{"id":1220,"date":"2012-12-04T15:06:39","date_gmt":"2012-12-04T15:06:39","guid":{"rendered":"http:\/\/www.fieldsinc.com\/?p=1220"},"modified":"2016-09-13T17:13:21","modified_gmt":"2016-09-13T17:13:21","slug":"tjcsvyrrn_fraser_ms-eileen-h-fraser-ma-rn","status":"publish","type":"post","link":"https:\/\/www.fieldsinc.com\/tjcsvyrrn_fraser_ms-eileen-h-fraser-ma-rn","title":{"rendered":"\u221aTJCsvyrRN_Fraser_Ms. Eileen H. Fraser, MA, RN"},"content":{"rendered":"<p><a href=\"http:\/\/www.fieldsinc.com\/wp-content\/uploads\/2012\/12\/12Eileen-\u201cLee\u201d-Fraser-M.A.-RN-BC.png\"><img fetchpriority=\"high\" decoding=\"async\" class=\"aligncenter  wp-image-647\" title=\"12Eileen \u201cLee\u201d Fraser M.A. RN-BC\" src=\"http:\/\/www.fieldsinc.com\/wp-content\/uploads\/2012\/12\/12Eileen-\u201cLee\u201d-Fraser-M.A.-RN-BC.png\" alt=\"\" width=\"363\" height=\"331\" \/><\/a><\/p>\n<h1 align=\"center\">Eileen \u201cLee\u201d Fraser M.A. RN-BC<\/h1>\n<p><span style=\"font-size: large;\"><strong>Surveyor Program(s)<\/strong>: Hospital, Behavioral Health Care<\/span> <span style=\"font-size: large;\"><strong>Surveyor Tenure<\/strong>: x 2009<\/span> <span style=\"font-size: large;\"><strong>Lives<\/strong>: Illinois<\/span> <span style=\"font-size: large;\"><strong>TJC Bio: <\/strong> <\/span><\/p>\n<ul>\n<li><span style=\"font-size: large;\">Eileen \u201c Lee\u201d Fraser is a Registered Nurse with over thirty years of experience in Health and Behavioral Health nursing. <\/span><\/li>\n<li><span style=\"font-size: large;\">Lee is ANCC Board Certified in Psychiatric\/Mental Health Nursing, and maintains licensure in Illinois and New Mexico.<\/span><\/li>\n<li><span style=\"font-size: large;\">Ms. Fraser has held positions in diverse healthcare programs in the U.S., and has lived and worked in Southern Italy. <\/span><\/li>\n<li><span style=\"font-size: large;\">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.<\/span><\/li>\n<li><span style=\"font-size: large;\">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. <\/span><\/li>\n<li><span style=\"font-size: large;\">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. <\/span><\/li>\n<li><span style=\"font-size: large;\">Lee&#8217;s honors include recognition for clinical and organizational services. She was the recipient of the national award for \u201cInnovation and Quality in Healthcare\u201d, 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.<\/span><\/li>\n<li><span style=\"font-size: large;\">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.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-size: large;\"><strong> Other Background<\/strong>: <\/span><\/p>\n<ul>\n<li><span style=\"font-size: large;\">Is coordinator and consulting clinical liaison for Gero-Psychiatric services at Chestnut Health Systems in Granite City, Ill.\u00a0 [Source: Meet the New BHC Surveyors in BHC News Issue #2, 2009]<\/span><\/li>\n<li><span style=\"font-size: large;\">Served as Director of Psychiatric Services for adult and adolescent hospital based programs in Illinois and Wisconsin.<\/span><\/li>\n<li><span style=\"font-size: large;\">Served as lead clinician, program manager, educator and systems integration specialist for community based MH programs in Illinois. <\/span><\/li>\n<\/ul>\n<p align=\"left\"><span style=\"font-size: large;\"><strong>Comments &amp; Recommendations <\/strong><\/span><\/p>\n<div>\n<div><span style=\"color: #339966; font-size: 14pt;\"><strong>2015<\/strong><\/span><\/div>\n<ul>\n<li><span style=\"font-size: 14pt;\">\u00a0Pending\u2026<\/span><\/li>\n<\/ul>\n<\/div>\n<div><span style=\"font-size: large; color: #339966;\"><strong>2013<\/strong><\/span><\/div>\n<ul>\n<li><span style=\"font-size: large;\">\u00a0Units are clean and bright. \u00a0Obvious that we work as a team here, from nursing to housekeeping. \u00a0&#8220;Remarkable job bringing the use of WRAP to life&#8221;. \u00a0Excellent job with Infection Control Tracer. \u00a0Complimentary that we didn&#8217;t have any PC standard deficiencies and that it is evident that we take care of our patients. <span style=\"font-size: xx-small; color: #ffffff;\">11\/2013<\/span><\/span><\/li>\n<li><span style=\"font-size: large;\">Very complimentary. \u00a0Likes the teams to be prepared.<span style=\"font-size: xx-small; color: #ffffff;\">11\/2013<\/span><\/span><\/li>\n<\/ul>\n<div><span style=\"font-size: large; color: #339966;\"><strong>2012<\/strong><\/span><\/div>\n<ul>\n<li><span style=\"font-size: large;\">The information on your surveyor profile is an excellent summary of the experience we had with her.