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The CONDITION is not met:

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

1. Ensure the Governing Body (GB) provided adequate oversight of the Dietary Department and ensure that there was ongoing communication between the Registered Dietitian (RD) and Food Service Director (FSD) (Refer - A 0618 and A 0620)

2. Ensure there was a plan in place for prevention of vector infestation. The facility's kitchen was closed for three days due to rodent infestation. (Refer A0286)

The cumulative effect of this deficient practice resulted in the facility's inability to provide quality care in a safe environment.

Based on interviews and record review, the facility failed to:

1. Ensure the Governing Body (GB) provided adequate oversight of the Dietary Department and ensured that there was ongoing communication between the Registered Dietitian (RD) and Plant Manager, who also functioned as Food Service Director (FSD).

2. Ensure there was a plan in place for prevention of vector infestation. The facility's kitchen was closed for three days due to rodent infestation.

The GB's failure to provide adequate oversight of the Dietary Department placed patients at risk for food-borne illnesses and contamination.

Findings:

On 3/4/20 at 12:15 p.m. during a Complaint Validation survey, the Clinical Director (CD) stated that the Dietary Department was not considered a separate category and was included under "Environment of Care (EOC) Committee". The CD also stated if a dietary issue came up, it would be presented during the EOC and infection control (IC) monthly council meetings by the Plant Manager (PM), who also functioned as the Food Service Director. The CD then stated that the Registered Dietitian (RD) worked on a part time basis, and it was mainly the PM who was involved in the daily management of the Dietary Department.

The review of the 2019 3rd and 4th Quarter Infection Control (IC) Rounds documents dated 9/24/19 and 12/7/19 respectively, indicated the Dietary Department report included cleanliness of the food prep area, refrigerator and freezer, and if food items were labeled with "open" and "expiration" dates. There was no documented evidence available to support that the inspection included overall cleanliness of the kitchen, such as the floor, inspection under areas such as storage carts and appliances, as well as monitoring for potential vermin entrance sites.

The facility document titled, "Amended and Related Bylaws of the Board of Governors of Del Amo Hospital", dated 1/1/2011, Article IV "Purpose of the Facility" indicated the following:

"The Board shall be accountable for the safety and quality of care, treatment and services of the Facility. The primary purposes of the Facility are to own and operate health care facilities and to perform such other activities for such other purposes as authorized by the Corporate Entity's governing corporate documents and as authorized by the Corporate Governing Body from time to time."

The CONDITION is not met:

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

Ensure that the Dietitian participated in the Quality Assurance Performance Improvement (QAPI) Committee meetings. (See A 0273)

Ensure that the Dietitian conducted ongoing QAPI projects that focused on high risk, data -driven provision of patient safety and sanitary environment. (See A 0273)

The cumulative effect of these deficient practices resulted in the facility's inability to provide care in a safe environment.

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

Ensure the Registered Dietitian (RD) participated in the Quality Assurance Performance Improvement (QAPI) Committee meetings on a regular basis.

Ensure the Dietitian conducted ongoing QAPI projects with the Dietary staff that focused on high risk, data -driven provision of patient safety and a sanitary dietary environment.

Findings:

On 3/5/20 at 12:15 p.m., during an interview with the Clinical Director (CD), she acknowledged that the facility did not have a Performance Improvement (PI) plan in place in the event of vermin infestation.

On 3/5/20 at 3:40 p.m. during an interview, the RD stated that she did not attend QAPI meetings unless there was a significant change in dietary standards. The RD also stated she had not yet conducted an in-service with the dietary staff regarding measures to take in order to prevent future infestations.

According to the facility document titled, "Amended and Related Bylaws of the Board of Governors of Del Amo Hospital Article V", and dated 1/1/2011, the principal duties and responsibilities of the Board shall be to...ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the facility.

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

1. Ensure that the Dietitian attended the Quality Assurance Performance Improvement (QAPI) meetings on a regular basis.

2. Ensure that quality control measures were performed on a regular basis for the Dietary environment, such as hand-washing by kitchen staff, wearing gloves when handling food, monitoring of food temperature logs.

3. Ensure that Dietary Department rounds were conducted on a consistent basis in order to prevent entry of vermin (animals and insects that are difficult to control i.e. lice, bedbugs or fleas, mice, rats, and cockroaches, etc) into the building.

