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    Complaint
Surveying Agency    CMS
Survey Dates (inclusive)    10-30-06 thru 11-02-06 and 11-13-06 thru 11-16-06
Survey Days (e.g., Mon - Weds)    Tuesday-Friday
Number of Surveyors    3
Priority Focus Areas    Compalints from patientes/residents about hot water and room cleanliness
Last Survey Ending Date    11-16-06

Profile - Surveyor #1    Mary Kabriel, RN, State Survey Manager
Profile - Surveyor #2    Nancy Romine, RN
Profile - Surveyor #3    Marvene Bulker, RN

# of Non-Compliant Standards    4

RI/PC/MM/IC Cites (Stnd#/EP#/Brief Descrip/Surveyor)    The three surveyors found 4 CMS deficiencies:

A 041 (CoP 482.12 (a)(2)- Grievances: The Patient/Family Handbook lacked a notice of where to contact the state agency(need phone/address).

A 056 (CoP 482.13 (c)(1)- Personal Privacy: The pay phones in the CMS/federal program (PSP)lack privacy. Some of the patient showers were missing curtains and curtain rings.

A 057 (CoP 482.13 (c)(2)- Receive Care is a Safe Setting: Water temps in patient rooms in PSP and the Activity Therapy building bathroom were too low.

A 318 (CoP 482.41 (a)- Maintenance of Physical Plant: Deficiencies were found in outlier buldings (Cafeteria, Activity Therapy bldg, others) that are used by the PSP patients and some PSP patient rooms. These deficiencies included drinking fountains not working, toilets flush slowly, missing tile pieces on floor, dusty window sills, missing paint on walls, torn vinyl on exam table, cobwebs on ceiling, frayed carpet seams, missing formica on tables, mold build up in showers.

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

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

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

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

Preliminary Survey Result    CMS: No Conditions of Participation Out

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   

• The 3 surveyors were from the Kansas Deparment of Health and Environment (KDHE). They were contracted to complete a CMS survey as well as one from KDHE.  They found 15 KDHE reguation deficiencies in the following areas:  Patient Rights, Patient Compliants, Governing Body, Nursing RN Supervision, Nursing Policies/Procedures, Medical Records/ Confidentiality, Dietary Department, Laundry, Psychiatric Department, General Sanitation/ Housekeeping, Written Procedures,Adequate handwashing facilities, Commom drining cups, Adequate toilet facilities, Enforcement of sanitation procedures.

• The three KDHE/CMS surveyors returned on 4-3-07 thru 4-5-07 to check on corrections. They found 1 KDHE deficiency and 2 CMS deficiencies. The CMS deficiencies included:

1. A 057- Recieve Care in a Safe Setting: found the Beauty Shop door unlocked and various chemicals for hair treatments were stored in there.
2. A 318- Overall Hospital Environment: found one unit on an older buidling to be unsafe. This unit was moved to another physical location in 08-07.

Janice Lubeck