QA Investigation Results

Pennsylvania Department of Health
EAGLEVILLE HOSPITAL
Health Inspection Results
EAGLEVILLE HOSPITAL
Health Inspection Results For:


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Initial Comments:
This report is the result of a full State Licensure survey conducted on February 11, 2021, and completed on March 9, 2021, at Eagleville Hospital. 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:




111.16 LICENSURE
REFUSE

Name - Component - 00
111.16 Refuse

Leakproof, nonabsorbent containers with close fitting covers shall be used for the disposal of all garbage and kitchen refuse. Garbage and kitchen refuse shall be removed from the dietetic department in a manner which will not permit transmission of disease or create a nuisance or a breeding places for flies, insects, or rodents. A garbage containers shall be thoroughly cleaned inside and out, each time emptied. All places in which refuse is stored shall be tightly sealed and leakproof.

Observations:

Based on policy, observation and interview with staff (EMP), it was determined the facility failed to ensure the refuse/waste disposal cans in the Dietary Department contained lids and or covers to maintain a sanitary manner.

Findings include:

Review of facility policy "E-3 Refuse, Recyclables, Sewage, and Liquid Waste," last revised August 1, 2020, revealed "Inside receptacles for refuse and recyclables must be kept covered if contain food residue, are not in continuous use, after they are filled. Refuse and recyclable containers must be thoroughly cleaned at a frequency necessary to prevent them from buildup of soil or becoming attracted to pests and in a way that does not contaminate food, equipment, or utensils."

An observational tour conducted on February 11, 2021, at 4:18 PM with EMP11 and EMP13 in the food preparation area of the Dietary Department revealed an uncovered refuse/waste disposal container. Further observation revealed the refuse/waste disposal container was filled with food residue and dietary department waste.

An observational tour conducted on February 11, 2021, at 4:19 PM with EMP11 and EMP13, in the dishwashing area of the Dietary Department revealed an open refuse/waste disposal container located near the dishwashing sink. Further observation revealed the refuse/waste disposal container was soiled with food residue and stains from liquids.

An interview conducted on February 11, 2021, with EMP11 and EMP13, at 4:20 PM confirmed the presence of an uncovered refuse/waste disposal container containing food residue and dietary department waste in the food preparation area. EMP11 further confirmed the refuse/waste disposal container near the dishwashing sink was soiled with residue from liquids and food waste items. EMP11 stated "We normally clean the refuse containers outside, but the snowy weather has interfered with that."








Plan of Correction:

Food Service Operations immediately removed any garbage can without an attached hinged lid to keep units covered.

On February 12, 2021, all refuse receptacles in the food preparation and dishwashing areas were cleaned and sprayed with a new hose connected to water outlet. Power washing will continue weekly on cleaning schedule to prevent any form of soil build-up.
All food service employees were provided with retraining regarding management of refuse on March 19, 2021. Documentation of this retraining will be available to surveyors upon request.

The Director of Food Management will measure compliance with this Plan of Correction through daily utility job flows and cleaning assignments. The Director of Food Management will perform daily monitoring of compliance with this corrective action plan through use of a daily checklist. The checklist will be available to surveyors upon request.
The Director of Operational Support has included monthly audits of the effectiveness of the Food Service's refuse disposal operations and dish machine as part of monthly Environment of Care rounds. Any issues will be promptly reported for correction to the Director of Food Management. The monthly rounding sheet will be provided to surveyors upon request.

The Director of Food Management will report compliance with this Plan of Correction to the Quality Management Committee and the quarterly meetings of the Environment of Care Committee. The results of the Plan of Correction will be reviewed at the Joint Conference Committee of the Eagleville Hospital Board of Directors scheduled for June 3, 2021.

The Chief Operating Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.



111.26 (b)(1)(2) LICENSURE
DISHWASHING

Name - Component - 00
111.26
(b) There shall be periodic checks at established intervals of:
(1) washing, rinsing, and sanitizing temperatures and cleanliness of machines and jets; and
(2) thermostatic controls

Observations:

Based on review of facility policy, documents, observation, and interview with staff (EMP), it was determined the facility failed to maintain the cleanliness of the dishwashing machine in the Dietary Department.

