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Based on review of facility documents, staff interviews, and observations, it was determined that the Governing Body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

42 CFR 482.13 Patient's Rights

42 CFR 482.22 Medical Staff

42 CFR 482.23 Nursing Services

42 CFR 482.28 Food and Dietetic Services

42 CFR 482.41 Physical Environment

42 CFR 482.42 Infection Control

Based on observation, review of facility policy and procedures, and staff interviews, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

1. The facility failed to provide personal privacy for all patients. (Cross refer to Tag A 143)

2. The facility failed to provide personal storage space for all patients to store personal belongings. (Cross refer to Tag A 143)

3. The facility failed to ensure the safety for all patients. (Cross refer to Tag A 144)

Based on observation, review of facility policy and procedure, review of facility documents, and staff interviews, it was determined that the facility failed to ensure that all patients have the right to personal privacy.

Findings include:

Reference #1: Facility document "Plan For Accommodation of Patient Overflow" states, "... If your unit receives a new patient AND no bed is available: ... 2. Inform the patients and staff that the Study Room will be used as a bedroom between 8 PM and 8 AM. It will no longer be available for general patient use during those hours. ... 5. Patient belongings: when a patient is sleeping in the Study Room, he/she may store extra belongings in the unit storage room. Provide the patient with a hamper and all other supplies as usual. ... ."

Reference #2: Facility policy titled "Locked Storage Areas for Patient Belongings" states, "It is the policy of Greystone Park to provide each patient with a (limited) locked storage area for his/her personal belongings. (Wardrobe, Bedside Table, and up to one (1) Plastic Storage containers in the Unit Shared Patient Storage Area). ... D. Nursing staff is responsible for educating each patient about: 1. Retaining the locker key. ... 5. Obtaining access to the locker. ... "

1. During a tour of inpatient unit A2 on 6/21/17, the following was observed:

a. At 11:30 AM, Patient #6 was observed sleeping while sitting on a sofa in the Study Room. Two pillowcases filled with items were next to the patient.

b. Upon interview, Staff #45 stated that Patient #6 was an overflow patient assigned to the unit.

(i) Upon interview, Patient #6 stated that he/she sleeps on a bed in the Study Room at night. He/she stated that there is no one else in the room with him/her at night.

(ii) Patient #6 stated that his/her things are stored in the storage closet and when he/she needs something, he/she asks a staff member.

(iii) Patient #6 stated that the staff did not provide him/her with toothpaste or a toothbrush.

c. A tour of the unit storage room revealed a plastic bag filled with clothing sitting on top of a wooden dresser. Staff #45 stated that the plastic bag and the dresser were provided for Patient #6's use.

(i) There were no toiletries or personal care items located in the plastic bag or dresser drawers.

d. Upon interview, Staff #45 stated that housekeeping brings a bed and privacy divider into the Study Room at 8 PM for the patient to sleep on. The security camera is covered while the patient is sleeping in the Study Room. The bed and privacy divider is removed from the Study Room at 8 AM.

(i) Staff #45 stated that the patient's personal care items are probably in the pillowcases that are next to him/her. Staff #45 stated that the staff allow Patient #6 to keep the belongings next to him/her because it keeps the patient quiet.

(ii) Staff #45 stated that Patient #6 uses the bathroom in the hallway, or if that is occupied, the bathroom in the Recovery Room is opened for the patient.

2. During a tour of inpatient unit F3 on 6/21/17, the following was observed:

a. At 2:05 PM, Patient #7 was observed in the Day Room watching television. Staff #52 stated Patient #7 was the overflow patient assigned to the unit.

b. Upon interview, Patient #7 stated that he/she sleeps on a bed in the Study Room.

(i) Patient #7 stated that his/her things are in the storage room and if he/she wants something, he/she asks a staff member.

(ii) Patient #7 stated that at night, he/she can hear the door to the Study Room open, "but I don't see anyone."

c. A tour of the unit storage room revealed a plastic bag identified as Patient #7's belongings.

(i) The plastic bag contained clothes, a toothbrush, and toothpaste.

(ii) There was no plastic storage container or wooden dresser in the storage room provided for Patient #7's use.

d. Upon interview, Staff #52 stated that housekeeping brings in the bed and a privacy divider for the overflow patient at 8 PM. The security camera is covered while the patient is sleeping in the Study Room. Housekeeping removes the bed and privacy divider at 8 AM.

(i) Staff #52 stated that if Patient #7 would like to lie down during the day, or is not feeling well, he/she can lie down in the comfort suite, or housekeeping will be notified to set up the patient's bed in the Study Room.

3. During a tour of inpatient unit D2 on 6/22/17, the following was observed:

a. At 2:05 PM, Patient #13 was observed lying in bed in the Study Room. The privacy divider was around the patient's bed and the security camera was covered.

b. Staff #70 identified Patient #13 as the overflow patient assigned to the unit.

(i) Upon interview, Staff #70 stated that the bed and privacy divider remain set up in the Study Room at all times. Housekeeping does not take the bed and privacy divider away.

c. Upon interview, Patient #13 stated that he/she sleeps in the room alone at night.

(i) Patient #13 stated that his/her belongings are stored in the storage room, and he/she asks a staff member if he/she needs them.

d. A tour of the unit storage room revealed a cluttered room with multiple bags of patient belongings stored on the floor and on shelves.

(i) One (1) bag in the back of the storage room was identified as Patient #13's belongings.

(ii) The plastic bag contained clothing. There were no personal care items in the plastic bag.

(iii) There was no plastic storage container or wooden dresser in the storage room provided for Patient #13's use.

(iv) Upon interview, Staff #13, Staff #42, and Staff #70 were unable to confirm whether Patient #13 received personal care items, specifically a toothbrush and toothpaste, and where these items were stored.

4. The facility failed to ensure the patient's right to privacy.

5. The facility failed to provide all patients with a wardrobe, bedside table, and plastic storage container to secure their belongings, as specified in the above referenced policy.

6. The facility failed to maintain the comfort and dignity of all patients by ensuring all patients received and had access to personal care items.

Based on staff interview, it was determined the facility failed to maintain a safe environment.

Findings include:

1. Upon interview with Staff #5 on 6/20/17, he/she stated the following:

a. The Division of Mental Health and Addiction Services (DMHAS) "is notified daily of the hospital census."

b. The hospital is "not allowed" to reject patient admissions that are received from DMHAS.

c. The "overflow patients are now being placed in the day rooms."

d. There is no written policy and procedure addressing the referral of patients with a full census.

Based on document review and staff interview, it was determined that the facility failed to ensure that adequate Medical Staff is provided.

Findings include:

The facility failed to ensure that there was adequate Medical Staff pertaining to patient care.
(Cross refer to Tag A 347)

Based on document review and staff interviews, it was determined that the governing body failed to ensure there is adequate medical staff for the quality of the medical care provided to the patients.

Findings include:

1. Upon interview, Staff #5 stated that there have been "changes in staffing [psychiatrist] in the past 6 to 7 years. Lost [sic] positions slotted/allocated by the Department of Mental Health and Addiction Services (DMHAS)."

a. Staff #5 stated, "There is a decrease in staffing [psychiatric] and coverage. Can't [sic] attract psychiatrists. Can't [sic] compete with surrounding facilities, salary and benefits."

b. Staff #5 also stated that in addition to the vacant positions, there are several psychiatrists out on a leave of absence, that also require coverage.

2. Upon review of the current psychiatric vacancies, the "Greystone Park Psychiatric Hospital Department Of Psychiatry W/Position Numbers" organizational chart indicated the following:

a. There are currently nineteen (19) full time psychiatrists listed on the day shift, Monday through Friday, for coverage at the facility.

(i) There are currently two (2) vacant psychiatry positions on the weekday shift.

(ii) There is also one (1) psychiatrist on the weekday shift, out on a Leave of Absence (LOA), requiring coverage.

