HospitalInspections.org

Based on a review of facility policy, documents and interview with staff (EMP), it was determined the Governing Body failed in their responsibilities to oversee the enforcement of facility policies and procedures and manufacturer's equipment recommendations to ensure quality patient care (0144, 0756); failed to effectively oversee and direct infection control activities of the hospital (0749 and 0756); and failed to ensure that the medical staff maintained high standards of practice (0049).

A review of the "Amended and Restated Operating Agreement of Prospect CCMC (Crozer Chester Medical Center), LLC" effective date January 1, 2017, revealed, "The Board of Managers delegates, on a standing basis, performance of the following duties and functions to its "Operations Committee (Local Advisory Board)" (v) Oversee enforcement of policies required to ensure the provison of appropriate quality of care to patients;... (vii) Oversee and direct all quality improvement activities of the Hospital, including but not limited to assuring that there are ongoing programs to: provide that all quality improvement actions are evaluated, assure that safety expectations are established, measure and assess the Hospital's ongoing performance and reduction of risks to patients, and establish priorities on at least an annual basis to reduce risks to patients;... (xi) Oversee and direct all infection control activities of the Hospital;... (xx) Assure that the Medical Staff establishes and enforces polices designed to achieve and maintain high standards of ethical professional practice;... ."

Cross reference to:
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.42(a(1) Infection Control Program
482.42(b) Infection Control Responsibilities
482.12(a)(5) Medical Staff Accountability
482.21 QAPI
482.21(b)(2)(ii), (c)(1),(c)(3) Quality Improvement Activities

The facility's Governing Body failed to provide oversight and ensure the provision of quality standards and practices resulting in a continuation of ineffective operational processes and service delivery standards.

Based on review of facility policy, documents and interview with staff (EMP), it was determined the governing body failed to ensure the medical staff was accountable to the governing body for proper hand hygiene practices.

A review of the "Amended and Restated Operating Agreement of Prospect CCMC, LLC" effective date January 1, 2017, revealed, "The Board of Managers delegates, on a standing basis, performance of the following duties and functions to its "Operations Committee (Local Advisory Board)" (v) Oversee enforcement of policies required to ensure the provison of appropriate quality of care to patients;... (vii) Oversee and direct all quality improvement activities of the Hospital, including but not limited to assuring that there are ongoing programs to: provide that all quality improvement actions are evaluated, assure that safety expectations are established, measure and assess the Hospital's ongoing performance and reduction of risks to patients, and establish priorities on at least an annual basis to reduce risks to patients;... (xi) Oversee and direct all infection control activities of the Hospital;... (xx) Assure that the Medical Staff establishes and enforces polices designed to achieve and maintain high standards of ethical professional practice;... ."

A review of facility document "Infection Prevention Committee Report" dated November 22, 2017, included the facility staff's hand hygiene compliance for fiscal year 2017 from October 2016 through September 2017, prior to staff entering and after leaving a patient's room, by type of staff. The data reviewed revealed the following - compliance prior to entering a patient room, the physicians observed had 92% compliance, and the residents and interns observed had 84% compliance. For compliance after leaving a patient's room, the physicians observed had 92% compliance, and residents and interns observed had 82% compliance. The benchmark for compliance was 100%.

A review of the 2016 fiscal year information for the same data collected for fiscal year 2016 from October 2015 through May 2016 revealed the following: for compliance prior to entering a patient room, the physicians observed had 90% compliance, and residents and interns observed had 97% compliance. For compliance after leaving a patient room, the physicians observed had 88% compliance, and residents and interns observed had 96% compliance. The benchmark for compliance was 100%.

A review of facility document " Local Advisory Board Committee Meeting Minutes" for July 28, 2016, January 19, 2017, May 18, 2017, and June 15, 2017, did not reveal any reports by the medical staff to the governing body related to the medical staffs failure to meet the hand hygiene benchmark for compliance of 100%.

An interview conducted on January 16, 2018, at 1:00 PM with EMP6 revealed that they were not aware of any reports by the medical staff to the local advisory board or actions taken by the local advisory board with regard to the medical staffs failure to meet the hand hygiene benchmark for compliance of 100%.