Findings include:

Review of facility policy "Cleaning and Sanitizing Food Contact Surfaces" last revised August 1, 2020, revealed "Forms and Record Keeping: Required: Cleaning Schedules, Sanitizer Log, Dish Machine Log... Both cleaning and sanitizing agents must be provided and available for use during all hours of operation... Washing, rinsing and sanitizing procedures must be posted and adhered to at all manual and mechanical ware washing equipment in use [sic]."

A review on February 11, 2021, of facility document "Daily Closing Checklist" dated February 10, 2021, completed by EMP14, revealed a checklist of items to check daily. Further review revealed "Dishwasher cleaned out, scrubbed down, and turned off" was checked as completed.

An observational tour conducted on February 11, 2021, at 4:25 PM with EMP11 and EMP13, in the dishwashing area of the dietary department revealed a large amount of a brownish residue underneath the cleaning mechanism inside the dishwasher and a thick layer of dust on top of the dishwasher.

An interview conducted on February 11, 2021, at 4:25 PM with EMP11 and EMP13 confirmed a large amount of a brownish residue underneath the cleaning mechanism inside the dishwasher and a thick layer of dust on top of the dishwasher in the dishwashing area of the dietary department.

















Plan of Correction:

Dietary Dishwashing Machine

The Food Service operation staff performed a thorough cleaning of the dish machine on February 12, 2021.
The entire exterior and interior of unit were cleansed and de-limed. The de-liming process will be performed on a weekly basis.

A service technician was called in to inspect machine on March 31, 2021. He reported that the machine was fully cleaned and functioning properly.
The Director of Food Management conducted a retraining on the de-liming process on April 1, 2021 with all responsible utility staff. Documentation of this re-training will be available to surveyors upon request.

The Director of Food Management will assure compliance with this corrective action plan is sustained through utility job flows and cleaning assignments. The Director of Food Management will conduct daily monitoring of the cleanliness of the equipment through a checklist. This documentation, will be made available to surveyors upon request. The Director of Operational Support will audit the cleanliness of the dishwashing equipment as part of monthly Environment of Care rounds.

The Director of Food Management will report compliance with this corrective action plan to the Quality Management Committee and the Environment of Care Committee. The results of the Plan of Correction will be reported to the Joint Conference Committee of the Eagleville Hospital Board of Directors.

The Chief Operating Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.



113.28 LICENSURE
DISTRESSED DRUGS, DEVICES, COSMETICS

Name - Component - 00
113.28 Distressed drugs, devices, and cosmetics.

Drugs, devices, and cosmetics under the control of the pharmacist which are outdated, visibly deteriorated, unlabeled or inadequately labeled, recalled, discontinued, or obsolete shall be indentified by the pharmacist and shall be disposed of in compliance with applicable State and Federal laws and regulations.

Observations:

Based on a review of facility policy, observation, and interview with staff (EMP), it was determined the facility failed to properly identify and dispose of medication that was outdated, unlabeled or obsolete.

Findings include:

A review of facility policy "Medication Administration and Documentation" last revised February 2021 revealed "24) Care of multi-dose vials: a. Vial will come from pharmacy with a sticker in place for dating when opened and expiration date.. b. Sticker will be completed upon opening the vial with the date opened and expiration date... c. Vials must be checked weekly during the... unit checks and outdated vials sent back to Pharmacy."

An observation on February 11, 2021, at 11:44 AM with EMP5 and EMP7 of the Patient Care Building in-patient unit PC-1 medication room, revealed a partially used vial of tuberculin solution in the medication refrigerator. The vial did not contain a sticker with the date of open and the date of expiration.

An interview conducted on February 11, 2021, at 11:44 AM with EMP5 and EMP7 confirmed the partially used vial of tuberculin solution in the medication refrigerator was not dated with the date of open and the date of expiration.





Plan of Correction:

Nursing Staff will conduct daily audits to verify that open and expiration dates are documented on all refrigerated vials. The daily temperature logs on each unit's medication refrigerator have been modified to also document the daily checks of multi-dose vials. This documentation will be available upon request to the surveyors.

