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Based on a review of facility documents, and staff interview (EMP), it was determined the Governing Body failed to ensure that contracted Nutrition Services followed the hospital's adopted policy by failing to ensure event/incident reports were analyzed within their designated time frames for 10 of 14 events reviewed, and by failing to ensure that events were analyzed for one of 14 events reviewed.

Findings:

Review of Board of Trustee Bylaws of Conemaugh Memorial Medical Center, dated August 2019, revealed "... The responsibilities and obligations of the Board shall include ... 3.11 (t) Designating particular indivduals or departments responsible for evaluating and monitoring quality of care in particular patient services, and fostering communication between such individuals or departments through establishing timeframes for discussion of these issues. When the Hospital provides a patient care service for which there is no designated department, establishing an appropriate monitoring and evaluation process ... ."

Facility document entitled Contracted Service Company Patient Related Services Matrix revealed, ... Management Services (Contracted Food Service Management) ... March 3, 2019-March 3, 2022 ... Section II of contract, ... will adhere to Hospital policy, ... policies, procedures, and codes of conduct ... Exhibit A of the Contract and Policy D24 outline objectives concerning overall service and quality ... Patient satisfaction goals, set by Department of 50% according to Press Ganey surveys ... . "

Review of the facility policy entitled Event/Incident Reports, reviewed August 2018, revealed, "... It is the policy of Conemaugh Health System that all events/incidents be reported promptly. Prompt reporting of events/incidents is necessary to protect patients, visitors, employees and students against hazards as well as to provide a complete and accurate record of the event/incident ... Requirements ... 8. When notified of an event/incident in his/her area, management is responsible for immediately taking action to mitigate harm to involves parties, for performing and documenting follow-ups, and for taking appropriate action to prevent a recurrence ... 10. Role definition in SEM will be granted by the Risk Management Department according to the following guidelines ... Complete the event report on line promptly once an event is discovered. Manager: Complete initial investigation of event report, completing the first level follow-up of event including the assignment of severity as soon as possible after receiving email notification. Risk Management: Review events as email notification arrives. Assigns follow-ups as needed ... Department Leader (Director/Manager) ... Responsible for logging into SEM daily and checking for any events that have occurred in department since the last time they reviewed their event queue. When an event is reported, Department Director/Managers are notified via e-mail to log into SEM and view the details. Responsible for completing or assigning follow-up investigations within the designated time frame and for running reports. Responsible for implementing interventions to prevent recurrence as appropriate ... Investigator ... Responsible for completing follow-up investigations on events as assigned and for documenting findings in the SEM system database ... ."

1. Review of approximately 60 events related to Nutrition Services, dated January 1, 2019, through present was conducted. A sample of 14 events from July and August 2019, was selected from the 60 for further review. Ten of 14 events were not analyzed within the designated time frame, and one of 14 events revealed no documentation that the event was analyzed/investigated.

Based on a review of facility documentation and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to identify, analyze and implement preventative actions to resolve Dietary Complaints/Grievances and events/incidents in a timely manner.

Findings Include:

Conemaugh Memorial Medical Center ... PolicyStat ID: 5765751 ... Policy Area: Organization-General ... Patient Safety and Clinical Quality Performance Excellence Program Plan dated January 2019. "... Memorial Medical Center's Board of Trustees is committed to making communities healthier. ... Performance Excellence objectives will be prioritized with line of sight to our strategic plan, national benchmarks, voice of the customer, and will be evaluated every quarter for gaps through our strategic planning process to ensure our mission of making communities healthier. Performance Excellence is the process we use to attain this success in managing our day-to-day business activities and making decisions throughout the organization. We must be able to enhance Clinical Excellence, Service Excellence and Fiscal Soundness while maintaining regulatory compliance... E. Our High Five Guiding Principles. Delivering high quality patient care. Supporting physicians. Creating excellent workplaces for our employees. Taking a leadership role in our communities. Ensuring fiscal responsibility. Strategic Plan Deployment/Journey of excellence and Planning Process. ... In order to maintain organizational focus on our deployment of our strategic plan, monthly operating reviews are held in which the DLP Quality Scorecard is overviewed. Bi-annual reports are given regarding progress on Quality, Patient Safety and Patient Experience to the Quality Oversight Committee at Duke LifePoint. In addition, MMC's dashboards are used as a systematic evaluation of our organizational performance. Our strategic plan deployment permeates through our organization as depicted in the following schematic. ... A. Board of Trustees. The Board is responsible to set the direction for performance excellence in collaboration with the Medical Staff and senior management. Leadership, inclusive of Medical Staff Leadership, actively plans and prioritizes quality and patient safety activities of the organization. This plan and any changes will become effective after review and approval of the Board of Trustees. ... Performance Excellence Committee of the Board. Although ultimate responsibility and authority for organization-wide performance excellence rests with the Board of Trustees, the Board delegates oversight responsibility and authority to the Performance Excellence Committee (PEC) of the Board. This committee is composed of members of the Board of Trustees, Medical Staff Leadership, GME Resident delegates, Administration, and Community Representatives. PEC shall serve as the Board's working committee on all matters pertaining to performance excellence. It will be the vehicle to enhance trust and communication among the board, corporate officer team, Medical Staff, Allied Health Staff, and employees on quality-related matters by providing candid and confidential forum for discussion. The Performance Excellence Committee's key responsibilities are to review and make appropriate recommendations on the following: ... Top-level, corporate commitment to performance excellence; information flow throughout organization; Objective measures to gauge the quality of care and services being provided such that all patients with the same health problems and care needs are receiving the same quality of care; Quality management programs and quality related policies; The degree to which the organization meets patients expectations; ... Accreditation, licensure, and related regulatory survey findings; Patient Safety and Clinical Quality Performance Excellence Program Plan ... Performance Excellence Process ... Performance Excellence Teams (PET) have been selected by each operating unit, and are inclusive of all levels of staff within those operating units. Operating units may be service lines, departments, divisions, administrative units, or simply functionally related services. Overall direction to the PET teams and CPE will be provided by the Performance Excellence Steering Committee, following the same process principles as described for the individual operating units. ... ."


... (Contracted Dietary Agency) Policy and Procedure ... H023 ... Subject: Quality Assessment and Performance Improvement ... Policy Category: Leadership, dated August 2019. "What is a policy? At ..., we guarantee the best service in the business. ... Our policies represent those 'non-negotiable' aspects of our services, the ones that ensure we are able to deliver exceptional quality, regardless of the circumstances. Policy: (acute care settings only) The hospital must develop, implement, and maintain an effective, ongoing hospital-wide, data-driven quality assessment and performance improvement (QAPI) program. The Food and Nutrition Services Department must participate as part of the hospital's QAPI program and have no less than TWO (2) active quality or performance-based measurements in place at any given time. Procedure: Director and Registered Dietician Nutritionist requests to participate in the hospital's quality program Attends quality meetings Works with the QAPI team to assess quality assessment and performance improvement opportunities and executes a minimum of TWO (2) QAPI projects that follows the hospital's approved format for the QAPI program. This is required to meet the CMS Condition of participation for QAPI 482.21. (Acute Care only) ... procedure: The results of the monitors will be tabulated and recorded on the Performance Improvement Indicator form by assigned manager or designee. All areas identified on the monitor that are not within compliance must include an action plan for correction. It must be determined how improvement will be achieved. Results of the monitors are to be discussed weekly or monthly at a manager's meeting, so that corrective action remains a team effort. Results also need to be discussed with all appropriate department staff members. The department reports their results to the community according to the community's schedule. It is importance [sic] to look for trends in the results of the monitors, especially if improvement is not noted. It may be necessary to identify one specific problem area of a monitor to evaluate in more detail. All performance monitors should be kept in a specific binder. It is strongly recommended that a yearly calendar be developed, defining who is responsible for completing each weekly, monthly or quarterly monitor. ... ."

... (Contracted Dietary Agency) Policy and Procedure ... H005 ... Subject: Patient Visitation: Daily Rounds ... Policy Category: Leadership, dated August 2019. "... Visitation Rounds Participants ... Ask the nursing staff to share any feedback regarding Food & Nutrition Services and notify you regarding any patients who may not be appropriate to visit. ... Immediately address issues that are within scope of responsibility and record corrective actions. ... Take prompt action to resolve identified problems. ... All records should be retained by a designated individual and items needing further action should be tracked. Problems identified will be reviewed at regular team meetings with corrective actions/solutions developed as needed. The management team should meet weekly to discuss the problems identified on visits and develop solutions. Director Assures follow-up with all patients voicing significant problems. Assures a service recovery program is in place. (Apologize and fix it now.) ... ."


