Initial Comments:
This report is the result of a full State Licensure survey conducted on April 12- 14, 2021, at Allied Services Institute of Rehabilitation Medicine. 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:
101.64 LICENSURE
HOSPITAL RESPONSIBILITIES
Name - Component - 00
101.64 Hospital responsibilities
A hospital shall comply with all
applicable environmental, health,
sanitation, and life-safety standards
which are not under the direct
jurisdiction of the Department. This
shall include but not be limited to
radiologic health, sanitation, food
services, pharmacy, electric wiring,
and life-safety code compliance. When
the hospital has been inspected by
another regulatory agency, it shall
have on the record during the survey
by the Department written confirmation
of compliance as provided by the rules
and regulations of appropriate
agencies.
Observations:
Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure the utensil rack over the food preparation area was clean; failed to ensure employees working in the dietary department wore hair restraints that restrained all hair; failed to ensure food temperatures were taken on cold food on the tray line prior to distribution to patients; and the facility failed to ensure employees in the dietary department performed hand hygiene after removing gloves and before moving onto other dietary department tasks.
Findings include:
Review on April 12, 2021, of the facility's "Food Production" policy, revealed "1. General: All food while being stored, prepared or served shall be protected against contamination from dust ... 9. Cleanliness of Equipment and Utensils: ... d. Non-food contact surfaces of this food service system, including shelves, hoods, and fans shall be cleaned as necessary to be free from accumulation of dust, dirt or other debris ..."
Review on April 12, 2021, of the facility's "Food Service Department General Information" policy, revealed "1. Philosophy: The purpose of the Food Services Department of Allied Services is to prepare and serve three nutritious, attractive and palatable meals daily for the patients and staff ... 4. Supervision: a) The Director of Food Services plans and monitors programs of the Food Service Department. B) The food Service Department is under the day to day supervision of the Assistant Food Service Director. The Assistant Food Service Director is responsible for the day to day activities of the department, including all personnel functions. ... 7. Personnel Policies: ... b. Proper hair covering shall be worn by all employees according to length or style of their hair ... f. Hands must be washed before beginning work within the department, after each trip to the restroom and whenever necessary. ... 13. Preparation and Service of Food: a. Food shall be prepared by the acceptable methods to conserve maximum, nutritive values, flavor and appearance, and is attractively served at the proper time and temperatures to meet individual needs ... 14. Maintenance of Staff Hygiene and Equipment: ... b. Sanitary conditions shall be maintained in the storage, preparation and serving of food at all times. Procedures for effective cleaning of all equipment have been established, and shall be constantly followed. ..."
Review on April 12, 2021, of the facility's "Food Safety" policy, revealed "Foods must be handled in a safe and sanitary manner. Purpose: Food should be handled with much caution. Hot food held at temperatures of 140 degrees or higher and cold food at 40 degrees or lower may be used again. ... Procedure: Food Service employees are required to follow the following outlined procedures when handling food ... IV. Food Preparation & Serving: ... 6. Hot foods are served at 140 degrees Fahrenheit or above; cold foods 33 - 40 degrees Fahrenheit. Temperature of Hot and Cold foods are taken with a sanitized thermometer located in production and serving area. These temperatures are recorded in the Temperature Log Book in compliance with specifications on the Log sheet. ..."
Review on April 12, 2021, of the facility's "Hand Washing / Glove Use" policy, revealed "Employees are to wash their hands in conjunction with good personal hygiene practices. The frequency for hand washing includes: ... B. Between handling of dirty dishes or equipment and handling clean food or utensils. ... H. After each touching of inanimate objects that may be a source of contamination if the next contact with the hands is food or food contact surfaces. Purpose: To aid in the prevention and transmission of infectious and/or contagious diseases as well as the potential for contamination of food and food related equipment. ... Gloves. ... 2. Gloves should not be used to avoid hand washing. After any action with gloves that would require hand washing, food-handlers must throw away the gloves, wash their hands, and then put on new gloves. ..."
1. Observation on April 12, 2021, at 11:45 a.m. of the dietary department revealed a utensil rack over the food preparation area with a visible accumulation of dust on all the horizontal cross-braces. This dust measured approximately the size of a nickel when gathered.
Interview with EMP1 and EMP2 on April 12, 2021, at the time of the observation confirmed the utensil rack over the food preparation area had a visible accumulation of dust on all the horizontal cross-braces and this dust measured approximately the size of a nickel when gathered.