(iii) Staff #5, a psychiatrist, is currently in the role of the "Acting Director of Psychiatry," and his/her shifts also require coverage.

b. It was confirmed with Staff #5 that the day shift, Monday through Friday, is currently under staffed by four (4) psychiatrists, due to vacancies, a LOA, and coverage for Staff #5.

c. There are currently three (3) full time psychiatrists scheduled on the evening and night shifts, seven nights a week, for coverage at the facility. The evening shift is staffed with two (2) psychiatrists, and the night shift is staffed with one (1) psychiatrist.

(i) There is currently one (1) vacant psychiatrist position on the evening and night shifts.

(ii) There is one (1) psychiatrist on the evening and night shifts out on a Leave of Absence (LOA), requiring coverage.

d. It was confirmed with Staff #5 that the evening and night shifts are currently under staffed by two (2) psychiatrists, due to a vacancy and a LOA.

3. Staff #5 stated, "The psychiatrists are covering additional units and patients on the day shift," Monday through Friday, "due to these shortages." He/She stated they are also "mandated to cover various shifts. This complicates the schedule the next day, [sic] safety concerns when going in for an emergency."

4. Staff #5 stated that the inadequate medical staffing has been discussed with Staff #73, the State Medical Director.

5. Upon interview, Staff #11 stated the following:

(i) The "guideline" for psychiatrist coverage on the units for the weekday schedule, is one (1) psychiatrist to twenty five (25) patients for sixteen (16) of the units; and one (1) psychiatrist to seventeen (17) patients for the other two (2) admission units, "give or take," and an additional three (3) psychiatrists for the cottages.

(ii) However, he/ she stated, the "practice" that has been used in the facility for psychiatric coverage is as follows:

One (1) psychiatrist per unit, for sixteen (16) units

Three (3) psychiatrists for the two (2) admission units

Three (3) psychiatrists for the seven (7) cottages.

The total full time psychiatrists required for this "practice" on the weekday hours, requires twenty two (22) psychiatrists.

6. The above was confirmed with Staff #11.

7. The facility failed to maintain adequate medical staffing.

8. Review of the "Department of Psychiatry Meeting" minutes indicated the following:

a. The minutes from the February 1, 2017 meeting indicated, "... Clinical Issues: a. ... The Medical Staff will meet with --- [Staff #77], to further discuss additional options regarding hiring and incentives. ... "

b. The minutes from the February 15, 2017 meeting indicated, " ... Clinical Issues: a. ... --- [Physician Staff #5] is working on getting the Board of Trustees additional information they requested to compose their letter to the commissioner. The Medical Staff met with --- [Staff #77], to discuss additional options regarding hiring and incentives. There were no new developments in regards to this subject. ..."

c. The minutes from the April 19, 2017 meeting indicated, " ... Clinical Issues: ... j. The MOD [medical officer on duty] schedule has eleven vacant midnight shifts. Psychiatrists will be mandated to take a night shift to cover, based on reverse seniority. ... l. Beginning May 1, 2017, some B2 and G2 patient will divided amongst psychiatrists. [Physician Staff #5], and [physician name] will keep their most difficult patients. ..."

d. The minutes from the June 7, 2017 meeting, indicated, "... Clinical Issues: a. [physician name] , completed her last day at GPPH [Greystone Park Psychiatric Hospital] as full time Clinical Psychiatrist and Acting Medical Director on June 2, 2017. b. Due to psychiatry shortage, the hospital is still experiencing daily unit coverage issues for B2, G2, Admissions and the Cottages. ... d. The hospital is in crisis regarding psychiatry shortage. e. ---[Physician Staff #5] visited with an APA [American Psychiatric Association] representative and asked the representative what current initiatives the APA [American Psychiatric Association] is working on for psychiatrist. The response was that there will be an increase in salary to $270.00 effective July 1st [sic]. f. There was a meeting between --- [Staff #11] and --- [Staff #5], agenda items included Issues:
a. Psychiatry may lose fulltime line
b. Psychiatry may lose 1 MOD [medical officers on duty] Line (evening shift)
c. Further discussions on the 25:1 ratio of patients to doctors is being reviewed
d. Psychiatry Department coverage
e. Medical Director coverage..."

9. Review of the "Minutes of the Medical Staff Organization," dated January 19, 2017, indicated the following:

a. " ... V1. Staffing Crisis ... the staffing crisis and safety of work conditions were discussed. Adjustment of salaries was discussed. All present agreed that we should also submit a letter and leadership agreed "it wouldn't hurt." It was agreed to have a letter prepared for consideration within one week. ...VIII. Recruitment Physician recruitment and retention were discussed by --- [Staff #5] and --- [Staff #9]. There was a [sic] unanimous consensus that efforts are hindered by the present salaries. ...XII. Concerns The following concerns were noted:
--- [physician name] over the emergency medical response
--- [physician name] over safety conditions
--- [physician name] over no breaks for the MOD's [medical officers on duty]
--- [physician name] over the arrival time of admissions
--- [Physician Staff #9], and --- [Physician Staff #5], responded to the concerns and remained open to additional ideas."

10. Review of the "Managing Physicians Meeting Minutes," indicated the following:

a. The minutes from the November 3, 2016 meeting indicated, " ... Agenda A. Psychiatrist Recruitment Update Discussion: --- [Staff #11], reviewed the various Division's efforts to recruit and hire Psychiatrists. However, State Hospitals have significant vacancies despite advertising and recruitment efforts. ... "

b. The minutes from the December 1, 2016 meeting indicated, " ... Action Taken: Managing Physicians will be advised of the recruitment efforts on an ongoing basis. ... "

c. The minutes from the January 5, 2017 meeting indicated, " ... Update on Psychiatry Recruitment Discussion: ... --- [Staff #11], reviewed the recent steps to increase Psychiatrist recruitment and hiring. However, several new Managing Physicians expressed frustration about the lack of salary changes or hiring incentives that they believe are necessary to actually bring in staff. Several reported that they will be losing Psychiatric staff to retirement in coming months as there are no retention rewards or incentives. In particular, --- [other facility] and --- [other facility] are still critically short staffed, and the GPPH [Greystone Park Psychiatric Hospital] situation is worsening. --- [physician name] made a recommendation to divert admissions to hospitals with the shortages.
Action Taken: The issues will be taken back to the Division, and --- [Staff #77], will be asked to come to a future meeting to discuss the concerns directly."

d. The minutes from the March 2, 2017 meeting indicated, " ... D. Psychiatrist Recruitment Discussion: ... Managing Physicians expressed the view that the staff vacancies cannot be addressed unless the salary is made more competitive. ..."

e. The minutes from the April 6, 2017 meeting indicated, " ... G. Psychiatry Staffing Discussion: Managing Physicians discussed upcoming changes in staffing. Several GPPH [Greystone Park Psychiatric Hospital] psychiatrists will be retiring or going on leave, and the facility will have several more vacancies despite some psychiatrist staff in the pipeline. ...Action Taken: The issues with be taken up with --- [Staff #11]. ... "

f. The minutes from the May 4, 2017 meeting indicated, " ... B. Psychiatrist Recruitment-Hiring Psychiatric APN's [Advance Practice Nurse] Discussion: ... GPPH [Greystone Park Psychiatric Hospital] are [sic] having difficulty filling MOD [medical officer on duty] shifts because they have vacant MOD [medical officer on duty] positions and staff are not willing to work at the current MOD [medical officer on duty] rate. Hiring psychiatric APN's is another option... GPPH has four staff who qualify as APN's, but they are not prescribing or functioning in these conditions. ...
Action Taken: The Department is considering an increase in the psychiatrist's hourly MOD [medical officer on duty] rate, but salary or other compensation issues are not being considered at present."

11. Review of the February 1, 2017 "Update Medical Staff By-laws," indicated the following:

a. There was an update of the By-laws for the Medical Staff, "Expedited Credentialing and Privileging" under "IV. Procedure ...F. During periods of staffing crisis, if the expedited credentialing does not resolve the staffing crisis, the Governing Body may resort to using an outside agency and/or locum tenens physicians to temporarily resolve the crisis and maintain the standard of clinical care."