\u00a0 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 \u2013 thanking this housekeeper at length for her service to the mentally ill. \u00a0 She is a <strong>stickler for cleanliness on the units<\/strong> (including floors\/baseboards\/corners) and asked many staff members about safety issues like R-A-C-E , fire extinguishers and fire drills\/evacuations.\u00a0 She participated in system tracers on Data\/PI, Infection Control, and HR\/Competency.\u00a0 Focused on forms being completely filled out and logical follow up to screenings\u2026.ex:\u00a0 are risk factors identified on admission addressed in the treatment plan\/MD orders?\u00a0 She is very willing to listen to explanations and accepts minimal documentation to back up your explanation.\u00a0\u00a0 Very easy and pleasant to work with. Receptive to any changes we asked about for the schedule. <span style=\"color: #ffffff; font-size: xx-small;\">12\/2012 <\/span><\/span><\/li>\n<\/ul>\n<p><span style=\"color: #339966;\"><strong><span style=\"font-size: large;\">2010<\/span><\/strong><\/span><\/p>\n<ul>\n<li><span style=\"font-size: large;\">Conducted tracer or survey activities in patient care, infection control, human resources, information management, leadership, medication management, waived testing, and NPSGs \u00a0 Very positive in her interactions, educational and willing to talk through findings and expectations. Very engaging in a pleasant and non threatening way. <span style=\"color: #ffffff; font-size: xx-small;\">03\/10<\/span><\/span><\/li>\n<\/ul>\n<div><strong><span style=\"font-size: large;\"><span style=\"color: #339966;\">2009<\/span><\/span><\/strong><\/div>\n<div>\n<ul>\n<li><span style=\"font-size: large;\">Friendly, easy going but very knowledgeable.\u00a0 Focuses on issues pertinent to nursing &#8211; will allow leadership to provide additional information if something needs clarifying even during interactions with line staff.\u00a0 Many years experience in the behavioral health system.\u00a0 A dedicated history buff. 11\/2009 <\/span><\/li>\n<li><span style=\"font-size: large;\">She has an extensive background working in behavioral health settings.\u00a0 She is very pleasant to survey with, very knowledgeable about her area, and is very patient oriented.\u00a0 She truly enjoyed interacting with our clients on the unit \u2013 becoming \u2026 emotional during an interview when the client was describing his home situation to the point she had to end the interview early to regain her composure.\u00a0 She is very down to earth and appears to really enjoy the accompaniment of fellow nurses during tracer activities. <span style=\"color: #ffffff; font-size: xx-small;\">11\/09<\/span><\/span><\/li>\n<\/ul>\n<\/div>\n<div><span style=\"font-size: large;\"><strong>Relevant Surveying History<\/strong>: <\/span><\/div>\n<div>\n<table style=\"width: 966px; height: 66px;\" border=\"0\" align=\"center\">\n<tbody>\n<tr>\n<td><span style=\"font-size: large;\">\u2022 Eastern Regional State Hospital<span style=\"font-size: xx-small; color: #ffffff;\">11\/19\/2013<\/span><\/span><\/td>\n<td><span style=\"font-size: large;\">\u2022\u00a0Central Louisiana State Hospital<span style=\"font-size: xx-small; color: #ffffff;\">12\/26\/12<\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td><span style=\"font-size: large;\">\u2022\u00a0Alaska Psychiatric Institute<span style=\"font-size: xx-small; color: #ffffff;\">03\/12\/10<\/span><\/span><\/td>\n<td><span style=\"font-size: large;\">\u2022 Searcy Hospital<span style=\"font-size: xx-small; color: #ffffff;\">11\/20\/09<\/span><\/span><\/td>\n<\/tr>\n<tr>\n<td><span style=\"font-size: large;\">\u2022 Eastern State Hospital<span style=\"font-size: 8pt; color: #ffffff;\">5\/15<\/span><\/span><\/td>\n<td><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"font-size: large;\"><span style=\"color: #ffffff; font-size: xx-small;\">102<\/span> <\/span><\/p>\n<\/div>\n<hr \/>\n<p style=\"text-align: center;\"><span style=\"font-size: x-large; background-color: #808000; color: #ffffff;\"> ** Sample Survey Citations (Premier Level)** <\/span><\/p>\n<p style=\"text-align: center;\">[private Membership premier]<\/p>\n<p>[\/private]<\/p>\n<hr \/>\n<p><span style=\"color: #800080;\"><strong><span style=\"font-size: large;\">Sample Citations:<\/span><\/strong><\/span> <span style=\"font-size: large;\"><strong>2013<\/strong><\/span><span style=\"font-size: 13px;\">\u00a0<\/span><\/p>\n<ul>\n<li><span style=\"font-size: large;\"><span style=\"color: #800080;\"><strong>EC.02.06.01<\/strong><\/span><\/span><span style=\"font-size: large; color: #800080;\"><strong>\/EP 1\/<\/strong><\/span><span style=\"font-size: large;\">\u00a0 Exposed pipes under sinks in 4 patient bathrooms<\/span><\/li>\n<li><span style=\"font-size: large;\"><span style=\"color: #800080;\"><strong><strong>NPSG.15.01.01\/EP 1\/\u00a0<\/strong><\/strong><span style=\"color: #000000;\">Our suicide assessment did not include environmental factors<\/span><\/span><span style=\"color: #000000;\">\u00a0<\/span><\/span><\/li>\n<li><span style=\"font-size: large;\"><span style=\"color: #800080;\"><strong>HR.01.06.01\/EP 3\/\u00a0<\/strong><span style=\"color: #000000;\">A few positions\/roles did not have competencies defined<\/span><\/span><\/span><\/li>\n<li><span style=\"font-size: large;\"><span style=\"color: #800080;\"><strong><strong>RC.01.01.01\/ EP 7\/<\/strong><\/strong> <span style=\"color: #000000;\">Release for S\/R was not completed on one chart.\u00a0 Also, the debriefing had not been completed for another chart<\/span><\/span><\/span><span style=\"font-size: 13px;\">\u00a0<\/span><\/li>\n<\/ul>\n<p><span style=\"font-size: large;\"><strong>2012<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"font-size: large;\"><span style=\"color: #800080;\"><strong>PC.01.03.01\/EP 1\/<\/strong><\/span> Observed in Record Review:\u00a0for 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\/<\/span><\/li>\n<li><span style=\"font-size: large;\"><span style=\"color: #800080;\"><strong>PC.02.01.11\/EP 3\/<\/strong><\/span> 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 <\/span><\/li>\n<li><span style=\"font-size: large;\"><span style=\"color: #800080;\"><strong>PC.02.02.03\/EP 11\/<\/strong><\/span> 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.\u00a0An 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\/<\/span><\/li>\n<\/ul>\n<p><strong><span style=\"font-size: large;\">2010<\/span><\/strong><\/p>\n<ul>\n<li><span style=\"font-size: large;\"><span style=\"color: #800080;\"><span style=\"font-size: large;\"><span style=\"color: #800080;\"><strong>HR.01.07.01\/EP 1\/<\/strong><\/span><span style=\"color: #000000;\">\u00a0 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. \u2022 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. &#8211; Indirect, Surveyor #2<\/span><\/span><\/span><\/span><\/li>\n<li><span style=\"font-size: large;\"><span style=\"color: #800080;\"><strong>NPSG.07.01.01\/EP 1\/<\/strong><\/span> 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 &#8211; Indirect Impact, Surveyor #2 <\/span><\/li>\n<li><span style=\"font-size: large;\"><strong><span style=\"color: #800080;\"><strong>RC.01.02.01<\/strong>\/EP 3\/<\/span><\/strong> During patient tracer activity, it was noted that there were three separate signatures that were not timed on a Master Treatment Plan. \u2022 During record review, it was noted that there were three separate signatures that were not timed on a Master Treatment Plan. \u2022 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. &#8211; Indirect, Surveyor #2<\/span><\/li>\n<\/ul>\n<p><em>You may provide surveyor feedback by clicking on the \u2018Comments\u2019 link above (2nd line, top left) and\/or via the <a href=\"http:\/\/www.fieldsinc.com\/wp-content\/uploads\/2012\/07\/SPHCC%C6%92_PSQnew.pdf\">New Post Survey Questionnaire (PSQ)<\/a>. <\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Eileen \u201cLee\u201d Fraser M.A. RN-BC Surveyor Program(s): Hospital, Behavioral Health Care Surveyor Tenure: x 2009 Lives: Illinois TJC Bio: Eileen \u201c Lee\u201d 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 [&hellip;]<\/p>\n","protected":false},"author":60,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":true,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-1220","post","type-post","status-publish","format-standard","hentry","category-cat_srvyrprofiles"],"_links":{"self":[{"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/posts\/1220","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/users\/60"}],"replies":[{"embeddable":true,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/comments?post=1220"}],"version-history":[{"count":25,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/posts\/1220\/revisions"}],"predecessor-version":[{"id":10958,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/posts\/1220\/revisions\/10958"}],"wp:attachment":[{"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/media?parent=1220"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/categories?post=1220"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/tags?post=1220"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}