The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

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 <<Facility>> 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.