12. The Governing Body failed to ensure that the medical staff had adequate coverage for the quality of the medical care provided to the patients.

Based on review of the facility staffing plan, review of facility documents and staff interviews, it was determined that the facility failed to provide an organized nursing service that includes an adequate number of licensed personnel to provide nursing care to all patients as needed.

Findings include:

1. The facility failed to ensure staffing for registered nurses, licensed practical nurses, and assistive personnel was in accordance with the facility staffing plan. (Cross refer to Tag A 392)

Based on review of the facility staffing plan, review of facility documents, and staff interviews, it was determined that the facility failed to provide an adequate number of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed.

Findings include:

Reference: Facility policy titled, "Nursing Services Directive" states, "I. Statement: Greystone Park will provide Nursing Services staff adequate in number and educational preparation to meet the Nursing care needs of our patients. Staffing levels will be planned, predictable, flexible, determined by patient care needs, and will be regularly and systematically reviewed and, when necessary, adjusted. ... ."

1. On 6/23/17, the staffing plan, nurse staffing sheets, and patient assignment sheets were reviewed for 6/10/17 and 6/11/17 for inpatient units A3, D2, D3, E2, F2, F3, and G2.

2. Upon interview, Staff #56 stated that LPNs are used in the facility as an additional nurse. If the staffing plan calls for two (2) RNs, the facility allowed one (1) RN and one (1) LPN to staff the unit.

3. The following staffing shortages were evident:

a. On inpatient unit A3, the unit was short staffed on the following dates and times:

(i) On 6/10/17, for the night shift, 11 PM - 7 AM, one (1) RN and three (3) Healthcare Services Technicians (HSTs) staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) RN and one (1) HST.

(ii) On 6/11/17, for the day shift, 7 AM - 3 PM, one (1) RN, one (1) LPN, and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST.

b. On inpatient unit D2, the unit was short staffed on the following dates and times:

(i) On 6/10/17, for the day shift, 7 AM - 3 PM, one (1) RN, one (1) LPN, and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST.

(ii) On 6/10/17, for the evening shift, 3 PM - 11 PM, one (1) RN, one (1) LPN, and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST.

(iii) On 6/10/17, for the night shift, 11 PM - 7 AM, one (1) RN and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) RN and one (1) HST.

(iv) On 6/11/17, for the day shift, 7 AM - 3 PM, one (1) RN, one (1) LPN, and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST.

c. On inpatient unit D3, the unit was short staffed on the following dates and times:

(i) On 6/10/17, for the evening shift, 3 PM - 11 PM, two (2) RNs and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST.

(ii) On 6/10/17, for the night shift, 11 PM - 7 AM, one (1) RN, one (1) LPN, and two (2) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed two (2) HSTs.

(iii) On 6/11/17, for the day shift, 7 AM - 3 PM, two (2) RNs and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST.

d. On inpatient unit E2, the unit was short staffed on the following dates and times:

(i) On 6/10/17, for the night shift, 11 PM - 7 AM, one (1) RN and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) RN and one (1) HST.

(ii) On 6/11/17, for the day shift, 7 AM - 12 PM, two (2) RNs and three (3) HSTs staffed the unit. From 12 PM - 3 PM, the number of HSTs staffing the unit decreased from three (3) to two (2). The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST from 7 AM - 12 PM, and two (2) HSTs from 12 PM - 3 PM.

e. On inpatient unit F2, the unit was short staffed on the following dates and times:

(i) On 6/10/17, for the evening shift, 3 PM - 11 PM, one (1) RN, one (1) LPN, and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST.

(ii) On 6/10/17, for the night shift, 11 PM - 7 AM, one (1) RN and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) RN and one (1) HST.

(iii) On 6/11/17, for the day shift, 7 AM - 3 PM, one (1) RN, one (1) LPN, and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST.

f. On inpatient unit F3, the unit was short staffed on the following dates and times:

(i) On 6/10/17, for the night shift, 11 PM - 7 AM, two (2) RNs and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST.

g. On inpatient unit G2, the unit was short staffed on the following dates and times:

(i) On 6/10/17, for the night shift, 11 PM - 7 AM, two (2) RNs and two (2) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed two (2) HSTs.

(ii) On 6/11/17, for the day shift, 7 AM - 3 PM, two (2) RNs and three (3) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) HST.

i. On inpatient unit G3, the unit was short staffed on the following dates and times:

(i) On 6/9/17, for the night shift, 11 PM - 7 AM, one (1) RN and four (4) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) RN.

(ii) On 6/11/17, for the night shift, 11 PM - 7 AM, one (1) RN and two (2) HSTs staffed the unit. The staffing plan called for two (2) RNs and four (4) HSTs. The unit was short staffed one (1) RN and two (2) HSTs.

4. The staffing shortages were confirmed with Staff #56.

5. During a tour of inpatient unit A1 on 6/22/17, Staff #32 and Staff #35 were interviewed.

a. Staff #32 stated the following:

(i) "We are always short staffed usually at night, and on the weekends sometimes."

(ii) "We always complain to the union. We fax them forms but nothing happens."

(iii) Staff #32 was asked if he/she felt unsafe due to staffing shortages. He/she stated, "Yes."

b. Staff #35 stated "we are short staffed mostly on the weekends and on the night shift."

6. During a tour of inpatient unit B1 on 6/22/17, Staff #38 and Staff #39 were interviewed.

a. Staff #38 stated that "staffing for HSTs is a problem on weekends and nights. Weekends are a big problem."

b. Staff #39 stated that "staffing is a problem on all shifts, but especially weekends and nights."

(i) He/she stated, "We can't go home sometimes because of staffing. They tell us we have to stay and wait for them to find somebody to come in."

(ii) Staff #39 was asked how long after their shift ends does a staff member have to wait for another nurse to relieve them. He/she stated, "Sometimes we stay for more than an hour."

7. During a tour of inpatient unit D2 on 6/22/17, Staff #68 and Staff #70 were interviewed.

a. Staff #68 stated, "We don't have enough staff. I'm just gonna say it. They work us. I don't know how they expect us to do this."

(i) Staff #68 was asked if he/she feels conditions on the unit are unsafe due to staffing shortages. He/she stated, "Yes, it is very unsafe. Like right now, we have HSTs off the unit with patients. And they still want us to try to help patients get to activities."

(ii) Staff #68 was asked at what time period does he/she feel staffing shortages occur the most. He/she stated, "The weekends especially."

b. Staff #70 stated that "all shifts are short staffed."

(i) He/she stated that "administrators are aware of staffing" shortages, but "nothing happens."

8. The facility failed to provide an adequate number of nurses and assistive personnel to provide nursing care to all patients as needed.

Based on observations, staff interview, document review and review of medical records, it was determined that the governing authority failed to ensure the daily management of Food and Dietetic Services. Also, the governing authority failed to ensure that the nutritional needs of the patients are met in accordance with practitioners' orders.

Findings include:

1. The Director of Food Service failed to ensure that the Food Management Staff maintained the daily operation of service ware and food service equipment to be cleaned and sanitized in accordance with the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24), facility policy, and manufacture's instructions for use. (Cross refer to Tag A 620)

2. Based on observation, staff interview and document review, it was determined that the Director of Food Service failed to ensure that the Food Management Staff maintained the daily operation of Food Services to comply with the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24) and facility policy. (Cross refer to Tag A 620)

3. The Director of Food Service failed to ensure that the Supervising Clinical Nutritionist effectively evaluated, and provided consultation regarding the quality of the feeding program to the Food Service Administrator in accordance with his/her job description. (Cross refer to Tag A 620)

4. The Supervising Clinical Nutritionist failed to ensure that the dietitian staff evaluated and reported patient tolerance to therapeutic nutrition supplements in accordance with his/her job description. (Cross refer to Tag A 621)

A. Based on observation, staff interview and document review, it was determined that the Director of Food Service failed to ensure that the Food Management staff maintained the daily operation of serviceware and foodservice equipment to be cleaned and sanitized in accordance with the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24), facility policy, and manufacture's instructions for use.