An interview conducted on January 16, 2018, at 1:20 PM with EMP1 confirmed that there was no documentation of any actions taken by the Local Governing Board with regard to the medical staffs failure to meet the benchmark for hand hygiene compliance of 100%.

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

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. ... ."

1. A review of the facility's "Burn Treatment Center (BTU) Infection Control Policy" last revised 2016 revealed, "d. Equipment Maintenance ... 5) At the end of each day a Clorox solution is run through the hose system of the shower trolley with some solution retained for overnight sanitation. ... ."

A review of facility document "Hospital Therapy Products, Inc.'s Disinfectant Procedure for the Control Panel and Hose Reels in the Burn Treatment Unit (BTU) hydrotherapy rooms " revealed, "Add 5 cc or one teaspoon of standard Clorox bleach... ."
A tour of the BTU on November 16, 2017, at 2:30 PM with EMP2 and EMP5 revealed no documentation for cleaning of the shower trolley (hydrotherapy room) hoses.
A phone interview conducted on November 20, 2017, at 1:50 PM with EMP9 confirmed that since 2006 the BTU had used Chlorhexidine instead of bleach to flush the hydrotherapy room (shower trolley) hoses. Further interview confirmed that the procedure did not follow the facility's policy or the manufacturer's recommendation for cleaning of the hydrotherapy room hoses. In addition, the facility was unable to produce daily cleaning logs for the hydrotherapy room hoses.


2. A review of facility policy "Standard Precautions" last reviewed January 2017 revealed, "1. Hand Hygiene - Hands should be decontaminated immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients and environments. It may be necessary to decontaminate hands between tasks and procedures on the same patient to prevent cross contamination of different body sites. a. hand washing: Wash hands with soap and water after contact with blood, all body fluids, non-intact skin, mucous membranes and other contaminated items whether or not gloves were worn. b. Alcohol-based hand sanitizers: These products may be used if hands are not visibly soiled. ... ."

A review of a May 25, 2017, 11:17 AM e-mail from EMP4 to EMP3 revealed, "During my audits in the Burn Center I witnessed a physician (EMP5) scratch his nose and scalp, put on PPE, and then walk into a patient's room (room 4 - 93% Total Body Surface Affected (TBSA) burns and Multi Drug Resistant Organism (MDRO) Pseudomonas) and did not wash his hands prior to putting on PPE or prior to touching the patient. The two residents that were with EMP5 were then going to walk into the room with only a gown on and I asked them to wash their hands prior to entry and they stated "we've never had to wash our hands before."
An interview conducted on November 16, 2017, at 10:30 AM with EMP3 confirmed the above events occurred during audits in the BTU on May 25, 2017. Further interview confirmed the medical staff had not followed the facility's Standard Precautions policy for hand hygiene.

Based on a review of facility policy, documentation and interview with staff (EMP), it was determined that the facility's governing body failed to assume responsibility to implement an effective comprehensive Quality Assurance Program for the Burn Treatment Unit (BTU).

which included performance improvement activities for the medical staff.

Findings include:

A review of the facility's Quality Performance and Improvement Plan Fiscal Year 2017 revealed, "Functions of the Quality Performance & Improvement Process In order to accomplish the purpose of the Quality Performance and Improvement process, the following functions are undertaken to improve organizational performance. ... . 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. ... . 6. Implementing improvement and patient safety activities based on assessment; ... 8. Ensure that important internal processes and activities throughout the organization are continuously and systematically assessed and improved; 9. Allocate adequate resources for assessing and improving the organization. ... . all hospital-based departments and ambulatory services shall have a Quality Assessment and Performance Improvement (QAPI) plan. ... . 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. ... ."

1. A review of the "BSSM/PI" [Burn Surgeon Staff Meeting/Performance Improvement] committee meeting minutes for January 5, 2017, revealed, "EMP5 stated the reviewers indicated we need an introductory manual for the residents to review, whether it is emailed or available online. ... . Recommended Action - Education needs to be determined. ... ."

