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Based on a review of facility policy, facility documentation, observation and interview with staff (EMP) and patient, it was determined that the facility failed to ensure that the patient's right to care in a safe setting was provided.

Findings include:

A review of facility policy "Patient Rights and Responsibilities" last reviewed February 2017 revealed, "13. You have the right to good quality care and high professional standards that are continually maintained and reviewed, to receive care in a safe setting. ... ."

A review of the Environment Service Department's "Special Service Record" logs for January 1, 2017, to August 30, 2017, revealed 226 reports of pest sightings throughout the main hospital campus buildings. The pests listed on this log included: mice, bugs, gnats, roaches, hornets nest, fruit flies, bed bugs, lice, crickets, spiders, ants, centipedes, mosquitoes, fleas and beetles. The areas identified included: Emergency Department, Physical Medicine and Rehabilitation, Labor and Delivery Unit, Burn Trauma Center, Operating Suite sterile supply room, Short Procedure Unit, Post Anesthesia Care unit, 3 South Nursing Unit, 2 South Nursing Unit , 2 North Nursing Unit, Intensive Care Unit (ICU), Histology, Audiology Department, Maternal Fetal Medicine, Electro-Encephalogram (EEG) Unit, Radiation Oncology, Laboratory, Pathology, Cancer Center, Pediatric Unit, and Patient Registration. The log listed roaches were found on: 3 South Nursing Unit - June 11th in patient rooms 3004, 3011, 3012 & 3016 and treated July 12th; July 14th and treated July 17th; July 25th at nurse's station and treated July 27th; August 2nd at nurse's station & patient room 3003 and treated August 3rd; August 20th in patient room 3003 and treated August 21st; August 21st in patient rooms 3000 & 3003 and August 22nd in patient room 3002 and treated August 24th. The log listed mice were found on: 3 South Nursing Unit - June 19th in patient room 2022 and treated June 19th; June 26th and treated June 26th; August 22nd and treated August 24th; 2 North Nursing Unit - June 13th in patient rooms 2021, 2022 & 2023 and treated June 25th; and Kitchen - July 5th and treated but date treated was not documented.
An interview conducted on August 30, 2017, at 10:30 AM with EMP2 confirmed the presence of the pest report sightings throughout the hospital that were identifed on the Special Service Record.

An interview conducted on August 30, 2017, at 11:30 AM with EMP4 confirmed that the presence of pests throughout the facility and especially in patient care areas was not a safe or sanitary environment of care.

An interview conducted on August 30, 2017, at 12:00 PM with EMP5 revealed that when mice were sighted on the 3 South Nursing Unit during June 2017 and August 2017, the patients were immediately moved out of their rooms and the Environmental Services staff or Western tech placed mouse traps the same day. EMP5 stated that the patient rooms were thoroughly cleaned before patients were allowed to return after 48 hours. EMP5 stated that they identified food not contained in the staff break room which they cleaned up but they still had roach sightings about a week ago. EMP5 stated that they responded the same when mice were sighted in June and August.
Observation of 3 South Nursing Unit at 1:00 PM revealed glue boards &/or mouse traps on the floor under the wall HVAC units in several patient rooms and sugar packets not contained in the staff lounge.
Observation of 2 North Nursing Unit at 1:30 PM revealed glue boards &/or mouse traps on the floor under the wall HVAC units in several patient rooms.
An interview conducted on August 30, 2017, at 4:00 PM with EMP1 confirmed that the patients' rights to receive care in a safe setting were compromised by the presence of pests in the hospital and patient care areas during the above noted times.

Based on a review of facility policy, facility contract agreement, facility documentation, tour of facility, and interview with staff (EMP), it was determined that the facility failed to provide adequate oversight and prevention of rodents and pests throughout the facility.