1. Review of the July 17, 2019, Performance Improvement meeting minutes revealed, "... Patient Relations Quarterly Report. Dietary showed a bump this quarter secondary to the change in vendors. Dietary concerns were as follows-29 issues. 27 of these occurred since the change in vendors on May 28, 2019. Issues such as late trays, poor food quality and lack of availability after hours were very popular. ... ."

2. Review of facility documentation revealed, "Draft ... Ideal Patient Experience (IPE) Steering Team ... Wednesday, July 24, 2019. ... EMP26 reviewed the Patient Relations reports (January - June 2019) including Complaints and Grievances Breakdown. Top box concerns include: issues with staff responsiveness and communication, care issues/treatment plan and Food and Nutrition Services concerns. ... Discussion occurred relative to attendance at the leadership rounds which could assist with identifying patient issues that could be addressed while the patient is still on site. ... ."

3. Review of a sample of 14 events dated July 11, 2019, through August 19, 2019, related to Nutrition Services, revealed ten of 14 events were not analyzed within the designated time frame, and one of 14 events revealed no documentation that the event was ever analyzed/investigated.

4. Interview with EMP22 on August 29, 2019, at 2:30 PM, revealed, "... Yes, I am aware of trends, it's not where we want it to be. ... ."

Based on a review of facility documentation, medical records (MR), interviews with facility staff (EMP), and tours of the Dietary Department and various Nursing Units, it was determined that Conemaugh Memorial Medical Center failed to follow adopted policies to ensure adequate staffing and maintenance of a sanitary environment, and by failing to investigate and resolve Dietary complaints from patients and staff, and failed to document that the patient received their ordered diet for four of five medical records reviewed (MR12-MR15).

Findings include:
... (Contracted Dietary Agency) Policy and Procedure ... D007 ... Subject: Tray Identification/Delivery/Pick-Up ... Policy Category: Patient Services, dated August 2019. "What is a policy? At ..., we guarantee the best service in the business. Accordingly, some elements of our business dictate the need for processes to be completed in exactly the same way, without exception. Our policies represent those 'non-negotiable' aspects of our services, the ones that ensure we are able to deliver exceptional quality, regardless of the circumstances. Policy: It is the policy of the Food and Nutrition Services Department to prepare, pass and retrieve trays of food that are nutritious, appetizing, palatable, and of appropriate temperature. Food and Nutrition Services Department Responsibilities: ... Trays are delivered to each nursing unit by Food and Nutrition Department so that not more than 14 hours lapse between the serving of the dinner and the serving of breakfast. ... Procedure: Tray Preparation Procedures: 1. The Ambassador ensures that all tray line components are in working order prior to each meal service. 2. Assign the appropriate number of team members to work with the hospital census. ... ."

Food and Nutrition Services Management Agreement between DLP Conemaugh Memorial Medical Center, LLC d/b/a Conemaugh Memorial Medical Center (Hospital) and its assigns and ... , LLC and its assigns, and shall be governed in accordance with the laws of the state of Pennsylvania. The agreement dated March 3, 2019, revealed, "... Hospital and ... agree as follows: ... (agency) has based its' staffing recommendation and fee structure on this information. Should there be a change in these statistics, the Hospital and ... agree that this Agreement be amended to reflect the necessary adjustments to staffing and the associated Monthly Contract Price. ... The Hospital will ensure that the Facility (including the kitchen) is in good, clean, sanitary, working condition, as the beginning of ... services. ... A. Hospital will provide and maintain a fully adequate initial inventory and supply of Tablewares and Smallwares for satisfactory operating requirements, in ... reasonable opinion, at the Hospital's expense. ... ."

