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Based on review of facility documents and staff interview (EMP), it was determined the Governing Body failed to assess the effectiveness of the performance improvement program for the 2015 calendar year.

Findings include;

Review on September 20, 2016 of the facility's "Performance Improvement Program 2016," revealed "III. Purpose: The Performance Improvement Program is designed to provide a systematic and organized mechanism to promote safe and quality patient care and services. Through an integrated, interdisciplinary process, patient care and services shall be continuously monitored and evaluated to promote optimum outcomes. ... VII. Organization and Responsibility: Performance Improvement is the responsibility of everyone employed by, on the medical staff of, or contracted with Behavioral Health Services of Wyoming Valley. A. Governing Board The Governing Board shall review and evaluate patient care activities to assess, and improve the overall quality, safety, and efficiency of patient care and services. The Governing Board is ultimately accountable for safety and quality, and has legal responsibility and operational authority for hospital performance. The Board delegates operational responsibility to the Medical Staff and Administration. The Governing Board authorizes the establishment of a multidisciplinary committee, the performance improvement committee, to implement the Performance Improvement (PI) Program. To fulfill this obligation, the Governing Board will: ... Assess the program's effectiveness and efficiency annually, and if necessary, require modification to organizational structure and systems to improve outcomes; ... "

Review on September 19, 2016, of governing body meeting minutes from January 2015 to August 2016 revealed no documentation the governing body reviewed the effectiveness of the performance improvement program for the 2015 calendar year.

Interview with EMP1 on September 20, 2016, confirmed there was no documentation in the governing body meetings of an annual overall assessment of the PI program for effectiveness and efficiency.

Based on review of facility policy, an observation tour of the food preparation area and cafeteria, and staff interview (EMP), it was determined the facility failed to ensure that dietary services were provided in a safe and sanitary manner.

Findings include:

Review on September 21, 2016 of the policy provided by the facility "Community Health Systems Professional Services Corporation ... Environmental Tours Policy," dated August 25, 2014, revealed "Policy It is the policy of <> to rigorously evaluate the environmental safety of its facilities. This is accomplished primarily through the Facility's Environmental Tours Program. Purpose To identify environmental deficiencies, hazards, and unsafe practices within its facilities and to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environmental safety risks. ... Frequency ... 2. Environmental tours are performed annually in non patient care areas. 3. Additional evaluations are performed as needed based on other considerations such as previous tour results, change of practice or policy, performance improvement activities, educational needs and other identified needs. Procedure ... 10. An overall performance goal of 90% compliance is established for each function. ... 12. Overall function scores of less than 90% compliance are reviewed by Function Team Members assigned to the respective function. 13. Follow up evaluations are performed to ensure corrective actions are effectively implemented and sustained. ..."

Review of the last facility dietary environmental tour completed on November 15, 2015, revealed numerous issues. The dietary environmental tour had a score of 75%. There was no documentation that a follow up evaluation was completed. There was no documentation the issues were corrected. There was no documentation another tour was performed to ensure issues were resolved.

Interview on September 21, 2016, with EMP2 confirmed the follow up evaluation for the environmental tour issues of November 15, 2015, was not completed. EMP2's name was entered/typed in on the tour sheet. EMP2 could not recall completing the tour. EMP7 was also listed on the tour. EMP7 confirmed it was the manager's responsibility to complete the follow up evaluation.

Observation tour on September 21, 2016 revealed the following findings:

The food preparation area was a space approximately 10' x 15'. The entry door into the food preparation area was a swinging door. It was filthy with greasy, black, handprints. Upon entering the area to the immediate left there was a sink and eyewash station. The wall above the sink was greasy, and the pain was peeling. On the floor, there was a water filter connected to the piping. The filter was rusty brown, and the top was covered with greasy lint. EMP4 was unable to provide documentation or state when the filter was last changed. The floor in the entire food preparation area was dirty with debris and an accumulation of grease. The back door to the loading dock was propped open, and there were flies everywhere. There were cigarette butts on ground. There were two large open grease containers next to food preparation space. There were no lids on two garbage cans.

There were two freezers and one cooler in the food preparation area. Each freezer contained 2" to 3" of a frost buildup. One freezer had broken gaskets. These gaskets were falling off. The top of the freezer was soaked with condensation. The third cooler had a glass door which was stained with drips. The eggs stored in the cooler were not dated. The floor of cooler dirty with stains, drips and debris.

The wall corners thru out the food preparation area were damaged.

A janitor's cart was stored in food preparation area. There was full water bucket on the janitor's cart.