Findings include:

Reference #1: Prevention and Control of Infection policy states: "I. Purpose: 1. To provide a workable guide for Food Service Department Staff for the care and preparation of wholesome, nutritious meals, safe for consumption by patients and staff. 2. To prevent infection through food as a multiplier using good food handling practices. 3. To prevent infection through food as a vehicle by controlling extrinsic environmental factors. 4. To comply with Chapter 24 of the New Jersey Administrative Code governing Food Establishments. ...4. Proper Inspection, Handling, Preparation & Serving of Food, ...b. Foods while being stored, prepared and served must be protected from dust, flies and other contamination. ......Responsibilities For The Care of Equipment & Material, ...A. Sanitization, 3. Manual Sanitizing a. Remove all food debris, Wash. c. Rinse, d. Immerse in sanitizing solution per manufacturer's instructions. e. Allow to air dry. f. The approved sanitizer may be an iodophor, chlorine or a quaternary compound. ..."

Reference #2: N.J.A.C. 8:24-4.7 (a) states, "Equipment food-contact surfaces and utensils shall be sanitized." 8:24-4.7 (b) states, "Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning."

Reference #3: The Prevention and Control of Infection ... Manual Washing & Sanitizing of Equipment & Utensils policy states, "A sink with three compartments is used to manually sanitize equipment and utensils ... After washing, equipment and utensils shall be rinsed free of detergent solution and shall be sanitized and allowed to air dry ... To wash: Pour measured amount of low suds detergent, per manufacturers' suggestion, into first compartment, one (1) ounce of Iodophor to five gallons of water ... To Rinse: After washing, place equipment and utensils in second compartment for rinsing to remove detergent ... To Sanitize: prepare third compartment with a sanitizing solution of Water (75 -120 degrees F) and a measured amount of Iodophor (3 ounces to five gallons) of water ... Immerse equipment and utensils into sanitizing solution for at least one minute ... Remove from solution and allow to air dry on drain board. After equipment and utensils are dry, take to storage area for storing."

Reference #4: Facility policy, Manual Washing and Sanitizing of Equipment and Utensil states, "To sanitize: prepare bus bucket with a sanitizing solution of one gallon of water (75 degree Fahrenheit - 120 degree Fahrenheit, and a measured amount of Sani-512 or bleach (0.375 ounces of Sani-512/gallon of water OR 11.25cc bleach/gallon of water)...i. Test solution to ensure 300 ppm, ii. Immerse equipment and utensils into sanitizing solutions for at least one minute. iii. Remove from solution and allow to air dry on tray rack."

Reference #5: Premier Plus SI Manual Liquid Pot/Pan and Dish Detergent Instructions For Use states, "Always put detergent in sink first and permit water to flow on it. Pots and Pans - Use 1 oz. of detergent to 5 gallons of water. Soak pots and pans for a few minutes depending on the degree of encrustation. Wipe clean, rinse, sanitize and air dry."

1. During an interview on 6/22/17 at 10:50 AM, Staff #23 stated that he/she has responsibility of the day-to-day operation of the Food Service Program of the facility.

a. On 6/23/17, the Food Service Administrator's personnel file contained a job specification titled, "Program Specialist 3 Social/Human Services." The Food Service Administrator's job expectations are not position specific and do not clearly delineate the responsibility that he/she has over Food Services. Program Specialist 3 Social/Human Services job specifications states, "...Examples of Work, Supervises or performs the more complex and sensitive administrative, analytical and professional work to promote the planning, operation, implementation, monitoring and/or evaluation of social/human service program areas designed to improve the medical, social or other circumstances of the client population served. ...Conducts onsite evaluations or audits to monitor compliance with federal and State regulations."

2. On 6/21/17 at 11:30 AM, in the presence of Staff #3, Staff #19 stated that the Pot and Pan Washer has been "out of order for years" and has requested it be removed from the Main Kitchen to allow for more storage. He/ She was unable to verbalize the number of years it has been "out of order." Staff #19 also confirmed pots, pans and serving utensils are washed in a single three (3) compartment sink.

a. During interview, Staff #25 was unable to provide the surveyors with the appropriate ratio of sanitizer to water. He/She stated, "I'm not sure" of the ratio.

b. Staff #25 was unaware of how much water the sink compartment containing the sanitizing solution holds. He/She stated, "I'm not sure, maybe 15 or 20 gallons."

c. Staff #25 was not able to verbalize how to sanitize pots and pans in accordance with References #1, #2, #3, #4.

3. On 6/21/17 during an interview with Staff #22 in Serving Room F2, he/she stated "2 squirts and a cap full of bleach" is what's used to disinfect trays.

a. Staff #22 also stated "bleach is not used on serving utensils." Staff #22 did not identify a sanitizing agent that would be used on the utensils.

b. Staff #22 stated he/she "did not know how much water was needed in the sink" to reach the proper ratio of water to cleaner.

c. Staff #22 was unaware of how long trays and serving utensils should soak prior to cleaning and rinsing. He/She stated, "I don't know how long they should soak."

d. Staff #22's description of the bleach sanitizing solution used to disinfect trays is not in accordance with Reference #4.

4. On 6/22/17 at 1:30 PM at the 3 compartment sink, the sanitizing solution was not maintained in accordance with facility policy and References #1, #2, #3 and #4. Upon request, Staff #76 measured the concentration of the sanitizing solution at the three compartment sink with a sanitizer test strip. The reading measured below 300 ppm. Staff #76 prepared a new batch of sanitizing solution with 4 ounces of Sani-512 and not 0.375 ounces in accordance with Reference #3. The reading measured above 300 ppm on the sanitizer test strip and Staff #76 was told by Staff #23 to add additional water to dilute the solution so that it would be 300 ppm.

5. While sanitizing kitchen equipment at the 3 compartment sink, Staff #76 placed a pan in the sanitizing solution and immersed the pan into the sanitizing solution. Staff #76 then immediately removed it rather than allow the pan to immerse in the sanitizing solution for one minute in accordance with References #1, #2, #3, and #4. Staff #23 instructed Staff #76 to sanitize the pots and pans for 30 seconds, which is not in accordance with References #1, #2, #3, and #4. Staff #76 then stacked a pan on top of similar pans rather than putting it on a rack to let it air dry in accordance with Reference #3. On the adjacent racks, there were wet pans that were stacked one on top of another (ex: 8 wet pans stacked, 11 wet pans stacked) which is not in accordance with References #3.

6. Staff #75 prepared a detergent solution to clean the Microban Food Slicer that had a build-up of black/brown debris underneath the meat holder. While preparing the detergent solution, Staff #75 filled a one compartment sink with an undetermined amount of hot water. Staff #75 then took the cover off a container of Premier Plus SI Manual Liquid Pot/Pan and Dish Detergent and poured an undetermined amount of detergent concentrate from the container into the water, which is not in accordance with Reference #5. Staff #75 then proceeded to clean the slicing machine with the solution, which is not in accordance with Reference #5.

B. Based on observation, staff interview and document review, it was determined that the Director of Food Service failed to ensure that the Food Management staff maintained the daily operation of Food Services to comply with the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24) and facility policy.

Findings include:

Reference #1: Prevention and Control of Infection policy states: I. Purpose: "1. To provide a workable guide for Food Service Department Staff for the care and preparation of wholesome, nutritious meals, safe for consumption by patients and staff. 2. To prevent infection through food as a multiplier using good food handling practices. 3. To prevent infection through food as a vehicle by controlling extrinsic environmental factors. 4. To comply with Chapter 24 of the New Jersey Administrative Code governing Food Establishments. ...4. Proper Inspection, Handling, Preparation & Serving of Food, ...b. Foods while being stored, prepared and served must be protected from dust, flies and other contamination. ...Monitoring And Logging of Refrigerator/Freezer Temperature Controls, ...4. Temperatures of potentially hazardous foods must be maintained at 33-41 degree F for refrigerated or 0 degree F to -10 degree F for hard frozen food. 5. Refrigerators shall be maintained according to the following: d. Frozen foods: -10 - 0 degree F, ..."