Review of "Food and Nutrition Policy Stat ID 6636997" revealed, "Introduction The provision of nutritional care and food services plays an important role in both the physical and psychological well being of our patients, employees and members of the community. Unsanitary food service practices can result in the transmission of disease and food-borne illness, adherence to strict sanitation standards and food handling practices is imperative. Prevention of infection in the Food and Nutritional Department requires healthy personnel, a clean environment, properly maintained equipment, uncontaminated supplies and a constant awareness of proper sanitation and hygiene practices. Department Director Responsibility. A. Department Director: The Department Director is responsible for overseeing and enforcing the overall infection control program. ... Prevention and Infection Control Committee serve as a resource and consultant to the department. The Department Director is responsible for, but not limited to: ... 2. Ensuring proper maintenance and cleaning of all equipment within the department. Ensuring that only properly cleaned equipment is utilized in the department. Enforcing cleanliness and safe food-handling practices. 5. Providing safe food service for patients, employees and visitors. ... 7. Preparing food procurement and processing specifications that meet safety and sanitation standards. 8. Developing and enforcing procedures in storage, handling and disposal of garbage ... 12. Assists in surveillance practice. Practice ... C. Education ... 3. Basic orientation for all new Food and Nutrition Department personnel includes personal hygiene, sanitation, hand hygiene, Hazard Analysis and Critical Control Point (HACCP) procedures and use/cleaning of equipment ... G. Food Products and Storage ... H. ... 10. The following items are to be discarded after use, cooked cereal, items in cream sauce, cream soup, mashed potatoes, fish items and food items held at warming temperatures for more than two hours ... I. Procedures: 1. All procedures, i.e., cleaning coffee urns, sanitizing the nozzles on the frozen dessert, soda, juice, coffee and cappuccino machines, use and care of the food slicers, are performed according to guidelines and policies of the department as listed on the various cleaning sheets ... Equipment and Supplies ... E. Dishes and silverware are washed using a dish washing machine. The water is maintained at 140 degrees F or more during washing and at a minimum temperature of 180 degrees F for ten seconds during final rinsing. Automatic chemical sanitation in place in the event of final rinse not working. Pots and pans and baking trays are hand washed and then sanitized using a chemical. F. Dish Washing Machine 1. Is drained and flushed after each meal and cleaned according to cleaning schedule. Cleaning and Sanitizing: A. Utility: 1. Push brooms are used to collecting debris from floor, food is put away or open food is covered prior to sweeping. 2. Floors are wet mopped daily. 3. All sweeping and mopping is done during off-hours of the department except in emergency situations. 4. Storage facilities for raw and cooked food are cleaned and sanitized weekly. B. 1. All work surfaces, utensils, and equipment are cleaned and sanitized after each use, all counters are cleaned daily and as needed. 2. All food carts are sanitized after each meal. 3. Ranges and grill surfaces are cleaned daily ... Environment: ... E. Environmental Cleaning: 1. A clean environment is maintained during procedures. 2. Germicidal cleaning procedures are used at the end of the day. 3. Extensive cleaning is scheduled at regular intervals ... ."

... (Contracted Agency) Policy Number E019, Area and Equipment Cleaning Procedures" dated 8/2019." "Policy: Area and Equipment Cleaning Procedures are written for all areas and equipment in the department. ... The procedures are written to cover all necessary safety precautions. ... Procedure: Refer to cleaning procedures as outlined in policies and equipment manuals. Director trains team members on cleaning procedures and use of reference materials; training is documented. Director/Manager/Supervisor assigns daily cleaning responsibilities in each position workflow."

... (Contracted Agency) Policy Number E026, Area and Equipment Cleaning Frequency/Schedules, Dated 8/2019 revealed Policy: A cleaning frequency is determined for all areas and equipment in the Food and Nutrition Services Department. An Area and Equipment Cleaning Frequency listing serves as the basis for 1) assignment of cleaning duties to staff, and 2) sanitation inspections. All staff is trained and assigned area and equipment cleaning tasks pertinent to their area...Method A: Use of a Cleaning Matrix-Construct a Daily Cleaning Matrix ... List all daily tasks and denote position numbers/names ... Add items to be cleaned weekly on daily form and denote which day they should be cleaned. ... Identify team members who will be utilized for Monthly/Special Cleaning Projects. Identify days of the week on which each team member will complete monthly/special cleaning tasks. ... ."

