Pennsylvania Department of Health
SHRINERS HOSPITALS FOR CHILDREN, PHILADELPHIA
Patient Care Inspection Results

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SHRINERS HOSPITALS FOR CHILDREN, PHILADELPHIA
Inspection Results For:

There are  16 surveys for this facility. Please select a date to view the survey results.

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SHRINERS HOSPITALS FOR CHILDREN, PHILADELPHIA - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of an unannounced onsite complaint investigation (CHL23C168N) conducted on March 23, 2023, and completed April 4, 2023, at Shriners Hospitals for Children, Philadelphia. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.





 Plan of Correction:


111.12 LICENSURE EQUIPMENT:State only Deficiency.
111.12 Equipment

The type, size, and layout of equipment shall provide for ease of cleaning, optimal workflow, and efficient food production to meet the scope and complexity of the regular and therapeutic diet requirements of the patients. Equipment and work areas shall be clean and orderly. Effective procedures for cleaning all equipment and work areas shall be followed consistently to safeguard the health of the patient.
Observations:

Based on observation, a review of facility policy, documents and interview with staff (EMP), it was determined the facility failed to maintain sanitary conditions and effective procedures for cleaning of the Food Services Department equipment and food preparation areas.

Findings include:

A review of facility policy "Food Services ...Equipment Handling and Cleaning," last reviewed September 2022 revealed "PURPOSE: To ensure a high quality of sanitation to all food service equipment and surfaces and to minimize the risk of microorganism growth that could cause food borne illness. PROCEDURE: General Clean Procedure: 1. On all food contact surfaces or food service equipment use the [XXXX] name redacted cleaning product. 2. Use a scrub pad or rag and clean the entire surface of the oven, table or refrigerator including all corners and racks."

A review on March 23, 2023, of facility document "Shriners Hospitals for Children Nutrition Services Cook- 1 Job Description" revealed a specific schedule for food preparation tasks. Further review revealed "Clean area and designated cleaning assignments per cleaning list by position."
A review on March 23, 2023, of facility document "Shriners Hospitals for Children Nutrition Services Cook- 2 Job Description" revealed a specific schedule for food preparation tasks. Further review revealed "Clean area and designated cleaning assignments per cleaning list by position."
A review on March 23, 2023, of facility document "Shriners Hospitals for Children Nutrition Services Cook- PM Job Description" revealed a specific schedule for food preparation tasks. Further review revealed "Clean area and designated cleaning assignments per cleaning list by position."
A request was made on March 23, 2023, to EMP4 for the designated cleaning assignments indicated in the job descriptions for Cook-1, Cook-2, and Cook-PM job. No documents were provided.
1. An observation on March 23, 2023, at 12:04 PM with EMP2, EMP3, EMP4 and EMP5 of the Sixth Floor Kitchen's dish-washing area revealed a metal cart with crumbs and dried food residue on the shelves that was holding sanitized meal trays.
An observation on March 23, 2023, at 12:06 PM with EMP2, EMP3, EMP4 and EMP5 of the Sixth Floor Kitchen's environmental services closet revealed layers of food residue, grime, and trash was in the floor-mounted mop sink.
An interview conducted on March 23, 2023, at 12:04 PM with EMP4 confirmed there was crumbs and food residue on the cart holding sanitized meal trays in the kitchen's dish-washing area. In addition, EMP4 confirmed the environmental service closet's floor-mounted mop sink was coated with layers of food residue, grime, and trash.
2. An observation on March 23, 2023, at 12:08 PM with EMP2, EMP3, EMP4 and EMP5 in the sixth floor Kitchen revealed a metal rack holding clean floor mats with heavy dirt and grime buildup on the base and wheels of the metal rack.
An interview conducted on March 23, 2023, at 12:08 PM with EMP4 confirmed there was heavy dirt and grime buildup on the metal rack holding clean floor mats.
3.An observation on March 23, 2023, at 12:10 PM with EMP2, EMP3, EMP4 and EMP5 of the sixth floor Kitchen's food preparation area revealed dried residue and grime on the hand washing sink paper towel holder,water mineralizations residue on the hand washing sink faucet; and layers of dried liquid residue and grime on the pest trap located under the hand washing sink.
An observation on March 23, 2023, at 12:12 PM with EMP2, EMP3, EMP4 and EMP5 of the sixth floor Kitchen's food preparation area revealed dried residue and grime on the floor and walls behind the ice machine. Further observation revealed heavy layers of dried food and liquid residue on the floor and sides of the two cold food storage boxes.
An interview conducted on March 23, 2023, at 12:14 PM with EMP4 confirmed there was dried residue and grime on the hand washing sink paper towel holder, water mineralizations residue on the hand washing sink faucet, and dried residue and grime was coating the pest trap located under the hand washing sink. EMP4 further confirmed there was dried food and dried residue and grime on the floor and walls behind the ice machine and heavy layers of dried food and liquid residue on the floor and sides of the two cold food storage boxes ("deli boxes"). EMP4 stated "The deli-boxes should be cleaned every night but they are not. We do not have a schedule for cleaning items in the kitchen. We have issues with staffing and keeping the kitchen clean."
4. An observation on March 23, 2023, at 12:14 PM with EMP2, EMP3, EMP4 and EMP5 of the sixth Floor Kitchen revealed dried food residue stains and grime on the floor, on the wheeled carts, and on the stainless steel shelving throughout the food preparation area.
An interview conducted on March 23, 2023, at 12:18 PM with EMP 4 confirmed there was dried food residue stains and grime on the floor, on the wheeled carts, and on the stainless steel shelving throughout the food preparation area in the Sixth Floor Kitchen.
An interview conducted on March 23, 2023, at 1:58 PM with EMP4 confirmed the kitchen staff did not have consistent job assignments and did not use audit check lists to audit completed cleaning tasks in the kitchen area. EMP4 stated "The person assigned to the position of 'Cook 2 varies on each shift. They have an assigned cleaning task depending on the area of the kitchen they are in, but we do not have the cleaning tasks posted in the kitchen."