Reference #2: N.J.A.C. 8:24-4.11(e)4 states, "Items that are kept in closed packages may be stored less than six inches above the floor on dollies, pallets, racks, and skids that are designed as specified under NJAC 8:24:4.2(s)."

Reference #3 : N.J.A.C. 8:24-3.5(a) states, "Stored frozen foods shall be maintained frozen."

Reference #4: N.J.A.C. 8:24-3.5(f) states, "Except during preparation, cooking or cooling, or when time is used as the public health control as specified under (g) below, potentially hazardous food shall be maintained: 1. At 135 degrees F or above, except that roasts cooked to safe cooking temperatures or reheated as specified under NJAC 8:24-3.4(g)5 may be held at a temperature of 130 degrees F; or 2. At refrigeration temperatures."

Reference #5: N.J.A.C. 8:24-5.5(k) states, "Storage areas, enclosures, and receptacles for refuse, recyclables, and returnables shall be maintained in good repair."

Reference #6: N.J.A.C. 8:24-6.2(k) states, "The presence of insects, rodents and other pests shall be controlled to minimize their presence on the premises by ... eliminating harborage conditions."

Reference #7: N.J.A.C. 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #8: N.J.A.C. 8:24-3.3(z) states, "Food shall be protected from contamination that may result from a factor source or source not specified above."

Reference #9: Meal Observation Report, Food Item, Temperature degree F, Temp danger Zone 41 degrees - 135 degrees.

Reference #10: N.J.A.C. 8:24-4.5(a) states, "Equipment and equipment components shall be maintained in a state of repair and condition that meets the requirements specified under NJAC 8:24-4.1 and 4.2."

Reference #11: N.J.A.C. 8:24-4.6(c) states, "Non food-contact surfaces of equipment shall be free of an accumulation of dust, dirt, food residue, and other debris."

Reference #12: N.J.A.C. 8:24-6.5(b) states,"The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #13: N.J.A.C. 8:24-4.1(j) states, "Non food contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion resistant, nonabsorbent, and smooth material."

Reference #14: Facility policy, "Dress Code" states, "...4. Disposable Clean aprons and hairnets shall be available for use by food service and other personnel when entering the kitchen or the serveries."

1. On 6/23/17 at noon in the Dementia Patient Care Food Area, the pureed meat measured 121 degree Fahrenheit on the temperature measuring device. The food temperature was not maintained in accordance with Reference #1, #4 and #9.

2. Frozen foods were not stored in accordance with References #1 and #3. The digital temperature measuring device for the Stand-up Freezer in the Dry Ingredient Room that contained 17 cases of Cotton Candy Ice Cream, read 18 degrees Fahrenheit and not 0 degree F to -10 degree F for hard frozen food in accordance with Reference #1. The individual container of Cotton Candy Ice Cream, in the Stand-up Freezer in the Dry Ingredient Room, was 20 degrees Fahrenheit. Staff #23 stated that the ice cream had been moved back to the Dietary Department because the freezer in Park Place was not maintaining the proper temperature.

3. The Main Kitchen floor near Handwashing Sink #6 was not maintained clean in accordance with Reference #12. There was an accumulation of water and dark brown/black residue on the flooring adjacent to the wall behind the ovens/soup kettles.

4. The Main Kitchen Equipment was not maintained in accordance with Reference #10. In the Main Kitchen, the following equipment was not operational: Walk-In Blast Chiller, Pots and Pans Washer, Warewashing machine, a Blodgett Oven, and a AltoSham Combi Therm Oven.

a. On 6/21/17 at 11:30 AM in the presence of Staff #3 and Staff #19, the Main Kitchen warewashing machine and the Pot and Pan washer were out of order. During interview, Staff #19 stated the Pot and Pan Washer has been "out of order for years" and has requested it be removed from the Main Kitchen to allow for more storage.

b. On 6/22/17 at 1:20 PM near the warewashing machine, Staff #23 stated that on 6/15/17, the tank was replaced on the warewashing machine, when a test run was completed the rinse cycle did not meet 180 degrees Fahrenheit and the PSI was 30, too high. When they tried to adjust the valve, it was stuck. Staff #23 stated that the main water supply to the building needs to be shut off to complete the project and the department needs to wait for another hospital project that needs to be completed at the same time. Staff #23 stated that they have been having problems with the warewashing machine off and on for five years.

i. On 6/23/17 at Noon in the Dementia Patient Care Food Area, the patients received their lunch on Styrofoam serviceware rather than on the facility melamine serviceware.

ii. On 6/23/17 at noon, when asked how long patient meals have been served on Styrofoam to patients, Staff #69 stated, "2 1/2 years" since he/she has worked at the facility.

iii. On 6/23/17, when asked how long he/she has served food to patients on Styrofoam serviceware, Staff #74 stated "five years."

iv. On 6/23/17, when asked how long patient meals have been served on Styrofoam to patients, Staff #23 stated off and on for five years. Staff #23 confirmed that the warewashing machine is not operational and has had problems "on and off for five years."

c. Staff #23 provided a Corrective Action Plan Response dated 2/22/17 that evidenced one Alto Sham and one Blodgett oven in the main kitchen were not operational. Under Action Taken, it states that multiple entries for equipment repair have been submitted. On the date of the survey, one Alto Sham and one Blodgett oven in the main kitchen was not operational.

5. The Microban Food Slicer was not maintained in accordance with Reference #11. The Microban Food Slicer that had previously been cleaned had a build-up of black/brown debris underneath the meat holder.

6. Located Near Walk-In Refrigerator #2, the portable food service cart was not maintained in accordance with Reference #13. The top shelf of the food service transport cart had two open areas that exposed the internal material. The open areas of the shelf surface area do not allow for effective cleaning and disinfection of the cart.

7. The ceiling in the Dry Ingredient Room was not maintained in accordance with Reference #5 and #7. In the Dry Ingredient Room, there was a ceiling tile with an approximate 3-4 inch brown colored spot.

8. The door to Refrigerator #1 was not maintained in accordance with Reference #10. The bottom latch was broken off.

9. In Room #F006, items failed to be stored in accordance with Reference #2. A Proctor Silex coffee pot in a cardboard box, was being stored directly on the floor.

10. Frozen items were not stored to prevent damage to the food packaging in accordance with Reference #8. In freezer #1, there were 5 partially crushed boxes (at one edge) of Oriental Blend Vegetables (12, 2 lb containers in each box) that were being stored on a upside down milk crate. Directly above the 5 boxes of Oriental Blend Vegetables, there were 2 boxes of (48 pieces, 4 oz.) Hormel Magic Cup.

11. In the Main Kitchen, approximately 10 small flying insects were observed in the Main Kitchen area. Staff #23 stated that there has been an issue in the Main Kitchen and the facility was changing pest control companies. The Main Kitchen area was not maintained clean and free of flying insects in accordance with Reference #6.

12. On 6/20/17 at 1:20 PM, in the Dietary Department, Staff #19 stated that 14 (fourteen) out of 18 (eighteen)warewashing machines on the patient care units were not operational. The four (4) operational units were on Units A1, D1, D2, and E2. The patient care units warewashing machines were not maintained in accordance with Reference #10.

13. On 6/21/17 at 1:30 PM, at the entry to the Dietary Department on a table, there was a large number of hairnets (greater than 20) that were taken out of the protective covering and exposed to the air. The hairnets were not maintained clean in accordance with Reference #14.

C. Based on observation, staff interview and document review, it was determined that the Director of Food Service failed to ensure that the Supervising Clinical Nutritionist effectively evaluated, and provided consultation regarding the quality of the feeding program to the Food Service Administrator, in accordance with his/her job description.