The Nurse Manager educated all nursing staff on this process and responsibility on April 17, 2021. Documentation of the education will be available at the request of the surveyors.

The Chief Nursing Officer will report compliance with this Plan of Correction to the Quality Management Committee and thereafter to the Joint Conference Committee of the Eagleville Hospital Board of Directors.

The Chief Nursing Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.



147.1 LICENSURE
GENERAL PROVISIONS - PRINCIPLE

Name - Component - 00
147.1 Principle

A clean, safe environment shall be provided and maintained within the hospital in accordance with standards specified by the Department of Environmental Services in 25 Pa. Code 173.1-173.17, in addition to the provisions of this subpart.

Observations:

Based on review of facility documents, observation, and interview with staff (EMP), it was determined that the facility failed to maintain a clean and safe environment for patient care services.

Findings include:

A review of facility document "7-Step Cleaning Process" revealed "1. Pull trash/linen: Check infectious waste, Remove soiled linen, ...Clean waste receptacles. 2. High Dust: High dust everything above shoulder level or out of reach...3. Damp Wipe: Damp wipe all contact surfaces, Clean and disinfect everything you are able to reach, ... Start with the door and work around the room in a circular pattern. Be sure to focus on frequently touched surfaces... 4. Clean Bathroom... 5. Dust Mop Floor... 6. Damp Mop... 7. Inspect the Room...

An observational tour conducted on February 11, 2021, at 11:02 AM -11:55 AM with EMP5 and EMP7 in the Patient Care (PC) building, in-patient unit PC-1 revealed the following:

Observation of the "Seclusion Room" revealed a two room suite consisting of a carpeted "anteroom" with a bathroom and a seclusion room separated by a door with a viewing window. Further observation revealed peeling paint and rust on the bathroom door and viewing window, and scattered pieces of a black foam like material, dust and debris on the carpet in the "anteroom."

An interview conducted on February 11, 2021, at 11:50 AM with EMP5 and EMP7, confirmed the presence of scattered pieces of black foam like material, dust and debris on the carpet, and peeling paint and rust on the bathroom door and viewing window of the Seclusion Room.

Observation of the "Treatment Team Meeting Room" revealed high level dust on top of a cabinet. Further observation revealed recreational items for patient use were stored uncovered on top of the cabinet.

An interview conducted on February 11, 2021, at 11:52 AM with EMP5 and EMP7, confirmed the presence of high level dust on top of a cabinet where recreational items for patient use were stored uncovered in the Treatment Team Meeting Room.

Observation of the Medication Room revealed dried liquid residue on the medication cart, and dust and debris on the floor. In addition, layered green and white mineral waste residue was covering the turn handles of the handwashing sink and the same residue covered the drain in the sink basin.

An interview conducted on February 11, 2021, at 11:54 AM with EMP5 and EMP7, confirmed the presence of dried liquid residue on the medication cart, dust and debris on the floor, layered green and white mineral waste residue covering the turn handles and drain of the handwashing sink in the medication room

Observation of the Unit Pantry revealed dirt and grime on the floor along the cove base molding and dried liquid material on the wall by the entry/exit door.

An interview conducted on February 11, 2021, at 11:52 AM with EMP5 and EMP7, confirmed dirt and grime on the floor along the cove base molding and dried liquid material on the wall by the entry/exit door of the Unit Pantry.

Observation of storage room 127 revealed a patient examination table, IV poles, equipment poles, a crash cart, and a wire storage cart containing patient supplies were stored uncovered, in the room. Further observation revealed dust and debris on the floor and on the patient examination table, IV poles, equipment poles, and crash cart.

An interview conducted on February 11, 2021, at 11:55 AM with EMP5 and EMP7, confirmed a patient examination table, IV poles, equipment poles, a crash cart, and a wire storage cart containing patient supplies were stored uncovered, in the room. Further interview confirmed dust and debris on the floor and on the patient examination table, IV poles, equipment poles, and the crash cart in storage room 127.
_____________

An observational tour conducted on February 11, 2021, at 11:57 AM with EMP16 of the Main Pharmacy revealed layered thick gray matter (dust) on the shelves of the wall unit. Further observation of the Main Pharmacy revealed layered green and white mineral waste residue covering the turn handles of the handwashing sink. In addition, layered green and white mineral waste residue covered the hot and cold water turn handles and the faucet filter head of the same handwashing sink.