Cross Reference:
Regulation: 147.2: Maintenance of Safety & Sanitation










 Plan of Correction - To be completed: 07/17/2023

Multidisciplinary leadership team (Hospital Administrator, Director of Patient Care Services, Director of HR, Director of PI, Director of Director of Environmental and Nutrition Services, and acting Director of Plant and Facilities) developed an initial strategy and plan to address deficiencies. Components of plan detailed below. Completed 5/9/2023.

In addition to strategy development, the following interventions completed in the kitchen area:
- All walls, floors, carts, sinks, and kitchen equipment cleaned and sanitized.
- All door frames and two walk-ins in kitchen painted
- New bumper guard installed
- New kick plates installed on café door
Director of Environmental and Nutrition Services reviewed for completion and followed up that cleaning completed 4/3/2023.

Food Services staff will be in-serviced on policy FS 4.1 "Equipment Handling and Cleaning." In-service will include receiving feedback and ideas on policy and procedures for equipment handling and cleaning. This will include a sign-in sheet with signatures. Complete on 6/14/2023.

Director of Environmental and Nutrition Services will review and revise policy as appropriate based on staff discussion and best practice. Complete by 7/14/2023.

Director of Human Resources and Director of Environmental and Nutrition Services will review Nutrition Services job descriptions, focusing on job responsibilities for "Cook" positions. Cleaning duties added directly on to the departmental job duty/assignment lists for each employee by position worked. Complete by 6/14/2023.

Director of Environmental and Nutrition Services or designee will provide Food Services staff scheduled job/role assignment prior to start of shift and all cleaning assignments posted in the kitchen common area for daily reference. Complete by 6/14/2023.

(Quality Assurance)

Regular checklist used by Food Services and EVS staff for daily monitoring of the following:
- Dish-washing area – stainless steel shelves and cart cleanliness and sanitation
- EVS closet – overall cleanliness (includes trash and mop sink)
- Floor mat rack and mats cleanliness
- Hand washing sink cleanliness and sanitation (includes paper towel holder, faucet, direct surrounding area)
- Ice machine maintenance and surrounding area (floor and walls)
- Cold food storage boxes cleanliness and maintenance

Director of Environmental and Nutrition Services or designee will audit checklist daily for completion for three weeks, then weekly for three months beginning 6/19/2023. Director of Fiscal Services or designee will perform additional visual inspection of areas and document weekly.

Food Services staff will be in-serviced on checklist completion and audit process on 6/14/2023. This will include a sign-in sheet with signatures.

