Name    Sta'Cee Crawford, RN
E-mail    scrawfo1@dhh.la.gov
Facility Name    Central Louisiana State Hospital
Facility CEO    Patrick Kelley
Facility Address    242 West Shamrock Street
Pineville, LA  71360-6439
Wk:  (318) 484-6200  Main
Fx:  (318) 484-6274  QI Fax
Facility Description (Brief)    Central Louisiana State Hospital (CLSH) is a free standing, full service psychiatric hospital licensed by the State of Louisiana, fully accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and certified by the Centers for Medicare/Medicaid Services (CMS).

CLSH provides acute, intermediate, and long-term mental health care, treatment and rehabilitative services to children, adolescents and adults.
# Facility Beds - Adult    # Facility Beds - Adult
# Facility Beds - Child & Adol    # Facility Beds - Child & Adol
# Facility Beds - Sub Abuse    # Facility Beds - Sub Abuse
# Facility Beds - Forensic    # Facility Beds - Forensic
# Facility Beds - MR/DD    # Facility Beds - MR/DD
# Facility Beds - TotaL    346
# Facility Beds - CMS Distinct Part    # Facility Beds - CMS Distinct Part
Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    IDK
Survey Days (e.g., Mon - Weds)    IDk
Number of Surveyors    1

Priority Focus Areas    1.  Information Management
2.  Communication
3.  Assessment and Care/Services
4.  Patient Safety
Last Survey Ending Date    8/29-31/06

Profile - Surveyor #1    Robert E. Koenen, RN/Leader
-He's a teacher
-Focus EOC, very thorough building tours,unlocked fences and inspected all generators
-Likes direct answers, little patience for BS
-1st day very much about business, warms up after 2nd day
Profile - Surveyor #2  Vishal K. Adma, MD, MS
-Quiet, patient
-Soft spoken and sometimes hard to hear
-Focus:  medications/med management
-Cited NPSG2 @ critical lab

# of Non-Compliant Standards    1
APR/NPSG Cites (Tag#/EP#/Brief Descrip/Surveyor)    2C  Order for stat lab in the morning- interpreted as a critical test and not back in the 5 hr timeframe b/c of hosp policy
RI/PC/MM/IC Cites (Stnd#/EP#/Brief Descrip/Surveyor)    

MM2.20  #7/9    /+   Adma
Med management@ expired meds on 2 different units (1 pt actually got expired med) - prob with insulin expiration dates b/c multi-dose vial labeled with opening date vs expiration and nurses gave inconsistent answer <want our help>

PC.8.70 #2    +   Koenen
During comp system tracer noted that clinical dietician had not received the training on death and dying

PC.4.10 #1        Koenen

PI/LD/HR/IM Cites

EC Cites    
EC.6.10  #5         Koenen
EC.5.20 #5         Koenen
EC.5.40  #12         Koenen
EC.A.6H                Koenen
EC.A.6J.1C             Koenen
EC.A.6J.8              Koenen

MS/NR Cites

**Surveyor Compliments (Policies, Procedures, etc noted by which surveyor)    +++ NPSG binder
+++ Med Reconciliation Form/Adma

**Misc Comments    **Misc Comments
Preliminary Survey Result    JC: Accredited/No Requirements for Improvement

Sta'Cee Crawford, RN