Findings include:

Reference #1: "Supervising Clinical Nutritionist" job expectation states, "Under the medical director or other professional care program administrator, plans and supervises the institution care program, and the professional Nutritionists assigned to the nutrition care program, in compliance with federal, state, and department program standards; ...Examples of Work: In cooperation with the medical staff or other professional care program administrator, assesses the nutrition needs of groups and of individuals; develops and implements nutrition care plans; evaluates and reports results. ...Ensures that federal, state, and department standards and requirements are met in planning and supervising the nutrition care program. ...Plans, reviews, and provides consultation for the implementation of nutrition care on the system level. ...Acts as consultant to the Food Service Supervisor regarding the food and nutrition needs, and regarding the maintenance of quality standards in the feeding program."

Reference #2: Prevention and Control of Infection policy states: "I. Purpose: 1. To provide a workable guide for Food Service Department Staff for the care and preparation of wholesome, nutritious meals, safe for consumption by patients and staff. 2. To prevent infection through food as a multiplier using good food handling practices. 3. To prevent infection through food as a vehicle by controlling extrinsic environmental factors. 4. To comply with Chapter 24 of the New Jersey Administrative Code governing Food Establishments. ...4. Proper Inspection, Handling, Preparation & Serving of Food, ...b. Foods while being stored, prepared and served must be protected from dust, flies and other contamination. ...Monitoring And Logging of Refrigerator/Freezer Temperature Controls, ...4. Temperatures of potentially hazardous foods must be maintained at 33-41 degree F for refrigerated or 0 degree F to -10 degree F for hard frozen food. 5. Refrigerators shall be maintained according to the following: d. Frozen foods: -10 - 0 degree F, ..."

Reference #3: Meal Observation Report, Food Item, Temperature degree F, Temp danger Zone 41 degrees - 135 degrees.

1. On 6/23/17, Staff #69 provided the 2017 Clinical Nutrition Department, Performance Improvement, Monthly Summary of Meal Observation Reports.

a. For 2017, the hot food temperatures were documented 4 of 5 times below the facility goal of 90% (January 88%, February 89%, March 88%, April 86%). For 2017, the cold food temperatures were documented 4 of 5 times below the facility goal of 90% (January 74%, March 79%, April 86%, May 87%). The quality standards for hot and cold foods were not maintained in accordance with References #1, #2 and #3.

b. The 1/2017 Monthly Summary of Meal Observation Report did not identify what may have contributed to hot and cold temperatures not being achieved.

c. The 4/2017 Monthly Summary of Meal Observation Report did not identify what may have contributed to cold temperatures not being achieved.

d. The 5/2017 Monthly Summary of Meal Observation Report did not identify what may have contributed to cold temperatures not being achieved.

e. On 6/23/17 at Noon in the Dementia Patient Care Food Area, the patients received their lunch on Styrofoam serviceware rather than on the facility melamine serviceware.

f. Staff #69 did not provide an evaluation of why there was a failure to maintain quality standards in accordance with References #1, #2 and #3.















































33557

Based on staff interview, document review and review of 2 of 3 Medical Records (#10, #11), it was determined that the Supervising Clinical Nutritionist failed to ensure that the dietitian staff evaluate and report patient tolerance to therapeutic nutrition supplements in accordance with his/her job description.

Findings include:

Reference #1: "Supervising Clinical Nutritionist" job expectation states, "Under the medical director or other professional care program administrator, plans and supervises the institution care program, and the professional Nutritionists assigned to the nutrition care program, in compliance with federal, state, and department program standards; ...Examples of Work: In cooperation with the medical staff or other professional care program administrator, assesses the nutrition needs of groups and of individuals; develops and implements nutrition care plans; evaluates and reports results. ...Ensures that federal, state, and department standards and requirements are met in planning and supervising the nutrition care program. ...Plans, reviews, and provides consultation for the implementation of nutrition care on the system level. ... "

Reference #2: Facility policy, "Nutrition Evaluation & Assessment" states, "...Qualitative Criteria: ...7. For those on nutrition supplements, indicate type of supplement, method of delivery and amount."

1. On 6/23/17 at 1:00 PM in the presence of Staff #69, 2 of 3 Medical Records (#10, #11) showed no evidence that the dietitian evaluated and reported results for Patient #10's and Patient #11's tolerance to therapeutic nutrition supplements.

a. Medical Record #10 contained a prescriber's order for "Boost 240 cc QID" (four times a day) dated 11/29/15. The subsequent nutrition progress notes dated 2/10/16, 5/19/16 and 8/17/16, showed no evidence of an evaluation of whether Patient #10 was consuming/not consuming Boost 240 cc QID. Staff #69 confirmed the above findings.

b. Medical Record #11 contained a prescriber's order for "Glytrol 240 cc BID" (two times a day) dated 12/1/16 that was recommended by the dietitian in a nutrition progress note dated 11/30/16. There were no subsequent nutrition progress notes that evaluated if Patient #11 was consuming/not consuming Glytrol 240 cc BID. Staff #69 confirmed this finding.

c. Staff #69 stated that the above issue "has been a problem with the dietitian staff."

d. The facility policy titled, "Nutrition Evaluation & Assessment" that states, "...Qualitative Criteria: ...7. For those on nutrition supplements, indicate type of supplement, method of delivery and amount" does not include a reassessment procedure to ensure that the dietitian staff evaluates nutrition supplement consumption.

Based on observations, document review and staff interviews, it was determined that the facility failed to ensure the building is constructed and maintained to ensure the safety of the patients, visitors, and staff.

Findings include:

1. The facility failed to ensure the overall hospital environment is maintained for the safety and well-being of patients. (Cross refer to Tag A 701)

2. The facility failed to ensure proper procedures are in place for proper routine storage of and removal of trash. (Cross refer to Tag A 713)

3. The facility failed to ensure adequate facilities are maintained for the services provided. (Cross refer to Tag A 722)

4. The facility failed to ensure facilities and equipment is maintained to an acceptable level of safety and quality. (Cross refer to Tag A 724)

5. The facility failed to ensure the extent and complexity of facilities are adequate for the services provided. (Cross refer to Tag A 725)

Based on observation, it was determined that the facility failed to ensure the overall hospital environment is maintained for the safety and well-being of patients.

Findings include:

1. On 6/21/17 at 1:00 PM, in the presence of Staff #3 and Staff #22, the floor drain under the sink in the serving area of Unit F2 was missing the protective grate.

a. The floor under the sink in Unit F2 had visible food particles and dirt buildup providing a source of food for insects and vermin.

2. On 6/22/17 at 11:15 AM, in the presence of Staff #3, the following observations were made on Unit A2:

a. In Room #A2207, the wall in the patient toilet room showed evidence of prior water damage, chipping, peeling and discoloration.

b. In Room #A2210, the wall in the patient toilet room showed evidence of prior water damage, chipping, peeling and discoloration.

(i) The faucet had visible corrosion on the aerator preventing water from discharging.

c. In Shower Room #A2215, the faucet of the hand-washing sink had visible corrosion on the aerator preventing water from discharging.

3. On 6/22/17 at 12:15 PM, in the presence of Staff #3, the following observations were made in Unit D2:

a. In Room #D2201, the wall in the patient toilet room showed evidence of prior water damage, chipping, peeling and discoloration.

4. On 6/22/17 at 12:30 PM, in the presence of Staff #3, the patient toilet in the Clinic Waiting Room was not equipped with the following ligature resistant hardware:

a. Faucet/Sink

b. Door handles

c. Hinges

d. Toilet

5. On 6/22/17 at 12:40 PM, in the presence of Staff #3, the light switch in X-Ray Room #I145 was loose from the wall.

6. On 6/22/17 at 12:50 PM, in the presence of Staff #3, the wall in the patient toilet room in Room #E3309 showed evidence of prior water damage, chipping, peeling and discoloration.