Findings:

On 3/5/20 at 12:10 p.m., during an interview, the Clinical Director (CD), stated that Dietary Department concerns fell under the Environment of Care Committee, and that the Plant Manager conducted monthly rounds of the whole facility, including the kitchen and outside area around the kitchen.

At 3:40 p.m. the same day, during an interview, the RD stated she did not attend the GB or QAPI meetings unless there was a change, such as American Dietetic Association (ADA) labeling i.e., controlled carbohydrate diet (CCHO) to "Heart Healthy" diet, and an update on eating disorders (stated she presented this to the administrative staff many years ago).

At 4:10 p.m. the same day, during an interview with the Plant Manager, he stated that monthly rounds were conducted of the kitchen as well as the outside area behind the kitchen.

According to the facility document titled, "Amended and Related Bylaws of the Board of Governors of Del Amo Hospital, dated 1/1/2011,
Article V, included the following:

"The principal duties and responsibilities of the Board shall be to...ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the facility."

Based on observation, staff interview, and review of facility documents, the hospital failed to meet the condition of participation for Food and Dietetic Services by failing to:

1. Provide organized dietetic services as evidenced by findings of unsafe food handling practices and inadequate supervision of the dietary department including lack of adequate implementation of training programs for dietary staff. During the survey, the hospital kitchen was closed due to rodent infestation. There was no training regarding rodent infestation, and there was no increase in pest control monitoring program. The registered dietitian did not know about the rodent problem in the dietary services. (refer to A619.)

2. Ensure that the job requirements of the Food service director were in compliance with federal and state licensure requirements. The Food Service director was responsible for different departments in the hospital including environmental, dietary, maintenance, security, transportation and IT. Operation of the dietary services was one of those responsibilities. The lack of daily management of the dietary services was evident by the lack of communication between the registered dietitian and the Food service director, lack of in-services regarding pest control and unsafe food handling practices (refer to A620.)

3. Develop a data driven quality assessment and performance improvement program that reflected the scope and complexity of its food and nutrition services. The performance improvement program developed by the director of food services was limited to the environmental care services of the hospital and no data was collected in the area of food services. During the survey, the hospital kitchen was closed by the county environmental health department for rodent infestation that affected the safety of all patients. An effective system was not developed to measure the effectiveness of its processes and ensure the sanitary maintenance of dietetic services department. (refer to A619, A620)
The cumulative effect of these systemic issues resulted in the facility's inability to ensure that the hospitals' food and nutrition services provided a safe patient care environment.

Based on observation, interviews and record reviews, the hospital failed to ensure that the Food and dietetic services department was properly organized. The person in the position of leadership had a number responsibilities and the hours dedicated to the department was not appropriate to the scope and complexity of the food service operations. These failures resulted in deficient practices that affected the quality of care being provided due to poor food safety practices which included Rodent infestation and the closure of the hospital kitchen by the County Environmental Health department. Also there was the lack of coordination between the food service and clinical nutrition services. The registered Dietitian failed to provide input in areas of food service for which she was responsible as required by law.

These failures had the potential to put 146 patients, staff and visitors and risk for food borne illness

Findings:

1. During an observation of the nourishment room in the Transitional care unit (TCU) on March 4, 2020, at 1:00 PM, the temperature of the refrigerator was observed at 55 degrees Fahrenheit. Inside the refrigerator were juices, milk and yogurt for patients. A temperature check of the yogurt indicated it was noted at 50 degrees Fahrenheit (the FDA recommends that milk products be stored below 40 degrees Fahrenheit (www.fda.gov).

During an observation of the nourishment room in the Children's treatment center unit (CTC) on March 4, 2020, at 1:15 PM, the temperature of the refrigerator was observed at 48 degrees Fahrenheit. Inside the refrigerator were milk and juices for patients. A temperature check of the milk carton indicated it was at 44 degrees Fahrenheit. (the FDA recommends that milk products be stored below 40 degrees Fahrenheit (www.fda.gov).

During a concurrent interview with Food Service Director (FSD), the FSD stated that maintenance staff was assigned to check temperature of the refrigerator. The temperature log was kept with the maintenance and not posted on the refrigerators. The FSD could not determine how long the milk had been out of the safe temperature range.

A review of the hospital policy titled "Food, leftover and supply storage" (revised 1/7/20) indicated that, "the refrigerator temperature shall be kept at a reading of 40 reading degrees Fahrenheit or less at all times. The temperatures are logged twice daily by the engineering Department. Documentation was maintained by the dietary manager/director."