Review of Board of Trustee Bylaws of Conemaugh Memorial Medical Center, dated August 2019, revealed "... The responsibilities and obligations of the Board shall include ... 3.11 (t) Designating particular individuals or departments responsible for evaluating and monitoring quality of care in particular patient services, and fostering communication between such individuals or departments through establishing timeframes for discussion of these issues. When the Hospital provides a patient care service for which there is no designated department, establishing an appropriate monitoring and evaluation process ... ."

... (Contracted Agency) Policy & Procedure Policy Number: D005 ... Resolution of Patient Complaints ... Review Date: 8/2019 ... "Policy: The Food and Nutritional Services Department will document, resolve and trend patient complaints. Procedure: 1. Process all patient complaints through the Director, Production Manager, or RD. Ambassador 2. Document the complaint on a Patient Complaint Log Form and forward the form to the appropriate manager. Dietician/Manager 4. Investigate and resolve the complaint. Include follow-up with the patient registering the complaint. (A visit to the patient with an explanation is required. A fruit basket, a meal ticket, etc., as appropriate, may be given.) 5. Complete the Patient Complaint Log Form and forward it to the appropriate manger. Director 6. File and trend patient complaints - include on meal rounds report. ... ."

... (Contracted Agency) Policy and Procedure ... D025 ... Subject: Diet Orders ... Policy Category: Patient Services dated August 2019. "What is a policy? At ..., we guarantee the best service in the business. Accordingly, some elements of our business dictate the need for processes to be completed in exactly the same way, without exception. Our policies represent those 'non-negotiable' aspects of our services, the ones that ensure we are able to deliver exceptional quality, regardless of the circumstances. Policy: Diets are ordered in writing by the responsible physician prior to the service of the diet. Procedure: Physician Writes/Enters diet order in medical record/information system. Uses terminology consistent with the diet manual. Rewrites entire diet order when any component of a combination diet is revised. Writes a diet order for 'NPO' when a patient is not allowed oral intake. Writes a new diet order to resume oral intake for patients who have been NPO. Orders 'tube feeding' and specifies the formula, rate, strength and hours over which the tube feeding will be given. Orders amount of free water flush. Orders any oral diet to accompany tube feeding (i.e. clear liquid). ... Contacts Clinical Nutrition Manager for approval of any diet not in the diet manual. Notes any food allergies or sensitivities. Clinical Nutrition Manager/Designee Arranges for a Diet Census Report to be printed at set times. At a minimum, the report includes the patient's name, diet order, the second identifier (usually birthdate), food allergies, and any additional notes needed to provide the diet as the physician intends. Approves any ordered diets that are not in the diet manual. Interprets diet orders that are inconsistent with the diets listed in the diet manual/addendum. Provides a reference for use by Food/Nutrition(see below). Interprets orders for tube feedings and nutritional products not on the formulary. Provides a reference for use by Food/Nutrition (see below). If information about between meal feedings is not included on the Diet Census Report, establishes a system to maintain this information. Food and Nutrition Keeps the most current copy of the Diet Census Report readily available for reference. Updates the information on the report, as changes are made, until the next report prints. Uses the information on the Diet Census Report to manage accuracy of the menu for each patient. Accommodates special diets and altered diet schedules. Interprets incorrect dietary terminology following the attached guide or contacts the Clinical Nutrition Manager/Designee. Interprets orders for products not listed on formulary or contacts the Clinical Nutrition Manager/Designee Contacts nursing to determine Nursing/Food Nutrition split of fluid allotment for fluid restricted diets. Serves meals/snacks after receipt of written diet order via the hospital information system. Verbal orders are not accepted. Nursing (if physicians do not enter orders directly into the hospital information system): Enters diet changes into the hospital information system/patient's electronic medical record for the next meal by the following times: Breakfast 730a Lunch 1230p Dinner 500p If a tray is needed before the next scheduled meal, the nurse pages the Ambassador to place the request. Although the Ambassador has taken the order by phone and can begin to assemble the tray, the meal will not be served until the Ambassador has the written order from the hospital information system. Notifies Food/Nutrition of action to be taken. In the Event of Physician Order for Test/Therapies Request form Food/Nutrition as Appropriate 'Hold' 'First Out' 'Early Trays' 'Hold on Unit' * * 'Hold on Unit', can only be used for patients having fasting blood tests conducted on the Nursing Unit. Other trays must be held in the kitchen, since there are not adequate food-holding facilities on the floor. ... ."

