QA Investigation Results

Pennsylvania Department of Health
CLARKS SUMMIT STATE HOSPITAL
Health Inspection Results
CLARKS SUMMIT STATE HOSPITAL
Health Inspection Results For:


There are  6 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
This report is the result of a full Medicare recertification survey conducted on November 5 - 7, 2018, at Clarks Summit State Hospital. It was determined the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.



Plan of Correction:




482.13(c)(2) STANDARD
PATIENT RIGHTS: CARE IN SAFE SETTING

Name - Component - 00
The patient has the right to receive care in a safe setting.


Observations:

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure 26 patient beds did not pose a risk as a ligature point on Ward 4, Ward 5, Ward 6, and Ward 7.

Findings include:

Review on November 5, 2018, of facility policy, "Patient Bill Of Rights,"no date listed, revealed "You have a right to be treated with dignity and respect. ...11. You have the right to receive care in a safe setting. ..."

Review on November 5, 2018, of facility policy, "Assessment and Reduction of Suicide and Ligature Risk," effective date May 2018, revealed "Policy Statement: ...directs that all patients have a right to receive care in a safe setting. As one component of providing care in a safe setting, hospitals must identify patients at risk for intentional harm to self, identify environmental safety risks for such patients including but not limited to ligature risk, and communicate the results of any risk assessment and what interventions have been ordered. This policy describes how CSSH will provide these requirements. ..."

Observation tour of Ward 4 on November 5, 2018, revealed the special care room and patient rooms 14-3, 14-4, and 14-5 had electric beds with side rails with open loopable points.

Observation tour of Ward 5 on November 5, 2018, revealed two special care rooms, and patient rooms 14-11 and 14-14 had electric beds with side rails and open loopable points.

Interview with EMP14 on November 5, 2018, confirmed these electric beds with ligature points pose a risk for a person with suicidal thoughts.

Observation tour of Ward 6 on November 5, 2018, revealed the special care room, and patient rooms 15-2, 15-3, 15-4, 15-5, 15-6 had electric beds with side rails with open loopable points.

Observation tour of Ward 7 on November 5, 2018, revealed patient rooms 16-3, 16-4, 16-12, 16-14, 16-16 had electric beds with side rails with open loopable points.

Interview with EMP15 on November 5, 2018, confirmed these electric beds with ligature points pose a risk for a person with suicidal thoughts.





Plan of Correction:

Processes that led to the deficiency cited:
Clarks Summit State Hospital instituted an Improving Organizational Performance (IOP) committee on 5/1/2018. A part of the IOP's scope is to assess the environment of care for potential ligatures and hard-points. The electric beds with side rails and open loopable points was not among the items addressed by the IOP members.
Procedure for implementing the plan of correction:
On day 1 of the DOH survey, 11/5/18, upon bringing the side rail issue to the hospital's attention, all side rails on the 26 electric beds located in the special care rooms and identified patient rooms on units 4, 5, 6, and 7 were removed by Clarks Summit State Hospital staff.
On 11/8/18 the Chief Executive Officer directed the Chief Medical Officer to convene a meeting of the Improving Organizational Performance (IOP) no later than 11/9/18 to develop a process to assess ligature risk related to the electric beds.
On 11/9/18 The Chief Medical Officer convened the IOP meeting and present were a staff psychiatrist, a psychiatric nurse practitioner, the Director of Therapeutic Activities and the Chief Medical Officer. All electric bed styles were identified. The IOP then made a location visit to review each electric bed style for ligature risk.
The Chief Medical Officer assessed the removed and securely-stored side rails on 11/14/18. Due to their construction, the high loopability risk present on the side rails removed from the electric beds was not able to be eliminated or mitigated.
The Chief Medical Officer compiled the bed style assessment information into a spreadsheet on 11/14/18, identifying loopable risk elements and the presence or absence of each element on each electric bed style.
Additional actions:
1. The side rails removed from the electric beds were securely stored away from patient areas. They were permanently retired from use on 11/14/18.
2. All patients currently assigned to an electric bed will be assessed by the attending medical doctor, with attestation of completion and result to the Chief Medical Officer, to determine if the electric bed remains medically necessary. This will occur by close of business 11/23/18.
3. Any patient assessed to require an electric bed will require a prescriber order stating the need and reason for an electric bed. This order can be for up to 30 days and will be reviewed at least at the monthly medication review or whenever clinically indicated. Each initial and subsequent order for an electric bed will require a co-signature from the Medical Director prior to emplacement.
4. Any patients assessed to require an electric bed will have a Suicide Risk Assessment (SRA) completed by the treatment team leader, with attestation of completion and result to the Chief Medical Officer. This will occur by close of business 11/23/18.
5. Any patients assessed to require an electric bed will be assigned a room that is in close proximity to the unit nurse's station.
6. Patients assigned to an electric bed will have an assessment of ongoing need for the electric bed and an SRA completed by the medical attending and treatment team leader respectively at every treatment team and whenever clinically indicated.
7. Any roommates of patients assigned to an electric bed will have an SRA completed by the treatment team leader, with attestation of completion and result to the Chief Medical Officer. This will occur by close of business 11/23/18.
8. Any patients assigned to an electric bed or roommates of a patient assigned to an electric bed found to have a positive SRA will be treated as per policy A-046, Assessment and Reduction of Suicide and Ligature Risk. This policy provides for constant visual observation of the patient as well as an evaluation of the patient environment for identification, elimination and mitigation of suicide risks.
9. Any patients assigned to an electric bed and with a negative SRA will be rounded on at least every 15 minutes by Nursing Department staff who will surveil every patient room containing electric beds and will determine the presence or absence of a neck ligature. This will documented on a ligature checklist, filed in the patient chart and reported to the charge nurse. If a neck ligature is discovered a Medical Alert will be called immediately.
10. The ligature checklist form will be developed by the Chief Medical Officer and in-serviced to all Nursing Department staff by the Chief Nursing Executive no later than close of business 11/21/18.
11. All patients currently assigned to an electric bed who are determined not to require an electric bed will have their electric bed exchanged for a non-electric bed by close of business 11/28/18.
12. All electric beds not assigned to a patient will be securely stored away from patient areas.
13. A purchase order for additional ligature resistant non-loopable and smooth-edged platform beds will be completed as soon as the quote is received from the manufacturer. The Environmental Services Director began negotiations with the manufacturer on 11/13/18, and the purchase order will be placed by 11/30/18. The beds will be emplaced as soon as they arrive on campus.
14. All rooms containing an electric bed assigned to a patient will have signage prominently displayed outside the room identifying the presence within of one or more electric beds.
15. Proposals for any new bed styles shall be reviewed prior to purchase by the Executive Staff, Clinical leadership, and the IOP committee. The purpose will be to ensure that the proposed bed style is reviewed for loopable hard-points.
16. The IOP will continue to meet monthly to continually review the environment of care in order to identify and eliminate, mitigate and/or increase staff awareness of ligature and hard-point risk. The Chief Medical Officer will report on the IOP findings, recommendations, and future directions at least monthly to the Executive Staff beginning with the 11/21/18 meeting.
Monitoring procedure to ensure the plan of correction is effective:
1. The Medical Director shall conduct a weekly audit to confirm that every patient assigned to an electric bed has a valid order.
2. The Chief Nurse Executive shall be informed by the Medical Director whenever an electric bed is ordered. The Chief Nurse Executive shall conduct a weekly audit to confirm that every patient assigned to an electric bed has documentation of completed neck ligature rounds.
3. The Chief Medical Officer shall be informed by the Medical Director whenever an electric bed is ordered. The Chief Medical Officer shall conduct a weekly audit to confirm that every patient assigned to an electric bed has a completed and timely SRA and that appropriate response to the SRA finding has been initiated.
4. The Chief Medical Officer shall conduct a weekly audit to confirm that every roommate of a patient assigned to an electric bed has a completed and timely SRA and that appropriate response to the SRA finding has been initiated.

