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*TJCsvyrRN_Hansen_Barbara J. Hansen, RN, MA

1308 Barbara J. Hansen, RN, MA

Barbara J. Hansen, RN, MA

Surveyor Program(s):  Accreditation Manual for Behavioral Health Care Hospitals, Integrated Survey Process and Special Survey (Sentinel Event, served on numerous API (Accreditation Process Improvements Initiative) projects

Surveyor Tenure: x 1990

Lives: Kalamazoo, Michigan

TJC Bio:

  • Received Nursing diploma from Bronson Methodist Hospital School of Nursing, Kalamazoo, Michigan
  • Received Bachelor of Science in Health Studies and Nursing and also a Masters in Counseling and Education from Western Michigan University, Kalamazoo
  • Prior to joining the Joint Commision in 1990, Ms. Hansen held postions as the Vice President/Chief Operating Officer, Director of Clinical Services, inpatient/outpatient, and Psychiatric Clinical Nurse Specialist at Borgess Mental Health Center, Kalamazoo, Michigan
  • Also has prior work experience as Nurse Educator at the State of Michigan Mental Health System
  • Affiliated with Board of Directors of Borgess Mental Health Center, the National Association of Mental Health Administrators, the American Nurses Association, and the Michigan Chapter of the National Association of Mental Health
  • Has clinical experience in child, adolescent and adult psychiatry and chemical dependency

Other Background:

  • Graduate of Little Company of Mary Hospital School of Nursing (Evergreen Park, IL – 1959)

Comments & Recommendations

  • Comments Pending Facility Feedback
  • Veteran surveyor/very experienced. Prefers a didactic approach during survey and capitalizes on “teaching moments.” Very open to team involvement in the survey and amenable to tracer activity with two staff accompanying her. Asked several questions of unit staff and observed a treatment group as well. Interviewed patients on each unit.
  • She is really into Infection Prevention and Control; was very appreciative that when she asked for additional information, I had it for her the next time I saw her.


  • The RN was very thorough. She cited our behavioural health side for all of the EOC stuff because the engineer did not go to our BHC program and that was the bulk of our citations. She was very thorough with infection control plans, assessments, and follow through with antibiotic use and with labs etc… she is a nurse and focused a lot on nursing care. She was also very particular with competency and staff files. She seemed at times pretty stern and strict but overall she was very good.
  • Was very chatty… very concerned about infection control standards… very friendly…seasoned surveyor… actually very helpful… good experience overall
  • Be sure to keep her supplied with hot coffee at all times. That is THE most important tip.
  • Appreciates a sweet bite in the morning. She has mellowed significantly over the years that I have known her. She was also focused on data driven processes and encouraged us to limit what was collected as data to ensure that we only collected data that yielded information that was useable. We had a very pleasant survey experience with Barbara this time (she was here twice before). She said she may retire at the end of this year.

Relevant Survey History:

• Lincoln Regional Center 1/14/11, 1301 • Norristown State Hospital 2/13/09
• Chicago-Read Mental Health Center 5/17/07, 8/5/10 • Elgin Mental Health Center 1407
• Richmond State Hospital 1308


** Sample Survey Citations (Premier Level)**

[private Membership premier]


Sample Citations: 2014 – Pending Facility Feedback

  • XX.01.0#.01/EP#/Observed in…
  • XX.01.0#.01/EP#/Observed in…
  • XX.01.0#.01/EP#/Observed in…
  • XX.01.0#.01/EP#/Observed in…


Sample Citations: 2013

  • HR.01.06.01/EP5/In the HR file of a support service staff member, there was lack of documentation that the individual demonstrated the ability to perform the duties of the position. A list of duties, with check marks, was provided. The form was not signed by an evaluator or dated, to validate the information.
  • IC.02.02.01/EP2/ Observed in the sterile supply cabinet in the Dental Office, the instruments were packaged incorrectly. Multiple instruments were sterilized in the same package and not separated and scissors were processed in a closed position not consistent with recognized standards for sterilizing instruments.
  • PC.02.01.01/EP1/ Treatment plan did not include hyperglycemia ( blood glucose of 150 at non-psychiatric medical hospital before admission to Chicago-Read, with a slightly elevated HbA1c after admission; the patient was also judged to be obese; and was prior to admission, and while in-hospital, on an atypical antipsychotic.  Reviewing the assessment, the initial nursing treatment plan, and the treatment team document, the Treatment Plan was serviceable, with danger to self and psychosis listed for psychiatric section (HTN & bronchitis as medical), but the team should have listed as a separate problem that the patient had sustained head trauma several months prior to admission.  Observed in the tracer record of an individual with substance abuse issues, there was lack of evidence that the potential for complications associated with recent substance use was addressed in the initial nursing plan of care on admission.
  • LD .01.03.01/EP2/ The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:§482.51 – (A-0940), §482.12 – (A-0043).
  • LD.04.03.09/EP4/ The organization had recently entered into an agreement with a local Joint Commission accredited hospital to provide radiological services off-site. A process for ensuring competencies of the radiologist compliant with the Medical Staff standards of this manual had not been developed and implemented. The radiologists were not privileged by this organization.
  • LD.04.03.09/EP6/ Written performance measures were identified for clinical contracts including laboratory services. However, the organization was not collecting data to evaluate these services in relation to the standards of The Joint Commission and the Conditions of Participation of CMS.
  • In other 2013 surveys she also cited the following standards:  IC 01.05.01, EP2; IC. 01.04.01, EP1, IC.02.02.01, EP 2; HR. 01.02.05, EP1; HR.01.06.01, EP 1, 6


