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Based on a review of facility documentation and staff interviews (EMP) it was determined the facility failed to trend patient complaint/grievance data per their Complaint and Communication policy to monitor the effectiveness of the safety of dietary services and quality of care.

Findings include:

Review of facility policy "Patient Complaints and Communication" revealed, "...Policy: It is the policy of the Food and Nutrition Services Department to document, resolve, and trend patient complaints ... ."

During interview on August 16, 2018 at approximately 12:30 PM, EMP3 confirmed that all complaints or grievances received in the dietary department regarding issues related to the services provided by the dietary department are acknowledged, investigated, and resolved per facility policy but no trending of these complaints or

Based on review of medical records, medical staff rules and regulations, and staff interviews (EMP), it was determined the facility failed to follow the requirements for dictation of a post procedure report immediately after completion of the procedure for three of six medical records reviewed (MR2, MR3, and MR4).

Findings include:

Review of Medical Staff Rules and Regulations, last revised October 2016, revealed, " ... History and Physicals ... 4. Additional Documentation Requirements: Prior to any procedure, the attending physician or resident physician must record a note, which reflects the indication for the procedure. A post procedure note must be recorded immediately following the procedure. A post procedure report must be dictated or entered in the electronic file immediately after completion of the procedure. The transcribed procedure report must be signed by the physician performing the procedure as soon as possible after the procedure. Only the physician who performed the procedure may authenticate the report by signature. In a group practice, no other member of the group may authenticate the report for the physician who performed the procedure."
1. Review of MR2 revealed a surgical procedure was performed on June 11, 2018. Further review revealed the post procedure report was dictated on June 13, 2018.

2. Review of MR3 revealed a surgical procedure was performed on July 30, 2018. Further review revealed the post procedure report was dictated on August 2, 2018.

3. Review of MR4 revealed a surgical procedure was performed on June 24, 2018. Further review revealed the post procedure report was dictated on June 25, 2018.

4. Interview with EMP1 on August 17, 2018 at approximately 3:00 PM confirmed the above findings.

Based on a tour of the facility's dietary area, review of facility documentation, and staff interview(s) (EMP) it was determined the facility failed to maintain a sanitary and orderly environment in their dietary area.
Findings include:

A review of facility policy "Sanitation Program" reviewed March 1, 2018, revealed " ...Purpose: To maintain a clean, safe, and effective environment of care and to prevent the transmission of disease-carrying organism...The Executive Chef monitors sanitizing schedules and procedures. Equipment, walls, floors and storage areas are routinely cleaned with the appropriate sanitizing compounds... ."

Review of facility policy "Food Storage" revealed. "...Dry Bulk Food (flour, sugar, cereal) ...Store scoops for these items in the holder ... ."

During tour of the facility dietary on August 17, 2018 at approximately 10:00 AM accompanied by EMP2, EMP3, and EMP6 the following observations were made:

White Dry Bulk food container for rice located in the sushi processing area was observed with black sticky film on the outer surface of container and food scoop observed laying inside the container on top of the rice.

A sugar storage container was observed with a black sticky film over the top and the sides of the container.

Three white Dry Bulk Food storage containers placed adjacent to each other (brown rice, bread crumbs, and white rice) were observed in the general dietary processing area covered in a black sticky film.

A Hobart food mixer located in the cooking section of the dietary area was observed with a clear sticky substance around the base of the mixer's motor head.

Two refrigerators, one located in the cold prep area and the other refrigerator towards the front entrance of the dietary area were observed to have a black, sticky substance on the top of the refrigerators.

Several dozen of recently delivered sandwich buns and sliced bread wrapped in plastic and stored on metal racks were observed stored in a corner on the entrance area from the food service loading dock.

During tour EMP2, EMP3, and EMP6 confirmed these observations.

Based on a review of facility documentation and staff interview (EMP), it was determined the facility faciled to employ a full-time Director of Nutrition/Food Services.

Findings include:

A review of the facility's job description for Director of Nutrition/Food Services effective 6/11/2014 revealed "...Job Purpose...Plans, directs and coordinates the activities of the Food Service Department in accordance with the facility's mission to provide quality nutrition and food services to patients,visitors and staff. Establishing policies and procedures to provide administrative direction for menu formation, food preparation, distribution and service, budgeting, purchasing, sanitation standards, safety, staffing and staff development..."

A review of the facility's organizational chart in addition to a review of an outside facilities (OTH1) organizational chart revealed that EMP2 is designated as the Director of Nutrition/Food Services for two facilities.

During interview on August 17, 2018, at approximately 10:00 PM EMP2 revealed that in addition to being the Director of Food and Nutrition Services at this facility he also function in the same capacity at another facility (OTH1) within the same health system.

Based on a review of facility documentation and staff interviews(EMP), it was determined the facility failed to follow their plan for utilization review and generate reports adequate enough to permit identification of patient care problems that included a description of the method for evaluating the appropriateness and medical necessity of admissions and continued stays.

Findings include:

Review of facility documentation "Magee-Womens Hospital of UPMC Utilization Review Plan" dated March 2018, revealed "1. The Board of Directors and the Medical Staff of Magee-Womens Hospital of UPMC authorizes a Utilization Review Committee consisting of the Health Management Medical Director, other Magee physicians as assigned, Director of Health Management, Manager of Health Management, Nursing Unit Directors, Director of Quality and others. This staff committee reports to the Medical Executive Committee and is charged with carrying out this Utilization Review Plan. ... 3. The UR Committee assures that review of patients, including beneficiaries of Medicare and Medicaid, is conducted with respect to the medical necessity of a. Admissions to the institution: b. The duration of stays; and c. Professional services furnished, including drugs and biologicals ... 5. The UR Committee reviews all cases reasonably assumed by to be outlier cases because of an extended length of stay. 6. The UR committee reviews professional services that are reasonably assumed to outlier's based on extraordinarily high costs. The purpose of these reviews is to determine medical necessity and to promote the most efficient use of available health facilities and services."

Review of "Utilization Review Committee" dated May 28, 2015, revealed no documentation of case reviews. Further review revealed no documentation of Utilization Review meeting minutes until August 16, 2018.

Interview with EMP4 on August 17, 2018, at approximately 10:15 AM confirmed the above findings and revealed "I am not going to be able to find the meeting minutes [prior to August 2018]."

Review of "Magee-Womens Hospital Utilization Review Committee Thursday, August 16, 2018, 7:00 AM ... X. Case Review Bariatric Dialysis pt (patient)" Further review revealed no documentation of the discussion.

Review of "Utilization Review Committee Thursday, May 3, 2018 ... Case Review Bariatric pts ... - Protective services - court order to SNF (skilled nursing facility)." Further review revealed no documentation of the discussion.

Interview with EMP5 on August 16, 2018, at approximately 1:00 PM confirmed the above findings and revealed "I did not include the case discussions in the minutes."

Interview with EMP4 on August 17, 2018, at approximately 9:30 AM confirmed there was no documentation of admissions to the institution or the duration of stays in the Utilization Meetings. Further interview revealed "The information is not reported in a clear concise fashion anywhere."

Review of "Medical Executive Committee Meeting Record" dated January 22, 2018, February 26, 2018, March 26, 2018, April 23, 2018, May 21, 2018, and June 18, 2018, failed to include Utilization information as per the Utilization Review Plan."

Interview with EMP4 on August 17, 2018, at approximately 9:30 AM when asked if information about Utilization Review is discussed at the Medical Executive meetings confirmed the above findings and revealed, "No."

Interview with EMP7 on August 17, 2018, at approximately 11:00 AM confirmed the above findings and revealed "I know it [utilization review] is being discussed but it's not in the minutes." Further interview revealed, "Medicine Service Line meeting discusses issues of admissions and length of stay. It is not documented."