Findings include:

1. A review of facility service contract agreement with Western Pest Services effective date September 2013, revealed the contract was still in effect. It required the Western Pest control personnel be on-site twice weekly for inspection and treatment of cockroaches, all crawling non-wood destroying insects, mice and rats but excluded bed bugs, brown recluse spiders and mold; and weekly on-site inspection and treatment for interior rodent control; and monthly on-site inspection and treatment for exterior rodent control. Also treatment for Carpenter ants, fire flies, bed bugs and mosquitoes required a separate agreement or addendum that could not be waived by the customer (and was not present). It also did not include prevention of wood infesting organisms such as termites, powder post beetles, wood bores, carpenter ants, carpenter bees, wood wasps, or wood decay fungus or any other pest not specifically covered. It included free emergency service during normal working hours. "If a pest sighting is reported to Western, we will respond no later than the end of the following business day. If requests for additional service require response at times other than Western's normal business hours, there will be an additional fee. ... ."

A review of the Environmental Service Department's (EVS) "Special Service Record" logs for January 1, 2017, to August 30, 2017, revealed 226 reports of pest sightings throughout the main hospital campus buildings. The pests listed included mice, bugs, gnats, roaches, hornets nest, fruit flies, bed bugs, lice, crickets, spiders, ants, centipedes, mosquitoes, fleas and beetles. The areas identified included: Emergency Department, Physical Medicine and Rehabilitation, Labor and Delivery, Burn Trauma Center, Operating Suite sterile supply room, Short Procedure Unit, Post Anesthesia Care Unit, 3 South Nursing Unit, 2 South Nursing Unit, 2 North Nursing Unit, Intensive Care Unit, (ICU), Histology Department, Audiology Department, Maternal Fetal Medicine Department, Electro-Encephalogram Department, Radiation Oncology Department, Laboratory Department, Pathology Department, Cancer Center, Pediatric Nursing Unit, and Patient Registration. The log included - the date reported, the pest sighted with location, the person reporting and the date the Western service technician was on-site for treatment of each sighting with the technician's initials. The log revealed that the Western tech was on-site for remediation from one to four or more days after the reported sighting and several log sightings were not dated when initialed by the Western tech as treated. Roaches were found most recently on: 3 South Nursing Unit - June 11th, in patient rooms 3004, 3011, 3012 & 3016 and treated July 12th; July 14th and treated July 17th; July 25th at nurse's station and treated July 27th; August 2nd at nurse's station & patient room 3003 and treated August 3rd; August 20th in patient room 3003 and treated August 21st; August 21st in patient rooms 3000 & 3003 and August 2nd in patient room 3002 and treated August 24th. Mice were found most recently on: 3 South Nursing Unit - June 19th in patient room 2022 and treated June 19th; June 26th and treated June 26th; August 2nd and treated August 24th; 2 North Nursing Unit - June 13th in patient rooms 2021, 2022 & 2023 and treated June 25th; and Kitchen - July 5th but date treated was not documented.

An interview conducted on August 30, 2017, at 10:30 AM with EMP2 confirmed that the EVS Department did not have a pest control policy or protocol for when to call the pest control contractor between the twice weekly scheduled visits. EMP2 confirmed that they did not have documentation of any measures taken by the EVS staff between the twice weekly Western Pest Control visits or of resolution for each pest sighting. Further interview confirmed that rodents and pests were an ongoing problem in the facility.

2. A review of the EVS "Scope of Service" last revised January 2013 revealed, "All occupants, whether they are short or long term, permanent or temporary, who at any time occupy or visit the hospital buildings of Crozer Chester Medical Center and Community Hospitals are entitled to the highest level of quality. Their experience should reflect a time sensitive, clean, safe and aesthetically pleasing visit. ... . Sites/areas for which Environmental Services does not provide service... Nutrition and Dietetics kitchen and storage areas... . When services is not performed in-house, the contracted service for the same responsibility of Environmental Services, e.g." Pest Control... . Environmental Services entire operation is based on a collaborating and functional relationship with other departments and services. ... . Collaboration with other departments and Services: Environmental Services entire operation is based on a collaborating and functional relationship with other departments and services. ... . Each division must have a close working relationship to insure smooth operations... ."