The audit data presented at Quality Improvement Committee on a monthly basis beginning 7/17/2023. The committee will create any action plans, if necessary, based on the results.

The Quality Improvement Committee will evaluate data, action plans, and measure the results for three months.

The Board Medical Committee, of the Board of Governors, will audit monthly for 3 months the Quality Improvement Committee minutes and audit data to ensure compliance with the audit program.

Initial survey findings and strategy for correction reviewed with The Board Medical Committee, of the Board of Governors, on 5/18/2023.

Items submitted for purchase on 5/12/2023:
- Trash cans in kitchen with dollies
- 4 new speed racks
- 3 mobile carts
- 1 new floor mat hanger
- All new dish racks
- New clean dish cart for transport
- New soap and sanitizer buckets
- New wall hanging system for mops and brooms

The Director of Fiscal Services and the Director of Environmental and Nutrition Services responsible for the plan of correction.

147.2 LICENSURE MAINTENANCE OF SAFETY & SANITATION:State only Deficiency.
147.2 Maintenance of safety and sanitation

The hospital shall be equipped, operated, and maintained so as to sustain its safe and sanitary characteristics and to minimize all health hazards in the hospital, for the protection of both patients and employes.
Observations:

Based on observation and interview with staff (EMP) it was determined the facility failed to maintain the central supply department and loading dock in a safe and sanitary manner.

Findings include:

1. An observation on March 23, 2023, at 11:32 AM with EMP2, EMP3, EMP4, EMP5 and EMP7 of the central supply department revealed paper and plastic refuse was spread throughout the area under the storage risers. Further observation revealed a three-shelf cart used to transport supplies throughout the hospital was coated with grime and residue.
An interview conducted on March 23, 2023, at 11:35 AM with EMP4 and EMP7 confirmed paper and plastic refuse was spread under the storage risers throughout the central supply department. EMP7 further confirmed the three-shelf cart used to transport supplies throughout the hospital was coated with grime and residue. EMP7 further confirmed there was no schedule in place for regular cleaning in the central supply department.
2. An observation on March 23, 2023, at 11:40 AM with EMP2, EMP3, EMP4, and EMP5 of the facility loading dock revealed the dock was littered with trash and refuse. Further observation revealed trash and refuse lying on the steps leading to the loading dock driveway.
An observation on March 23, 2023, at 11:43 AM with EMP2, EMP3, EMP4, and EMP5 of the hallway between the loading dock and central supply department revealed trash and refuse on the floor in the hallway. Further observation revealed heavy layers of liquid residue and grime on the door leading to the interior of the hospital and the central supply department.
An interview conducted on March 23, 2023, at 11:43 AM with EMP2, and EMP4 confirmed the loading dock and steps to the driveway was littered with trash and refuse. EMP 2 further confirmed there was trash and refuse in the hallway and heavy layers of liquid residue and grime on the door leading to the interior of the hospital and central supply department.
Cross Reference:
Regulation: 111.12: Equipment.









 Plan of Correction - To be completed: 07/17/2023

Multidisciplinary leadership team (Hospital Administrator, Director of Patient Care Services, Director of HR, Director of PI, Director of Director of Environmental and Nutrition Services, and acting Director of Plant and Facilities) developed an initial strategy and plan to address deficiencies. Components of plan detailed below. Completed 5/9/2023.

In addition to strategy development, the following interventions completed in the central supply department and loading dock areas:
- Central supply area (including hallway) swept and refuse removed throughout area
- Loading dock area swept and residue cleaned
- Carts cleaned and sanitized
Director of Environmental and Nutrition Services reviewed for completion and followed up with Supply Chain Coordinator that cleaning completed 4/3/2023.

(Quality Assurance)

Central Supply Department and Environmental Services (EVS) will be in-serviced on cleaning checklist and audit process on 6/13/2023. This will include a sign-in sheet with signatures.

Regular checklist used by Central Supply and EVS staff for daily monitoring of the following:
- Storeroom – Have the floors been swept of debris? Is there and visible liquid on the floor that needs to be mopped up? Is the area clear of items stored on the ground?
- Storeroom Carts - Are the carts clean from dirt and debris? Are the carts in good working condition?
- Loading Dock Area - Is the area on and surrounding the loading dock clear of trash and debris? Is the area organized and all items stored in the proper locations for safety? If there are any issues not directly related to Shriners Children's, have we contacted Temple Hospital Central Supply or Environmental Services?

