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Surprise Survey of Mental Health Hospital Concludes with Outstanding Review



The Dini-Townsend Hospital, located in Sparks, NV, just accomplished something that is rarely achieved. It underwent an unannounced survey by the Centers for Medicare and Medicaid Services (CMS) and received a survey result with “no exceptions.” This means the surveyors believe the hospital is doing everything exactly right.

Rosalyne Reynolds, Dini-Townsend hospital administrator, has never heard of such an outcome in her 38 years of experience. “There’s usually always something surveyors want you to improve upon,” Reynolds said. “This is credit to our great staff and I am extremely proud of them.”

Dini-Townsend Hospital is part of the Northern Nevada Adult Mental Health Services and serves people who have serious and persistent mental illnesses.  Many of the hospital’s patients also have substance use disorders and are indigent. Yearly admissions to the hospital average 900 for inpatient care and 4,000 for outpatient care.

CMS surveys are unscheduled and conducted randomly every three years. Surveyors usually consist of nurses and doctors with specific experience in relevant medical fields. CMS evaluates health care organizations that bill Medicaid and or Medicare for their services. The survey process, which was conducted over a two-day period, examined the physical environment, patient safety, completeness of documentation and assessments, as well as, appropriate and therapeutic use of seclusions or restraints.  “Surveyors especially want to see treatment planning that is individualized to the patient,” Reynolds said.

Reynolds says their top-notch performance is a result of their focus on process improvement and quality patient care. The staff is managed using a coordinated team approach which includes two Quality Improvement staff members who continually monitor and evaluate patient care processes and outcomes.

“This isn’t something you can prepare for in a few weeks,” Reynolds said. “Adhering to standards of patient care needs to be an on-going priority and you must have a consistent plan for service evaluation and improvement.”

According to Reynolds, doing well on this survey is testament to her belief that patient care is professionally delivered in a safe environment and designed to be individually planned for each person to address their specific need.

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