The food cart used to transport food was stored in an alcove with brooms and a dustpan. The inside of the food cart was greasy and contained food debris. EMP4 was unable to provide documentation or state when or how the food cart was cleaned.

Several ceiling tiles in the food preparation area were cracked, dirty and greasy. The air condition vents in the food preparation were filthy were greasy and contained brown/gray dust.

The sink in the food preparation area was blocked with standing water and rust.

On the third floor there was a cafeteria area for the patients. The cafeteria floor was rusty, and there was also a heavy accumulation of black dirt. There was a dishwasher in the cafeteria area. The floor around the dishwasher appeared rusty and black-stained with dirt and food residue. EMP5 stated work requests were submitted to repair the floor. The repairs were not completed.

EMP2 confirmed the hospital has a contract with a vendor for the food service.

EMP2 stated lunch and dinner for the facility were transported from Wilkes-Barre General Hospital. Breakfast was prepared in the food preparation area described above. The food service contractor was responsible for cleaning the food preparation area.

The facility voluntarily shut down the food preparation area for cleaning and repair on September 20, 2016. The facility plan was to have all food for patients prepared and transported from Wilkes-Barre General Hospital.

Interview on September 20, 2016, with EMP6 confirmed there was no documentation of cleaning for the food preparation area and the cafeteria. There were cleaning schedules on the bulletin board. There was no evidence the tasks were completed. EMP6 confirmed the contracted service was responsible for the dietary area described above.

Based on review of facility documents, medical records (MR) and Department's data base and interview with staff it was determined the facility failed to ensure all restraint events were documented in the medical record, failed to ensure a physician's order was obtained for the restraint for five of five medical records reviewed (MR1, MR2, MR3, MR4 and MR5) and failed to ensure a patient was not restrained in the prone position for two of two applicable medical records reviewed (MR3 and MR5).

Findings include:

Review of facility's Policy "Restraint and Locked Seclusion,"dated last reviewed February 4 , 2016, revealed "Policy: Restraints and locked seclusion will be used only in clinically justified situations in which there is an imminent risk of a physical injury harming him/herself or others. Specifically, they are a treatment modality used when less restrictive interventions have been determined to be ineffective to protect the patient, staff or others from harm. Use of restraints or seclusion is based on the patient's needs in the immediate care environment. It is viewed as an exceptional or extreme practice for any individual. Philosophy: In order to provide the highest quality of patient care and focus on the patient's well-being, First Hospital is committed to fostering an atmosphere which limits restraint and locked seclusion. Our approach to restraint and locked seclusion will protect the patient's health and safety and maintain his/her dignity, rights, and well-being. The leadership of First Hospital is dedicated to creating an environment which not only limits their use to clinically, justified emergency situations in which there is an imminent risk of a patient physically harming himself/herself or others but when used emphasizes the discontinuation of restraint or locked seclusion as soon as possible and and reduces their use through preventative and/or alternative strategies. Restraint and seclusion are not used as a substitute or treatment, as punishment or for the convenience of staff. Once a seclusion or restraint procedure is initiated, it should be as limited in time as possible. The staff and individual work together to lessen the duration of each episode. This requires planning, use of resources, education, and use of performance improvement. The focus of performance improvement process will be to identify opportunities, when appropriate, to reduce restraint or seclusion use. Aggregate data will be assimilated and assessed as it relates to usage on all units, shifts, multiple episode, and extended lengths of time. ... Definition: I. Restraints. A. Defined per CMS 42 CFR 482.13(e)(1) as (A) any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. Restraint is considered involuntary and requires individual specific physician orders. ... Procedures: ... II. Restraints ... D. In an emergency situation, if a physician is not present due to extenuating circumstances, a registered nurse is permitted to initiate the use of restraints for the protection of the patient and/or others, and the registered nurse must immediately contact the physician on duty/on call and obtain a verbal order. ... F. If an RN completes the face- to- face evaluation, the RN must consult the psychiatrist as soon as possible after the completion of the face-to-face evaluation. In the event the patient is released within one hour, the RN must still consult the MD. I. ... 2. Written orders for non-mechanical restraints are limited to ten minutes. Non-mechanical restraints that apply pressure or weight on the respiratory system in [sic] not permitted. The application of the prone position non-mechanical is not permitted. ... IV. Debriefing and Review of incident: A. Review of incident between consumer and psychiatrist: Within 24 hours of the termination of the locked seclusion and/or restraint, a review of the incident leading to the restraint and/or locked seclusion will occur between the patient and the psychiatrist. B. Review of the incident with involved staff: All staff involved in a restraint/locked seclusion incident must be debriefed by a SCM instructor and/or supervisor in order to address circumstances leading to the incident, prior to de-escalation techniques utilized, staff's response, techniques utilized by the staff and to allow staff to express feedback regarding the incident. The goal of the review process is designed to reduce the number of restraints and locked seclusion. C. Data collection: The following information is present on a monthly basis to the Performance Improvement Committee: Number of restraints/locked seclusion incidents Number of patient involved injuries Justification for the ESPI Trends Medication Concerns Staff Concerns Least Restrictive alternatives attempted."