Responsible Person for the Plan of Correction: Chief Medical Officer


A0144: Ward 4 Tour:
On 11/5/18 the side rails on the electric beds in the special care room and patient rooms 14-3, 14-4, and 14-5 were removed by the Clarks Summit State Hospital staff.
A0144: Ward 5 Tour:
On 11/5/18 the side rails on the electric beds in both special care rooms and patient rooms 14-11, and 14-14 were removed by the Clarks Summit State Hospital staff.
A0144: Ward 6 Tour:
On 11/5/18 the side rails on the electric beds in the special care room and patient rooms 15-2, 15-3, 15-4, 15-5, and 15-6 were removed by the Clarks Summit State Hospital staff.
A0144: Ward 7 Tour:
On 11/5/18 the side rails on the electric beds in both special care rooms and patient rooms 16-3, 16-4, 16-12, 16-14, and 16-16 were removed by the Clarks Summit State Hospital staff.





482.28(a)(1) STANDARD
DIRECTOR OF DIETARY SERVICES

Name - Component - 00
The hospital must have a full-time employee who-

(i) Serves as director of the food and dietetic services;

(ii) Is responsible for daily management of the dietary services; and

(iii) Is qualified by experience or training.


Observations:

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure all hair was restrained by hair nets and jewelry was limited for staff working in the dietary department; the facility failed to ensure foods added to the menu were reflected on the food temperature log; the facility failed to ensure food temperatures were recorded and monitored for safety; and, the facility failed to ensure food substitutions on the menu were reviewed and approved by the Dietician.

Findings include:

1) Review on November 6, 2018, of the facility's "Infection Control Program Dietary Department Personal Requirements for Personnel" policy, last reviewed October 2018 revealed "... Food service employees are defined as an individual whose occupations involve the preparation or serving of food or beverages. Examples are food service workers and cooks. ... 1. Hair Covering: a.) All female employees must wear hairnets that completely cover the hair at all times in all food service areas. b.) All male employees with short hair must wear disposable caps or white clean caps. c.) Male employees with over-the-ear or longer hair must wear hairnets that completely cover the hair at all times in the food service areas. d.) male employees with beards must wear "beard bags" at all times in the food services areas. ... 5. Limit jewelry to: a. wedding rings b. pierced earrings if close to earlobe c. watches worn by supervisory personnel or staff not involved in food preparation or handling. ..."

Observation on November 6, 2018, of EMP4, EMP5 and EMP6 revealed these employees preparing and distributing food for patient consumption without all hair restrained in the hair net.

Interview with EMP1, EMP2 and EMP3 on November 6, 2018, at the time of the observation confirmed EMP4, EMP5 and EMP6 were preparing and distributing food for patient consumption without all hair restrained in the hair net.

Observation on November 6, 2018, of EMP7, EMP8 and EMP9 revealed these employees preparing and distributing food for patient consumption with long necklaces hanging from around their necks.

Interview with EMP1, EMP2 and EMP3 on November 6, 2018, at the time of the observation confirmed EMP7, EMP8 and EMP9 were preparing and distributing food for patient consumption with long necklaces hanging from around their necks. EMP1 revealed necklaces are not to be worn by dietary employees when working in the dietary department.

Observation on November 6, 2018, of EMP10 and EMP11 revealed these employees preparing and distributing food for patient consumption without all facial hair restrained in the facial covering.

Interview with EMP1, EMP2 and EMP3 on November 6, 2018, at the time of the observation confirmed EMP10 and EMP11 were preparing and distributing food for patient consumption without all facial hair restrained in the facial covering.

2) A request was made of EMP1, EMP2 and EMP3 for the facility's policy, procedure or guideline for dietary staff to reference when adding new menu items to the patient menu. None was provided.

Review on November 6, 2018, of the Diet Spreadsheet Week at a glance revealed dietary served pork sausage for breakfast on February 28, March 3 and 17, 2018 and pork-ham on March 10 and 13, 2018.

