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Based on observation, document review and staff interview, it was determined the hospital failed to fully implement the plan of correction for the deficiencies cited on the previous survey. The hospital had not yet completed all physical plant work and had not developed policies and procedures, compliance monitoring systems and a staff training and competency verification program to ensure corrections to the physical environment were sustained.
Findings:

At the time of the revisit survey, the following physical plant issues remained:
~ incomplete renovation of the endoscopy suite and associated support areas
~ sewer gas smells in parts of the hospital
~ water leaks to the ceiling in the endoscopy suite and surgical instrument processing areas

The hospital had not developed policies and procedures and monitoring tools to address the following as documented in the plan of correction:
~ prevention of unauthorized changes to the physical plant departmentally and hospital-wide
~ appropriate traffic flow in the endoscopy suite and associated support areas and the identification the unrestricted, semi-restricted and restricted areas
~ endoscopy suite security and access
~ ventilation, airflow, air pressures, temperature and humidity in the endoscopy suite and support areas
~ prohibition of dehumidifiers and fans in the endoscopy suite and support areas
~ appropriate storage of endoscopy equipment and supplies
~ storage of sterile and non-sterile supplies in the endoscopy suite
~ linen storage in the endoscopy suite
~ supply receiving in the endoscopy suite
~ waste management in the endoscopy suite
~ environmental cleaning requirements and schedules for the endoscopy suite and support areas
~ preventive maintenance for endoscopy equipment and preventive maintenance schedules
~ equipment malfunctions, testing failures, back-up procedures and required documentation
~ environmental rounds, documentation requirements and actions to be taken
~ prevention of environmental contamination in the endoscopy suite
~ safe handling and storage of chemicals in the endoscopy suite
~ use of manufacturers' guidelines for products and equipment
~ staff training program for all equipment used in the endoscopy suite

The hospital had not developed a comprehensive staff training program and competency evaluation process for the requirements listed above.

The hospital leadership confirmed through interview these items had not been completed.

Based on observation, document review and staff interview, it was determined the hospital had not fully developed the infection control program to include the development of infection control policies and procedures, compliance monitoring systems and a staff training and competency verification program to ensure corrections to the infection control practices were sustained.
Findings:

1. The hospital had not developed the following policies and procedures and compliance monitoring tools as documented in the plan of correction:

~ infection preventionist responsibilities for validating compliance with infection control standards within surgical services
~ surgery department director responsibilities for validating compliance with infection control standards within surgical services
~ infection control compliance monitoring tools for surgical services to include endoscopy procedures and endoscopic instrument processing
~ high-level disinfection processes to include required documentation for each department that performs this function
~ departmental staff training and competency verification for high-level disinfection procedures
~ staff infection control training program specific to endoscopy services
~ endoscopic instrument decontamination to include required documentation
~ departmental requirements and instructions for proper clean and sterile supply storage
~ requirements for documentation of instrument disinfection and sterilization practices
~ staff responsibilities for documenting and reporting disinfection and sterilization failures
~ infection preventionist responsibilities for the oversight of reprocessing single-use patient care items and compliance with FDA requirements
~ identification of critical, semi-critical and non-critical reprocessed items
~ manual instrument decontamination and disinfection and documentation
~ automated instrument disinfection and documentation
~ immediate use steam sterilization practices and documentation
~ infection control surveillance program for endoscopy services
~ hospital-wide departmental environment cleaning and disinfection requirements and schedules
~ use of EPA registered hospital disinfectants for each department
~ approved environmental cleaning tools
~ prohibited environmental cleaning tools
~ infection control practices related to the transportation of material in and out of the endoscopy suite
~ perioperative nurses' responsibilities for infection control practices and surveillance
~ use, care and maintenance of staff emergency eye wash stations
~ endoscope equipment and patient identification documentation

2. The hospital had not developed a comprehensive staff training program and competency evaluation process for the infection control requirements listed above.

The hospital leadership confirmed through interview these items had not been completed.

Based on observation, document review and staff interview, it was determined the hospital failed to fully implement the plan of correction for the deficiencies cited on the previous survey related to surgical services. The hospital had not developed policies and procedures, compliance monitoring systems and a staff training and competency verification program to ensure corrections to surgical services were sustained.
Findings:

1. The hospital did not provide any surgical services policies and procedures that had been revised or updated since the previous survey. None of the previous policies had documentation they were based on national standards of practice.

2. The hospital had not developed the following policies and procedures and compliance monitoring tools as documented in the plan of correction:
~ surgical department (endoscopy) scope of services
~ instrument processing scope of services
~ pre-operative, intraoperative and post-operative patient care
~ patient safety in the surgery department
~ procedure-specific policies and procedures
~ surgical services surveillance program

3. The hospital did not provide surgical policies and procedures based on national standards of practice related to the following:
~ access to the operative and recovery areas
~ traffic flow patterns within the surgery department
~ aseptic and sterile technique and surveillance
~ scrub techniques
~ cleaning between cases
~ terminal cleaning
~ surgical attire
~ use of equipment for rapid and routine sterilization
~ use of equipment for endoscope processing
~ surgery equipment monitoring, inspection, testing and maintenance program
~ sterile packaging
~ sterile storage
~ temperature and humidity requirements, monitoring and maintenance
~ identification of infected and non-infected cases
~ department specific housekeeping procedures and personnel responsibilities
~ pre-operative patient care requirements
~ surgical consents and releases
~ clinical procedures specific to the scope of services (case protocols)
~ patient identification requirements
~ surgical counts
~ surgery scheduling
~ personnel policies unique to the OR
~ resuscitative techniques
~ DNR status
~ care of surgical specimens
~ infectious/biomedical/hazardous waste handling
~ outpatient surgery post-operative care planning and coordination
~ post-operative follow-up
~ alcohol-based skin preparations in anesthetizing locations
~ surgical fires
~ surgery emergency equipment requirements
~ post-operative care procedures
~ post-operative patient monitoring requirements
~ surgical register requirements
~ operative report requirements

4. The hospital had not developed a comprehensive staff training program and skills competency validation process that included all the elements listed above.

The hospital leadership confirmed through interview these items had not been completed.