A review of the "BSSM/PI" committee meeting minutes for March 16, 2017, revealed, "EMP5 stated the reviewers indicated we need an introductory manual for the residents to review, whether it is emailed or available online. ... . Recommended Action - 1/19/17 Education needs to be determined. ... ."

A review of the "BSSM/PI" committee meeting minutes for April 6, 2017, revealed, "EMP5 stated the reviewers indicated we need an introductory manual for the residents to review, whether it is emailed or available online. ... . Recommended Action - 4/6/17 - Pre and post-test being worked on. Recommended readings being updated. ... ."

An interview conducted on January 16, 2018, at 1:40 PM with EMP1 confirmed that the the resident manual was still in process and there was no original or new deadline by which the BSSM/PI committee determined it needed to be done.

2. A review of facility's medical residents' orientation documentation revealed no documentation of training on proper hand washing and use of personnel protective equipment for the 29 medical residents who rotated on the BTU starting June 2016 and June 2017.
An interview conducted on November 16, 2017, at 4:00 PM with EMP1 confirmed the BTU residents and medical staff were not given direct training or competencies for proper hand washing and use of personnel protective equipment.

3. A review of the BTU's Quality measures for fiscal year October 2016 - September 2017, and for fiscal year October 2017 - September 2018 did not reveal any quality improvement measures identified to address the physicians and residents lack of hand washing compliance.

A review of the Quality of Care Committee meeting minutes for 2016 and 2017 did not reveal any action steps identified to address the physicians and residents hand hygiene noncompliance.
A phone interview conducted on January, 3, 2018, at 3:00 PM with EMP1 confirmed that the hospital's Quality Measures for fiscal year October 2016 - September 2017, and for fiscal year October 2017 - September 2018 for the BTU did not reveal any measures specific to proper hand washing, use of personal protective equipment by staff or proper use and cleaning of hydrotherapy equipment. Further interview confirmed that the quality committee had not developed or implemented any action steps to address the physician and residents' lack of compliance with hand hygiene.
Cross Reference
482.12 Governing Body
482.21(c)(1) Program Activities
482.42(a)(1) Infection Control Program
482.42(b) Infection Control Responsibilities











































34230

Based on review of facility documents and interviews with staff (EMP), it was determined that the facility failed to implement an effective ongoing, data-driven, hospital-wide QAPI (Quality Assessment Performance Improvement) program as evidenced by failing to show continued performance improvement initatives were measured, analyzed and tracked to determine the effectiveness and safety of services provided by the hospital (A756); proper handwashing (A049); proper use of personnel protective equipment (A144); proper use and use and cleaning of the hydrotherapy rooms hoses (A144, A749) and establishing an introductory orientation manual for the residents and interns for the Burn Treatment Unit (BTU) (A283).

A review of the facility's Quality Performance and Improvement Plan Fiscal Year 2017 revealed, "Functions of the Quality Performance & Improvement Process In order to accomplish the purpose of the Quality Performance and Improvement process, the following functions are undertaken to improve organizational performance. ... . 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. ... . 6. Implementing improvement and patient safety activities based on assessment; ... 8. Ensure that important internal processes and activities throughout the organization are continuously and systematically assessed and improved; 9. Allocate adequate resources for assessing and improving the organization. ... . all hospital-based departments and ambulatory services shall have a Quality Assessment and Performance Improvement (QAPI) plan. ... . 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. ... ."


Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting
482.21(c)(1) Program Activities
482.42(a)(1) Infection Control Program
482.42(b) Infection Control Responsibilities
482.21(b)(2)(ii), (c)(1),(c)(3) Quality Improvement Actvities
482.12(a)(5) Medical Staff-Accountability

Based on a review of facility policy, documentation and interview with staff (EMP), it was determined that the facility failed to implement ongoing performance improvement activities specific to the Burn Treatment Unit (BTU) related to proper hand washing, use of personal protective equipment by staff, proper use and cleaning of hydrotherapy equipment and introductory education for residents and interns to the BTU .