There was no documentation on the Tray Temperature Monitoring Form indicating dietary staff tested the temperature of the pork sausage or the pork-ham to ensure these food products were a safe temperature for serving to the patients.

Interview with EMP1 on November 6, 2018, at approximately 10:50 AM revealed the dietary department added pork sausage and pork-ham to the menu, the Food Temperature Monitoring Form was not modified to reflect the addition of these new food items and there was no documentation dietary staff tested the temperature of these food items to ensure they were at a safe temperature for serving to the patients.

3) Review on November 6, 2018, of the "Food Serving Temperature" policy, dated August 30, 2017, revealed "Policy Statement: The Dietary Department of Clarks Summit State Hospital will serve food at a safe temperature within designated guidelines. Purpose: To ensure all food, hot and cold, is served and consumed at a safe temperature. Responsibility: Food Service Workers, Food Service Supervisors and Dietitians ..."

Review on November 6, 2018, of the "Holding Foods for Service Hot-Holding Guidelines" no review date, revealed "1. Keep "hot foods hot." Hot-holding equipment must keep foods at 140 degrees F.[Fahrenheit] or higher. 2. Measure internal temperatures every 2 hours and record. 3. Stir at regular intervals. 4. Keep foods covered. 5. Discard food after 4 hours if not held at or above 140 degrees F. 6. Never mix fresh food with food being held. 7. Prepare food in small batches. 8. Never use hot-holding equipment to reheat foods. 9. Store utensils properly and use long handled sanitized utensils. 10. Change utensils every 4 hours. 11. Practice good personal hygiene."

Review on November 6, 2018, of the "Cold-Holding Guidelines" no date, revealed "1. Keep "cold foods cold." Cold-holding equipment must keep food at 40 degrees F or lower. 2. Do not store food directly on ice. 3. Keep foods covered. 4. Change utensils every 4 hours. 5. Store utensils properly and use long handled sanitized utensils. 6. Practice good personal hygiene."

Review on November 6, 2018, of the facility's "Tray Temperature Monitoring Form" no review date, revealed columns for dietary staff to document temperatures at 6:45 A.M. and 7:45 A.M. for Breakfast food items and temperatures of Juice 40 , Milk 40 , Cereal 175, Eggs 145, Hot beverages 150 and Toast; at 10:45 A.M. and 11:45 A.M. for Lunch food items and temperatures of Soup 180, Regular Meat 180, Ground Meat 180, Pureed Meat 180, Potato/Starch 160, Vegetable 160, Chopped Vegetable 160, Ground Vegetable 160, Milk 40, Hot Beverage 150 and Dessert 40; and at 3:30 P.M. and 5:00 P.M. for Supper food items and temperatures of Soup 180, Regular Meat 180, Ground Meat 180, Pureed Meat 180, Potato/Starch 160, Vegetable 160, Chopped Vegetable 160, Ground Vegetable 160, Milk 40, Hot Beverage 150 and Dessert 40. There is documentation on this form indicating Food tested, in compliance with appearance and temperature and a space for the Food Service Supervisor to sign.

The Tray Temperature Monitoring Form for January 1, 24 and 27, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages.

The Tray Temperature Monitoring Form for January 27, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages for breakfast; soup, regular meat, ground meat, pureed meat, potato/starch, vegetable, chopped vegetable, ground vegetable, milk, hot beverage and dessert for lunch and supper.

The Tray Temperature Monitoring Form for February 23, 24, 25, 26 and 27, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages.

The Tray Temperature Monitoring Form for February 28, 2018, revealed no temperatures documented on the following: soup, regular meat, ground meat, pureed meat, potato/starch, vegetable, chopped vegetable, ground vegetable, milk, hot beverage and dessert for lunch.

The Tray Temperature Monitoring Form for March 10 and 13, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages.

The Tray Temperature Monitoring Form for July 13, 2018, revealed no temperatures documented on the following: soup, regular meat, ground meat, pureed meat, potato/starch, vegetable, chopped vegetable, ground vegetable, milk, hot beverage and dessert for lunch.

The Tray Temperature Monitoring Form for August 11, 12, 15 and 16, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages.

The Tray Temperature Monitoring Form for September 8, 2018, revealed no temperatures documented on the following: juice, milk, cereal, eggs and hot beverages.

The Tray Temperature Monitoring Form for October 5 and 26, 2018, revealed no temperatures documented on the following: soup, regular meat, ground meat, pureed meat, potato/starch, vegetable, chopped vegetable, ground vegetable, milk, hot beverage and dessert for lunch.

Interview with EMP1, EMP2 and EMP3 on November 6, 2018, at approximately 11:45 AM confirmed there were no documented food temperatures taken on the hot and cold foods on the tray line prior to distribution to patients to ensure the foods were at the proper temperature.

4) Review on November 6, 2018, of the facility's "Menu Substitutions" policy, dated June 29, 2017, revealed "Procedure: 1. Menus are planned by the Director of Dietetic Services II and the Clinical Dietitian Manager. The menus consist of two cycles: Fall/Winter and Spring/Summer. Each consists of a four week cycle menu. 2. When unexpected changes to the menu are necessary, they must be approved by the Director or the Clinical Dietitian Manager. In their absence, the Clinical Dietitian or the Food Manager may approve the change. Menu changes may occur due to delivery problems, equipment breakdown, emergency situations, etc. 3. Once menu changes are approved, they are to be recorded in the dietary office using the designated form showing proper approval and reason for the change."

Review on November 6, 2018, of the Menu Substitution List revealed the following food substitutions were not approved by the Director or the Clinical Dietitian Manager:
November 6, 2017, dietary substituted zucchini for peas.
November 13, 2017, dietary substituted tomato salad for cucumber salad.
January 4, 2018, dietary substituted salisbury steak for roast beef and ham for bologna.
January 20, 2018, peas and carrots for broccoli.
January 30, 2018, salisbury steak for pork roast.
February 7, 2018, zucchini for carrots.
February 20, 2018, scrambled eggs for omelets; donuts for coffee cake and lactaid milk for soy milk.
March 19, 2018, three bean salad for coleslaw.
May 23, 2018, three bean salad for cabbage.
October 30, 2018, broccoli salad for coleslaw.

There was no documentation the food substitutions were approved by the Director or the Clinical Dietitian Manager

Interview with EMP1, EMP2 and EMP3 on November 6, 2018, at approximately 11:50 AM confirmed the above food substitutions were not approved by the Director or the Clinical Dietitian Manager.





Plan of Correction:

DEFICIENCY # 1: Hair not restrained in hair net, long necklaces hanging from around workers necks, all facial hair not restrained in facial covering.
1) Plan for correcting specific deficiency. The plan should address the processes that led to the deficiency cited:
The Infection Control Program Dietary Department Personal Requirements for Personnel of October 2018 notes the following:
Hair covering: all female employees must wear hairnets that completely cover the hair at all times in all food service areas. All male employees with short hair must wear white clean caps. Male employees with over the ear or longer hair must wear hairnets that completely cover the hair at all times in all food service areas. Male employees with beards must wear beard bags at all times in all food service areas.
Jewelry: limit jewelry to a wedding ring, pierced earrings if close to earlobe, and watches worn by supervisory personnel or staff not involved in food preparation or handling.
Upon assessment to determine what led to the non-compliance with the aforementioned, it is believed the policy breach occurred because the Food Service Manager and the Food Service Supervisors overlooked the requirement and there was no process in place to monitor the requirements.

2) Procedure for Implementing Acceptable plan of correction: The Clinical Dietitian Manager and the Food Service Manager conducted in–service training on 11/07/18 and 11/08/18 with all dietary staff to re-educate on the Infection Control Program Dietary Department Personal Requirements for Personnel of October 2018.
There was an opportunity for questions and answers. A training record will be maintained on file in the Dietary Department.

