Name    Rhonda Wilson
E-mail    rhonda.wilson@illinois.gov
Facility Name    Chester Mental Health Center
Facility CEO    Pat Kelley
Facility Address    1315 Lehman Dr.
Chester, IL 62233
Facility Description (Brief)    Maximum Security State Forensic Mental Health Facility
# Facility Beds - Adult    280
# Facility Beds - Child & Adol    None
# Facility Beds - Sub Abuse    Included in adult numbers
# Facility Beds - Forensic    Included in adult numbers
# Facility Beds - MR/DD    Included in adult numbers
# Facility Beds - TotaL    280
# Facility Beds - CMS Distinct Part    N/A
Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    March 27-29, 2007
Survey Days (e.g., Mon - Weds)    Tues-Thurs
Number of Surveyors    4
Priority Focus Areas    Patient Safety
IM
IC
Staffing
Last Survey Ending Date    January 2004

Profile - Surveyor #1    Gayle Corrien Nash-RN
Surveyor since 2001.  Survey team leader.  Very strict, focued on handwashing, IC, Competency.  Focused heavily on 1-2 staff members once found a problem in an area and was relentless in the tracer.
Profile - Surveyor #2     Leo Kirven, Jr., MD
Elderly feable gentleman.  Old school.  Focused on legability and medication reconciliation.  Had psychiatric experience. Not in a hurry.
Profile - Surveyor #3     Jerry Dykman-BS in Administration.  Surbveyor since 1993.  Understanding, cooperative.  Very interested in keeping the facility best interests in mind.  Tried to teach resolution if a problem was found.
Profile - Surveyor #4    Mike Messer  CHFM
Life Safety Code Specialist on site for one day.  Quiet, kind and informative.

# of Non-Compliant Standards    12

APR/NPSG Cites (Tag#/EP#/Brief Descrip/Surveyor)   

7A  EP1  Handwashing guidelines.  No data of tracking and observation of handwashing via audits.  (Noted by RN Surveyor)

8A EP2 No formal Medication Reconciliation Form in place.  Didn't accept accountability system in place. (Noted by RN Surveyor)

2E Hand -Off Communication
Nursing hand off report observed by surveyor and was considered inadequate.  Inability to prove that proper hand-off was occurring.
(RN and Administrative surveyor)

UP 1C Time out for universal protocol.  No time out was conducted here by a dentist for tooth extraction.  Surveyor stated teeth have unilaterality. (RN) 

9A Fall Reduction Program  EP3 and EP6  No identified interventions t reduce fall risks.  Didn't have adequate fall data or outcome indicators. (Physician)

RI/PC/MM/IC Cites (Stnd#/EP#/Brief Descrip/Surveyor)   

IC 5.10 EP1  IC program evaluated the effectiveness of IC interventions.  Found inadequate data to trend and analyze the IC program (RN surveyor)

PC 7.10  EP2 Food conditions on tray.  Our trays delivered to the unit were not properly covered. (RN)

IC 7.10 EP1  Not a sufficient # of IC staff.  We had .40 staff allocation and they wanted more.  Ideal 1.8 FTE
(RN)

PI/LD/HR/IM Cites (Stnd#/EP#/Brief Descrip/Surveyor)   

IM 6.10 EP 10 and 13.
10-Didn't have one year of medical record deficiency rates information upon arrival of the JC.  We had staff change and missing 5 months.  Our rates were acceptable but fatal error in not having them so = Contitional Accreditation.  Tried appeal to Accreditation Committee without success. (Administrator)
13-Legability finding- Found 3 records with notes difficult to read (Physician)

HR 1.10 EP1 Staffing  Not enough due to state hospital with position unfilled. (All 3)

HR 3.10  Staff Competency EP6  Competency assessment process is based on the assessment methods.  Finding assessment method was not identified on the competency forms (RN)

EC Cites (Stnd#/EP#/Brief Descrip/Surveyor)    EC 5.40 EP10  The hospital maintains fire safety equipment and building features.  We missed on fire extinguisher inspection in the last year of the kitchen automatic fire extinguisher system (1 Day engineer)

MS/NR Cites (Stnd#/EP#/Brief Descrip/Surveyor)    None

**Surveyor Compliments:    Stated we had done a good job of trying to reduce S/R use and had a good data follow-up system. Complimentary of follow-up and care despite what they felt was a definite staffing concern.

**Misc Comments    Overall much more rigoreous than the last survey.  Very driven by outcome measures from dat review.  Data alone is not enough.

Preliminary Survey Result    JC: Conditional Accreditation

Rhonda Wilson