Findings include:

A review of the facility's Quality Performance and Improvement Plan Fiscal Year 2017 revealed, "Functions of the Quality Performance & Improvement Process In order to accomplish the purpose of the Quality Performance and Improvement process, the following functions are undertaken to improve organizational performance. ... . 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. ... . 6. Implementing improvement and patient safety activities based on assessment; ... 8. Ensure that important internal processes and activities throughout the organization are continuously and systematically assessed and improved; 9. Allocate adequate resources for assessing and improving the organization. ... . all hospital-based departments and ambulatory services shall have a Quality Assessment and Performance Improvement (QAPI) plan. ... . 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. ... ."

A review of the BTU's Quality measures for fiscal year October 2016 - September 2017, and for fiscal year October 2017 - September 2018 did not reveal any measures specific to proper hand washing, use of personal protective equipment by staff and proper use and cleaning of hydrotherapy equipment.

A review of the Quality of Care Committee October 23, 2017, meeting minutes revealed, the Infection Control Committee's report, "Burn Treatment Center MDRO Pseudomonas: recommendation to improve hand hygiene and to strictly follow manufacturer's recommendations for the hydrotherapy room. ... ."
A review of Infection Prevention Committee's November 22, 2017, report included the facility staff's hand hygiene compliance for fiscal year 2017 from October 2016 through September, prior to staff entering and after leaving a patient room, broken down by type of staff. For compliance prior to entering a patient room, the physicians observed had 92% compliance, and residents and interns observed had 84% compliance. For compliance after leaving a patient room, the physicians observed had 92% compliance, and residents and interns observed had 82% compliance. The benchmark for compliance was 100%.
A review of the 2016 fiscal year information for the same data collected for fiscal year 2016 from October 2015 through May 2016 revealed, for compliance prior to entering a patient room, the physicians observed had 90% compliance, and residents and interns observed had 97% compliance. For compliance after leaving a patient room, the physicians observed had 88% compliance, and residents and interns observed had 96% compliance. The benchmark for compliance was 100%.
A review of the Quality of Care Committee meeting minutes for 2016 and 2017 did not reveal any action steps identified to address the physician, residents and interns hand hygiene noncompliance.
A phone interview conducted on November 20, 2017, at 1:50 PM with EMP9 confirmed that the Burn Treatment Center's Quality measures for fiscal year October 2016 - September 2017, and for fiscal year October 2017-September 2018 did not include measures specific to proper hand washing, use of personal protective equipment by staff or proper use and cleaning of the hydrotherapy hose equipment.

A phone interview conducted on January, 3, 2018, at 3:00 PM with EMP1 confirmed that the residents and interns compliance with hand hygiene had decreased during October 2016 through September 2017 compared to October 2015 through May 2016. Further interview confirmed that the quality committee had not identified any action steps to address the physician and residents' hand hygiene noncompliance.
2. A review of the "BSSM/PI" [Burn Surgeon Staff Meeting/Performance Improvement] committee meeting minutes for January 5, 2017, revealed, "EMP5 stated the reviewers indicated we need an introductory manual for the residents to review, whether it is emailed or available online. ... . Recommended Action - Education needs to be determined. ... ."

A review of the "BSSM/PI" committee meeting minutes for March 16, 2017, revealed, "EMP5 stated the reviewers indicated we need an introductory manual for the residents to review, whether it is emailed or available online. ... . Recommended Action - 1/19/17 Education needs to be determined. ... ."

A review of the "BSSM/PI" committee meeting minutes for April 6, 2017, revealed, "EMP5 stated the reviewers indicated we need an introductory manual for the residents to review, whether it is emailed or available online. ... . Recommended Action - 4/6/17 - Pre and post-test being worked on. Recommended readings being updated. ... ."

An interview conducted on January 16, 2018, at 1:40 PM with EMP1 confirmed that the resident education manual was still in the development process and there was no original or new deadline by which the BSSM/PI committee determined it needed to be done.

