Eileen “Lee” Fraser M.A. RN-BC

Surveyor Program(s): Hospital, Behavioral Health Care Surveyor Tenure: x 2009 Lives: Illinois TJC Bio:

• Eileen “ Lee” Fraser is a Registered Nurse with over thirty years of experience in Health and Behavioral Health nursing.
• Lee is ANCC Board Certified in Psychiatric/Mental Health Nursing, and maintains licensure in Illinois and New Mexico.
• Ms. Fraser has held positions in diverse healthcare programs in the U.S., and has lived and worked in Southern Italy.
• She has been Director of Psychiatric Services for hospital based programs in Illinois and Wisconsin, and has developed and directed Outpatient and In-home services for Community Mental Health.
• Her focus areas have included trans-cultural nursing, with an emphasis in population based programming, and systems integration within the State of Illinois Provider Network, where she directed the formulation of strategic alliances between Behavioral Health, Primary Care, and Social Services for special needs populations.
• As an educator and trainer, Lee has designed and delivered clinical course work and professional workshops on both the state and national levels for over twenty years.
• Lee’s honors include recognition for clinical and organizational services. She was the recipient of the national award for “Innovation and Quality in Healthcare”, presented by Pfizer Medical Humanities, and the American Society on Aging, receiving the award on behalf of her program and services with Chestnut Health Systems of Illinois.
• She is the outgoing Editorial Board Chair of the Mental Health and Aging Publication for ASA, and has been the author, and co-author of a series of clinical training manuals developed for the state and community based programs in Gero-Psychiatric Services.

Other Background:

• Is coordinator and consulting clinical liaison for Gero-Psychiatric services at Chestnut Health Systems in Granite City, Ill.  [Source: Meet the New BHC Surveyors in BHC News Issue #2, 2009]
• Served as Director of Psychiatric Services for adult and adolescent hospital based programs in Illinois and Wisconsin.
• Served as lead clinician, program manager, educator and systems integration specialist for community based MH programs in Illinois.

Comments & Recommendations

•  Units are clean and bright.  Obvious that we work as a team here, from nursing to housekeeping.  “Remarkable job bringing the use of WRAP to life”.  Excellent job with Infection Control Tracer.  Complimentary that we didn’t have any PC standard deficiencies and that it is evident that we take care of our patients. 11/2013
• Very complimentary.  Likes the teams to be prepared.11/2013

• The information on your surveyor profile is an excellent summary of the experience we had with her.  She is extremely knowledgeable and has a very personable demeanor. She enjoys talking to all staff members, and was very moved after talking to one of our housekeepers who displayed a genuine concern for our clients – thanking this housekeeper at length for her service to the mentally ill.   She is a stickler for cleanliness on the units (including floors/baseboards/corners) and asked many staff members about safety issues like R-A-C-E , fire extinguishers and fire drills/evacuations.  She participated in system tracers on Data/PI, Infection Control, and HR/Competency.  Focused on forms being completely filled out and logical follow up to screenings….ex:  are risk factors identified on admission addressed in the treatment plan/MD orders?  She is very willing to listen to explanations and accepts minimal documentation to back up your explanation.   Very easy and pleasant to work with. Receptive to any changes we asked about for the schedule. 12/2012

2010

• Conducted tracer or survey activities in patient care, infection control, human resources, information management, leadership, medication management, waived testing, and NPSGs   Very positive in her interactions, educational and willing to talk through findings and expectations. Very engaging in a pleasant and non threatening way. 03/10

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** Sample Survey Citations (Premier Level)**

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Sample Citations: 2013 

• EC.02.06.01/EP 1/  Exposed pipes under sinks in 4 patient bathrooms
• NPSG.15.01.01/EP 1/ Our suicide assessment did not include environmental factors 
• HR.01.06.01/EP 3/ A few positions/roles did not have competencies defined
• RC.01.01.01/ EP 7/ Release for S/R was not completed on one chart.  Also, the debriefing had not been completed for another chart 

2012

• PC.01.03.01/EP 1/ Observed in Record Review: for a patient that had been admitted on 10/19/11 for behaviors related to Bi Polar illness and social stressors, it was noted that the physician had initiated an initial risk assessment to determine risk for several areas which included /Indirect/
• PC.02.01.11/EP 3/ Observed in Building Tour: Unit Z did not have an AED device for use in resuscitation. The other patient units did have these devices available and strategically placed. The staff indicated that the plan for emergencies on this unit included obtaining the AED from Unit 17 which was housed in another non adjoining building. This unit had recently ( October 2012) reopened for use with patients ,and other equipment needed for emergency response had been made available;however, no AED had been placed there. This was inconsistent with the equipment located at the other units. Patients on this unit included older adults and patients with compromised
• PC.02.02.03/EP 11/ Observed in Tracer Activities: A package of frozen tortillas were observed in the freezer on 12/6. The printed expiration date was 11/24. In the Unit Z kitchen sixteen individual serving cups with fruit were stored in the walk-in refrigerator without dates. An uncovered styrofoam cup with ice and a brown liquid, which was believed to be tea, was in the patient refrigerator in the cafeteria. It did not have a date to ensure a safe storage duration, and no assurance existed that it had not been partially consumed or mishandled. /Direct/

2010

• HR.01.07.01/EP 1/  During the Competence session it was noted that an RN had not had the annual performance Evaluation that was indicated as having been due in 2009. Policy for the organization requires this to be completed annually. • During the competence review of employees, it was noted that a Recreational Therapist was overdue for the 2009 Performance Evaluation. State regulations and the organization policy require this to be completed on an annual basis. – Indirect, Surveyor #2
• NPSG.07.01.01/EP 1/ During Data and Infection control data sessions it was noted that the data re: Hand Hygiene Surveillance for all four quarters of the year 2009, were not completed . The absence of the data rendered the follow up processes of aggregation and analysis, and potential interventions incomplete for the year. The API Infection Control Plan identifies this as a requirement – Indirect Impact, Surveyor #2
• RC.01.02.01/EP 3/ During patient tracer activity, it was noted that there were three separate signatures that were not timed on a Master Treatment Plan. • During record review, it was noted that there were three separate signatures that were not timed on a Master Treatment Plan. • During patient tracer activity, it was noted that a part of the Master Treatment Plan was moderately unreadable due to illegibility. Even after being reviewed by two staff members there was never a complete translation provided. – Indirect, Surveyor #2

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