Name    Stuart Pope RN, MSN
E-mail    stuart.pope@greil.mh.alabama.gov
Facility Name    Greil Memorial Psychiatric Hospital (GMPH)
Facility CEO    Allen Stewart
Facility Address    2140 Upper Wetumpka Road, Montgomery, Alabama 36107
Facility Description (Brief)    76 Bed Psychiatric
# Beds - Adult    76
# Beds - Child & Adol    # Beds - Child & Adol
# Beds - Sub Abuse    # Beds - Sub Abuse
# Beds - Forensic    # Beds - Forensic
# Beds - MR/DD    # Beds - MR/DD
# Beds - TotaL    76
# Beds - CMS Distinct Part   

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    March 4-5, 2008
Survey Days (e.g., Mon - Weds)    Monday-Tuesday
Number of Surveyors    3
Priority Focus Areas   

• Patient Safety
• Assessment and Care
• Physical Environment
• Communication
• Medication Management

Last Survey Ending Date    March 15, 2005

Profile - Surveyor #1  John Eiland, MSN, RN
23 years in Military shows. Very straight forward. Very precise.  Focus was on EOC and plans. Gave many suggestions as to how to improve plans. Looked for "spirit" of the law.  Was obviously influenced by surveys before ours and I think that helped. Liked that we had things together and he did not have to ask or look. We had all of the things in the activity guide there plus bylaws and plans (PI and Plan of Care. I felt he was overall fair but not someone you want to argue with. Provide him with the info (data) and give him time to make up his own mind.

Profile - Surveyor #2   Dwight A. Owens, M.D.
Does not miss anything. My second survey with him. Focus on NPSG and Pharmacy. Also is big into Forensics and competency for those that care for forensic patients. We only had three in the hospital and much time was spent on this subject. When things start going bad he can get even tougher. If you will allow him to he will teach and consult. When he does you need to listen.

Profile - Surveyor #3    Richard Smith, CHE
I did not spend much time with him but this is my second survey with him also and he is very tough. He will also teach and consult if allowed.

# of Non-Compliant Standards    3

APR/NPSG Cites (Tag#/EP#/Brief Descrip/Surveyor)    none

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

• PC.5.10, EP 1
  • During an individual patient tracer, it was observed that on Feb 26, 2008, the attending physician ordered a chest x-ray for a patient with a positive PPD and it was not done at time of survey.
  • During the same individual patient tracer, it was observed that the attending physician ordered an EKG on Feb 26, 2008, and it was not done at time of survey.

PI/LD/HR/IM Cites (Stnd#/EP#/Brief Descrip/Surveyor)    none

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

• EC.4.20, EP 4 - Observed in Emergency Management Tracer at Greil Memorial Psychiatric Hospital site. Discussions with emergency management personnel indicated that the hospital had an identified role in the event of a community wide disaster. However, the organization had not participated in any past community wide drill nor addressed the organization's assets and resources to be offered to the community . The hospital is scheduled to participate in the next community based drill.

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

• MS.4.15, EP9 - During an individual patient tracer, it was observed that the hospital had a forensics patient, who had been deemed incompetent to stand trial, on the unit. At the time of the survey, the hospital did not have a process to determine whether there was sufficient clinical performance information to make a decision to grant, limit or deny forensic psychiatry privileges to the attending physician providing care for this particular patient. The attending physician did schedule forensic psychiatric training during the survey.

**Surveyor Compliments: 

• Both surveyors liked that we had all the documents ready and available. 
• They commented many times about our data being "real" and that we did not try to "cook the books." We had data posted in areas that all staff could see and some PI Data that visitors could see and they liked that.
• Loved the attention that was given to NPSGs and Adverse Drug Reactions and Averse Drug Events. Also, LASA and High Alert Meds. Pharmacy was very NEAT and the comment was that it was "beautiful."

Preliminary Survey Result    JC: Some Requirements for Improvement

Stuart Pope RN, MSN