Director of Environmental and Nutrition Services, Supply Chain Coordinator or designee will audit checklist daily for completion for three weeks, then weekly for three months beginning 6/19/2023. Director of Fiscal Services or designee will perform additional visual inspection of areas and document weekly.

The Director of Environmental and Nutrition Services and Supply Chain Coordinator will partner on maintaining the loading dock. Dock shared with Temple University Hospital. Escalation by the Director of Fiscal Services to Temple's Director of Environmental Services will occur if noncompliance concerns on the attached/shared areas of Temple University Hospital identified during auditing (Temple's dock, hallway to supply entrances, etc.). Escalation will be documented (audits begin 6/19/2023).

The audit data presented at Quality Improvement Committee on a monthly basis beginning 7/17/2023. The committee will create any action plans, if necessary, based on the results.

The Quality Improvement Committee will evaluate data, action plans, and measure the results for three months.

The Board Medical Committee, of the Board of Governors, will audit monthly for 3 months the Quality Improvement Committee minutes and audit data to ensure compliance with the audit program.

Initial survey findings and strategy for correction reviewed with The Board Medical Committee, of the Board of Governors, on 5/18/2023.

The Director of Fiscal Services and the Director of Environmental and Nutrition Services responsible for the plan of correction.

147.11 LICENSURE ENVIRONMENTAL SERVICES DEPARTMENT:State only Deficiency.
147.11 Principle

Housekeeping, laundry, and maintenance functions shall be effectively organized, directed, and staffed by qualified personnel.
Observations:

Based on a review of facility documents, observation, and interview with staff (EMP) it was determined the facility failed to ensure acceptable Environmental Service standards were maintained in patient care areas, visitor restrooms, visitor and patient dining areas, and the main hospital Lobby area.
Findings include:
A review on March 23, 2023, of facility document "PM Night Shift Supervisor Checkout List" revealed a specific schedule to complete rounds on the First, Second, Third, Fourth, Fifth, Sixth, Seventh and Eighth Floors to ensure all areas were vacuumed, dust mopped, and bathrooms cleaned in all areas by the night shift supervisor.
1. An observation on March 23, 2023, at 10:35 AM with EMP3, EMP4 and EMP5 of the fifth floor medical surgical unit "Shower Room" revealed there was grime and green residue on the floor drain in the center of the room, and a dead insect in the sink.
An interview conducted on March 23, 2023, at 10:40 AM with EMP3, EMP4 and EMP5 confirmed the fifth floor medical surgical unit "Shower Room" had grime and green residue on the floor drain in the center of the room, and a dead insect in the sink.
An observation on March 23, 2023, at 10:50 AM with EMP3, EMP4 and EMP5 of the fifth floor medical surgical unit environmental services closet revealed the "Floor-Mounted Mop Sink" was coated with layers of dirt and grime.
An interview conducted on March 23, 2023, at 10:53 AM with EMP4 confirmed the fifth and sixth floors medical surgical units environmental service closet "Floor-Mounted Mop Sinks" were coated with layers of dirt and grime. EMP4 stated "The environmental services closet gets used a lot."
An observation on March 23, 2023, at 11:11 AM with EMP3, EMP4 and EMP5 of the stairwell between the sixth and seventh floors revealed heavy layers of grime and dust on the pipes rising from the landing to the ceiling.
An interview conducted on March 23, 2023, at 11:11 AM with EMP4 confirmed the pipes rising from the landing to the ceiling in the stairwell between the sixth and seventh floors was not cleaned regularly and there was heavy layers of grime and dust on the pipes. EMP4 stated "We clean the stairwell landings on the main floor levels daily. We clean the steps and the landing between floors weekly. The pipes would get cleaned as a special project."
2. An observation on March 23, 2023, at 11:23 AM with EMP2, EMP3, EMP4 and EMP5 of the Physical Therapy area revealed dirt and grime build-up on the floor surrounding the floor-mounted parallel bars.
An interview conducted on March 23, 2023, at 11:25 AM with EMP4 confirmed there was dirt and grime build-up on the floor surrounding the floor-mounted parallel bars apparatus in the Physical Therapy area. EMP4 stated "We'll have to get that the next time the parallel bars are moved."
3. A review on March 23, 2023, of facility document "ESD Laundry Position 6:00 AM to 2:30 PM" revealed a specific schedule to dust mop the Lobby floor, clean and restock the bathrooms on the First Floor, and dust the Lobby weekly.
An observation on March 23, 2023, at 12:05 PM with EMP4 revealed dust and crumbs on the chairs in the lobby and dried brown residue on the outside of the toilets in the ladies' restroom, in addition to water mineralizations build-up on the on the water faucets and grime in the drains in the public water fountains outside the ladies restroom.
An interview conducted on March 23, 2023, at 12:20 PM with EMP4 confirmed there was rust and food crumbs on the lobby floor and on the chairs in the lobby and residue on the outside of the toilets in the ladies restroom. Further interview confirmed water mineralizations build-up was on the water faucets and grime was in the drains of the public water fountains outside the ladies restroom.
Cross Reference:
Regulation: 111.12: Equipment.





