Western State Hospital 9601 Steilacoom Boulevard. S.W Lakewood, WA 98498 Organization Identification Number: 1630 Program(s) Hospital Accreditation Survey Date(s) 05/14/2012-05/15/2012 Executive Summary Hospital Accreditation : As a result of the accreditation activity conducted on the above date(s), you have met the criteria for Accreditation with Follow-up Survey. An Accreditation with Follow-up Survey decision can only be made by the Accreditation Committee; therefore, your survey findings will be presented to the Accreditation Committee for a final decision. If your organization wishes to clarify any of the standards you believe were compliant at the time of survey, you may submit clarifying Evidence of Standards Compliance in 10 business days from the day this report is posted to your organization's extranet site. If Central Office review of the Clarifying Evidence of Standards Compliance results in your program no longer meeting criteria for Accreditation with Follow-up Survey, an Announced Clarification Validation Survey may occur. You will have follow-up in the area(s) indicated below: o As a result of a Condition Level Deficiency, an Unannounced Medicare Deficiency Follow-up Survey will occur. Please address and correct any Condition Level Deficiencies immediately, as the follow-up event addressing these deficiencies will occur within 45 days of the last survey date identified above. The follow-up event is in addition to the written Evidence of Standards Compliance response. Evidence of Standards Compliance (ESC) Unannounced Accreditation Follow-up Survey - An unannounced follow-up survey will be conducted approximately three months after Accreditation Committee. o o If you have any questions, please do not hesitate to contact your Account Executive. Thank you for collaborating with The Joint Commission to improve the safety and quality of care provided to patients. Organization Identification Number: 1630 Page 1 of 15 The Joint Commission Summary of Findings Evidence of DIRECT Impact Standards Compliance is due within 45 days from the day this report is posted to your organization's extranet site: Program: Standards: Hospital Accreditation Program EC.02.01.01 LD.03.06.01 PC.01.02.03 PC.01.03.01 EP3 EP3 EP3 EP1 Evidence of INDIRECT Impact Standards Compliance is due within 60 days from the day this report is posted to your organization's extranet site: Program: Standards: Hospital Accreditation Program LD.01.03.01 LD.03.01.01 LD.04.01.05 LD.04.03.01 LD.04.04.05 NR.02.01.01 PC.03.05.15 WT.05.01.01 EP2 EP2,EP3,EP7 EP4 EP14 EP14 EP1 EP1 EP3 Organization Identification Number: 1630 Page 2 of 15 The Joint Commission Summary of CMS Findings CoP: Corresponds to: Text: ?482.12 Tag: A-0043 Deficiency: Condition HAP - LD.01.03.01/EP2 ?482.12 Condition of Participation: Governing Body The hospital must have an effective governing body legally responsible for the conduct of the hospital as an institution. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body. CoP: Corresponds to: Text: ?482.13 HAP Tag: A-0115 Deficiency: Standard ?482.13 Condition of Participation: Patient's Rights A hospital must protect and promote each patient's rights. CoP Standard ?482.13(c)(2) ?482.13(e)(16)(ii) Tag A-0144 A-0185 Corresponds to HAP - EC.02.01.01/EP3 HAP - PC.03.05.15/EP1 Deficiency: Condition Deficiency Standard Standard CoP: Corresponds to: Text: ?482.21 HAP Tag: A-0263 ?482.21 Condition of Participation: Quality Assessment and Performance Improvement Program The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, datadriven quality assessment and performance improvement program. The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. CoP Standard ?482.21(b)(2)(ii) ?482.21(d)(4) Tag A-0276 A-0303 Tag: A-0385 Corresponds to HAP - LD.03.01.01/EP2 HAP - LD.04.04.05/EP14 Deficiency: Standard Deficiency Standard Standard CoP: Corresponds to: Text: ?482.23 HAP ?482.23 Condition of Participation: Nursing Services The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. Organization Identification Number: 1630 Page 3 of 15 The Joint Commission Summary of CMS Findings CoP Standard ?482.23(b)(4) ?482.23(b)(5) CoP: Corresponds to: Text: ?482.62 Tag A-0396 A-0397 Tag: B136 Corresponds to HAP - PC.01.03.01/EP1, PC.01.02.03/EP3 HAP - NR.02.01.01/EP1 Deficiency: Condition Deficiency Standard Standard HAP - PC.01.03.01/EP1 ?482.62 Condition of Participation: Special staff requirements for psychiatric hospitals. The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures, and engage in discharge planning. CoP Standard ?482.62(d) ?482.62(b) ?482.62(d)(2) B146 B142 B150 Tag Corresponds to HAP - LD.04.03.01/EP14 HAP - LD.03.06.01/EP3 HAP - LD.03.06.01/EP3 Deficiency Standard Standard Standard Organization Identification Number: 1630 Page 4 of 15 The Joint Commission Findings Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Element(s) of Performance: 3. The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment. Environment of Care Hospital Accreditation EC.02.01.01 The hospital manages safety and security risks. Patient Safety Scoring Category : C Insufficient Compliance Score : Observation(s): EP 3 ?482.13(c)(2) - (A-0144) - (2) The patient has the right to receive care in a safe setting. This Standard is NOT MET as evidenced by: Observed in Individual Tracer at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. Door closers on patients rooms on the wards toured