2. Observation of EMP4 on April 12, 2021, 11:30 a.m. revealed this employee had mid-back length hair which was in a ponytail and pulled through the back of the ball cap. EMP4's hair was not contained in a hair restraint and this employee's hair fell to the front of this employee several times while preparing patient meal trays on the tray line.
Interview with EMP1 and EMP2 on April 12, 2021, at the time of the observation confirmed EMP4 had mid-back length hair which was in a ponytail and pulled through the back of the ball cap; EMP4's hair was not contained in a hair restraint and this employee's hair fell to the front of this employee several times while preparing patient meal trays on the tray line
Observation of EMP5 on April 12, 2021, 11:35 a.m. revealed this employee's hair was not completely restrained by the hair net. EMP5 was checking and preparing patient meal trays for distribution to the patient care unit.
Interview with EMP1 and EMP2 on April 12, 2021, at the time of the observation confirmed EMP5's hair was not completely restrained by the hair net and EMP5 was checking and preparing patient meal trays for distribution to the patient care unit.
3. Review on April 12, 2021, of the facility's "Diet Spread Sheet Week 2 Monday through Friday" revealed the facility had cold menu items scheduled for distribution to patients on the tray line for breakfast, lunch and dinner. These cold menu items included: yogurt, milk, parfaits, ice cream, fruit cup, cheesecake trifle, pudding, potato salad, cucumber salad and coleslaw.
Review on April 12, 2021, of the facility's Trayline Temperature Evaluation -Hot Prep forms for February, March and April 2021 revealed areas for dietary staff to document the temperatures of hot foods taken on the tray line prior to serving.
Interview with EMP1 and EMP2 on April 12, 2021, at approximately 1:10 p.m. confirmed the form dietary staff utilize to document tray line temperatures is used only to document the temperatures of hot foods.
A request was made of EMP1 and EMP2 on April 12, 2021, for documentation the dietary staff performs temperatures on cold foods taken on the tray line prior to serving to ensure the cold foods are palatable. None was provided.
Interview with EMP1 and EMP2 on April 12, 2021, at approximately 1:15 p.m. revealed the facility does not perform temperatures on cold foods on the tray line prior to serving to ensure the cold foods are palatable.
4. Observation of EMP5 on April 12, 2021, at approximately 11:37 a.m. revealed this employee remove their gloves and walked to the trash receptacle. EMP5 then lifted the trash receptacle lid with an ungloved hand and disposed of the gloves. EMP5 then collected brown cups used for coffee and place them in the delivery tray cart for delivery to the patient care unit. EMP5 did not wash their hands after touching the trash receptacle lid or before touching brown cups and placing them in the delivery tray cart for delivery to the patient care unit.
Interview with EMP1 and EMP2 on April 12, 2021, at the time of the observation confirmed EMP5 removed their gloves and walked to the trash receptacle; EMP5 lifted the trash receptacle lid with an ungloved hand and disposed of the gloves; EMP5 collected brown cups used for coffee and place them in the delivery tray cart for delivery to the patient care unit. EMP1 and EMP2 confirmed EMP5 did not wash their hands after touching the trash receptacle lid or before touching brown cups and placing them in the delivery tray cart for delivery to the patient care unit.
Observation of EMP4 on April 12, 2021, at approximately 11:38 a.m. revealed this employee removed their gloves and walked to the trash receptacle. EMP4 then lifted the trash receptacle lid with an ungloved hand and disposed of the gloves. EMP4 then walked to the delivery cart containing patient trays, adjusted patient trays, closed the cart door and proceeded to push the cart out of the dietary department for delivery to the patient care unit. EMP4 did not wash their hands after touching the trash receptacle lid or before touching and adjusting patient trays in the delivery cart.
Interview with EMP1 and EMP2 on April 12, 2021, at the time of the observation confirmed EMP4 removed their gloves and walked to the trash receptacle; EMP4 lifted the trash receptacle lid with an ungloved hand and disposed of the gloves; EMP4 walked to the delivery cart containing patient trays, adjusted patient trays, closed the cart door and proceeded to push the cart out of the dietary department for delivery to the patient care unit. EMP1 confirmed EMP4 did not wash their hands after touching the trash receptacle lid or before touching and adjusting patient trays in the delivery cart.
Plan of Correction:Allied Services Institute of Rehabilitation Medicine Food Service Department understands the importance of personnel policies, maintenance of staff hygiene, preparation of service of food & temperature of food. The Assistant Vice President of Food Service is responsible for the development and implementation of the corrective action plans.
