Name    Janice Lubeck
E-mail    janice.lubeck@lsh.ks.gov
Facility Name    Larned State Hospital  TJC org# 3186
Facility CEO    Mark E. Schutter, Ph D
Facility Address    1301 KS Hwy 264, Larned, KS 67550
Facility Description (Brief)    State Psychiatric Hospital with three programs: Psychiatric Services Program (PSP), State Security Program (SSP), and Sexual Predator Treatment Program (SPTP).
# Beds - Adult    555
# Beds - Child & Adol    25
# Beds - Sub Abuse    03
# Beds - Forensic    260
# Beds - MR/DD    0
# Beds - TotaL    580
# Beds - CMS Distinct Part    104

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    Aug 28-31, 2006
Survey Days (e.g., Mon - Weds)    Mon-Thurs.
Number of Surveyors    4
Priority Focus Areas    Patient Safety, Communication, Organizational Structure,
Information Management
Last Survey Ending Date    8-31-06

Profile - Surveyor #1     Jay S. Flock, MD
Profile - Surveyor #2     H.D. Brown, FACHE, Administrator
Profile - Surveyor #3     Marsha A. Barnden, MSN
Profile - Surveyor #4     David K. Samples, LSC

# of Non-Compliant Standards    14

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

• NPSG 1: Lab blood specimens had handwritten labels. Did not have a policy for managing a name alert situation.
• NPSG 2: Found 3 phone orders that had not been read-back.
• NPSG #3: Various types of insulin were stored together, did not have a high-alert sticker on them. Several drugs found in the Night Locker had high-alert sticker on them, but were not part of the approved list of LASA medications.
• NPSG 8: Six observations of incomplete medication reconciliation processes; lack of physician participation, lack of date on form, missing form, lack of patient participation.

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

• PC.7.10, EP 2: A patient food refrigerator temp log was not complete- did not note corrective actions taken. The main kitchen had a thermometer missing and some outdated salad dressings. Staff were confused about discard dates for various food items.
• PC. 8.10, EP1: Found 5 instances of missing or incomplete Initial Intake Assessments for patients.
• PC.9.30, EP 3: Found only 2 AED machines on the campus- thought that was not enough.
• PC. 12.70 EP 2: Found 4 instances where the patient's S/R orders were not signed in one hour, according to hospital policy.
• PC.16.10, EP 1: Lab form lacked quantitative reference ranges for glucose.
• MM.2.20, EP 2: Found 2 instances of medication refrigerator logs not including the corrective action taken.
• MM.2.20, EP 7: Found 3 instances of expired medications.
• MM.2.20, EP 15: Found 3 instances of various medication refrigerator logs not being complete- lacked a cleaning date, and lack of daily temp recording.
• MM.3.10, EP 1: Found 2 instances where PRNs lacked a rationale for use.
• IC. 2.10, EP 1: Hospital had not identified risks to patients based on the results of the infection control data.
• IC.2.10, EP 2: Hospital had not performed a risk analysis and annual formal review.
• IC.5.10, EP 1: Hospital had not formally evaluated and revised the infection control goals and program.

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

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

• EC.5.20, EP 1: Needed an equivalency for sliding prision-type doors with a  3-4 " gap underneath them; found penetrations/ voids in the boiler/mechanical room; and found an exist stairwell door propped open with a wooden wedge.

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

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

Liked our Medication Administration Record (MAR)and the First Dose form;
liked the pharmacy rewrites;
found the Biopsychosocial very inclusive; liked the on-line system: significant things are highighted with red; found the patient Treatment Plans showed measurable objectives.

Preliminary Survey Result    JC: Conditional Accreditation
Will you send us a copy of your survey report?    Yes
Will you send us a copy of your ESC?    Yes

**Misc Comments, Suggestions, Etc    We had a return visit from one Joint Commission surveyor on 9-21-07.
He cleared all of the RFIs and left us with one Supplemental finding:
IC. 2.10, EP 1. Larned State Hospital has returned to Full Accreditation status.

Janice Lubeck