Based on a review of facility policy, facility documentation and interview with staff (EMP) it was determined that the infection control officer was not responsible to assess the cleaning and use of the hydrotherapy room hoses in the Burn Treatment Unit (BTU).

Findings include:

A review of the facility's Infection Prevention & Control Department Organization and Services dated 2017 revealed, "The programs intent is to identify, prevent, control and reduce the incidence of nosocomial infections. ... . Services/Duties ... Consultation, evaluation & monitoring as appropriate for cleaning, disinfecting, sanitation... . The objectives of the Infection Prevention & Control Program are: To provide a mechanism that will promote the identification, prevention, and control of infections that may occur in patients... . To establish methods to monitor, evaluate and minimize the risk of transmission of infection to all patients, visitors and personnel. ... . To provide a mechanism that will promote the identification, prevention, and control of infections that may occur in patients, visitors, and hospital personnel. To establish methods to monitor, evaluate and minimize the risk of transmission of infection to all patients, visitors and personnel. ... . The goal of the Infection Prevention & Control Program is to insure a safe, healthy environment for all patients... . This is accomplished through surveillance activities, isolation precautions, written infection control policies, continual staff education... . The Infection Control Department adheres to all laws, standards, regulations and recommendations issued by federal, state and local agencies as well as other accrediting agencies. These include but are not limited to: Center for Disease Control and Prevention (CDC)... Pennsylvania State Health Department... ."

A review of the Infection Preventionist's job description revealed, "perform annual risk assessment, provide education, trend antibiotic susceptibility/resistance, hand hygiene initiatives, consultation, evaluation, and monitoring as appropriate for cleaning, disinfecting, sanitation, environmental rounds.
A review of facility policy "Cleaning, Disinfection, & Sterilization" last reviewed January 2017 revealed, "It is the responsibility of the Department of Infection Prevention and Control to review and update cleaning... policies, to serve as a content expert regarding questions around cleaning..., and to investigate cleaning... failures as such events may result in transmission of infectious agents. ... ."
A review of the facility's Infection Control Risk Assessment Tool for fiscal year September 2016 - October 2017 revealed that it did not include the cleaning of the hydrotherapy room hoses in the BTU.

An interview conducted on November 16, 2017, at 1:30 PM with EMP6 confirmed that EMP6 was not responsible to assess the cleaning and use of the hydrotherapy equipment on the BTU. Further interview confirmed that the facility was unable to identify anyone assigned to maintain infection control practices for the cleaning of the hydrotherapy room hoses in the BTU.

Based on a review of the facility's Quality Performance Improvement Plan, facility policy, facility documentation and interview with staff (EMP), it was determined that the facility failed to identify the need for annual education and competency training for Burn Treatment Center (BTU) staff related to hand hygiene, proper use of personal protective equipment and proper use and cleaning of hydrotherapy equipment; and annual education and competency training for BTU staff.
Findings include:
A review of the facility's Quality Performance and Improvement Plan Fiscal Year 2017 revealed, "Functions of the Quality Performance & Improvement Process In order to accomplish the purpose of the Quality Performance and Improvement process, the following functions are undertaken to improve organizational performance. ... . 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. ... . 6. Implementing improvement and patient safety activities based on assessment; ... 8. Ensure that important internal processes and activities throughout the organization are continuously and systematically assessed and improved; 9. Allocate adequate resources for assessing and improving the organization. ... . all hospital-based departments and ambulatory services shall have a Quality Assessment and Performance Improvement (QAPI) plan. ... . 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. ... ."
A review of the facility's policy "Infection Prevention & Control Risk Assessment" last revised January 2017 revealed, "Strategies for Prevention:... Employee Education... ."
1. A review of facility's medical residents orientation documentation who rotated on the BTU starting June 2016 and June 2017 revealed no documentation of education and competency training on proper hand washing and the use of personnel protective equipment for the 29 medical residents.
An interview conducted on November 16, 2017, at 4:00 PM with EMP1 confirmed the BTU medical residents were not given direct training or competencies for proper hand washing and for the use of personal protective equipment.
2. A review on December 14, 2017, of facility policy "Nursing Education - Clinical Competencies" last revised 12/13/2016, revealed, "Effective, efficient, safe, and patient-centered skills that are performed through a variety of methods and demonstrates aptitude and knowledge in a particular topic in order to be qualified or capable to perform the duties of one's position. The competency assessment must be thorough and focus on the particular competency needs for the clinical staff's assignment. Procedure 1. Competencies are assessed and validated: a. During orientation b. Annually 2. Competencies are identified by: a. Observation/simulation... e. Quality improvement reports... 3. Competencies are validated using the following methods: a. Education with post test b. Return demonstrations ... d. Observation of work... 4. Competency validation/education may be performed through: a. Online/electronic education b. Staff meetings c. Skills days d. continuing education program e. unit specific education... h. one to one sessions 5. On an annual basis, the department of nursing education will identify specialty specific competencies... . 6. Competency records are maintained as computer and/or hard copies files in the Human Resources Department. ... ."