7. On 6/22/17 at 12:55 PM, in the presence of Staff #3, the wall in the patient toilet room in Room #E3306 showed evidence of prior water damage, chipping, peeling and discoloration.

8. On 6/22/17 at 1:00 PM, in the presence of Staff #3, the wall in the patient toilet room in Room #E3304 showed evidence of prior water damage, chipping, peeling and discoloration.

a. The molding was missing at the base where the wall meets the floor.

b. The bathroom was covered with round brown colored marks on the floor and wall.

Based on observation and staff interview, it was determined that the facility failed to ensure proper procedures are in place for the routine storage of and removal of trash.

Findings include:

1. On 6/20/17 at 12:20 PM, in the presence of Staff #3, a rolling trash cart with overflowing trash was located in the Staff Corridor of Unit A1.

2. On 6/20/17 at 12:25 PM, in the presence of Staff #3, a rolling trash cart with overflowing trash was located in the Staff Corridor of Unit B1.

3. Upon interview on 6/20/17, Staff #3 confirmed that rooms for trash storage do not exist within the facility.

Based on observation and staff interview, it was determined that the facility failed to ensure adequate facilities are maintained for the services provided.

Findings include:

Reference #1: New Jersey Economic Development Authority, Greystone Park Psychiatric Hospital, Bid Specification, DCA Project #5174-04 dated June 15, 2005. Section 01420, References, Part 1-General, 1.3, "Industry Standards, A. Applicability of Standards: Unless the Contract Documents include more stringent requirements, applicable construction industry standards have the same force and effect as if bound or copied directly into the Contract Documents by reference. ... B. Publication Dates: Comply with standards in effect as of date of the Contract Documents. ... 1.4. AIA, American Institute of architects. ..."

Reference #2: 2001 Guidelines for Design and Construction of Health Care Facilities, 11.2.A4, Patient toilet rooms, (1) Each patient shall have access to a toilet room without having to enter the general corridor area.

Reference #3: 2001 Guidelines for Design and Construction of Health Care Facilities, 11.2.A5, Patient storage locations, (1) Each patient shall have within his or her room a separate wardrobe, locker, or closet suitable for hanging full-length garments and for storing personal effects.

1. On 6/20/17 at 12:00 PM, in the presence of Staff #3, the Study Room in Unit A1 did not meet the design requirements set forth by the American Institute of Architects at the time of plans went out for bid. The approved plans went out to bid on August 15, 2005. The 2001 Guidelines for Design and Construction of Health Care Facilities issued by the American Institute for Architects was the AIA guidelines in effect at the time the plans were issued for bid. Refer to Reference #1, Reference #2, and Reference #3.

a. During interview, Staff #3 confirmed the Study Room is used as a patient sleeping room between the hours of 8:00 PM and 8:00 AM, seven days a week.

(i) During a tour of the Study Room on Unit A1, no patient toilet was located or accessible from within the room.

(ii) Staff #3 confirmed patients assigned to the Study Room must use the common patient toilet in the corridor.

(iii) Staff #3 confirmed portable wardrobes are brought in to the Study Rooms between 8:00 PM and 8:00 AM.

(iv) Staff #3 confirmed patients do not have access to these wardrobes, lockers, or closets during the daytime hours of 8:00 AM and 8:00 PM. Patients must request their personal items from the staff.

Based on observation, document review, and staff interview, it was determined that the facility failed to ensure facilities and equipment are maintained to an acceptable level of safety and quality.

Findings include:

1. A review of the Physical Plant Maintenance Logs on 6/22/17, provided evidence that the Maintenance Department is backlogged with requests for maintenance.

a. The Plumbing department has 1,913 outstanding work order requests. The oldest pending work order is dated 3/23/15.

(i) The facility was unable to provide evidence that this condition was resolved.

b. The Electrical Department has 407 outstanding work order requests. The oldest pending work order is dated 11/2/15.

(i) The facility was unable to provide evidence that this condition was resolved.

c. The Carpentry Department has 365 outstanding work order requests. The oldest pending work order is dated 5/19/15.

(i) The facility was unable to provide evidence that this condition was resolved.

Based on observation, document review, and staff interviews, it was determined that the facility failed to ensure that the extent and complexity of facilities are adequate for the services provided.

Findings include:

Reference: Greystone Park Psychiatric Hospital Statistical Report for 6/19/2017

1. On 6/20/17, a review of the facility's current census for 6/19/17, printed as of 7:40 AM on 6/20/17, provided evidence that the facility has twenty seven (27) patients over their listed bed capacity of 468.

2. Staff #3 confirmed the bed capacity of 468.

a. Staff #3 confirmed that the facility has eighteen (18) isolation rooms. Twelve (12) of the twenty-seven (27) patients were placed in Isolation Rooms which were already occupied by one (1) patient each. The facility currently has no patients requiring isolation precautions. Isolation Rooms were occupied with two (2) patients on Units A1, B1, F1, G1, B2, D2, E2, F2, A3, D3, E3, and F3.

(i) During interview, Staff #3 confirmed that fifteen (15) of the twenty-seven (27) patients were not assigned to a bedroom. These Patients were located on Units A1, B1, E1, F1, A2, D2, E2, F2, A3, E3,

(ii) Staff #3 confirmed that patients not assigned to bedrooms, sleep in the Study Room between the hours of 8:00 PM and 8:00 AM.

b. During interview, Staff #3 confirmed the facility has averaged twelve to fifteen (12-15) patients over their available beds, for the past twelve months.

A. Based on observations, staff interviews, facility document review and review of facility policy and procedure, it was determined that the facility failed to ensure that a sanitary environment to avoid sources and transmission of infections and communicable diseases was provided.

Findings include:

The facility failed to provide a functional and sanitary environment for the provision of patient care services by adhering to professionally acceptable standards of Infection Control. (Cross refererence to Tag 0749).

A. Based on staff interview and document review conducted on 6/22/17 and 6/23/17, it was determined that the facility failed to ensure that staff are screened for tuberculosis (TB) annually according to the CDC (Centers for Disease Control and Prevention) Guidelines.

Findings include:

Reference #1: CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, published in the Morbidity and Mortality Weekly Report at MMWR 2005; 54 (No. RR-17) states, "All HCWs should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. tuberculosis. After baseline testing for infection with M. tuberculosis, HCWs should receive TB screening annually (i.e., symptom screen for all HCWs and testing for infection with M. tuberculosis for HCWs with baseline negative test results). HCWs with a baseline positive or newly positive test result for M. tuberculosis infection or documentation of previous treatment for LTBI or TB disease should receive one chest radiograph result to exclude TB disease. Instead of participating in serial testing, HCWs should receive a symptom screen annually. This screen should be accomplished by educating the HCW about symptoms of TB disease and instructing the HCW to report any such symptoms immediately to the occupational health unit. "

Reference #2: CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 states, "All HCWs who have duties that involve face-to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program."

Reference #3: Facility document, Division of Mental Health and Addiction Services Administrative Bulletin 3:36, states, "A. Tuberculin Skin and TB Tests... 4. In accordance with these standards, hospital employees shall comply with their hospital's policy/procedure for annual or periodic tuberculin skin tests."

1. Upon interview, Staff #9 stated that annual TB Testing is not mandatory for staff.

a. Upon review of Employee Health files, there was no evidence of annual TB testing in 16 of 16 files.

2. Upon interview, Staff #26 stated that CDC is the nationally-recognized guideline the facility has selected for its Infection Control program.

B. Based on observation, staff interview and review of manufacturer's instructions for use (IFUs), it was determined that the facility failed to ensure that it follows the manufacturers' instructions for the germicidal wipes.

Findings include:

Reference: Medline Micro-Kill Germicidal Alcohol Wipe contact time label instructions state, "1 Minute Kill Time."

1. During an interview in the Dental Clinic on 6/22/17, Staff #62 stated that he/she was unsure of the contact time for the germicidal wipe. He/she stated, "about two minutes." The wipes are used for cleaning patient care areas in between patients in the Dental and Podiatry Clinics.