3) Monitoring procedure to ensure plan of correction is effective:

Hair coverings to restrain hair and limiting the wearing of jewelry to be compliant with the policy were added to the Food Service Supervisors daily checklist. Revisions to the checklist to add these elements were completed by the Food Service Manager on 11/09/18. The in-service on the checklist will occur by 11/19/18 and will be given by the Food Service Manager. Staff will be given the opportunity for questions and answers. A training record will be maintained on file in the Dietary Department.

The Food Service Manager will audit the Food Service Supervisors daily checklist on regular business days to ensure compliance starting 11/20/18. The results of the audit will be reported weekly to the Director of Dietetic Services beginning on 11/27/18.
The Director of Dietetic Services will report monthly starting 12/19/18 to the Chief Operating Officer any corrective action that took place.

4) Person responsible for implementing Plan of correction: Director of Dietetic Services


DEFICIENCY #2:
Tray Temperature Monitoring Form did not have a category to reflect all foods on the tray line.
All food temperatures were not monitored and documented by the Food Service Supervisors.
1) Plan for correcting specific deficiency. The plan should address the processes that led to the deficiency cited:

The failure to ensure that foods added to the menu were reflected on the food temperature log and the failure to ensure food temperatures were monitored for safety was determined to be the result of inconsistent application of the Quality of Food on Tray Line Policy and Procedure of July 29, 2017, specifically breakfast meats (pork, sausage, ham). This policy notes, "Temperature of food items on the tray line is monitored by the Food Service Supervisor responsible for checking the meal. A tray temperature monitoring form is completed at the beginning of the tray line and after 1 hour if the tray line is still in progress to ensure optimal quality and safe temperatures".

2) Procedure for Implementing Acceptable Plan of correction:
1) The Tray Temperature Monitoring Form will be revised by the Director of Dietetic Services by 11/16/18 to include a category for all items that may be potentially served.
2) The Director of Dietetic Services will conduct an in-service training to re-educate the Food Service Manager and the Food Service Supervisors on the Dietary Department's Quality of Food on Tray Line Policy and Procedure by 11/16/18 and the revised Tray Temperature Monitoring Form. Staff will be given an opportunity for questions and answers. A training record will be maintained on file in the Dietary Department.

3) Monitoring procedure to ensure Plan of correction is effective:
The Food Service Manager will audit the Tray Temperature Monitoring Form on regular business days to ensure:
1.) all items served are recorded on the form
2.) the form is completed accurately by the Food Service Supervisors.
The audit tool will be developed by the Food Service Manager by 11/28/18.
The results of the monitor will be reported weekly by the Food Service Manager to the Director of Dietetic Services. The first report will be generated by the Food Service Manager on 12/05/18.
The Director of Dietetic Services will report monthly starting 12/19/18 to the Chief Operating Officer any corrective action that took place.
4) Person responsible for implementing Plan of correction:
Director of Dietetic Services

DEFICIENCY #3: Food temperatures not documented.

1) Plan for correcting specific deficiency. The plan should address the processes that led to the deficiency cited:

The failure to ensure that food temperatures were not documented on the temperature monitoring form was due to the Food Service Supervisors not consistently completing the temperature monitoring form for every meal, and did not record all temperatures. This was determined to be the result of inconsistent application of two policies.
1.) The Quality of Food on Tray Line Policy and Procedure of July 29, 2017. This policy notes, "Temperature of food items on the tray line is monitored by the Food Service Supervisor responsible for checking the meal. A tray temperature monitoring form is completed at the beginning of the tray line and after 1 hour if tray line is still in progress to ensure optimal quality and safe temperatures".
2.) The Food Serving Temperature Policy and Procedure of August 30, 2017. This policy notes, "The Dietary Department of Clarks Summit State Hospital will serve food at a safe temperature within designated guidelines. Purpose: To ensure all food, hot and cold, is served and consumed at a safe temperatures".

