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Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure all hair was restrained by hair restraints for staff working in the Dietary Department, failed to ensure soapy cleaning water was stored away from food and failed to ensure the personal clothing of staff working in the facility laboratory areas was protected when working with potentially contaminated blood and body fluids.


Findings include:

1) Review on June 20, 2017, of the facility's "Foodservice System Hourly Uniformed Staff Requirements" policy, effective January 1, 2017, revealed "Purpose: To provide guidelines for employees to project a professional image that is appropriate for the work setting and abides by GHS infection control, safety and regulatory standards. ...Required Hair Restraints: (see Below) PA Food Code 46.152. Hair Restraints (a) General requirement. Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair that are effectively designed and worn to keep their hair from contacting exposed food; clean equipment, utensils and linens; and unwrapped single-service and single-use articles. All staff must cover all hair completely including bangs and pony tails. Two different hair covering types may be used to cover all hair (Example: pony tail while wearing a baseball hat would require the pony tail to be completely covered by a hair net or bouffant net plus the hat.) ..."

Observation on June 20, 2017, at approximately 11:10 AM of the facility Dietary Department tray line revealed dietary staff preparing and distributing food for patients as follows:

EMP5 was in the Dietary Department preparing food for patient consumption, and this employee's bangs and hair were hanging below the hairnet.

EMP6 was in the Dietary Department preparing and distributing food for patient consumption, and this employee's hair was hanging below the hairnet.

EMP7 and EMP8 were in the Dietary Department preparing food for patient consumption, and these employees' hair was hanging below their hairnet.

EMP9 was in the Dietary Department preparing and distributing food for patient consumption, and this employee's bangs and hair were hanging below the hairnet.

EMP10, EMP11 and EMP12 were in the Dietary Department preparing and distributing food for patient consumption, and these employees' facial hair was not restrained with a cover.

Interview with EMP5 on June 20, 2017, at the time of the observations confirmed EMP5, EMP6, EMP7, EMP8 and EMP9 were in the Dietary Department preparing and distributing food for patient consumption and these employees' hair was hanging below their hairnet. EMP5 confirmed EMP10, EMP11 and EMP12 were in the Dietary Department preparing and distributing food for patient consumption and these employees' facial hair was not restrained with a cover.

2) Review on June 20, 2017, of the facility's "Foodservices Infection Control Policies," no review date, revealed "I. Purpose: Insure the use of clean and sanitary procedures in preparation and service of food. ... III. Food Preparation and Storage: ... 3. All non-food items are properly labeled. All cleaning products are stored away from food products. ..."

Observation on June 20, 2017, of the facility's Dietary Department revealed a counter measuring approximately 2' x 2' with one pail containing white suds sitting on the counter top. Interview with EMP5 revealed the pails contained soapy water for cleaning. On the counter top, there were three containers of cut tomatoes.

Interview with EMP5 on June 20, 2017, at the time of the observation confirmed the counter with the pail of soapy water for cleaning and the three containers of cut tomatoes. EMP5 confirmed food should not be stored near cleaning solutions.

3) Review on June 20, 2017, of the facility's "Infection Control" policy, last reviewed October 19, 2016, revealed "Principle: In efforts to prevent the spread of infection to the environment, patients and personnel during the provision of laboratory testing and services, Geisinger Medical Laboratories (GML) has implemented an infection control policy. ... Policy: ... Complies with regulatory and accreditation requirements to prevent and control infections related to laboratory services ... IV. Personnel Protective Equipment - Personal Protective Equipment (PPE) refers to clothing or equipment worn by employees for protection against a hazard. ... F. Lab coats 1. As outlined in Attachment A for use of personal protective equipment, all staff in technical areas including specimen processing are required to wear fluid resistant lab coats. Fluid resistant lab coats must be securely fastened. ..."

Review on June 20, 2017, of the facility's "Infection Control Attachment A Personnel Protective Equipment" last reviewed October 19, 2016, revealed check marks for the use of fluid resistant lab coats, securely fastened for: Specimen Handling Testing Discarding Specimens in Bulk Instrument Maintenance Cleaning Bone Saw Autopsy Dissecting Large, Unfixed Specimens Dissecting small or fixed specimens Level II spill cleanup.

Observation on June 20, 2017, at approximately 10:30 AM revealed EMP13, EMP14, EMP15, EMP16, EMP17 and EMP18 working in areas of the facility Laboratory with potentially contaminated blood and body fluids. Their laboratory coats were not securely fastened to protect their clothing from potentially contaminated blood and body fluids.

Interview on June 20, 2017, at the time of the observations with EMP12 confirmed EMP13, EMP14, EMP15, EMP16, EMP17 and EMP18 were working in areas of the facility Laboratory with potentially contaminated blood and body fluids. Their laboratory coats were not securely fastened to protect their clothing from potentially contaminated blood and body fluids.