were, in large part, inoperable as closers and presented a risk for hanging. This was observed during the tour of the Central 3 unit. Unless required by the local fire jurisdiction the removal of these devices might be a good option. Observed in Individual Tracer at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. Door knobs in patients rooms presented opportunities for patients to thread an item of clothing or bed clothes for the purpose of self harm. It could not be determined if a risk analysis of these environmental risks had been conducted and considered. Observed in Individual Tracer at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. Line of sight observation of both corridors on the nurses station of the Central Building patient care wards was difficult. In some areas one of the corridors is oblique to nurses desk Since there were times that an individual would not be present at the station just to conduct line of sight observation it would suggest that alternatives such as the installation or cameras should be considered. This had not been considered in a safety risk assessment. Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Leadership Hospital Accreditation LD.01.03.01 The governing body is ultimately accountable for the safety and quality of care, treatment, and services. Organizational Structure Organization Identification Number: 1630 Page 5 of 15 The Joint Commission Findings Element(s) of Performance: 2. The governing body provides for organization management and planning. Scoring Category : A Insufficient Compliance Score : Observation(s): EP 2 ?482.12 - (A-0043) - ?482.12 Condition of Participation: Condition of Participation: Governing Body This Condition is NOT MET as evidenced by: Observed in Leadership at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. The governing body/leadership did not ensure that the following Conditions of Participation 482.21, 482.62 and 482.12 were met as determined through observations, documentation and staff interviews: LD.01.03.01, LD.03.01.01, and LD.04.04.05, LD.03.06.01, , LD.04.03.01, and PC.01.03.01 . These standards and CoPs addressed quality and safety of patient care delivery, monitoring and surveillance of patients and adequacy of staffing. Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Element(s) of Performance: Leadership Hospital Accreditation LD.03.01.01 Leaders create and maintain a culture of safety and quality throughout the hospital. Quality Improvement Expertise/Activities 2. Leaders prioritize and implement changes identified by the evaluation. Scoring Category : A Insufficient Compliance Score : 3. Leaders provide opportunities for all individuals who work in the hospital to participate in safety and quality initiatives. Scoring Category : A Insufficient Compliance Score : 7. Leaders establish a team approach among all staff at all levels. Scoring Category : A Insufficient Compliance Score : Observation(s): Organization Identification Number: 1630 Page 6 of 15 The Joint Commission Findings EP 2 ?482.21(b)(2)(ii) - (A-0276) - [The hospital must use the data collected to--] (ii) Identify opportunities for improvement and changes that will lead to improvement. This Standard is NOT MET as evidenced by: Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. This recommendation was made at the triennial survey of this organization; the safety issues addressed were specific to environmental rounds and did not address the lack of staff adherence to policies on surveillance of patients such as every 15 minute observations. The documentation of the observations was by shift progress note only and did not give information as to each observation of high risk patients who were suicidal or at risk for violence. Pursuant to recent events the organization is in the process of developing revised methods of observation and monitoring and documentation. EP 3 Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site. The level of involvement at the staff level has been minimal given resistance on the part of many staff to acknowledge issues with the delivery of care and patient observation. Education has begun to build on the information and improvement plans of root cause analyses conducted. EP 7 Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site. There is considerable resistance to change by line staff such as nurses and mental health workers. The organization's Quality Director and leadership are in the process of attempting to engage staff in process improvement. Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Element(s) of Performance: Leadership Hospital Accreditation LD.03.06.01 Those who work in the hospital are focused on improving safety and quality. Staffing 3. Leaders provide for a sufficient number and mix of individuals to support safe, quality care, treatment, and services. (See also IC.01.01.01, EP 3) Note: The number and mix of individuals is appropriate to the scope and complexity of the services offered. Scoring Category : A Insufficient Compliance Score : Observation(s): Organization Identification Number: 1630 Page 7 of 15 The Joint Commission Findings EP 3 ?482.62(d)(2) - (B150) - (2) There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient's active treatment program. This Standard is NOT MET as evidenced by: Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. There was not sufficient staff as evidenced by the hospital presently has 