An interview conducted on February 11, 2021, at 11:59 AM with EMP 10 and EMP16 confirmed the layered thick gray matter (dust) on the shelves of the wall unit and the layered green and white mineral waste residue covering the hot and cold water turn handles and the faucet filter head of the same handwashing sink. EMP10 stated "I am unable to locate the housekeeping quality review inspection reports for the Main Pharmacy."
__________________

A review of facility document "Environmental Service Attendant... D1W (D'Arclay 1 West)/Price Building," undated, revealed "D1W - Clean offices, staff restroom, storage closets, laundry room, nurse's station, medication room, exam room, seclusion room and multipurpose room. Dust and mop the main corridor. Cleaning routine includes: trash collection, damp wipe trash containers, high dusting, damp dusting, spot wash walls. Bathroom cleaning includes: clean and disinfect toilet bowls, sink, showers, mirror, fixtures, replenish dispensers and spot clean walls. Stainless steel: clean and polish corner guard and kick plates."

An observational tour conducted on February 11, 2021, at 12:11 PM - 12:33 PM with EMP5, EMP7, and EMP15 of the D'Arclay building in-patient units D-1 West and D-2 West revealed the following:

Observation of in-patient Room 103 revealed reddish brown material covering the baseboard in the bathroom.

Observation of the D-1 West laundry room revealed dust and debris between the washer and dryer.

Observation of the nutrition area on D-2 West revealed dust and calcium deposits behind and under the ice machine.

An interview conducted on February 11, 2021, at 12:35 PM with EMP5, EMP7, and EMP15 confirmed the presence of reddish brown material covering the baseboard in the bathroom in Room 103, dust and debris between the washer and dryer in the D-1 West laundry room, and dust and calcium deposits behind and under the ice machine on D-2 West.
_____________________

A review of facility document "Risk Mitigation Assessment (FY 20 - FY 22)," dated December 2020, revealed "Targeted Mitigation Strategies. 1. Ligature 2. Contraband 3. Patient Aggression. Through the of [sic] review and assessment of these high risk areas, four common themes requiring the facilities [sic] response have been identified inclusive of environmental concerns/physical plant, patient/staff engagement, staff training and education and management engagement. 1. Environmental/Physical Plant. Executing safety measures within existing aging infrastructure:... Furniture/Fixtures.

An observational tour on February 11, 2021, at 11:05 AM with EMP5 and EMP7 of D'Arclay 1 West in-patient Room 138 revealed sharp edges on the bathroom mirror.

An interview conducted on February 11, 2021, at 11:05 AM with EMP5 and EMP7, confirmed the presence of sharp edges on the bathroom mirror in Room 138.

An observational tour on February 11, 2021, at 12:40 PM with EMP5, EMP7, and EMP15 of in-patient unit D'Arclay 2 East in-patient Room 222 revealed an opened, unsecured bottle of betadine on a shelf visible and accessible from the patient corridor. Further observation revealed the lid was open and approximately 1/4 inch of betadine remained in the bottle.

An interview conducted on February 11, 2021, at 12:40 PM with EMP7, confirmed an opened, unsecured bottle of betadine was visible and accessible from the patient corridor outside Room 222. EMP7 stated "This patient is allowed to do independent wound care. It would probably be better if the patient had to come get it when they were ready to do the wound care, to ensure the betadine solution was maintained safely."













Plan of Correction:

SECLUSION ROOM:

On February 12, 2021, the housekeeping staff cleaned the area identified in order to rectify the conditions noted (black foam material, dust and debris).
On February 15, 2021, the Manager of Environmental Services implemented a 10-step Action Plan, which included housekeeping staff being re-trained on high dusting and on the 7-Steps of Cleaning and Effectiveness Guidelines. These trainings were completed on February 19, 2021 and February 21, 2021, respectively, and all staff have demonstrated competency. Documentation of the retraining will be available to the Surveyor upon request.