A review of the Metz Food Services agreement effective March 12, 2014, revealed, "The parties' respective operational responsibilities for providing and paying vendors directly for the following items are indicated below: ... Pest Control - CKHS... ."
An interview conducted on August 30, 2017, at 11:15 AM with EMP2 confirmed that they did not collaborate with the contracted food services manager in the hospital kitchen with regard to pest control or cleaning, as it was included in the food service contract. EMP2 stated it was their understanding that it was the responsibility of the food services manager to keep a log of any pest sightings and to follow through with the Western tech when on-site, which was why EMP2 was not aware of the pest sightings in the hospital's kitchen/dietary areas or their management. Further interview revealed that EMP2 did not understand that the food services agreement put the responsibility for providing and paying the pest control services back on the Crozer Keystone Health System (CKHS).
Observation of the kitchen on ground level on August 30, 2017, at 2:30 PM revealed the Dietary Department's "Special Service Record" log for January 1, 2017, to August 30, 2017, that documented 22 reports of pest sightings throughout the dietary department. The pests listed included mice, roaches, fruit flies and a possum. The log included - the date reported, the pest sighted with location, the person reporting and the date the Western service technical was on-site for treatment of each with the same technician's initials. The log revealed that the Western tech was on-site for remediation usually the same day with several exceptions.

An interview conducted on August 30, 2017, at 3:00 PM with EMP9 revealed that they were the site manager for the contracted dietary service company and that they managed any known pest problems with the Western Pest Control tech who came weekly to the dietary department. EMP9 stated that they did not notify EMP2 or the EVS Department of their pest sightings. EMP9 stated that pest control is an ongoing problem in the kitchen department.
3. A review of the facility's "Governance and Management - Contracted Services Policy" effective date April 1, 2015, revealed, "On an annual basis, the responsible department head or manager must evaluate the services provided and document that evaluation on the attached Contracted Services Review form (Attachment 1). This will include a review of the performance expectations as documented in the contract and whether these expectations were met, not met, partially met and a plan of action as necessary. ... . The responsible department head or manager shall also maintain a file/binder for each contract that they oversee. This file shall include: ... e) monitoring of performance expectations, f) other pertinent documentation related to the contract. At least once per year, the responsible department head or manager shall provide a report, including the review of performance expectations, on the contracted services for which they are responsible to the Hospital Services Committee. The evaluation will be reviewed, including any plans of action when the performance expectations are found to not be met or are partially met. The minutes of the Hospital Services Committee meetings documenting discussions about contracted services will be submitted to the Medical Executive Committee. ... ."

A review of the facility's Western Pest Services agreement revealed an effective date of September 2013, that was still in effect.
A review of EMP2's Job Description effective date March 1, 2001, revealed, "Ensures the Medical Center's environment is maintained in a clean, aseptic, attractive and orderly fashion. ... . Assists in selection and evaluation of outside providers for related services not provided internally.

An interview conducted on August 30, 2017, at 11:15 AM with EMP2 confirmed that they were responsible for the annual performance evaluation of the Western Pest Services contract agreement and that no annual performance evaluations had been completed for this contract agreement since it became effective September 2013.

Based on a review of facility policy, facility documentation and interview with staff (EMP) it was determined that the infection control officer was not involved in the oversight and control of pests in the facility.

Findings include:

A review of facility's 2017 Infection Control Assessment and Plan revealed that it did not identify any infection control measures related to pest control.

A review of the facility's current Infection Control Risk Assessment Tool revealed that it did not include insect/pest control.

A review of EMP4's October 2016 Job Description revealed, "The Infection Preventionist ... is responsible for... the development of health system policies and procedures to insure rigorous infection control standards. ... ."

An interview conducted on August 30, 2017, at 11:30 AM with EMP4 revealed that they were involved when there were body lice and bed bugs identified, as infection control had a protocol that had to be followed and staff, patients and visitors required education, but was not usually involved when mice, roaches or other pests were identified, as it was an Environmental Services and pest control contractor issue to handle. EMP4 was not aware of the 226 reports of pest sightings throughout the main hospital campus buildings and the 22 sightings in the dietary department. EMP4 confirmed that the presence of these pests throughout the facility and especially in patient care areas was not a safe or sanitary environment of care. EMP4 confirmed that her job description was not specific for pest control oversight but that going forward they needed to be more involved.

Based on a review of facility Quality Performance and Improvement Plan, facility documentation and interview with staff (EMP), it was determined that the facility failed to identify a performance improvement plan to address the presence of pests in the facility.

