Name    Ellen Otomo
E-mail    Ellen.Otomo@illinois.gov
Facility Name    Chicago Read Mental Health Center
Facility CEO    Elaine Novak
Facility Address    4200 N. Oak Park Avenue
Chicago, IL  60634
Facility Description (Brief)    State psychiatric hospital, inpatient only, part of a tri-hospital metro Chicago system of 9 Illinois state operated facilities.  Age 18+
# Facility Beds - Adult    130
# Facility Beds - Child & Adol    0
# Facility Beds - Sub Abuse    Not separated
# Facility Beds - Forensic    0
# Facility Beds - MR/DD    Not separated
# Facility Beds - TotaL    130
# Facility Beds - CMS Distinct Part    24
Survey Type    Unannounced
Surveying Agency    JCAHO

Survey Dates (inclusive)    May 15-17, 2007
Survey Days (e.g., Mon - Weds)    Tues - Thurs
Number of Surveyors    2
Priority Focus Areas    Physical Environment
Patient Safety
Assessment and Care
Management of Information
Last Survey Ending Date    June, 2004 - last triennial; for cause

Profile - Surveyor #1   Jay S. Flocks, MD, Psychiatrist
and Team Leader.  Collegial, friendly, definitely without an "gotcha" mentality.  Fair,
found problems we were aware of.  If he saw evidence that we were actively working on
an area, he did not deliberately try to amass 3+ occurrences; however, if they
Profile - Surveyor #2    Barbara Hansen, RN;
Psychiatric Nurse Surveyor; also conducted EC survey. Wants coffee available all day.  Aside from tracer
findings, focused on external disaster preparedness,  competencies (looked for breathalyzer specifically) and
wants measurable performance

# of Non-Compliant Standards    10

APR/NPSG Cites (Tag#/EP#/Brief Descrip/Surveyor)    8A EP 1 Medication
reconciliation:  forms not consistently completed as per hospital policy.  RN

RI/PC/MM/IC Cites (Stnd#/EP#/Brief Descrip/Surveyor)    PC.8.10 EP       1,3,7   MD: 
Pain assessments:  not consistently reassessed and/or treated when positive pain screen occurs.  Wants pain as 5th vital sign.

PC.12.150 EP 2       RN:
15 minute documentation on several charts showed patient "calm" in restraint, yet not discontinued soon after this was charted.  Wants RN's to reassess more frequently.

MM.2.20  EP 2       MD:
Multidose vials opened, not consistently labeled with date, and some were past the 28 day expiration date.

MM.7.10  EP 3       MD:
Long acting
PI/LD/HR/IM Cites (Stnd#/EP#/Brief Descrip/Surveyor)    IM.6.10  EP      4       MD:
No dates entered for signature on the discharge summary; questioned reliability of medical record delinquency data.

HR.1.25  EP 1,2,3,5      RN:
No policies to address this standard were in place for volunteers; provisions did exist in the Medical Staff By Laws

EC Cites (Stnd#/EP#/Brief Descrip/Surveyor)    EC.7.40  EP        2      RN:
No documentation of testing of automatic transfer switches on the generator

EC.5.20  EP       RN:
Penetrations, Enclosed air conditioner, staff did not all have keys to a padlocked gate; one burned out exit light

EC.9.10  EP 3      RN:
Generator temp and oil pressure readings were rounded off, thereby not giving an acceptable variance range and does not reflect acutal readings

MS/NR Cites (Stnd#/EP#/Brief Descrip/Surveyor)    MS/NR Cites (Stnd#/EP#/Brief Descrip/Surveyor)

**Surveyor Compliments:  MD felt our medication reconciliation form "meets the standard perfectly" and took it as a best practice example.

MD felt our pain assessment form was a best practice
MD felt our documentation of restraint was "superb."

MD stated our leadership team was very strong, worked together very well, felt that it was obvious that the staff cared about the patients and were trying to do the right things right.  He said he would admit his own family here.

**Misc Comments       

JC: Accredited/No Requirements for Improvement

Ellen Otomo