The food service department's corrective action is as follows:
Hand Washing:
Allied Services Infection Preventionist held a staff education & in-service for all food service staff on 4/27/2021. The in-service reviewed the following:
- Policy & procedure for hand washing and glove use.
- Proper hand washing between tasks.
- Hand washing after touching inanimate objects.
- Frequency of hand washing.
- Hand washing after every glove use.
- Hand washing when changing gloves.
Under the supervision of the Food Service Manager the food service department supervisor will conduct daily audits for dayshift and evening shift. The food service manager will report quarterly at infection control meetings.
Completion date: 4-27-2021
Hair covering:
Food service manager held a staff education & in-serviced all food service staff on 4/22/2021. The in-service reviewed the following:
- Dress code/uniform policy.
- Proper hair covering will be worn for all employees according to length of hair.
- Hair must be contained in a hair net and kept off face.
- Excessive hair outside of food service cap must be contained by a hairnet.
- Ponytails outside of cap must be contained by a hair net.
Under the supervision of the food service manger the food service supervisors will conduct daily audits for dayshift and evening shift to ensure hair coverings are worn properly & cap is worn properly with a hairnet if necessary. The food service manager will report quarterly at infection control meetings.
Completion date: 4-22-2021
Utensil Rack:
Food service manager conducted an initial audit of the utensil rack to ensure it is dust free on 4/22/2021.
- Cleaning duties for cook position were updated from biweekly to weekly cleaning of utensil rack.
- Procedures for cleaning were reviewed with all cooks to ensure correct cleaning procedures are followed.
- Weekly sanitation check list was updated with weekly cleaning of utensil rack.
Food service supervisor will conduct daily audits of the utensil rack & sanitation check list to ensure cleaning duties are completed and initialed by cook position. The food service manager will report quarterly at infection control meetings.
Completion date: 4-22-2021
Temperature Logs:
The Assistant Vice President of Food Service Updated food temperature logs for hot & cold menu items on 4/21/2021. The food service manager reviewed the following with food service staff on the new temperature logs:
- Temperatures to be taken and logged prior to all meals.
- Temperatures to be completed for all menu items.
- Temperature log needs to be signed by staff responsible for completing temperature.
Food service manager completed initial audit on 4/22/2021 to ensure staff is completing food temperature log properly. Supervisor will conduct daily audits at the end of each meal to ensure temperature log is completed for all menu items. The food service manager will report quarterly at infection control meetings.
Completion date: 4-22-2021
109.1 LICENSURE
PRINCIPLE
Name - Component - 00
109.1 Principle
The hospital shall maintain a
nursing staff to provide nursing care
for the needs of the patients and a
nursing staff organization to be
responsible to the chief executive
officer or chief operating officer of
the hospital for the performance of
its members.
Observations:
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure an accurate weight was obtained on admission for one of three applicable medical records reviewed (MR9) and the facility failed to verify the accuracy of weight changes for two of two applicable medical records reviewed (MR9 and MR10).
Findings include:
Review on April 13, 2021, of the facility's "Height and Weights" policy, revealed "I. Purpose: to provide baseline for the calculation of weight gain / loss and for medication dosing data during the Rehabilitation process. II. Procedure: All patients will have their height and weight assessed at the time of admission but no more than within 8 hours of admission and recorded in the medical record. ... Weights ... Admission When the patient arrives in the hospital, the patient's weight will be obtained using the most appropriate scale. If it is impossible to weigh the patient at this time, communicate to the next shift that the weight has not yet been done and complete it within 8 hours. Weighing the Patient ... 9. Lock brakes of both bed/wheelchair and scale. 10. Ensure that the patient is wearing orthotic, prosthesis, etc for consistency in weights. 11. Before positioning patient on lift, press zero key and wait until the display shows 0.0 lbs. 12. If towels or pads should be on the seat, apply these before pressing the zero key. 13. Position patient to be weighed on the seat of the scale. Make sure the patient's feet are not touching the floor or the foot rest. 14. Press the weight key. Weight of patient will appear in the display after 5 seconds. Do not touch the seat or patient, as it will affect the weight displayed. 15. Assist patient back to wheelchair or bed. 16. Remove PPE and perform hand hygiene. 17. Clean scale and return to storage. 18. Perform hand hygiene. 19. Compare the weight to the previous weight (last weight taken) and if the patient's weight shows a loss or gain of 5lbs or more, begin at step 9 and obtain another weight. Communication/Documentation ... Any weight gain or loss of five (5) pounds or greater will be communicated to the nurse ..."
1. Review of MR9 on April 13, 2021, revealed this patient was admitted to the facility on January 25, 2021, and nursing staff documented MR9's admission weight on January 25, 2021, as 140 pounds. Nursing documented MR9's weight on January 26, 2021, as 125.4 pounds.
Interview with EMP6 and EMP8 on April 13, 2021, at the time of the medical record review confirmed MR9 was admitted to the facility on January 25, 2021; nursing staff documented MR9's admission weight on January 25, 2021, as 140 pounds and nursing documented MR9's weight on January 26, 2021, as 125.4 pounds. EMP6 and EMP8 revealed nursing staff recorded MR9's admission weight of 140 pounds from the sending hospital's documentation and an admission weight was not obtained on MR9 when admitted to the facility.
2. Review of MR9 on April 13, 2021, revealed nursing staff documented an admission weight of 140 pounds on January 25, 2021. Nursing documented MR9's weight on January 26, 2021, as 125.4 pounds. There was no documentation in MR9 indicating nursing staff verified the accuracy of MR9's weight of 125.4 pounds.
Interview with EMP6 and EMP8 on April 13, 2021, at the time of the medical record review confirmed MR9's admission weight of 140 pounds on January 25, 2021 and that nursing documented MR9's weight on January 26, 2021, as 125.4 pounds. EMP6 and EMP8 confirmed there was no documentation in MR9 indicating nursing staff verified the accuracy of MR9's weight of 125.4 pounds on January 26, 2021.
Review of MR10 on April 13, 2021, revealed nursing staff documented an admission weight of 231.6 pounds on October 8, 2020. Nursing documented MR10's weight on October 9, 2020, as 226.4 pounds. There was no documentation in MR10 indicating nursing staff verified the accuracy of MR10's weight of 226.4 pounds.
Interview with EMP6 and EMP8 on April 13, 2021, at the time of the medical record review confirmed MR10's admission weight of 231.6 pounds on October 8, 2020, and that nursing documented MR10's weight on October 9, 2020, as 226.4 pounds. EMP6 and EMP8 confirmed there was no documentation in MR10 indicating nursing staff verified the accuracy of MR10's weight of 226.4 pounds on October 9, 2020.
Plan of Correction:Allied Services Institute of Rehabilitation Medicine understands the importance of obtaining an accurate weight on admission and that verification of the accuracy of weight changes is the responsibility of the nursing staff.
The Assistant Vice President of Nursing is responsible for the development and implementation of the corrective action plan.
The hospital's corrective action plan is as follows;
The hospital has reviewed and revised the Nursing Department Policy and Procedure entitled 'Height and Weights'. The policy was revised to include;
- Weights should not be estimated at the time of admission.
- Any weight gain or loss of five (5) pounds or greater will be communicated to the nurse. The nurse should do the following;
o Confirm that the nurse aide did a second check of the weight.
o Review the EMR for evidence of why the weight may be different, i.e. a newly ordered diuretic, increased edema).
o Schedule another weight for the AM, as appropriate.
o Notify the dietician and/or physician, as appropriate
Completion date: 4/28/2021
The hospital has reviewed the Department of Nursing's revised policy for Height and Weights with RN, LPN and Nurse Aide Staff. Completion date: 4/30/2021
Under the direction of the Assistant Vice President of Nursing, the Assistant Director of Nursing is completing concurrent daily review of weights completed on admission, a repeat weight the day after admission, weight documentation following specific physician order and interventions by the nurse for a weight change of 5lbs.
Individual staff education is occurring as a result of the concurrent review.
The Department of Nursing has incorporated into the departmental quality assurance indicators the monitoring of documentation of weights completed on admission, a repeat weight the day after admission, weight documentation following specific physician order and interventions by the nurse for a weight change of 5lbs in order to sustain compliance with following the Department's policy.
The results of this monitoring will be reported by the Assistant Vice President of Nursing to the hospital's Medication Management Committee.
109.21 LICENSURE
POLICIES - PRINCIPLE
Name - Component - 00
109.21 Principle
Written nursing care and
administrative policies and procedures
shall be developed to provide the
nursing staff with methods of meeting
its responsibilities and achieving
goals.
Observations:
Based on review of facility policy, medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure medications were administered according to facility policy in two of two applicable MRs reviewed (MR24 and MR25).
Findings include:
Review on April 14, 2021, of facility policy "Medication Management Plan-Section VIII: Administration, " last reviewed January 2020 revealed "...Section VIII: Administration ... Time-Critical Scheduled Medications ... Non-time-critical scheduled medications are those where early or delayed administration within a specific range of either 1 or 2 hours should not cause harm or result in substantial sub-optimal therapy or pharmacological effect ... Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, every four hours or more) will be administered within 1 hour before or after the scheduled time ..."
Review of MR24 on April 14, 2021 revealed a medication order for [name of respiratory inhaler] 4 gm, one puff, QID (four times a day). Further review of MR24 revealed on April 10, 2021, the [name of respiratory inhaler] was administered at 7:25 a.m., 11:31 a.m., 3:22 p.m. and 8:45 p.m. On April 11, 2021, the [name of respiratory inhaler] was administered at 7:46 a.m., 12:00 p.m., 3:27 p.m. and 9:34 p.m. The [name of respiratory inhaler] was administered on April 12, 2021, at 7:28 a.m., 11:20 a.m., 2:51 p.m. and 8:11 p.m.
Interview with EMP9 on April 14, 2021, at 10:45 a.m. confirmed the scheduled dosing times for a respiratory medication ordered QID were 7:00 a.m., 11:00 a.m., 3:00 p.m. and 7:00 p.m. EMP9 confirmed as a non-time-critical medication, [name of respiratory inhaler], facility policy permitted the administration of the medication as early as one hour prior or as late as one hour after the scheduled administration time. EMP9 further confirmed MR24 received [name of respiratory inhaler] at 8:45 p.m. on April 10, 2021, at 9:34 p.m. on April 11, 2021, and at 8:11 p.m. on April 12, 2021. EMP9 acknowledged these administration times fell outside of the one-hour late time frame permitted per facility policy.
Review of MR25 on April 14, 2021 revealed a medication order for [name of respiratory inhaler] 4 gm, two puffs, QID. Further review of MR25 revealed on April 11, 2021, the [name of respiratory inhaler] was administered at 8:00 a.m., 11:55 a.m., 3:51 p.m. and 8:52 p.m. The [name of respiratory inhaler] was administered on April 12, 2021, at 7:49 a.m., 11:59 a.m., 3:58 p.m. and 9:50 p.m. On April 13, 2021, the [name of respiratory inhaler] was administered at 7:45 a.m., 12:02 p.m., 3:24 p.m. and 10:21 pm.
Interview with EMP9 on April 14, 2021, at 10:55 a.m. confirmed the scheduled dosing times for a respiratory medication ordered QID were 7:00 a.m., 11:00 a.m., 3:00 p.m. and 7:00 p.m. EMP9 confirmed as a non-time-critical medication, [name of respiratory inhaler], facility policy permitted the administration of the medication as early as one hour prior or as late as one hour after the scheduled administration time. EMP9 further confirmed MR24 received [name of respiratory inhaler] at 8:52 p.m. on April 11, 2021, at 9:50 p.m. on April 12, 2021, and at 10:21 p.m. on April 13, 2021. EMP9 acknowledged these administration times fell outside of the one-hour late time frame permitted per facility policy.
Plan of Correction:Allied Services Institute of Rehabilitation Medicine understands the importance of ensuring timeliness of administration of medications, in particular, respiratory medications.
.
The Assistant Vice President of Nursing is responsible for the development and implementation of the corrective action plan.
The hospital's corrective action plan is as follows;
The RN and LPN staff on the 3-11 shift were provided reinforcement that all medications must be given timely. Respiratory medications must be given within 1 (one) hour of the scheduled times.
Completed: April 15, 2021
The hospital is in the process of changing the Respiratory Medication Times Schedule to match the times of the Nursing Medication Times Schedule. This should provide for better compliance with the timeliness of medications.
Completed: May 18, 2021
Under the direction of the Assistant Vice President of Nursing, the Assistant Director of Nursing is completing concurrent daily review of the timeliness of all Respiratory Medications administered by the 3-11 shift nurses.
The Department of Nursing has incorporated into the departmental quality assurance indicators the monitoring of the timeliness of all Respiratory Medications administered by the 3-11 shift nurses.
The results of this monitoring will be reported by the Assistant Vice President of Nursing to the hospital's Medication Management Committee.
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