Name    Paul Ortner
E-mail    paul.ortner@alaska.gov
Facility Name    Alaska Psychiatric Institute  TJC Org #  1526
Facility CEO    Ron Adler
Facility Address    2800 Providence Drive, Anchorage, Alaska 99508
Facility Description (Brief)    80 bed Acute Psychiatric Hospital. Most adult patients average length of stay 10 days. Small 10 bed unit for chronic patients needing extended length of stays.
# Facility Beds - Adult    60
# Facility Beds - Child & Adol    10 adolescent only
# Facility Beds - Sub Abuse    0
# Facility Beds - Forensic    10
# Facility Beds - MR/DD    0
# Facility Beds - TotaL    80
# Facility Beds - CMS Distinct Part    80

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    3/6/2007 - 3/7/2007
Survey Days (e.g., Mon - Weds)    Tues-Weds
Number of Surveyors    2
Priority Focus Areas    RFIs: Communication, Information Management, Medication Management, Orgainizational Structure, Patient Safety, Physical Environment, Life Safety Codes.
Last Survey Ending Date    2/14/2004

Profile - Surveyor #1   Jay S. Flocks, MD
Surveyor since 2005 trained under the Accreditation Manual for Hospital.
Currently Clinical Professor of Psychiatry at University of California, San Diego. Prior to joining JC Dr. Flocks was a partner physician with Southern California Permanente Medical Group, Kaiser Permanente Medical Care Plan.
Dr. Flocks is board certified in Adult Psychiatry, and is currently licensed in California as an (MD.). Dr. Flocks is also a Distinguished Life Fellow of the American Psychiatric Association.

Very engaging, friendly. He had a real focus on applying simple statistical tools to our data for the purpose of determining siginificance. We have lots of data/graphs/oryx benchmarked which did not satisfy him, he wanted the significance to us internally. We did not get a RFI but it did show up as a supplemental. Made some really good points on data analysis and medication reconcilliation.

Profile - Surveyor #2   Nina Smith, RNC, M Ed.
ANCC certification as a Psychiatric and Mental Health Nurse. Prior to joining JC was the administrator, Chief Clinical Officer and Risk Manager for Centennial Peaks Hospital in Louisville, Colorado.
RN licensed in Colorado, Texas, and California
Very pleasant and easy to work with. Recognizes the challenges of acute psychiatric care and showed patience as we identified the manner in which we satisfied standards.

# of Non-Compliant Standards    7

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

• APR 8/EP1 - We did not have posted in public how The Joint Commission can be contacted regarding patient safety concerns that have not been addressed by the hospital, including contact information for TJC.

• NPSG 2C
  • EP 2 - We did not have defined the acceptable length of time between ordering critical test results and reporting.
  • EP 3 - We did not have defined the acceptable length of time between reciept of critical test results and response by physician.
  • EP 4  - Not collecting/analyzing data on timeliness of reporting critical test results.

• NPSG 8A/EP 2 - We have a medication reconcilliation process, but have a hard time getting our medical staff to follow it. There was a failure to reconcile a list at admission and some obvious ommissions from the list regarding information that came with a patient.

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

• MM.2.20
  • EP 2 - Missed logging medication refrigerator temperature for one day in the month long log.
  • EP 7 - Date of opening on insulin vial was smudged and unreadable, should considered expired if date of opening cannot be identified. 

• MM.3.20/EP 13 - A number of failures to meet hospital policy regarding medication orders. Such as: Order written for IM/PO without direction on how to choose which route.
  • Order written by PA-C not countersigned within 72 hours.
  • Order for antacid every 4-6 hours without giving direction on how to choose which time.
  • Order written and read back but not signed within 72 hours.

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

• HR.1.20/EP 3 - Primary source verification of licenses, certification, etc. was not complete in staff files. We did have licenses and certifications in the file, but needed to have primary verification also.

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

• EC.5.30/EP 1 - Were not able to show that we had a fire drill for each shift/each qaurter. We had enough drills, missed getting them spread out on all shifts.
• EC.A.3C.1 - Three penetrations were found above the ground floor in the untility chase area.
• EC.A.5C - On one unit no exit sign at the desk area to show the means of egress if you were standing in the bedroom hallway.

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

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

• We have a new building so they were very positive about the feel of the facility itself.
• Noted that staff seemed comfortable engaging them and open in thier conversations and responses to questions.

**Misc Comments  

Preliminary Survey Result    JC: Some Requirements for Improvement

Paul Ortner