Two-day survey turns into nine-hour success
Brattleboro Retreat receives high marks and helpful hints
Brattleboro (VT) Retreat, a freestanding psychiatric hospital, was expecting its most recent unannounced survey in March, but what was unexpected to staff members was the length of the survey, says Sharon Chaput, RN, C, CSHA, director of regulatory and quality management at Brattleboro.
“Our last unannounced survey was in March 2006, and judging from the last survey, we were expecting our entire facility to be done together,” says Chaput.
However, this time, the only programs surveyed were Brattleboro’s opiod treatment programs (OTP), including an inpatient adult detox and co-occurring disorders unit and an intensive outpatient suboxone treatment program with three treatment tracks. Another difference was that there was only one surveyor, and it lasted for one day.
Chaput says although the surveyor did not state why the survey was only one day, she and other staff members at Brattleboro were really happy that it was.
This was Brattleboro’s first survey since the release of the new opioid standards. The Substance Abuse and Mental Health Services Administration has given authority to The Joint Commission (formerly JCAHO) and will accept its accreditation.
Processes and posters galore
“The entire survey was very intense, especially for only being nine hours,” says Chaput. “Our surveyor hit all areas in our facility, and whenever there was a process to something, she asked for evidence and to be taken through each step.”
Emergency preparedness was one process the surveyor went through at Brattleboro. The surveyor traced the process all the way back to HR to make sure staff members had proper training, and then asked the counselor to walk through the entire process as though the safety check was happening.
“Throughout the entire tour, while conducting the environment of care and emergency standards review, the surveyor was very focused that only staff members answered questions and that the managers did not talk,” says Chaput.
The surveyor also picked out various staff members and asked them about the details of their job, two of whom included a mental health and housekeeping staff member.
“The mental health worker was asked about safety checks on the units, how she was trained, who did the assessment on one-to-one, fifteen-minutes, or thirty-minute assessments, and how the decision was made for each patient,” says Chaput. “For the housekeeper, the surveyor pointed to four or five different chemicals and asked what one would do if any of them were spilled.”
In Brattleboro, other posters are placed on the walls of the medication rooms where staff members can look for a refresher on how to deal with specific drugs.
“The surveyor spent a lot of time with soundalike/look-alike drugs [SALAD], and in the medication rooms there were SALAD, unapproved abbreviations, and high-risk high-alert medication posters where the nurses were able to read directly from to answer any of the surveyor’s questions,” says Chaput.
Details and interpretations
Because the survey was only nine hours, the surveyor paid close attention to each process that was carried out.
“During the environmental care suicide risk assessment, the surveyor looked at a sprinkler head, saying it had a loopable head, but we were able to identify that the sprinkler could only hold 50 pounds,” says Chaput. “The surveyor wanted to see proof of this, and we were able to go into our files and retrieve the information from the manufacturer, so we were not cited for this.”
Patient identification was another detail that Brattleboro was almost cited for, says Chaput. Brattleboro has four means of patient identification, which include the patient’s date of birth, picture (taken at admission), Social Security number, and medical record number.
“The surveyor noticed that sometimes when the patient’s picture is taken, it is blurry, dark, or hard to make out,” says Chaput. “The nurses can choose two means of identification for the wristbands, just not the picture. It’s good to have more than one.”
One process that the surveyor praised Brattleboro for was its suicide risk assessment. “The surveyor was very complimentary about the whole process for nursing suicide risk assessment,” says Chaput. “She gave us kudos, and all charts were 100% compliant.”
Brattleboro’s suicide risk assessment, which was developed by Vareen O’Keefe Domaleski, vice president of patient care services at Brattleboro, begins at admission, when the patient is identified and screened. The screening process shows whether the patient has any risks or is at risk to themselves or others.
“Some of the comments the surveyor said about the process was that it went above and beyond the standards,” says Chaput.
The surveyor was also impressed with the facility’s elopement process and that it was included in the suicide risk assessment. “The surveyor liked that we had interventions alongside the process and that we screened each patient accordingly,” says Chaput. “It allows for critical thinking and collaboration with the doctors when deciding what is right for the patient.”
Although Brattleboro received praise and was able to escape citations for specific processes, the facility received two indirect RFIs in environmental care, one in emergency preparedness, and one in infection control. But, according to the surveyor, it was still a successful survey.
“The surveyor did offer some helpful advice about how to interpret the survey results,” says Chaput. “She said to think of indirect finding as supplements and direct finding as RFIs, because if we ha been surveyed in 2008, we would have had four supplements and no RFIs, so it turned out to be a great survey for us.”