2. During an interview in the Podiatry Clinic on 6/22/17, Staff #68 stated that the contact time for the germicidal wipes was two (2) minutes.

3. The above findings were confirmed by Staff #26.

C. Based on observation and staff interview, it was determined that the facility failed to provide and maintain a functional and sanitary environment for surgical services.

Findings include:

1. During a tour of the Dental and Podiatry Clinics on 6/22/17, the following was observed:

a. Five (5) instruments contained small particles of debris in the hinges.

b. Six (6) instruments contained rust colored particles in the crevices.

c. Six (6) instruments contained a rusty colored film.

d. Seven (7) sterile packages contained reddish brown stains.

2. The above findings were confirmed by Staff #26, Staff #62 and Staff #63.

D. Based on observation and staff interview, it was determined that the facility failed to ensure that sterile items are stored in a manner that maintains sterility.

Findings include:

1. During a tour in the Dental and Podiatry Clinics on 6/22/17, twelve (12) sharp sterile packaged instruments were observed without protective covers on the tips, which could compromise the sterility of the package

2. The above findings were confirmed with Staff #26, Staff #62 and Staff #63.



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E. Based on observation, staff interview and document review, it was determined that the facility failed to ensure the implementation of policies and procedures addressing the proper cleaning and disinfecting of the blood glucose meter.

Findings include:

Reference #1: Center for Disease Control (CDC) website: http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html titled "Infection Prevention during Blood Glucose Monitoring and Insulin Administration" states, "... Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared."

Reference #2: Facility policy titled, "Blood Glucose Monitoring (Finger Stick)" states, " ...Quality Control of ABGT [Ancillary Blood Glucose Testing] System ...C. Monitor Cleaning is performed according to manufacturer instructions ...D. Completed manufacturer guidelines must be maintained in the same location as the blood glucose machine (monitor)."

Reference #3: Facility policy titled, "General Cleaning and Disinfection of the Accu-Chek Inform II Meter and Base" states, " ... III. Procedural Considerations: ... Do Not use any cleaning and disinfecting product other than the Super-Sani Cloth wipes."

Reference #4: Accu-Chek Inform II Blood Glucose Monitoring System Operator's Manual states, " ... Acceptable Cleaning/Disinfecting Agents ... Acceptable active ingredients and products for cleaning and disinfecting are: ... Clorox Germicidal Wipes ... Super Sani-Cloth Germicidal Disposable Wipe ..."

1. On 6/22/17 during a tour of the facility, the following was revealed:

a. On Unit A1 at 11:00 AM, an Accu-Chek Inform II Glucose Meter was found in the medication room.

2. Upon interview, Staff #32 stated that he/she cleans and disinfects the glucose meter with soap and water.

3. On Unit B1 at 11:44 AM, an Accu-Chek Inform II Glucose Meter was found in the treatment room.

4. Upon interview, Staff #40 stated that he/she cleans and disinfects the glucose meter with alcohol wipes.

5. Staff #32 and Staff #40 failed to provide Manufacturer's Instructions for Use for the Accu-Chek Inform II glucose meter.

6. The facility failed to ensure proper cleaning and disinfecting of the Accu-Chek Inform II glucose meter per Manufacturer's Instructions for Use.

F. Based on observation, staff interview and document review, it was determined that the facility failed to ensure an Infection Control program for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel is implemented.

Findings include:

1. On 6/22/17 at 11:26 AM, during a tour of Unit A1, in the laundry room (room #A134), the metal-like rim on the inside of the washing machine, contained a rust colored residue.

2. Staff #33 confirmed that cleaning and disinfecting of the washing machine is the responsibility of whomever is using it at the time.

3. The facility was unable to provide a policy for cleaning and disinfecting the washing machines.

4. On 6/22/17, during a tour of Units A1 and D2, there are shared patient storage areas in Room #A132 and Room #D231, which was cluttered with patient belongings.

a. The shared patient storage area is a locked closet.

5. Staff #13 confirmed that patient access to the shared storage area is arranged with nursing.

a. Not all belongings were labeled with the patient's identification.

b. Patient belongings were stored in bags on the floor.

c. The facility failed to provide a sanitary environment for patient belongings.

6. On 6/23/17, during a tour of the weight room (room #C106A), there was a "Hoist" weight lifting machine. The weight lifting machine contained knee pads, which are used to rest the back of the patients knees on during weight lifting.

a. The knee pads were cracked, missing vinyl-like material and were visibly dirty.

b. The exposed material is an uncleanable surface and does not allow proper cleaning and disinfection for patients.

7. The above finding was confirmed by Staff #35 and Staff #65.


























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Based on 5 of 5 medical records reviewed for discharge planning and staff interview, it was determined that the facility failed to ensure that documentation of the patient's progress towards discharge planning is complete.

Findings include:

Reference: Facility policy and procedure "Psychosocial Assessment" states, "... Social Services Primary Functions: ... 2. Progress note recording The Department of Social Service follows the hospital guidelines regarding documentation of patient's progress, social work interventions to achieve Patient's reintegration into community, patient's motivation and participation in programming, level of family involvement, available financial and other resources and also identified level of housing in community.
For 8 weeks upon admission, weekly social service note is completed and there after monthly progress note is completed by the assigned social worker ..."

1. On 6/21/17, review of Medical Record #1 revealed that the patient was admitted to the facility on 4/27/17 and discharged on 6/2/17. The Social Service Weekly Progress Note forms are documented on the following dates: 5/17/17, and on 6/2/17 a discharge note.

a. There was no evidence of Social Service Weekly Progress Note form for the weeks of 5/7/17 and 5/21/17.

2. On 6/20/17, review of Medical Record #2 indicated that the patient was admitted to the facility on 5/3/2017. The Social Service Weekly Progress Note forms are documented on the following dates: 5/10/17, 5/22/17, 6/6/17 and 6/15/17.

a. There was no evidence of Social Service Weekly Progress Note forms for the weeks of 5/14/17 and 5/28/17.

3. On 6/20/17, review of Medical Record #3 revealed that the patient was admitted the to facility on 4/3/17. The Social Service Weekly Progress Note forms are documented on the following dates: 4/13/17, 4/21/17, 4/26/17, 5/1/17, 6/6/17 and 6/20/17. A late note for 5/10/17 was completed on 6/20/17.

a. There was no evidence of Social Service Weekly Progress Note forms for the weeks of 5/14/17 and 5/21/17.

4. On 6/21/17, review of Medical Record #4 revealed that the patient was admitted to the facility on 5/18/17 and discharged on 6/6/17. The Discharge Plan section of the Social Service Weekly Note form dated 5/26/17 and 6/1/17 stated, "Atentativedischageplanfor [sic] this patient includes returning to his apartment and resuming services with __ [names of programs] ... ." The Progress Note section of the form for 6/1/17 stated how well the patient was doing and how successfully he/she had completed day passes with his/her mother and a discharge scheduled for 6/6/17. On 6/6/17, the patient was provided a discharge packet and was discharged to his/her apartment with follow up appointments.

a. There was no evidence in the medical record that the patient was kept abreast with his/her discharge planning. There was no intervention/confirmation in the medical record that the patient could return to his/her apartment.

b. Staff #79 stated that communication with housing, outpatient resources etc. occurs via e-mail or telephone that are not a part of the medical record.

5. On 6/21/17, review of Medical Record #12 revealed that the patient was admitted to the facility on 5/4/17. The Social Service Weekly Progress Note forms are documented on the following dates: 5/11/17, 5/19/17, 5/25/17, 6/2/17, and on 6/15/17 a discharge note.

a. There was no evidence of Social Service Weekly Progress Note form for the week of 6/4/17.

6. The above was confirmed by Staff #15 and Staff #19.

7. Without the required documentation, it is difficult to follow how discharge planning is reassessed, how the patient/family is involved in its process and what changes will be implemented.