1. Food and Nutrition Services meeting minutes dated June 2, 2019, revealed, "1. Team members still have concerns about not having enough staff 2. Some team members are still feeling unsure of the process."

2. Agenda for Patient Services Meeting dated April 25, 2019, revealed, "... Staffing number positions down in inpatient services (ideas: voluntary overtime), Staffing of the tray line/tray passers/ambassadors, Dish room (help in dish rooms during slow times) ... ."

3. Manager Meeting Agenda meeting minutes dated July 2, 2019, revealed, "... 2. Staffing-covering areas that are short-cross over from retail to help in dishroom ... ."
4. Review of the "Event Summary Report, Nutrition and Dietary Events" dated January 1, 2019, to August 28, 2019, was completed. It was noted that there were approximately 60 events reported related to Nutrition Services.

5. Interview was EMP23 on August 29, 2019, at approximately 10:00 AM revealed, "... Late trays-75-80% related to staffing. ... Weekends are tough. There is overtime. The Ambassadors work 12 hour shifts in order to cover menus, dirty trays, and delivery. ... ."

6. Interview with EMP22 on August 29, 2019, at 2:30 PM, revealed, "... When we switched Dietary vendors 28 employees left. That's a fair amount of turnover out of the gate. ... Yes, I am aware of trends, it's not where we want it to be. ... ."


7. During tour of the Adult Psychiatric Unit on August 12, 2019, at 8:20 AM there was noted to be a food cart in the Dining/Activity Room that was full of dirty trays from the previous day.
EMP4 stated, "The cart with dirty trays in it may sit in the Dining Room until 5PM today before it is picked up."
8. During a tour of Good Samaritan 6 on August 12, 2019, at 8:30 AM there was noted to be a food cart that had several dinner trays from the previous day on it.

EMP5 stated, "The main problem they have is with Dietary picking up the food cart when it is full. This problem has been going on for months. When we call Dietary, they say they are short staffed. The Dietary cart may sit there until lunch time before it is picked up."

9. Interview with EMP8 on August 12, 2019, at 9:20 AM revealed, "There is a problem here. Over the weekend the return cart was full. We had dirty trays sitting all over the Nurses Station. We can call for tray pick up, but no one comes. There have been problems with diets. People that are NPO are getting trays, even people that have been NPO for several days. Patients get the wrong consistency of their food. It will be correct in EPIC, but the tray is not right. We will get a thickened diet tray with a regular carton of milk on it. We have had problems with allergy issues with patients trays. I had a patient with a severe allergy to garlic and onion, and it was well documented. They sent the patient chicken pot pie. When I called to see what was in it, they couldn't tell me. The patients don't like the food. They order out or the family will often bring food in. The delivery times are not consistent. The trays are often late. Often the breakfast trays are late and then they are delivered an early lunch. It is hard with medication administration when meals are not brought at a regular time."