A phone interview conducted on December 14, 2017, at 2:00 PM with EMP1 confirmed that the facility did not require competency based training for BTU staff for hygiene with soap and water and alcohol based hand rub, contact isolation donning and doffing of PPE's, and shower trolley (hydrotherapy room equipment) use and cleaning after their initial orientation.

A phone interview conducted on December 14, 2017, at 3:45 PM with EMP12 confirmed that the annual competencies, required for the BTU staff did not include direct observation of competency for hand hygiene with soap and water and alcohol based hand rub, contact isolation donning and doffing of PPE's or shower trolley (hydrotherapy room equipment) use and cleaning. Further interview confirmed that the BTU staff had not had competencies for hygiene with soap and water and alcohol based hand rub, and contact isolation donning and doffing of PPE's since the initial hospital orientation.

A review on December 22, 2017, of 30 emailed BTU staff orientation training documents revealed that PF1 through PF10, hired from 1973 to 1994, did not contain any documentation that the staff had received training competencies for hand hygiene, PPE use and shower trolley use and cleaning on orientation or since. A review of PF11 through PF 30, hired from 1996 to 2017, revealed that the staff had received training competencies only on orientation to the BTU for hand hygiene, PPE use and shower trolley use and cleaning.

A phone interview conducted with December 22, 2017, at 11:30 AM with EMP1 confirmed that there was no documentation that ten BTU staff (PF1 through PF10) had received competencies during their initial orientation or since for hand hygiene, PPE use and shower trolley use and cleaning. Further interview confirmed that the BTU staff (PF11 through PF30) had not received competencies for hand hygiene, PPE use and shower trolley use and cleaning since their initial orientation to the BTU.

3. A review of an email received January 3, 2018, from EMP1 revealed, "Hand hygiene observation outcomes are reported to the Crozer/Taylor/Springfield (C/T/S) Infection Control Committee. From there, the minutes/reports from the C/T/S Infection Control Committee are sent to the CKHS System wide Infection Control Committee. The CKHS System wide Infection Control Committee meeting minutes are then reviewed by the Quality of Care Committee and Local Advisory Board. ... . The Quality of Care Committee, a sub-committee of the Local Governing Body "provides guidance in achieving the system's mission by improving the health status of residents of the communities served by: Coordinating continuous quality improvement efforts across the entire continuum of care provided by the system."

A review on November 16, 2017, of the Quality of Care meeting minutes for July 2016, January 2017, May 2017 and June 2017 revealed Patient Safety committee reports and system wide Infection Control committee minutes were reviewed and approved.

A review on January 3, 2018, of the Local Advisory Board meeting minutes for July 2016, January 2017, May 2017 and June 2017 revealed the Quality of Care committee reports and system wide Infection Control Committee minutes were reviewed and approved.

A phone interview conducted on January 3, 2018, at 3:00 PM with EMP1 confirmed that the governing body was updated and approved the Local Advisory Board meeting minutes for July 2016, January 2017, May 2017 and June 2017 which included the Quality of Care committee meeting minutes and system wide Infection Control Committee minutes.