20 full time equivalent nursing positions open. Additionally there are several registered nurses, licensed vocational nurses and mental health technicians who are on extended medical or worker compensation leave of absence. Review of the staffing records of the wards for four specific dates it was noted that each ward is under required staffing (considering acuity) by at least one staff member for each shift. ?482.62(b) - (B142) - ?482.62(b) The number and qualifications of doctors of medicine and osteopathy must be adequate to provide essential psychiatric services. This Standard is NOT MET as evidenced by: Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. It was acknowledged that the State Hospital is presently understaffed by 15 to 20 psychiatrists and other physicians. Some of the reasons for these shortages has to do with the higher salaries in other surrounding settings to which a number of staff have been recruited. Additionally, the conditions at the State Hospital, the intensity of the population and the fact that salaries are sufficiently lower than they are in freestanding psychiatric facilities and the private sector makes recruiting physicians and extended care practitioners extremely difficult. Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Element(s) of Performance: Leadership Hospital Accreditation LD.04.01.05 The hospital effectively manages its programs, services, sites, or departments. Staffing 4. Staff are held accountable for their responsibilities. Scoring Category : A Insufficient Compliance Score : Observation(s): EP 4 Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site. Nurses who assume the charge role on the wards must be competent to assure that there are sufficient staff for the safe surveillance and monitoring of all of the patients on the ward. Significant events in the recent past related to breaches in sufficient monitoring indicating staff were not accountable for their responsibilities. Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site. It was observed that patients on the C-3, C-8 and other wards are out of direct line of sight by staff. When the nursing staff is in the Chart Room and documentation area there are no staff in the nurses' station so that they cannot see down each hall and see what patients are doing. On one ward it was noted that there was a mental health worker who had one patient on one-on-one observation, this staff member could not oversee other patients on the unit. It is a requirement that all patients are accounted for. A serious event occurred when a patient with severe acting out behavior was not sufficiently monitored, entered another patients room at his peril and suffered the consequences. By policy it was required that staff are physically on the ward or at the nurses' station so that adequate observations of patients can be carried out. Organization Identification Number: 1630 Page 8 of 15 The Joint Commission Findings Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Element(s) of Performance: 14. For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The psychiatric hospital provides psychological services, social work services, psychiatric nursing, and therapeutic activities. Leadership Hospital Accreditation LD.04.03.01 The hospital provides services that meet patient needs. Patient Safety Scoring Category : A Insufficient Compliance Score : Observation(s): EP 14 ?482.62(d) - (B146) - ?482.62(d) Standard: Nursing services. The hospital must have a qualified director of psychiatric nursing services. In addition to the director of nursing, there must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide nursing care necessary under each patient's active treatment program and to maintain progress notes on each patient. This Standard is NOT MET as evidenced by: Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. The nursing department of the hospital is down 20 full time equivalents. There is usually one registered nurse assigned to each ward and a supervising registered nurse who carries as much as a three ward assignment. The levels of staffing for nursing have been under the required hours as much as one nursing staff member per shift for all wards. Specifically, this lead to insufficient surveillance in two events with serious consequences. Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Element(s) of Performance: Leadership Hospital Accreditation LD.04.04.05 The hospital has an organization-wide, integrated patient safety program within its performance improvement activities. Organizational Structure 14. The leaders encourage external reporting of significant adverse events, including voluntary reporting programs in addition to mandatory programs. Note: Examples of voluntary programs include The Joint Commission Sentinel Event Database and the U.S. Food and Drug Administration (FDA) MedWatch. Mandatory programs are often state initiated. Scoring Category : A Insufficient Compliance Score : Observation(s): Organization Identification Number: 1630 Page 9 of 15 The Joint Commission Findings EP 14 ?482.21(d)(4) - (A-0303) - (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is NOT MET as evidenced by: Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. The organization's policy addressing sentinel events did not stipulate the external reporting of serious incidents or sentinel events. The organizations policy didn't detail the process for reporting to the Department of Social Services. Recently the organization had reported sentinel events to The Joint Commission. The organization will be revising the policy. Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Element(s) of Performance: Nursing Hospital Accreditation NR.02.01.01 The nurse executive directs the hospital's nursing services. Staffing 1. The nurse executive coordinates: The development of hospital-wide plans to provide nursing care, treatment, and services. Scoring Category : A Insufficient Compliance Score : Observation(s): EP 1 ?482.23(b)(5) - (A-0397) - (5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This Standard is NOT MET as evidenced by: Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. Because of some of the shortages in staffing and the number of medical and compensated leaves (ie: reference 20 open nursing positions) there is generally only one registered nurse for each ward with a census of 30 or more and one supervisor who may be covering as many as three wards. There is not sufficient staff to carry out the degree of observation and monitoring required for this population of patients. Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Provision of Care, Treatment, and Services Hospital Accreditation PC.01.02.03 The hospital assesses and reassesses the patient and his or her condition according to defined time frames. Assessment and Care/Services Organization Identification Number: 1630 Page 10 of 15 The Joint Commission Findings Element(s) of Performance: 3. Each patient is reassessed as necessary based on his or her plan for care or changes in his or her condition. Note: Reassessments may also be based on the patient's diagnosis; desire for care, treatment, and services; response to previous care, treatment, and services; and/or his or her setting requirements. Scoring Category : C Partial Compliance Score : Observation(s): EP 3 ?482.23(b)(4) - (A-0396) - (4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. This Standard is NOT MET as evidenced by: Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. An initial assessment of suicidality was conducted and the form completed on this intensely suicidal patient upon admission. The patient then spent the first 24 hours of her hospitalization in restraints with one-on-one observation. The concern was that there were no subsequent assessments of the patients suicidal ideation especially as events had taken place that impacted the patients behavior. Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. In the record of another patient with suicidal ideation and with an active plan upon admission it was also noted that a suicide risk assessment form had been completed. However, subsequent issues related to behavior after restraint were addressed without a reassessment of the patients lethality of suicidal ideation. Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Element(s) of Performance: Provision of Care, Treatment, and Services Hospital Accreditation PC.01.03.01 The hospital plans the patient's care. Assessment and Care/Services 1. The hospital plans the patient's care, treatment, and services based on needs identified by the patient's assessment, reassessment, and results of diagnostic testing. (See also RC.02.01.01, EP 2) Scoring Category : C Insufficient Compliance Score : Observation(s): Organization Identification Number: 1630 Page 11 of 15 The Joint Commission Findings EP 1 ?482.62 - (B136) - ?482.62 Condition of Participation: Special staff requirements for psychiatric hospitals. This Condition is NOT MET as evidenced by: Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. Review of a treatment plan for a 19 year old female patient with depression, suspected borderline personality, history of abuse and neglect and almost continuous self injurious behavior requiring frequent episodes of restraint with minimal result did not have any indication in the treatment plan that there were updated goals related to restraint and the possibility that less restrictive interventions could be employed. She had been on 1:1 observation but the observation was decreased and this was not documented in the treatment plan. Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. The treatment plan for another 20 year old patient who's sexual acting out behaviors were out of control did not include a plan for interventions to place the patient on increased surveillance for his safety. This patient had some episodes of restraint with minimal result, usually tending to escalate his inappropriate behaviors. He was refusing all interventions and most of his medications. The plan addressed his continued hallucinations but reflected little about the necessity to change the way surveillance and monitoring of him on the ward was to be carried out so that he was protected from peers and peers were protected from him. Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. A third 41 year old male patient who's treatment plan did not address his increased agitation and what appeared to be a crescendo of anger that ended in serious result when involved in an altercation with another peer. This patient had many admissions. The plan indicated observation for his depressive disorder and polysubstance withdrawal, however did not address the need for increased surveillance which was not provided due to his demonstrated behaviors on the unit. ?482.23(b)(4) - (A-0396) - (4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. This Standard is NOT MET as evidenced by: Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. Review of open and closed medical records it was apparent that many of the master treatment plans and nursing care plans addressed only the Axis I for example bipolar illness with suicidal ideation and the staff had not updated these plan to reflect all of the problems associated with the patient. One patient with very violent behavior did not have his anger and impulsivity addressed sufficiently. Another addressed his visual and auditory hallucinations and his sexual acting out behaviors but did not plan for increased intervention for his obtrusive behavior such as his unwanted entry into other patient's rooms. Chapter: Program: Standard: Standard Text: Primary Priority Focus Area: Provision of Care, Treatment, and Services Hospital Accreditation PC.03.05.15 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital documents the use of restraint or seclusion. Assessment and Care/Services Organization Identification Number: 1630 Page 12 of 15 The Joint Commission Findings Element(s) of Performance: 1. For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of restraint and seclusion in the medical record includes the following: - Any in-person medical and behavioral evaluation for restraint or seclusion used to manage violent or self-destructive behavior - A description of the patient's behavior and the intervention used - Any alternatives or other less restrictive interventions attempted - The patient's condition or symptom(s) that warranted the use of the restraint or seclusion - The patient's response to the intervention(s) used, including the rationale for continued use of the intervention - Individual patient assessments and reassessments - The intervals for monitoring - Revisions to the plan of care - The patient's behavior and staff concerns regarding safety risks to the patient, staff, and others that necessitated the use of restraint or seclusion - Injuries to the patient - Death associated with the use of restraint or seclusion - The identity of the physician, clinical psychologist, or other licensed independent practitioner who ordered the restraint or seclusion - Orders for restraint or seclusion - Notification of the use of restraint or seclusion to the attending physician - Consultations Note: The definition of 'physician' is the same as that used by the Centers for Medicare & Medicaid Services (CMS) (refer to the Glossary). Scoring Category : C Partial Compliance Score : Observation(s): EP 1 ?482.13(e)(16)(ii) - (A-0185) - [When restraint or seclusion is used, there must be documentation in the patient's medical record of the following:] (ii) A description of the patient's behavior and the intervention used. This Standard is NOT MET as evidenced by: Observed in Sentinel Case Review at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. On the first day of this patient's admission, she spent 24 hours in restraint. The patient was admitted on the 12th of April, 2012 and her stay went through the 22nd of April. The Master Treatment Plan had not been updated to address this first episode of restraint. There was no Master Plan revision to address any episode of restraint for this patient. Observed in Sentinel Case Review at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site for the Psychiatric Hospital deemed service. The patient had been placed in restraint due to self injurious cutting behavior. The Master Treatment Plan was not updated to reflect the use of restraints. Also, the record of the every 15 minute checks performed on the patient during the first four days while she was on one-on-one observation were not included in the closed medical record other than a shift progress note suggesting that they had been carried out. Observation of the patient's behavior is not documented per every 15 minute observation and it cannot be ascertained if, in fact, the patient really was on constant observations. Chapter: Program: Waived Testing Hospital Accreditation Organization Identification Number: 1630 Page 13 of 15 The Joint Commission Findings Standard: Standard Text: Primary Priority Focus Area: Element(s) of Performance: 3. Quantitative test result reports in the medical record for waived testing are accompanied by reference intervals (normal values) specific to the test method used and the population served. Note 1: Semiquantitative results, such as urine macroscopic and urine dipsticks, are not required to comply with this element of performance. Note 2: If the reference intervals (normal values) are not documented on the same page as and adjacent to the waived test result, they must be located elsewhere within the permanent medical record. The result must have a notation directing the reader to the location of the reference intervals (normal values) in the medical record. WT.05.01.01 The hospital maintains records for waived testing. Analytic Procedures Scoring Category : A Insufficient Compliance Score : Observation(s): EP 3 Observed in Tracer Activities at Western State Hospital (9601 Steilacoom Boulevard S.W., Lakewood, WA) site. The reference ranges for the "Accu-Check" glucometer devices is not noted on the handwritten record of the results of testing. Organization Identification Number: 1630 Page 14 of 15 The Joint Commission Organization Identification Number: 1630 page 15 or 15