10. Tour of the Dietary Department was conducted on August 5, 2019, at 9:00 AM with EMP1, EMP2 and EMP15. Upon entering the kitchen corridor to the left in a small alcove, were two water fountains that were dull stainless steel in color, with dry basin and small amount of dust, paper and debris on the floor just below. The floors were blackened with dirt in many areas and felt sticky to our shoes. There were several flies noted. Upon entering the dishwashing area, there was noted to be a large shelf with dirty stainless steam tray basins/containers on it. Some food debris was adhered to the containers that appeared to be dried muffin batter, oatmeal/cream of wheat, chocolate pudding, scrambled eggs, and gravy. Immediately to the left of this shelf was a liquid that had dried and was adhered to the floor with visible yellow corn kernels. A large washing sink was then noted along this same wall to have multiple basins. One of the basins contained dirty commercial/industrial sized stock pots and pans stacked and turned upside down, with the sink half full of water. Another bin had smaller, dirty pots and pans soaking in a bluish colored liquid with brown/orange debris floating on the water. EMP2 confirmed that these dishes sat in the sinks overnight. The dishwashing area was noted to be very dirty. Spattered debris and unknown spots were observed on the metal area outside of the dishwasher unit, in addition the plastic/rubber flaps had an orange/pink cast noted around the edges. Unidentifiable debris, food and paper were observed in various areas on the floor and under the dishwasher machine and conveyor area. There were dirty dishes strewn throughout the dishwashing room. There were shelves of dirty food preparation containers such as utensils, pans, bowls, and baking sheets. Some were noted to have chocolate pudding in them and dried gravy. The refrigerators had a sour odor to them when opened. Upon entering the walk-in refrigerator there was a tall cart on wheels that contained multiple vertical shelves. It was covered with one large, white (non-transparent) plastic bag that was open at the bottom. The bag was not labled with an identification tag or date and upon lifting the bag, there were multiple shelves containing moderate sized meat loaf-like food items on each tray which were not individually covered or wrapped. A small hand washing sink was noted to have a brown paper towel lining the basin with the sink 3/4 full of water. There were multiple bottles of patient tube feedings that were laying on a shelf in the dishwashing room that had expired. In the hall outside of the dishwashing room there were several food truck carts lined up. These carts had food debris inside them and on the outside of their doors. The dry storage supply room floor was observed to have debris on it which included smashed packs of crackers, smashed packets of oily substances in multiple areas and paper garbage. There were small flying insects in this room. There were dried liquids on the floor that had not been wiped up. These areas were covered with black dirt. There was an area on the floor where a packet of a greasy butter like substance had been smashed. There were no liners on the bottom shelves of the shelving units.

11. A request was made to review Cleaning Logs for the Dietary Department, however, no documentation was ever received.

Interview EMP2 at approximately 10:15 AM on August 29, 2019, revealed, "... We were seeing complaints from patients as well as from Nursing. Late trays, poor quality of food. ... With the transition to the new vendor, the old company destroyed any previous documentation, including the Cleaning Logs. These were all documents from May 30, 2019, and before that date. New documentation system is being developed. A new master cleaning list is being worked on for the Department as well as one for each position, just not finalized and rolled out yet. ... ."

Telephone interview with EMP2 on September 19, 2019, at approximately 2:00 PM revealed, "The new vendor took over May 28 and we don't have any Cleaning Logs for them."



12. A review of Dietary Complaint/Grievance Log for August 2019, revealed that there were 35 complaints and Grievances on the Log. Twelve of the complaints on the Log were never entered into the facility event reporting system; 21 were entered as in-patient complaints and two were entered as grievances. The issues included but were not limited to: no trays being delivered, trays delivered late, trays not available, wrong diets on trays, and expired dairy products on trays.

13. A review of the "July Dietary Concerns - 29 Issues/27 since change over - Late trays - Poor Food Quality - Lack of Availability after hours ... ." Further breakdown of the dietary concerns were included late/missing trays; meal time insulin issue; staff not taking orders; food quality/cold; incorrect diet; food unavailable.

14. A random sample of 5 of 21 facility event reports were reviewed and failed to reveal documented evidence of an internal investigation by the Dietary Director, Production Manager, or the Registered Dietician (RD) in 4 of the 5 complaints reviewed .

15. An interview was with EMP26 conducted on September 11, 2019, at approximately 1:15 PM, confirmed that the Dietary Department failed to follow their policy by failing to conduct and to document an investigation into patients dietary complaints for 4 of 5 complaints reviewed.

16. Review of MR11-MR15 was completed relative to patient dietary orders written by a physician, and documentation of patient's receiving their ordered diet. During review of the medical record documentation provided by the facility relative to MR11-MR15, it was noted that MR12-MR15, all revealed at least one instance in which there was no documentation that physician dietary orders were executed.

Based on a review of facility documentation, tour of the Dietary Department, and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow adopted policies and procedures by failing to maintain a clean and sanitary environment.


Findings Include:

Annual Evaluation of the Infection Prevention and Control Plan for the Memorial Medical Center 2018, revealed, "... Surveillance of Infection Transmission Associated with Unprotected Exposure to Pathogens 1. Surveillance focuses on processes and practices that are known to reduce the risk for infection. a. Processes and practices include but are not limited to: i. aseptic technique, antibiotic stewardship, cleaning/decontamination, disinfection, hand hygiene, immunization of patients and staff, management of hazards during the design phases of construction/renovation projects and routine facility maintenance, management of the utility systems, ... ."