Findings include:

A review of facility "Quality Performance and Improvement Plan" for fiscal year 2017 revealed, "The purpose of the Quality Performance and Improvement processes for the Crozer Keystone Health System and Facilities is to positively affect the quality and safety of patient care and services provided, in order to continually improve patient health outcomes and organizational performance. ... . In order to accomplish the purpose of the Quality Performance and Improvement process, the following functions are undertaken to improve organizational performance: ... . 2. Designing new processes, based on the organization's mission, needs and expectations of patients/families, staff and others, as well as current performance processes. ... . 5. Maintaining a systematic process to collect and access data needed to design and assess new processes, assess the dimensions of performance relative to functions, processes and outcomes, measure the level of performance and stability of important existing processes, and determine whether changes improved the process. ... . 7. Identifying issues for study: collection and assessment of data and development of educational and/or improvement activities. ... . The following activities and functions are undertaken by the Organization's leaders to implement the Improvement process: ... 4. Setting priorities for performance improvement and patient safety activities; 5. Assessing performance systematically; 6. Implementing improvement and patient safety activities based on assessment; 7. Maintaining achieved improvements; 8. Ensure that important internal processes and activities throughout the organization are continuously and systematically assessed and improved; ... . The objectives, scope, organization and effectiveness of the quality assessment and improvement process will be evaluated annually. Findings will be reported and action will be taken as deemed appropriate. This evaluation will include, but will not necessarily be exclusive to, the Quality and Patient Safety Goals presented and approved annually to the Local Governing body from the Chief Quality Officer, Vice President Quality/Patient Safety. ... . All hospital-based departments ... shall have a Quality Assessment and Performance Improvement (QAPI) plan. ... . The QAPI plan shall be consistent with the CKHS mission and strategic plan with at lease one quality measure and one safety measure that is in alignment with the CKHS Quality Goals. ... . The Hospital Services Committee (HSC) serves as a multidisciplinary forum for monitoring and evaluating the quality and safety of patient care, treatment and services as well as patient and family experience of care. The Committee provides Leadership for planning and implementing an organized and systematic approach to quality assessment and improvement throughout the Crozer Keystone Health System by setting priorities for overall Quality, Patient Safety and Performance Improvement activities, and will evaluate the effectiveness... ."

A review of EMP2's Job Description effective date March 1, 2001, revealed, "Ensures the Medical Center's environment is maintained in a clean, aseptic, attractive and orderly fashion. ... . Prepares goals and objectives for department/ area based on Medical Center mission and accomplishment, plan for delivery of care and scope of services and communicates such to staff. Assesses departmental/ area progress on an ongoing basis as evidenced by QA reports. ... . Directs quality improvement process through managing and assessing systems to improve performance and to identify needs. ... ."

Review with EMP1 and EMP2 of the Environmental Services (EVS) Department Quality Plan did not reveal any quality indicators related to pest control.
An interview conducted on August 30, 2017, at 11:30 AM with EMP2 revealed that they had not identified pest control as a quality measure for EVS. Further interview with EMP2 confirmed that they had not reported the extensive pest sightings to the infection control staff or the quality committee.

A review with EMP4 of the hospital's 2017 Infection Control Assessment and Plan revealed that it did not identify anything related to pests or pest control. Review of the facility's current Infection Control Risk Assessment Tool revealed that it did not include insect/pest control. Review of the EVS Department's "Special Service Record" logs for January 1, 2017 to August 30, 2017, revealed 226 reports of pest sightings throughout the main hospital campus buildings. Review of EMP4's October 2016 Job Description revealed, "The Infection Preventionist ... is responsible for... the development of health system policies and procedures to insure rigorous infection control standards... . Conduct unit rounds to ensure compliance with infection control practices throughout the health system. ... ."
An interview conducted on August 30, 2017, at 11:30 AM with EMP4 revealed that they were only involved when there were body lice and bed bugs identified and not when mice, roaches or other pests were identified, as it was thought to be an issue for EVS and pest control to handle. Further interview confirmed that they were not aware of the 226 reports of pest sightings throughout the main hospital campus buildings in 2017. EMP4 confirmed that the presence of pests throughout the facility, especially in patient care areas was not a safe or sanitary environment of care. EMP4 confirmed that their job description did not include pest control oversight and they had not identified pest control as a quality measure for Infection control.