According to the 2017 U.S. Food and Drug Administration Food Code, time/temperature control for safety food shall be maintained 135 degrees Fahrenheit or above for hot food items or at 41 degrees Fahrenheit or less for cold food items.

During a tour of the kitchen on March 4, 2020, at 1:49 PM, the evaluator noted that the kitchen had been closed by the county environmental health department for operations due to rodent infestation. The kitchen staff were cleaning the kitchen in preparation for the re inspection by the county environmental health department scheduled for 3/5/20. The ice machine was full of ice and not emptied after rodent infestation and kitchen closure. In the dry storage area, the scoops were stored in contact with the food in the storage bins. There were six bins with flour, rice, sugar, white rice, brown rice and pinto beans with scoops stored inside.

During a concurrent interview with Food service director (FSD), he stated "I will tell the staff to empty the ice and clean the ice machine". He also stated that the scoops were probably washed and placed back in the food bin, but agreed that the scoops should be have been placed outside of the bins.

During a tour of the kitchen on March 5, 2020, at 2:18 p. m., the ice machine was still observed full of ice. FSD stated "I will ask maintenance to empty and clean ice machine".

A review of the Hospital infection control 2019-rounds, dated 9/24/19 and 12/7/19 indicated that, during the rounds it was noted that the scoops were stored inside the bins in contact with food. The problem had persisted and no corrective action was taken.

During a tour of the kitchen on March 5, 2020, at 2:18 pm the ice machine was still full of ice. FSD stated "I will ask maintenance to empty and clean ice machine".

A review of the 2017 U.S. Food and Drug Administration Food Code indicated that, during pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored, in food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon. It further states the handles of utensils, even if manipulated with gloved hands, are particularly susceptible to contamination.

During an interview with Food Service director (FSD) on March, 4, 2020, at 2:00pm, FSD stated that dietary staff reported noticing rodent in the kitchen. FSD stated that it was about 2-3 weeks ago that dietary staff reported seeing a rodent. FSD did not increase pest control management at that time. FSD also stated he directed his maintenance staff to purchase glue traps for the rodents. FSD stated he did not provide in-service to dietary staff on pest or rodent control or prevention. FSD also stated maintenance did not check the glue traps that
were set.

During an interview on March 5, 2020, at 3:00pm, the Registered dietitian (RD) RD stated she did not know about rodent problem in the kitchen. RD stated she did not provide in-service on pest control once the problem was identified.

A review of reports from Pest control company indicated that, pest control was on weekly schedule from 11/12/2020-2/11/2020. There was no other pest control service done until 3/3/20. On 3/3/20, the County Environmental Health Inspector found rodent infestation during a routine inspection.

2. A review of the Food and nutrition Services Organization Chart Demonstrated that there was no interrelationship between the Lead Clinical Dietitian and the Food Service director. The organization chart also demonstrated that the Food Service director was also the Director of plant operations. Director of plant operations had oversight over multiple departments including the facility Coordinator, plant operations, Environmental services, maintenance, Security staff, Information Technology, Nutritional Services, transportation services and materials management. The interview with the dietitian revealed the lack of coordination as identified during the survey visit.

The person in the position of Food service director(FSD) was also the director of plant operations and held the position for 12 years. The Hospital requirements for the position of Food Service Director were not in compliance with federal regulations. The (FSD) job description is for Director of plant operations and not specific to a Food Service director position. The FSD has multiple department to oversee, the kitchen is only one of those departments. A review of hospital in-service documents and interviews with Food Service director (FSD) verified that although the rodent infestation issue was noted previously, but there were no in-services provided to dietary staff on pest control or prevention by the (FSD) once the problem was identified. A review of sign-in sheet indicated that, hand book for Food safety was provided to staff on 1/20/2020, but there was no system to validate staff competency with food safety hand book. There were no pre or post-tests on the topics covered in the food safety hand book. The deficient practices identified during the survey including the rodent infestation were not being monitored and was not part of the performance improvement project, despite being at high risk and a problem prone area.

During an interview with the Registered Dietitian (RD) on March 5, 2020, at 3:00pm, RD stated that she reports to the Director of plant operation who is also the Food Service Director. The registered Dietitian stated that she is the clinical dietitian and works 30 hours a week. There is no clinical nutrition manager in the hospital, she reports directly to the Food service director. The RD stated that she did not know that there was a rodent infestation problem in the kitchen until the kitchen was closed by County officials. The RD also stated that she does not participate in the hospital wide Quality meetings also known as (HQC) or Hospital Quality Council. RD further stated that she does not have any performance improvement projects related to the Food and nutrition department including the kitchen.
The food and nutrition services lacked the organization and position of leadership that would have ensured the coordination, adequate training and safe food practices in the food and nutrition department.

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that the director of the food and dietetic services was a full time employee whose responsibility was in the daily management of the dietary services.

This deficient practice had the potential to affect the safety of all patients who ate food from kitchen. The census at the hospital was 146.

Findings:

During a tour of the kitchen on March 4, 2020, at 1:49 p. m the kitchen was observed closed for operations by the County Environmental Health Department for rodent infestation.

During an observation in the dry storage area located in the kitchen on March 4, 2020, scoops were observed stored inside the bins with handles touching the food. A review of the infection control rounds reports indicated the problem had been identified by the infection control department but the scoops were still stored inside the bins in direct contact with the food.

A review of staff in-services that were provided by the registered dietitian did not include dry storage or pest control management in-services.

A review of the pest control management company's reports indicated that there were weekly service from 11/12/19 to 2/11/20. There were no pest control services after 2/11/2020. Although the staff had identified rodents in the kitchen two or three weeks prior, but there was no pest control service provided in the kitchen until 3/3/2020 when kitchen was closed by County Environmental Health Department for rodent infestation.

During an interview with Food Service director (FSD) on March 5, 2020, at 12:30pm, FSD stated that he is the director of plant operation and is also responsible for the kitchen. He stated that he had been in the same role for 12 years and is also certified Dietary Services Supervisor. FSD stated that he had 30 direct reports and eight of them were are in dietary department. the FSD stated that he was in charge of maintenance and engineering department, environmental services department, life safety and dietary. He stated that kitchen staff had reported seeing rodent two or three weeks prior. He also stated that he asked his maintenance team to take care of the pest problem. FSD did not provide an in-service to dietary staff on pest control once the problem was identified.

During the same interview, FSD stated that since he was responsible for many departments in the hospital, the priority will be the department that will need him the most. He agreed that dietary services require a lot of work due to the complex nature of the department. He also stated that he spends 40% of his time in dietary services. FSD agreed that he is not only managing the dietary department, but had many other departments to oversee.

During a concurrent interview with the FSD, director of nursing (DON) and director of clinical services, the DON stated that every month, there was a hospital wide quality meeting called (HQC) Hospital quality council. When asked if dietary department is on the meeting, she said yes.

During a review of the sign in sheet for the HQC meeting dated 1/28/20 and 2/25/20, the evaluator noted the dietary department was not represented. FSD was present at the meeting representing facility management, plant operations or environmental care. No dietary issues were discussed or reported in the meeting minutes. FSD stated only environmental care was presented during those meetings.

During the same interview, FSD stated that he did not have any performance improvement projects related to the kitchen or dietary services. He added that during the meetings environmental care department was presented because they had a project. FSD also stated Registered Dietitian was not part of the HQC meeting, if there was any project in the nutrition services FSD would be present at the meeting. FSD stated there were no recent performance improvement projects in the nutrition services that he knew. There is no performance improvement project in the kitchen or dietary services.

A review of the job description for the Director of Food services, indicated his job title was Director of Plant Operations. The Director of plant operations plans, organizes supervises and directs the activities of the plant operations staff, including maintenance, environmental services, dietary, patient transportation, materials management and information systems.

A review of a memo dated 2/10/2019 from the hospital CEO indicated that the "responsibility of the safety and security officer for the hospital has also been assigned to the FSD. The Safety and security officer is responsible for intervention whenever environmental condition poses immediate threat to life, health, or damage to equipment or buildings but is not personally liable for any security violations or incidents."
The job description for the FSD did not describe any duties or responsibilities related to dietary services. The job description to the FSD was not specific to the Food and Dietary services.

Based on observation, interview, and document review, the hospital failed to maintain the kitchen, cafeteria and exterior grounds clean, in good repair, and free of conditions that attract pests.

The deficiencies had the potential to attract pest and support the adulteration of food through pest infestation.