 Plan of Correction - To be completed: 07/17/2023

Multidisciplinary leadership team (Hospital Administrator, Director of Patient Care Services, Director of HR, Director of PI, Director of Director of Environmental and Nutrition Services, and acting Director of Plant and Facilities) developed an initial strategy and plan to address deficiencies. Components of plan detailed below. Completed 5/9/2023.

In addition to strategy development, the following interventions completed:
- Floors 1 – 8 vacuumed and dust mopped
- 5th floor shower room cleaned
- Lobby chairs cleaned and floor stripped and re-waxed
- First floor bathrooms top scrubbed and walls and grout cleaned
- Rehab floors around parallel bars cleaned
- Stairwells dusted
Director of Environmental and Nutrition Services reviewed for completion and followed up that cleaning completed 4/3/2023.

Submitted for purchase on 5/12/2023:
- New wall hanging system for mops and brooms
- New soap and sanitizer buckets
- New rack for chemical closet and soap and sanitizer dispenser

(Quality Assurance)

Environmental Services (EVS) will be in-serviced on expanded cleaning checklist and audit process on 6/13/2023. This will include a sign-in sheet with signatures.

Regular checklist used by EVS staff for daily monitoring of the following:
- Restrooms - Are the mop sinks cleaned regularly and clear of dirt and grime? Mineralizations addressed? Are the closets in neat, organized, and stocked with the appropriate supplies?
- Lobby Area - Are the chairs and furniture wiped down and clear of crumbs and stains? Is the trash emptied? Are the floors swept and clear trash and debris?
- Stairwells - Have the stairwells been dusted on both sides and are clean of debris? Are the floors cleaned and clear of dirt?
- Janitors Closets - Are the mop sinks cleaned regularly and clear of dirt and grime? Are the closets in neat and organized and stocked with the appropriate supplies?
- Shower Room - Is the shower room floor clean and drain area clear of obstructions? Are the walls and fixtures clean and in working condition? Are there any signs of any insects
- Rehab Floors - Are the floors cleaned and residue on and around equipment removed?

Director of Environmental and Nutrition Services or designee will audit checklist daily for completion for three weeks, then weekly for three months beginning 6/19/2023. Director of Fiscal Services or designee will perform additional visual inspection of areas and document weekly.

The audit data presented at Quality Improvement Committee on a monthly basis beginning 7/17/2023. The committee will create any action plans, if necessary, based on the results.

The Quality Improvement Committee will evaluate data, action plans, and measure the results for three months.

The Board Medical Committee, of the Board of Governors, will audit monthly for 3 months the Quality Improvement Committee minutes and audit data to ensure compliance with the audit program.

Initial survey findings and strategy for correction reviewed with The Board Medical Committee, of the Board of Governors, on 5/18/2023.

An evaluation will be completed for adequacy of staffing and efficiency of the Environmental Services Department in June 2023. Any recommendations, action plans and corrective processes will be brought to the Board for review in July 2023.

Director of Environmental and Nutrition Services and acting Director of Plant and Facilities will evaluate and put a plan in place to identify which faucets and fountains in the hospital require replacement to address mineralizations beyond the cleaning included in the audit. Plan will be developed and go into effect 6/19/2023.

The Director of Fiscal Services and the Director of Environmental and Nutrition Services responsible for the plan of correction.


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