Review of Administration of Epidemiology, Prevention and Infection Control Program Policy Stat ID 6637012 revealed, "The purpose of this plan is to provide for a program of surveillance, prevention and control of infection ... (4) direct observation of patient care practices and (5) in addition to internal processes, there are links with external organization support systems to reduce the risk of infection from the environment of care including air, food, and water sources. Program Elements: ... B. Written policies and procedures that address surveillance, and prevention and control of infection, both hospital-wide and specific to each department ... L. ... Epidemiology, Prevention and Infection Control Committee Responsibility: The Epidemiology, Prevention and Infection Control (EPIC) Committee is a multidisciplinary committee of the medical staff with primary responsibility of approving the type and scope of surveillance activities, actions to prevent or control infections and all policies and procedures related to the hospital-wide Epidemiology Prevention and Infection Control Program, as well as individual departmental services, policies and procedures ... Membership ... dietary ... Surveillance Strategies: Surveillance Strategies have been identified which are of epidemiological importance to Memorial Hospital Center and the population served. ... ."


1. Tour of the Dietary Department was conducted on August 5, 2019, at 9:00 AM with EMP1, EMP2 and EMP15. Upon entering the kitchen corridor to the left in a small alcove, were two water fountains that were dull stainless steel in color, with dry basin and small amount of dust, paper and debris on the floor just below. The floors were blackened with dirt in many areas and felt sticky to our shoes. There were several flies noted. Upon entering the dishwashing area, there was noted to be a large shelf with dirty stainless steam tray basins/containers on it. Some food debris was adhered to the containers that appeared to be dried muffin batter, oatmeal/cream of wheat, chocolate pudding, scrambled eggs, and gravy. Immediately to the left of this shelf was a liquid that had dried and was adhered to the floor with visible yellow corn kernels. A large washing sink was then noted along this same wall to have multiple basins. One of the basins contained dirty commercial/industrial sized stock pots and pans stacked and turned upside down, with the sink half full of water. Another bin had smaller, dirty pots and pans soaking in a bluish colored liquid with brown/orange debris floating on the water. EMP2 confirmed that these dishes sat in the sinks overnight. The dishwashing area was noted to be very dirty. Spattered debris and unknown spots were observed on the metal area outside of the dishwasher unit, in addition the plastic/rubber flaps had an orange/pink cast noted around the edges. Unidentifiable debris, food and paper were observed in various areas on the floor and under the dishwasher machine and conveyor area. There were dirty dishes strewn throughout the dishwashing room. There were shelves of dirty food preparation containers such as utensils, pans, bowls, and baking sheets. Some were noted to have chocolate pudding in them and dried gravy. The refrigerators had a sour odor to them when opened. Upon entering the walk-in refrigerator there was a tall cart on wheels that contained multiple vertical shelves. It was covered with one large, white (non-transparent) plastic bag that was open at the bottom. The bag was not labled with an identification tag or date and upon lifting the bag, there were multiple shelves containing moderate sized meat loaf-like food items on each tray which were not individually covered or wrapped. A small hand washing sink was noted to have a brown paper towel lining the basin with the sink 3/4 full of water. There were multiple bottles of patient tube feedings that were laying on a shelf in the dishwashing room that had expired. In the hall outside of the dishwashing room there were several food truck carts lined up. These carts had food debris inside them and on the outside of their doors. The dry storage supply room floor was observed to have debris on it which included smashed packs of crackers, smashed packets of oily substances in multiple areas and paper garbage. There were small flying insects in this room. There were dried liquids on the floor that had not been wiped up. These areas were covered with black dirt. There was an area on the floor where a packet of a greasy butter like substance had been smashed. There were no liners on the bottom shelves of the shelving units.


2. Review of the 2019 IP Rounding schedule for Food and Nutrition Services revealed that there was no documented evidence of IP Rounding for the months of April, May, June or July 2019. There was no evidence of IP Rounds since the contracted Dietary vendor was changed.

Interview with EMP15 was conducted at approximately 11:15 AM on August 30, 2019. EMP15 stated, "I round in the Dietary Department every six months. That is what I do for my non-patient areas. ... I did not round in June due to the Department of Agriculture visit. ... I will monitor the area more closely for the next several months due to the conditions found in the kitchen."