The Manager of Environmental Services will conduct daily monitoring using job flows and a checklist for quality inspections. This documentation will be available to the surveyors upon request.
The Maintenance Department sealed and painted over the rust on the bathroom door frames and the viewing window.
The Manager of Environmental Services and Director of Operational Support will report on the effectiveness of these measures at the Quality Management Committee and Environment of Care Committee. The results of this Plan of Correction will be reviewed at the Joint Conference Committee of the Eagleville Hospital Board of Directors.
The Chief Operating Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.

TREATMENT TEAM MEETING ROOM:

On February 12, 2021, the housekeeping staff cleaned the area identified in order to rectify the conditions noted (high level dust on top of a cabinet, the storing of recreational items for patient use uncovered on top of the cabinet).

On February 15, 2021, the Manager of Environmental Services implemented a 10-step Action Plan, which included housekeeping staff being re-trained on high dusting and on the 7-Steps of Cleaning and Effectiveness Guidelines. These trainings were completed on February 19, 2021 and February 21, 2021, respectively, and all staff have demonstrated competency. Documentation of the Plan and the trainings will be available to the surveyors upon request.
The Manager of Environmental Services will conduct daily monitoring with job flows and a checklist used for quality inspections. The Manager of Environmental Services will report on these efforts at the Quality Management Committee and the quarterly meeting of the Environment of Care Committee. The results of this Plan of Correction will be reported to the Joint Conference Committee of the Board.

The Chief Operating Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.

MEDICATION ROOM:

On February 12, 2021, Nursing staff cleaned the area identified to rectify all conditions noted (dried liquid residue on the medication cart, dust and debris on the floor, mineral residue on the handwashing sink).

Nursing is responsible for keeping the medication cart clean. The nursing staff was educated that, should a staff member identify any issue with the cleanliness of the rest of the Medication Room, they must promptly notify the Manager of Environmental Services.

The Manager of Environmental Services will conduct daily monitoring of the cleanliness of the Medication Room with job flows and a checklist for quality inspections. These efforts will be reported by the Unit Nurse Manager and the Manager of Environmental Services at the Quality Management Committee and the Environment of Care Committee. The results of this Plan of Correction will be reported to the Joint Conference Committee of the Board.

The Chief Nursing Officer and the Chief Operating Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.

UNIT PANTRY:

On February 12, 2021, the housekeeping staff cleaned the area identified in order to rectify the conditions noted (dirt and grime on the floor along the cove base molding and dried liquid material on the wall by the entry/exit door).

On February 15, 2021, the Manager of Environmental Services implemented a 10-Step Action Plan, which included housekeeping staff being re-trained on high dusting and the 7-Steps of Cleaning and Effectiveness Guidelines. These trainings were completed on February 19, 2021 and February 21, 2021, respectively, and all staff have demonstrated competency. Documentation of this training will be available to the Surveyors upon request.

The Manager of Environmental Services will conduct daily monitoring with job flows and a checklist for quality inspections. The Manager of Environmental Services will report on these efforts at the Quality Management Committee and the Environment of Care Committee and the results will be reported to the Joint Conference Committee of the Board.

The Chief Operating Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.

STORAGE ROOM 127:

The housekeeping staff cleaned the area identified in order to rectify the conditions noted (dust and debris).
The Manager of Environmental Services implemented a 10-Step Action Plan, which included housekeeping staff being re-trained on high dusting and the 7-Steps of Cleaning and Effectiveness Guidelines. These trainings were completed on February 19, 2021 and February 21, 2021, respectively, and all staff have demonstrated competency. Documentation of this training will be available to the Surveyors upon request.
The Manager of Environmental Services will include this area in her daily quality inspections and assure regular cleaning as necessary.

The Director of Operational Support has obtained a storage cabinet with doors and shelves to store patient supplies. This cabinet was installed on April 12, 2021.

The Director of Operational Support has placed the issues identified in the storage room on the monthly Environment of Care rounding checklist for auditing and correction as needed.

