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Based on observation, interview and record review: the Governing Body failed to assure ECOLAB Pest elimination Contracted services were monitored and evaluated for effectiveness and delivered in a safe and sanitary manner.

Findings:

A review of the Facility document titled "ECOLAB Pest Elimination Division Service Request Log" documented Contracted services including: 1/5/20 in Emergency Room 10 confirmed Bed bug treatment; 3/13/20 small bug in NICU pod 511; 4/17/20 Cockroach in NICU hallway; 5/26/20 L&D room 1112 ants were observed.

A review of a Facility document titled, "Customer Service Reports," dated 5/26/20, indicated in the Interior Kitchen interior kitchen, cockroaches noted during service on cook line" and "rodent droppings need to be removed from under counter".

On 5/28/2020 at 1:30 PM during an interview with chief support services officer (CSSO), CSSO stated Ecolab Pest Control findings are reported to environmental services (EVS). EVS reports findings to environment of care (EOC).

During a review of the Facility contract for ECOLAB contract titled "Pest Elimination Agreement" included Pest management reviews: As necessary or required, ECOLAB and Customer will conduct periodic reviews of the pest management program to help ensure facility needs are taken care of.

During an interview with the corporate director of risk management (CDRM) on 5/28/2020 at 3:15 PM, there was no periodic review of the ECOLAB Pest Elimination contract. Hospital A did not monitor safety or effectiveness of ECOLAB Pest elimination Contracted service.

The Governing body failed to assure contracted services were monitored and delivered in a safe and effective manner.

Based on observation, interview and record review, the Quality Assessment Performance Improvement (QAPI) program failed to have:

1. Ongoing Studies monitoring and evaluating Hospital wide Pest Elimination program.

Findings:

A review of a document titled "Quality and Performance Improvement Dashboard 2019" did not include any ongoing studies on pest elimination. There was no ongoing QAPI oversight studies monitoring contracted services including ECOLAB Pest Elimination Program. There was no oversight of the Hospital Pest elimination contracted service.

During an interview, on 5/28/2020 at 1:30 PM with the Corporate Director of Risk Management (CDRM), the CDRM stated there was no ongoing pest elimination study. The CDRM was asked how Ecolab Pest Control contracted, services were monitored and evaluated. the CDRM stated there was none. The CDRM was asked for the Facility Policy and Procedure for the pest control plan there, the CDRM indicated that there was no Pest Control Quality Assurance Plan.

During an interview, on 5/28/20 at 1:40 PM, when asked about hospital wide oversight of Pest elimination program, the Chief Support Services Officer (CSSO) stated that Ecolab Pest Elimination reported their findings to environmental services (EVS). EVS then reported findings to Environment of Care (EOC). There were no studies tracking the ongoing Pest Elimination Program.

There was no documentation that EOC reported any concerns of pest elimination to Infection Control (IC).

During an interview with the Infection Control Director (ICD) on 5/20/2020 at 1:45 PM, the ICD stated the Infection Control Department did not have a pest elimination plan and no policy and procedure for pest control surveillance. The ICD did not oversee or monitor the hospital wide reporting of ECOLAB pest elimination program.

A review of the Facility document titled "ECOLAB Pest Elimination Division Service Request Log" documented Contracted services including: 1/5/20 in Emergency Room 10 confirmed Bed bug treatment; 3/13/20 small bug in NICU pod 511; 4/17/20 Cockroach in NICU hallway; 5/26/20 L&D room 1112 ants were observed.

A review of a Facility document titled "Customer Service Reports" dated 5/26/20, indicated in the interior kitchen ,"cockroaches noted during service on cook line" and "rodent droppings need to be removed from under counter".

There was no documentation of follow up evaluation, monitoring or tracking of ECOLAB pest Elimination report findings. There was no surveillance or evaluation of pest elimination hospital wide.

A review of a Facility Document titled "2020-2021 Performance Improvement Plan" indicated on page 10, "Infection Control and prevention ...meets to oversee the effectiveness of the hospital wide program for the surveillance, prevention and control infection".. And on page 4, "the Board of Directors is ultimately responsible for assuring the quality and effectiveness of patient care and services."

The Governing Body failed to oversee and implement a QAPI program that monitored and assured Patient care was provided in a safe and sanitary environment.

Based on observation, interview and record review, the hospital failed to meet the Condition of Participation in Infection Control by failing to:

1. Ensure the kitchen remained opened. The kitchen was closed due to a cockroach infestation in Hospital A. (Refer to Q 749)

2. Screen visitors for signs and symptoms of Covid-19 (coronavirus disease, a new infectious disease caused by a virus that can spread person to person via respiratory droplets, symptoms include fever, cough, and shortness of breath), prior to entering Hospital A. (Refer to Q 749)

3. Store food in a sanitary environment in Hospital A. (Refer to Q 749)

4. Discard expired food items in Hospital B. (Refer to Q 749)

5. Deliver food in closed carts to protect from the elements in Hospital A. (Refer to Q 749)

6. Ensure the infection control committe provided oversight in the dietary department and throughout Hospital A with regards to issues of pest or vermin control and proper food storage. (Refer to Q 749)

The cumulative effect of these systemic problems resulted in the hospital's inability to provide quality health care in a safe and sanitary environement.

Based on observation, interview, and record review, the facility failed to:

1. Ensure the kitchen remained opened. The kitchen was closed due to a cockroach infestation in Hospital A.

2. Screen visitors for signs and symptoms of COVID-19 (coronavirus disease, a new infectious disease caused by a virus that can spread person to person via respiratory droplets, symptoms include fever, cough, and shortness of breath), prior to entering Hospital A.

3. Store food in a sanitary environment in Hospital A.

4. Discard expired food items in Hospital B.

5. Deliver food in closed carts to protect from the elements in Hospital A.

6. Ensure the infection control committee provided oversight in the dietary department and throughout Hospital A with regards to issues of pest or vermin control and proper food storage.

These deficient practices had the potential for an unsanitary environment throughout the facility, possible cross-contamination of food, and patients to be served unsanitary or expired food.

Findings:

1. During an interview, on 5/27/2020 at 1:25 PM, the Director of Food and Nutrition Services (DFNS), stated the 'kitchen and cafeteria were closed yesterday because cockroaches were found in the kitchen by the Environmental Health Specialist (EHS) during yesterdays' inspection.

During the initial tour, on 5/27/2020 the kitchen and cafeteria were closed. Kitchen staff were observed through the window, cleaning the area.

On 5/28/2020 at 2:23 PM, the Infection Preventionist (IP) stated rounds were made in the kitchen. The IP stated that during the founds he checked the temperature logs, expiration dates, and cleanliness. The IP stated he was unable to produce documentation of the rounds conducted in the kitchen.

On 5/28/2020 at 2:27 PM, the Infection Control Director (ICD) stated that until February 2020, the team was making infection control rounds in the facility, however, the documentation was not specific and did not include pest control.

On 5/28/2020 at 2:37 PM, the Chief Support Services Officer (CSSO) stated the tool used in the environmental rounds did not include pest control.

On 5/28/2020 at 3:42 PM, during an interview, the DFNS stated that kitchen rounds were conducted daily, however; they had not documented the rounds on the "Daily Kitchen Sanitation Checklist". The DFNS stated they would start documenting the rounds every day.

A review of a notice, posted by the EHS, titled, "Notice of Closure," dated 5/26/2020, indicated the kitchen was closed for violation(s) of California Health and Safety Code and/or Los Angeles County Code, Code 114259, vermin harborage and 114259.1, vermin infestation (cockroaches).

A review of a document from the pest control company titled, "Customer Service Report," dated 5/26/2020, indicated that pest activity was found in the kitchen. Cockroaches were noted during service on cook line. In addition, findings included that the rear (exit) door to the kitchen did not close properly (1/4 inch gap or greater exist) and the door sweep needed to be installed or replaced to reduce the number of pest entering the area. Food debris was found under the counters and needed to be cleaned regularly. Floor drains in need of cleaning, please remove any food debris left in drains to prevent pest from harboring drain under triple sink.

A pest control policy was requested but not produced by the facility.

2. Upon entering the facility, on 2/27/2020 at 1:17 PM, the security guard (SG), in the lobby, (SG) was informed that the surveyors, need to speak with administration. The SG called an Executive Assistant (ExAsst) from the nursing office. The ExAsst came to meet the surveyors at the lobby, and the surveyors were taken to a conference room. The SG did not check the surveyor's temperatures or ask any screening questions pertaining to the signs and symptoms of COVID-19.

At 2:47 PM, the SG was observed taking temperatures of visitors prior to allowing them to enter the facility. The SG did not ask the visitors any questions regarding if the visitor had any signs or symptoms of COVID-19, or offered any hand sanitizer.

Concurrently, the Infection Control director (ICD) stated that all visitors need to be screened prior to entering the facility. The ICD stated that screening process included checking temperatures, providing a face mask, and offering hand sanitizer. The ICD stated that the two surveyors should have been screened prior to entering the facility.

During an interview, on 5/27/2020 at 3:02 PM, the SG stated he had been trained to check temperatures of all visitors. The SG stared the normal temperature was 98.6 F and if the temperature was above 100.4 F, the visitors were unable to enter the hospital. The SG stated he only checked visitors' temperatures and did not ask any screening questions about other signs and symptoms of COVID-19.

On 5/28/2020 at 9:12 AM, during an interview, the ICD stated they facility follows the Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH) guidelines. The ICD stated that SG's file did not include any documented evidence that the SG received training for screening visitors prior to entering the facility.

A review of an undated document found in SG's personnel file titled, "Infection Control Guidelines - COVID 19: Security Staff," that prior to walking into the hospital patients need to be asked if they have fever, respiratory symptoms, or shortness of breath. If patient answers yes to any of the above questions, they will immediately be provided a surgical mask prior to being allowed to proceed to
registration/appointment or service location. If patient answers no, they do not need to be provided with a surgical mask and can proceed to registration, appointment, or service location".

According the CDC's "Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings," dated updated 5/18/2020, recommendations to minimize the chance for exposure included universal source control. Regarding patient and visitors, recommendations included screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. Upon arrival and during the visit. Advise patients and visitors entering the facility, regardless of symptoms, to put on a cloth face covering or facemask before entering the building and await screening for fever and symptoms of COVID-19".

3. On 5/27/2020 at 3:25 PM, during an observation, food was stored in an unsanitary environment in Hospital A. The surgical waiting room was used as a food storage and serving area. The room did not contain a hand washing sink. Three corrugated cardboard boxes, containing individual-sized juices, were observed on the floor. One corrugated cardboard box, containing nourishment shakes, was observed with an attached shipping label. Individual-sized juices were placed on ice in dirty coolers.

In the basement of Hospital A, shelf stable food (such as salt, pepper, cream cheese, crackers) was stored in plastic bins, covered in plastic, adjacent to corrugated shipping boxes were observed. An open package of sugar was also observed in the basement.

Concurrently, the Director of Food & Nutrition Services (DFNS) stated they had no choice but to store the food in the basement and the surgical waiting room, since the kitchen was suddenly closed due to the discovery of the cockroaches on 5/26/2020. The DFNS stated she would remove the open sugar container.

On 5/27/2020 at 3:30 PM, the ICD stated patient food should be removed from outside corrugated shipping boxes. The ICD stated that the infection control personnel were not involved when the food storage had to be moved from kitchen and into the surgical waiting room or the basement.

The facility's policy and procedure titled, "Food and Nutrition-Production, Purchasing and Storage," dated 3/2016, indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Store dry and staple items at least 6 inches above the floor and 18 inches from ceiling.

A review of a document titled, "Audit Report," dated 5/5/2018 to 5/6/2018, indicated that on 6/24/2018, there was a cardboard issue in the dietary department. Comments: Please move all cardboard boxes up off the floor. This makes for unwanted guest to take up housing. Store on shelves, in cabinets or on plastic bins.

4. On 5/28/2020 at 9:50 AM, during a tour of the kitchen in Hospital B, the refrigerator contained expired food items. Twenty (20), 32-ounce (oz) cartons of heavy cream expired on 5/23/2020. Ten (10), 32 oz, cartons of half whole milk and light cream expired on 5/10/2020.

Concurrently, the chef acknowledged that the items were expired and removed the items from the refrigerator.

Concurrently, the Director of Food Service (DFS) stated they check for expired food every day and missed the expired foot items.

The facility's policy and procedure titled, "Food and Nutrition-Production, Purchasing and Storage," dated 3/2016, indicated that most products contain an expiration date. The words "sell-by" or "use-by" should precede the date. The "sell-by" date is the last date that food can be sold; do not sell products in retail areas or place on patient trays / residents' plates past the date on the product. The "use-by" date is the last date that a food can be consumed; do not sell products in retail areas or place on patient trays / resident plates past the date on the product. Foods past the "use-by" date should be discarded.

5. On 5/28/2020 at 2:01 PM, during the lunch service observation in Hospital A, food was brought in from Hospital B to Hospital A, due to the kitchen being closed in Hospital A. Food set up was taking place in the doctors dining room. Patient food trays were placed on open carts and delivered from the doctors dining room to the hospital and the mother-child building in public outdoor areas, exposing the food trays to the elements.

On 5/28/2020 at 11:57 PM, the Director of Food Services (DFS) for hospital B stated food was delivered in the open carts because the regular closed food carts were in the closed kitchen and had not been cleaned or sanitized.

6. During the initial tour, on 5/27/2020 the kitchen and cafeteria were closed. Kitchen staff was observed through the window, cleaning the area.

On 5/27/2020 at 3:25 PM, during an observation, food was stored in an unsanitary environment in Hospital A. The surgical waiting room was used as a food storage and serving area. The room did not contain a hand washing sink. Three corrugated cardboard boxes, containing individual-sized juices, were observed on the floor. One corrugated cardboard box, containing nourishment shakes, was observed with an attached shipping label. Individual-sized juices were placed on ice in dirty coolers.

In the basement of Hospital A, shelf stable food (such as salt, pepper, cream cheese, crackers) was stored in plastic bins, covered in plastic, adjacent to corrugated shipping boxes. An open package of sugar was also observed in the basement.

On 5/28/2020 at 1:45 PM, the Infection Preventionist (IP) for Hospital A stated infection control rounds were performed in the kitchen two week prior. The IP stated he checked daily temperature logs, required signatures on documents, expiration dates, and cleanliness. The IP stated he made the rounds two weeks ago, however the IP was unable to provide documentation of the infection control rounds in the kitchen.

On 5/27/2020 at 3:30 PM, The ICD stated that the infection control personnel were not involved when food had to be moved from the kitchen and into the surgical waiting room and the basement, after the kitchen was closed due to the cockroach infestation.

On 5/28/2020 at 2:27 PM, the Infection Control Director (ICD) stated that until February 2020, the team was making infection control rounds in the facility, however, the documentation was not specific or did not include pest control in the facility. The ICD stated that the pest control company's "Service Request Log" was not presented to the Infection Control Committee, and they were not aware of any pest control or vermin issues.

On 5/28/2020 at 2:37 PM, the Chief Support Services Officer (CSSO) stated the tool used in the environmental rounds did not include pest control. The CSSO stated that the pest control company did not send the reports to the environmental services (EVS) personnel or to the Infection Control Committee.

A review of a document titled, "Observation Tracer: Environment of Care," dated 2/3/2020, did not include any audits regarding pest control in the facility.

A review of a document titled, "Environment of Care (EOC) Rounds," dated 10/1/2019, in the dietary department, did not include any observations for pest or vermin.

A review of a document from the pest control company titled, "Customer Service Report," dated 5/26/2020, indicated that pest activity was found in the kitchen of Hospital A. Cockroaches noted during service on cook line. In addition, findings included that the rear (exit) door to the kitchen did not close properly (1/4 inch gap or greater exist) and the door sweep needed to be installed or replaced to reduce the number of pest entering the area. Food debris was found under the counters and needed to be cleaned regularly. Floor drains in need of cleaning, please remove any food debris left in drains to prevent pest from harboring drain under triple sink.

A review of a document titled, "Service Request Log," indicated that pests, such as ants, cockroaches, and bugs had been found in the facility, as follows. Ants were found on the following days, including; on 5/19/2020 in the administration office, on 5/26/2020 in the labor and delivery department, on 3/20/2020 in the purchasing kitchen.
Cockroaches were found on the following days; on 3/31/2020 in the 5th floor lounge room, on 4/17/2020 in the neonatal intensive care unit (NICU) hallway, on 4/27/2020 in the nursing office, on 2/25/2020 in the 5th floor lunch room, on 6/11/2019 in the admitting area in the Hospital A, on 6/17/2019 in the intensive care unit (ICU), on 10/3/2019 in the warehouse, and on 10/16/2019 in a room of the mother-baby building.
Either bugs or bed buds were found on the following days; on 1/5/ 2020 and 1/7/2020 in the emergency department, on 3/12/2020 in the labor and delivery nourishment room, on 3/13/2020 in the NICU, on 6/10/2019 in a patient room on the fourth floor, on 6/12/2019 and on 6/15/2019 in the mother-baby building.

A review of the facility's policy and procedure titled, "The Infection Prevention and Control Plan," dated 2019, indicated The Infection Prevention and Control Program is a hospital-wide program for the purposes of preventing and controlling infections and transmission of infection. The primary goal of the Infection Prevention program is to reduce the risk of acquisition and transmission of healthcare associated infections (HAI). All department and services are part of the Infection Prevention and Control Program are responsible for being knowledgeable of all standards, policies, procedures relative to assuring that infection prevention standards are maintained. Role of Infection Control Committee: Determine, evaluate, and revise on a monthly basis all hospital practices related to infection control, including: control measures such as isolation requirements, medical aseptic procedures, and hospital sanitation. Sanitary Physical environment: the infection control department assists in the prevention of the environment from unwanted microorganisms introduced by infectious patients, environment, and construction activities.

A review of the facility's "Infection Control Committee Minutes, "dated 1/18/2018, 4/12/2019, 7/12/2019, and 10/11/2019, did not include any discussions regarding pest or vermin control throughout the facility or in the Dietary department.