Findings:

During the Hospital Complaint Validation survey tour of the physical environment on 3/4/20 at 2:00 p.m., the evaluator observed that the following conditions existed:

1. The evaluator observed a box of pepperoni pizza that was stored on the floor of a walk in freezer in the kitchen.

During document review by the evaluator, policy and procedure titled Food, Left-over and Supply Storage dated 1/95 indicated that supplies shall not be stored on the floor. Also the policy and procedure titled Sanitary Safety dated 1/95 indicated that cases of food should never be stored on the floor.

2. The evaluator observed the accumulation of dust on top of equipment, including reach in refrigerators and freezers in the kitchen and the food storage room.

During document review, the evaluator noted that Cook-2 check-off list in the "Schedule for Daily Cleaning Kitchen Area/A.M, indicated that the areas had been wiped down and the outside surfaces of reach-in refrigerators had been cleaned

3. The evaluator observed stagnant water in the floor sink located at the ice table
area in the cafeteria.

During an interview at the same time as the observations, the Director of Plant Operations stated that the water was stagnant at the floor sink because when the kitchen staff cleaned the ice table they flushed food debris from the ice table into the floor sink.

4. At the exterior behind the kitchen there was pooled waste water/gray water with debris in it on the ground soil located near the trash and garbage/refuse dumpster.

During an interview at the same time as the observations, the Director of Plant Operations stated that the pooled wastewater was from the kitchen staff dumping mop water onto the soil.

5. At the exterior behind the kitchen there was a garbage/refuse dumpster that had both its lids fully opened. There was bagged garbage/refuse in the dumpster at the time of the observation.

During an interview at the same time as the observations, the Director of Plant Operations confirmed that the dumpster was used for the disposal of garbage/refuse.

During document review by the evaluator, policy and procedure titled Disposal of Waste dated 1/95 indicated that all trash receptacles are to be kept with a closed tight fitting cover.

6. On 3/5/20 at 12:00 p.m., during a continued tour of the physical environment, the evaluator observed that the kitchen staff were washing kitchen floor mats at the exterior behind the kitchen with the waste water/gray water flowing onto the ground soil located near the garbage/refuse dumpster.

On 3/5/20 at 2:00 p.m., during a continued tour of the kitchen, the evaluator observed that the following conditions existed:

7. In the kitchen there was a milk crate use to elevated boxes of food product from the floor in a reach in freezer number 13.

8. In the kitchen there was peeling paint at ceiling between a reach in cooler and the ice machine.

9. In the kitchen there was chipping paint at the wall above a food preparation table and sink.

During an interview at the same time as the observations, the Director of Plant Operations stated that the sink was used to drain the liquid out of canned food products.

10. In the kitchen there was a drain line located within a floor sink, bypassing the required air gap.

During an interview at the same time as the observations, the Director of Plant Operations stated that the drain line was from a steamer used to steam vegetables.

11. In the kitchen there was a piece broken off a corner masonry floor coving tile creating a rough, not smooth and not easily cleanable surface.

12. In the cafeteria, by the ice table, there were two drain lines at floor level over the floor sink, bypassing the required air gap.

13. In the cafeteria, there were sections of veneer missing from the tray slides at both sides of the cold table that exposed the absorbable and not easily cleanable plywood. Closer observation revealed that another section of veneer at one of the tray slides was being held on with translucent tape.

During interviews at the time of the observations, the Director of Plant Operations was informed of the deficiencies. During an earlier interview on 3/4/20 at 1:00 p.m., the Director of Plant Operations had stated that he was over maintenance, environmental services, and dietary, and that the three services reported to him.

The 2017 Food Code Recommendations of the United States Public Health Service Food and Drug Administration (2017 FDA Food Code) section 3-305.11 indicates that food shall be protected from contamination by storing the food at least 6 inches above the floor.

The 2017 FDA Food Code section 4-601.11 indicates that nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

The 2017 FDA Food Code section 5-203.13 indicates that at least 1 service sink or 1 curbed cleaning facility equipped with a floor drain shall be provided and conveniently located for the cleaning of mops or similar wet floor cleaning tools and for the disposal of mop water and similar liquid waste.

The 2017 FDA Food Code section 5-205.15 indicates that a plumbing system shall be maintained in good repair.

The 2017 FDA Food Code section 5-402.11 indicates that a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

The 2017 FDA Food Code section 5-501.15 indicates that receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

The 2017 FDA Food Code section 6-101.11 indicates that materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be smooth, durable, and easily cleanable for areas where food establishment operations are conducted.

The 2017 FDA Food Code section 6-201.11 indicates that floors, walls, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable.