23/  Observed    /Indirect/Surveyor #2
• PC.01.01.03/EP 4/ Observed   /Direct Surveyor#1
• PC.01.03.01/EP 1/ Observed   /Direct Surveyor #2
• PC.03.01.01/22/ Observed   /Direct Surveyor#1

RC/RI  Cites

IC/WT Cites

HR/LD Cites

• HR.01.02.05/EP 2/ Observed    /Indirect/Surveyor #2
• HR.01.03.11/EP 1/ Observed    /Indirect/Surveyor #2
• HR.01.07.01/EP 1/ Observed    /Indirect/Surveyor #2
   
• LD.04.03.09/EP 4/ Observed     /Indirect/Surveyor #1
• LD.04.03.09/EP 5/ Observed     /Indirect/Surveyor #1
• LD.04.03.09/EP 6/ Observed     /Indirect/Surveyor #1
• LD.04.03.11/EP 5/ Observed     /Indirect/Surveyor #1

IM/PI Cites

EC/EM//LS Cites 

• EM.01.01.01/EP 2/ Observed in Environment of Care Session The organization had not conducted a hazardous vulnerability analysis pertinent to the off-campus residential site. This site provided residential care to a specialized adolescent sex offender program.    /Indirect/Surveyor #3
• EM.03.01.01/EP 1/ Observed    /Indirect/Surveyor #3
• EM.03.01.01/EP 1/ Indirect Impact
• EC.02.01.01/EP 1/ Observed in Environment of Care Session The organization had not assessed and identified safety and security risk associated with the environment of care at the off-campus residential site. The program provided a specialized program for adolescent sex offenders.    /Direct/Surveyor #3
• EC.02.01.01/EP 3/ Observed    /Direct/Surveyor #3
• EC.02.03.05/EP 2/ Observed    /Direct/Surveyor #3
• EC.02.03.05/EP3/ Observed    /Direct/Surveyor #3
• EC.02.03.05/EP4/ Observed    /Direct/Surveyor #3
• EC.02.05.07/EP 6/ Observed    /Direct/Surveyor #3
• LS.01.01.01/EP 14/ Observed    /Direct/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.08.01.03/EP2/ Observed     /Indirect/Surveyor #1

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

• They complimented us on our work on having a person centered culture, our mission and vision and talked during their tours and tracers about how they could see this in place.  For instance, one of them complimented boards we have in each our patient units that has all of our staff pictures that identifies for the patients who will be working with them.  They thought this was a great example of being person centered.  They were complimentary of our treatment with the long term Not Responsible for Reason of Insanity (NRRI) patients.  We have a system in place to help them earn privileges and rewards without diminishing their hope due to the inability of being discharged from the hospital for a very long time.  We have Behavioral Baseline forms that help us track their daily attendance, ADL’s, and behaviors on the unit and they suggested we think about turning this in to their library as a best practice. 
   

Preliminary Survey Result    AAccreditation with Follow-up Survey

**Misc Comments, Suggestions, Etc    **Misc Comments, Suggestions, Etc

•  Note: Both our 45 and 60 day plans of correction were accepted and in August we will submit our Measures of Success.

Stacey Werth-Sweeney