1) Review on September 19, 2016,of MR1 revealed the patient was admitted to the Children's Unit of First Hospital Wyoming Valley on July 8, 2016. There was no documentation of a medical source contributing to the patient's behavioral issues. Documentation on August 15, 2016 revealed the family member requested an emergency family meeting with EMP17. The meeting was scheduled for August 15, 2016 at 4:15 PM. Concerns were voiced regarding a restraint staff used on the patient. Review of MR1 revealed no documentation the patient was placed in a restraint, an order for a restraint, a Registered Nurse (RN) contacting the psychiatrist on call for a restraint order, or a face-to-face evaluation by an RN.

Interview on September 19, 2016, at approximately 11:10 AM with EMP11 confirmed when a patient escalated the staff would put "Hands On" the patient, i.e. a physical hold. EMP11 confirmed if the hold was for two minutes or less, no order was obtained. EMP11 confirmed there was no order for a restraint or documentation of the physical hold for MR1.

Interview on September 19, 2016, at approximately 11:30 AM with EMP12 confirmed there was no documentation of an order for a restraint or documentation of the patient being "Held" in MR1.

Interview on September 19, 2016, at approximately 2:30 PM with OTH1 confirmed there was not an order a restraint in MR1 for the physical hold. OTH1 confirmed if a patient was put in a "Hold" there should be a physician's order.

Interview with EMP19 on September 20, 2016, at approximately 1:30 PM confirmed holds were sometimes used without an order or a face-to-face approval of an RN. EMP18 confirmed the staff had restraint training and a "hold" was considered a restraint.

Interview with EMP20 on September 20, 2016, at approximately 1:45 PM confirmed they have been on staff on the Children's Unit for nine months. Restraint training was provided to the staff. EMP20 confirmed it was confusing at times to distinguishes between certain restraints, such as a hold and an escort.

2) Interview with EMP13 on September 19, 2016, revealed the unit hallways and dayroom areas were under camera surveillance. Whenever a restraint was reported, a debriefing was conducted, followed by viewing the camera surveillance, if available. EMP13 noted if the infraction was minor, counseling was completed. If the infraction was more severe, the employee was referred to human resources. EMP13 confirmed placing a patient in the a prone position was an improper restraint technique, as it places weight on the patient's respiratory system.

Review on September 19, 2016, of the facility's debrief documentation for MR2 revealed on March 10, 2016, the patient was transported in a "hook" position, putting the patient at risk of a shoulder injury and putting the staff at risk for biting injury. There was no documentation in MR2 that the "hook" restraint was implemented. The restraint was discovered during the debrief and viewing the camera surveillance of the event. All employees involved were sent for counseling and re-educated on proper restraint techniques.

Review on September 19, 2016, of the facility's debriefing documentation for MR4 revealed on May 1, 2016, the patient was placed in a "hook" position for transport. There was no documentation in MR4 that the "hook" restraint was implemented for transport. This was discovered during the debriefing and viewing the camera surveillance of the event. All employees involved were sent for counseling and re-education on proper restraint techniques.

Review on September 19, 2016, of the facility's debriefing documentation for MR5 revealed that during two separate admissions, one on February 20, 2016, and the other on March 13, 2016, the patient was held in a prone position. On February 20, 2016, the patient was held prone for one and a half minutes. On March 13, 2016, the patient was held in a prone position for 9 minutes. There was no documentation in MR5 that the patient was held in the prone position. The events were discovered during the facility's debriefing and viewing the camera surveillance of the event. All employees involved were sent for counseling or reported to human resources as a result of these improper restraint methods.

Review on September 19, 2016, of the facility's debriefing documentation for MR3 revealed on February 6, 2016, the patient was held in a prone position face down against the floor. There was no documentation in MR3 that the patient was held in the prone position. The event was discovered during the facility's debriefing and viewing the camera surveillance of the event. All employees involved were counseled and re-educated on proper restraint techniques.

The surveyors were not able to view the camera surveillance during the survey, as it was not retained.