Name    Sandra D. Ross
E-mail    sandra.ross@illinois.gov
Facility Name    Alton Mental Health Center
Facility CEO    Susan Shobe
Facility Address    4500 College Age
Alton, IL 62002
Facility Description (Brief)    Psychiatric Hospital - - Civil and Forensic Units
# Facility Beds - Adult    125
# Facility Beds - Child & Adol  
# Facility Beds - Sub Abuse   
# Facility Beds - Forensic    110
# Facility Beds - MR/DD   
# Facility Beds - TotaL    125
# Facility Beds - CMS Distinct Part    15

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    9/10/07 - 9/12/07
Survey Days (e.g., Mon - Weds)    Monday - Wednesday
Number of Surveyors    2
Priority Focus Areas    Rights & Ethics,
Assessment & Care/Services, Physical Environment, Communication
Last Survey Ending Date    August 18 - 20, 2004

Profile - Surveyor #1   Dwight A. Owens, M.D.

Dwight A. Owens, M.D.  has been a Joint Commission surveyor since 2005, and is trained under the Accreditation Manual for Hospital.

Dr. Owens is presently a surveyor in the Hospital accreditation program.

He is the former Medical Director of the Fulton County Department of Mental Health, Developmental Disabilities and Addictive Diseases and currently is the CEO/Chief Psychiatrist for Peachstate Psychiatric Services in Atlanta.

Dr. Owens is board certified in General and Adult Psychiatry and is board eligible in the subspecialty of Forensic Psychiatry.  He has an active license in the state of Georgia and serves as faculty for the Osler Institute in Terre Haute, Indiana.

Profile - Surveyor #2  Stephen F. Knoll, C.R.N.A., M.A

Stephen Knoll is currently a resident of the State of Texas.

Mr. Knoll has been a Joint Commission surveyor since 2005, and is trained under the Accreditation Manual for Hospitals. Mr. Knoll is presently a surveyor in the Hospital Accreditation Program.

Prior to joining the Joint Commission, Mr. Knoll’s career has been in clinical, administrative and educational positions in anesthesia; executive experience with depth in hospital acute care, ambulatory, nursing and perioperative programs.  A large portion of his career was at The Queen’s Medical Center in Honolulu, Hawaii.  Most recently, he was a Vice President at Trinity Mother Frances Health System in Tyler, Texas and immediately prior to this position, he served as an Executive Director at Columbia Presbyterian Medical Center, New York, New York.

Mr. Knoll is currently licensed in the State of Texas and is a Registered Professional Nurse (R.N.).  He is also a member of the American College of Healthcare Executives.

# of Non-Compliant Standards    8

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

• NPSG 2C  Collected appropriate data for less than six months (Knoll)

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

• PC.3.120 - - comprehensive Substance Abuse assessments not done for patients with substance abuse diagnosis(Owens)
• PC.12.40 - - Personal Safety Plans (Behavioral health advance directive) not completed (Owens)
• IC.3.10 - - IC Plan did not indicate a specific quantifiable goal for hand hygiene program (Knoll)

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

• PI.1.10 - - had not collected data on behavior management techniques (Owens)

EC Cites (Stnd#/EP#/Brief Descrip/Surveyor)   

• EC.1.10 - - specimen refrigerator; out of range temperature indicated no action (as indicated per policy) (Owens)
• EC.5.20 - - wood porch for civil building did not have auto sprinkler (Knoll); pharmacy storage within 18" space below ceiling (Owens)
• EC.5.40 - - fire extinguishers not checked on a monthly basis (Owens)

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

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

**Surveyor Compliments: 

• Complimented on Suicide/Violence Risk Assessment process
• Very complimentary about Medication Management process

**Misc Comments  

Preliminary Survey Result    JC: Some Requirements for Improvement

Sandra D. Ross