The Chief Operating Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.

PHARMACY:

On February 11, 2021, the housekeeping staff cleaned the area identified in order to rectify the conditions noted (layered thick gray matter (dust), layered green and white mineral waste residue covering the turn handles of the handwashing sink). The dusty top shelf has been removed and discarded.
On February 15, 2021, the Manager of Environmental Services implemented a 10-step Action Plan, which included housekeeping staff being re-trained on high dusting and the 7-Steps of Cleaning and Effectiveness Guidelines. These trainings were completed on February 19, 2021 and February 21, 2021, respectively, and all staff have demonstrated competency. Documentation of this training will be available to the Surveyors upon request.
Due to the secure nature of the Department, the Director of Pharmacy will be responsible for monitoring the cleanliness of the Pharmacy facilities and will arrange routine cleaning.
The Director of Pharmacy and the Manager of Environmental Services will report on compliance with this Plan of Correction at the Quality Management Committee and the quarterly meeting of the Environment of Care Committee. The results of this Plan of Correction will be reported to the Joint Conference Committee of the Board.

The Chief Operating Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.

D'ARCLAY BUILDING:

On February 12, 2021, the housekeeping staff cleaned the areas identified by the Survey in order to rectify the conditions noted (Room 103: reddish brown material covering the baseboard in the bathroom, D-1 West laundry room: dust and debris between the washer and dryer, D-2 West: dust and calcium deposits behind and under the ice machine).

On February 15, 2021, the Manager of Environmental Services implemented a 10-Step Action Plan, which included housekeeping staff being re-trained on high dusting and the 7-Steps of Cleaning and Effectiveness Guidelines. These trainings were completed on February 19, 2021 and February 21, 2021, respectively, and all staff have demonstrated competency. In addition, responsible utility staff received training on the de-lime process on April 1, 2021. Documentation of these trainings will be available to the Surveyors upon request.

The Manager of Environmental Services will conduct daily monitoring with job flows and a checklist for quality inspections.

The Manager of Environmental Services will report on these efforts at the Quality Management Committee and the Environment of Care Committee and the results of this Plan of Correction will be reported to the Joint Conference Committee of the Board.

The Chief Operating Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.

RISK ASSESSMENT: Ligature Risks

On or about February 12, 2021, Maintenance Department staff removed the sharp edge on the bathroom mirror in Room 138 in the Patient Care Building. The staff installed custom-made, anti-ligature polycarbonate mirrors in all (9) bathrooms in the unit on or before April 16, 2021.

The Ligature Risk Assessment was expanded into a general risk assessment and updated in February of 2021. As a means of educating and reminding staff on the importance of identifying and correcting ligature risks, this issue is being placed as a regular agenda item on the Environment of Care Committee and the Quality Management Committee.
The Chief Executive Officer and/or Chief Regulatory Officer will report on any developments related to the Risk Assessment to the Joint Conference Committee of the Board.

The Chief Operating Officer and the Chief Regulatory Officer are responsible for this Plan of Correction, which will be completed by June 15, 2021.

RISK ASSESSMENT:
Patient Self-Applied Medications

On February 12, 2021, nursing staff removed an opened, unsecured bottle of betadine on a shelf visible and accessible from the patient corridor from Room 222 on D'Arclay 2 East.
The Unit Nurse Manager educated nursing staff on April 17, 2021 to retrieve any patient solutions immediately following patient self-wound care and to secure such medications in in the Medication Room. The Unit Nurse Manager will monitor compliance with this process on a daily basis.

The Unit Nurse Manager will report on the securing of patient care medications at the Quality Management Committee, and the results of this Plan of Correction will be reported to the Joint Conference Committee of the Board.

The Chief Nursing Officer will be responsible for this Plan of Correction, which will be completed by June 15, 2021.





Initial Comments:
This report is the result of a Department of Human Services, Chapter 5100 Mental Health Procedures Act Survey conducted on February 11, 2021, at Eagleville Hospital. It was determined the facility was in compliance with requirements of the Chapter 5100 Mental Health regulations.



Plan of Correction: