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Based on a review of facility documents and interview with facility staff (EMP), it was determined that the facility failed to follow adopted policies related to Tuberculin Skin Tests for four of 14 employees (PF4, PF5, PF6, and PF10), failed to follow adopted policies related to Hepatitis B vaccination for two of 14 employees (PF6 and PF13), and failed to maintain a sanitary physical environment.

Findings Include:

Review of Infection Prevention and Control Plan 2016, revealed, "1. Introduction: We maintain an active Infection Prevention and Control Program that includes prevention, surveillance and control of infections for the Meadows Psychiatric Center hospital Units and services (children, adolescents, adult, stabilization), or brought into the hospital from the community, as well as UCBH's Outpatient Services. The Infection Control Program develops and maintains surveillance activities to detect, record, and monitor infections, in order to institute the most effective and practical control measures. The goal of the Infection Control Program is to identify and reduce the risk of acquiring and transmitting infections among patients, employees, students and visitors and to reduce or eliminate healthcare associated infections. Infection Control surveillance and interventions will focus on incidence, prevalence and trends. ... 6. Surveillance The Infection Prevention and Control Program identifies priorities for surveillance through the annual Infection Control Risk Assessment. Both comprehensive (hospital-wide) and priority-directed (unit/program specific) approaches are utilized in the surveillance program. Methods of surveillance include data generated through the following means: daily assessment as related by direct patient care personnel (RN, LPN, MHT, Physician, Physician Assistant or CRNP), data collected through Infection Control Report forms, review of patient information in the medical record, direct observation, antibiotic reports culture and sensitivity results, reportable diseases through lab notification and environmental rounds. Age-specific infection control issues are monitored on children, adolescent and adult units. ... Effective measures to detect, control and reduce healthcare-associated infections include evaluation prior to admission, staff adherence to hand hygiene protocols, informational posters publicly displayed to educate staff, visitors and patients to such topics as respiratory etiquette, etc and signage discouraging visitors who are ill. Laboratory identification of potential infection rates from this data, with a goal of zero healthcare-associated infections. ... ."

The Meadows Psychiatric Center/Universal Community Behavioral Health Policies and Procedures ... Function: Infection Control ... Subject: Employee Health Program ... Section II. Number: 5 ... Reviewed July 2015 ... " I. Policy: The organization will offer Employee Health Program that includes regulatory requirements and provides for the basic needs of the staff within the cost restraints of the institution. ... II. Principle: To provide for employee protection from infectious diseases. To provide for a safe and healthy work environment for the employee. To provide a safer environment for the patient by improved employee health. To ensure adequate record-keeping. III. Equipment/Forms: Employee Absence Form Hepatitis B Vaccination Form Employee Accident Report Form IV. Procedure: A. All employees will be aware of the component of the Employee Health Program offered at the organization. 1. Two (2) Step Tuberculin Skin Test 2. Hepatitis B Vaccination Program 3. Exposure Protocol 4. Influenza Immunization Program B. Employee Health Program will be the responsibility of the Infection Control Practitioner and Human Resources. ... . "

The Meadows Psychiatric Center/Universal Community Behavioral Health Policies and Procedures ... Function: Human Resources ... Subject: Pre-Employment Health Evaluation Section: [blank] Number: 7 ... Reviewed: March 2010, "... I. Policy: The Meadows Psychiatric Center/Universal Community Behavioral Health (UCBH) shall require a Pre-Employment Health Evaluation to ensure the employees are in good health and capable of performing the essential functions of the position they are being hired for. ... II. Procedure ... D. All information obtained regarding the employee health history will be maintained by the Human Resources Department in a separate and confidential health file. ... ."

The Meadows Psychiatric Center/Universal Community Behavioral Health Policies and Procedures ... Function: Infection Control ... Subject: Two-Step Tuberculin (TST) Skin Test for Employees ... Section: II Number: 8 ... Revised: July 2015 ... "I. Policy: Two -step Tuberculin Skin Test (TST) will be performed on employees upon hire; the two-step TST is used to detect individuals with past tuberculosis (TB) infection who now have diminished skin test reactivity. ... IV. Procedure: ... 10. Administer second step TST within 7 to 21 days, following the procedure from initial TST administration, to employees whose first test was negative using the alternate arm. 11. Documentation of the employee's TST will remain a part of the employee's Human Resource file."

The Meadows Psychiatric Center/Universal Community Behavioral Health Policies and Procedures ... Function: Infection Control ... Subject: Vaccination Program Hepatitis B ... Section: II Number: 6 ... Revised July 2015. "I. Policy: To protect employees, patients and visitors from the risk of Hepatitis B. II. Principle: A. As per OSHA instruction CPL 202.44B, Hepatitis B Vaccinations will be available free of charge to employees that are at risk for contracting Hepatitis in the work place. The Meadows will this vaccine. B. Eligible employees include: Medical Staff ... Nursing Staff ... Maintenance/Housekeeping ... Dietary ... Social Worker/Case Managers ... Education ... Allied Therapy ... CD Counselors ... Unit Secretaries ... Phlebotomists ... Assessment and Referral Staff ... Crisis Staff ... Other employees who by the nature of their duties may have contact with blood and or body fluids. III. Procedure: A. The Meadows Psychiatric Center will administer the vaccine by using the following procedure: 1. Any employee wishing to receive the Hepatitis B vaccination series will mark the option indicating interested on the Hepatitis B Vaccination Form during new hire orientation. ... B. All employees will be informed of the Hepatitis B vaccination program as part of orientation. This is a voluntary program. ... 2. The signed HR Hepatitis B Vaccination Form will be a permanent part of the employees's record. ... ."

The Meadows Psychiatric Center/Universal Community Behavioral Health Policies and Procedures ... Function: Human Resources ... Subject: Hepatitis B Vaccinations ... Section: [blank] Number:49 ... Reviewed: March 2010. "Purpose: To protect employees, patients, and visitors from the risk of blood born diseases and Hepatitis B. Policy: 1. As per OSHA instruction CPL 202.44B vaccinations will be available free of charge to employees at risk for contracting Hepatitis B in the work place. The Meadows will provide this vaccine. ... Procedure: 1. All employees will be informed of the Hepatitis B vaccination program as part of orientation. This is a voluntary program. ... B. The signed Hepatitis B acknowledgement form will be a permanent part of the employee's medical record. C. The Hepatitis B employee record will be monitored by the Infection Control Nurse and the offsite location by the RN/Program Manager. The Infection Control Nurse maintains the Hepatitis B vaccine record. The consent form is maintained in the employee ' s medical file by Human Resources. 2. The Infection Control Nurse will administer the vaccine by using the following procedure: A. Employee will arrange with the Infection Control Nurse to set up an appointment ... ."

A review of the Dietary Policies and Procedures, dated March 10, 2016, entitled, "General Cleaning" revealed, "... I. Policy: All Dietary equipment and work surfaces must be thoroughly cleaned and sanitized after each use in order to protect the health of patients and employees. A cleaning check sheet is done weekly listing who is responsible for what equipment. II. Purpose: To establish guidelines for regular and consistent cleaning methods that are necessary to achieve high standards of sanitation, to eliminate chances of dirt build-up, to reduce the possibility of food contamination and to aid with pest control in the Dietary Department ... ."

A review of the Dietary Policies and Procedures, dated March 10, 2016, entitled,"Safety in the Main Kitchen" revealed, "... Floors: 1. Wipe up all spilled liquids and dropped food immediately ... Mixing Machines: 1. Follow Electrical Equipment Safety Rules when cleaning machines ... Filters and Hoods: 1. Clean weekly to keep free from grease and dust accumulation ... ."

The Meadows Psychiatric Center/Universal Community Behavioral Health Policies and Procedures ... Function: Infection Control ... Subject: General Cleaning ... Section: III Number: 13 ... Revised: June 2014 ... III. Procedure ... D. Bathrooms shall be cleaned at least daily. Special attention must be given to the toilet and fixtures. Ceramic tile grout around the commode and shower and cracks in hard surfaces (e.g., in Formica surfaces) should be free of mold. ... K. Housekeeping staff and their Supervisors must inspect their work on completion to ensure that the cleaning has been done properly. A written checklist should be developed to assist the inspection process. ... Cleaning Schedule: ... B. Patient care areas - Impatient Rooms High dusting, spot-cleaning of walls, windows, and doors; cleaning of light fixtures, ledges, tables, chairs, beds, and floors shall be performed daily and when the patient is discharged. ... ."

1. Review of PF4 health file revealed no documented evidence of an initial TST skin test or second step TST skin test, PF5 health file, PF6 health file, and PF10 health file revealed no documented evidence of a second step TST skin test.

Review of PF6 health file and PF13 health file revealed that the employees wished to have a Hepatitis B Vaccine on hire, however, there was no documented evidence that the Hepatitis B vaccine was ever administered.

An interview was conducted with EMP13 and EMP14 on July 29, 2016, at approximately 11:00 AM, EMP13 and EMP14 confirmed the above findings.

2. A tour of the Dietary Department was conducted on July 29, 2016, at 10:00AM, with EMP21, and EMP1. During the tour dust was observed on the rear posterior portion of the stove hood, on top of the refrigerator, on the cord and top of a mixer, and debris and dust was also noted on the floor in the Dietary Department. During the tour, it was also noted that behind the door of the eyewash room there were two cloth, blue laundry-like bags sitting directly on the floor.

An interview with EMP21 revealed that clean linens were in the bags located directly on the floor.

3. Review of facilty documentation entitled "Housekeeping Daily Checklist - The Meadows Psychiatric Center" revealed a checklist of daily scheduled tasks to be completed Monday - Friday. The checklist does not include daily schedules of tasks for Saturday or Sunday.

An interview conducted with EMP20, on July 29, 2016, confirmed the above findings and revealed, "We only have one housekeeper to cover the weekends. We only can do sinks, toilets and empty the trash on the weekends."