2) Procedure for Implementing Acceptable Plan of correction:
The Clinical Dietitian Manager and the Food Service Manager conducted an in-service training on 11/07/18 and 11/08/18 with Food Service Supervisors to re-educate them on the Dietary Department's Quality of Food on Tray Line Policy and Procedure.
Staff were given an opportunity for questions and answers. A training record will be maintained on file in the Dietary Department.

3.) Monitoring procedure to ensure Plan of correction is effective:
The Food Service Manager will audit the Tray Temperature Monitoring Form on regular business days to ensure:
1.) all items served are recorded on the form
2.) the form is completed accurately by the Food Service Supervisor.
The audit will be developed by the Food Service Manager by 11/28/18.
The results of the monitor will be reported weekly by the Food Service Manager to the Director of Dietetic Services. The first report will be generated by the Food Service Manager on 12/5/18.

The Director of Dietetic Services will report monthly starting 12/19/18 to the Chief Operating Officer any corrective action that took place.

4) Person responsible for implementing Plan of correction:
Director of Dietetic Services


DEFICIENCY #4: Menu Substitutions Not Approved

Plan for correcting specific deficiency. The plan should address the processes that led to the deficiency cited:
The failure to ensure that food substitutions on the menu were reviewed and approved by the dietician has been determined to be the result of inconsistent application of the Menu Substitution Policy and Procedure of June 29, 2017 by the Food Service Manager, Food Service Supervisors and Clinical Dieticians. This policy notes, "When unexpected changes to the menus are necessary, they must be approved by the Director of Dietetic Services or the Clinical Dietitian Manager. In their absence, the Clinical Dietitians or the Food Manager may approve the change." In addition, there was no approved Food Item Substitution Protocol nor was there a process in place to monitor the Menu Substitution List.

Procedure for Implementing Acceptable Plan of correction:
An in-service on the June 29, 2017 Menu Substitution Policy and Procedure was given to the Food Service Manager, Food Service Supervisors and the Clinical Dietitians by the Clinical Dietitian Manager on 11/07/18 and 11/08/18. There was on opportunity for questions and answers. A training record will be maintained on file in the Dietary Department.
As an interim measure until an approved Food Item Substitution Protocol and Policy update is generated and educated, an in-service training was conducted by the Clinical Dietitian Manager on 11/09/18 to educate the dietary management staff to contact the Clinical Dietitian Manager or the Clinical Dietitian should a change to the menu be necessary during non-regular business hours. Contact phone numbers for the Clinical Dietitian Manager and the Clinical Dietitians were provided. There was an opportunity for questions and answers. A training record will be maintained on file in the Dietary Department.
The Director of Dietetic Services will develop an approved Food Item Substitution Protocol by 11/30/18. The approved Food Item Substitution Protocol will be used during non-regular business hours by the Food Service Manager or the Food Service Supervisor on duty to make menu substitutions, if necessary.
The Director of Dietetic Services will revise the Menu Substitution Policy and Procedure by 11/30/18 to include the following statements: "When unexpected changes to the menu are necessary, they must be approved by the Director of Dietetic Services or the Clinical Dietitian Manager or the Clinical Dietitians. In their absence, if a menu substitution is necessary, an approved Food Item Substitution Protocol will be followed by the Food Service Manager or the Food Service Supervisor on duty." The approved Food Item Substitution Protocol will be attached to the policy.

The Director of Dietetic Services will educate the Clinical Dietitian Manager, Food Service Manager, Food Service Supervisors and the Clinical Dietitians on the revised Menu Substitution Policy and Procedure, Menu Substitution List, and Food Item Substitution Protocol by 12/07/18. Staff will be given the opportunity for questions and answers. A training record will be maintained on file in the Dietary Department.
Monitoring procedure to ensure Plan of correction is effective:
The Clinical Dietitian Manager will monitor the Menu Substitution List weekly for completeness and appropriate application of the Food Item Substitution Protocol beginning on 12/12/18 and report findings and any corrective action to the Director of Dietetic Services.
The Director of Dietetic Services will report monthly starting 12/19/18 to the Chief Operating Officer any corrective action that took place.

Person responsible for implementing Plan of correction: Director of Dietetic Services.