  • HR.01.02.01/EP1/ Observed in Competency Session – The organization had not not defined the qualifications, training and experience, for the Infection Control Manager to assume the responsibilities defined in IC.01.01.01 of this manual.
  •  HR.01.02.05/EP1/ The organization was not in compliance with state regulations requiring unlicensed staff be trained and registered when assisting and monitoring medication administration to minor residents. This was cited as a deficiency during a CMS on site survey. The organization was in the process of implementing the corrective action plan with a projected completion date (3 months prior to this survey).
  • IC.01.03.01/EP1/ The organization had not conducted a current risk assessment based on its geographic location, community and population served, to include risk associated with multidrug-resistant organisms.
  • IC.01.03.01/EP 2/ The organization had not conducted a current risk assessment based on care, treatment and services provided. Risk associated with specialized populations, such as the adolescent residential population, would also need to be considered.
  • IC.01.03.01/EP 3/ The organization had not conducted a current risk assessment based the analysis of surveillance activities and other infection control date.
  • PC.01.03.01/EP 1/ Observed in Infection Control Tracer: In one Infection Control tracer, the treatment plan did not address the plan of care for managing the patient’s medical needs associated with the MRSA, such as level of precautions and routine would care. The medical / nursing plan of care for a patient receiving maintenance dialysis did not address individual issues related to this individual in renal failure. The medication orders did not direct the the administration of doses day of treatment (hold or give), and did not authorize the organization to send medications with the patient day of treatment (self administration). The plan of nursing care did not address nursing interventions pertinent to pre and post treatment monitoring, for example.


  • NPSG.02.03.01/EP 3/ Data regarding length of time between the availability of the lab result at the laboratory, and then reporting the result to the unit were not collected.
  • PC.01.03.01/EP 1, 22/ Direct Impact, Dr. Flocks and Ms. Hansen: Inconsistent treatment plan updates, progress and goals not measurable; no objective scales or measurements used.
  • RC.02.03.07/EP 4/ Verbal orders not authenticated within 48 hrs.
  • WT.03.01.01/EP 5/ No evidence of second method of demonstrating competency on One Step Pregnancy Test.


  • NPSG.16.01.01– The hospital selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual (s) when the patient’s condition appears to be worsening. / Direct
  • IC.01.02.01– Hospital leaders allocate needed resources for the infection prevention and control program. / Indirect
  • IC.01.04.01– The hospital offers vaccination against influenza to licensed independent practitioners and staff / Indirect
  • IC.02.04.01– The hospital offers vaccination against influenza to licensed independent practitioners and staff / Indirect
  • LD.04.03.11– The hospital manages the flow of patients through the hospital. / Indirect


  • PC.08/EP1/ Observed in B South at Chicago-Read Mental Health Center site. During a patient tracer it was noted that pain was assessed in a patient with the word “denied” under the pain assessment, with no note as to previous experience of pain, acceptable level of pain and what has worked and not worked in the past.
  • PC.08/EP3/ During a patient tracer it was noted that a patient was assessed for pain on admission at 7/10. Pain was not reassessed for two days after that. There does not appear to be a uniform policy for reassessing pain, but 48 hours exceeds any reasonable standard of medical practice.
  • PC.08/EP7/ During a patient tracer it was noted that pain which was noted to be >5/10, was not treated either by analgesics or by other means, nor was the reason for not treating addressed in the medical record.

You may provide surveyor feedback by clicking on the ‘Comments’ link above (2nd line, top left) and/or via the New Post Survey Questionnaire (PSQ).

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