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.

DANVILLE STATE HOSPITAL 50 KIRKBRIDE DRIVE DANVILLE, PA 17821 April 12, 2018
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the Quality Improvement program included the review of specific performance indicators and /or data elements for all patient related services provided under contract with an outside company, including Dental, Laundry, and Respiratory services.

Findings include:

Review on April 12, 2018, of the facility's "Performance Improvement/Risk Management Program," last reviewed March 2018, revealed no guidance or program components regarding the identification and review of services provided to the facility under contract or arrangement as related to the clinical care of the patient.

Interview with EMP2 and EMP3 on April 12, 2018, at approximately 10:00 AM confirmed the facility's Performance Improvement/Risk Management Program did not provide guidance or program components regarding the identification and review of services provided to the facility under contract or arrangement as related to the clinical care of the patient. EMP3 confirmed there were no specific performance indicators and / or data elements for all patient related services provided under contract with an outside company.

Review on April 12, 2018, of the facility provided list of contracted services revealed Dental, Laundry, and Respiratory were services provided to the facility under contract.

Review on April 12, 2018, of the facility's Quality Improvement committee meeting minutes for January to December 2017 and January to March 2018 revealed no documentation the facility reviewed specific performance indicators and / or data elements for the Dental, Laundry, and Respiratory services.

Interview with EMP3 on April 12, 2018, at approximately 10:15 AM confirmed the facility's Quality Improvement committee meeting minutes for January to December 2017 and January to March 2018 revealed no documentation the facility reviewed specific performance indicators and / or data elements for the contracted services related to the clinical care of the patient. EMP3 confirmed Dental, Laundry, and Respiratory services were provided under contract to the facility.
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure all hair was restrained by hair restraints for staff working in the Dietary Department; the facility failed to ensure dietary staff washed their hands after contact with a trash container and after adjusting a hair net; the facility failed to ensure a sanitary environment in the walk-in freezers in the dietary department; the facility failed to ensure cleaning chemicals were stored away from food; and the facility failed to ensure a sanitary environment in the dietary department.

Findings include:

1) Review on April 10, 2018, of the facility's "7071 Food Services Program 7071.6 Sanitation And Safety" policy, last reviewed March 2018, revealed "A. General Policy It is the policy of the Department to provide a safe and secure working environment. Each food services department will develop its own policies and procedures and maintain them in the Food Service Department Operating Manual. ... C. Safety 1. Personal Hygiene and Grooming ... (a) Hair Covering 1. All female employes [sic] must wear hairnets that completely cover the hair at all times in all food service areas. 2; Male employes [sic] with short hair must wear disposable caps. 3. Male employes [sic] with over-the-ear and longer hair must wear hairnets that completely cover the hair at all times in all food services areas. 4. Male employes [sic] with beards must wear "beard bags" at all times in all food service areas. ..."

Observation on April 9, 2018, of EMP6, EMP7, EMP8, EMP9, EMP10, EMP11, EMP12 and EMP13 revealed these employees preparing and distributing food for patient consumption without all hair restrained in the hairnet.

Interview with EMP4 and EMP5 on April 10, 2018, at the time of the observation confirmed EMP6, EMP7, EMP8, EMP9, EMP10, EMP11, EMP12 and EMP13 were preparing and distributing food for patient consumption without all hair restrained in the hairnet.

2) Review on April 9, 2018, of the facility's "Good Handwashing Habits" policy, no review date, revealed "Frequent and thorough handwashing is one of the most effective ways of preventing the spread of infections, especially a [DIAGNOSES REDACTED] infection. Handwashing is important especially in the healthcare settings where there is a greater need to prevent infections. Hands should be washed going to work, before each meal, before and after using the restroom, between each client, and when performing procedures that require use of gloves. Hands should still be washed after disposable gloves are removed. ..."

Observation of EMP9 on April 9, 2018, revealed the employee lifted the lid of the trash can with gloved hands, placed garbage in the trash can, replaced the lid and proceeded to the food preparation area. EMP9 did not remove their gloves, wash their hands, and replace the gloves.

Interview with EMP5 on April 9, 2018, at the time of the observation confirmed EMP9 lifted the lid of the trash can with gloved hands, placed garbage in the trash can, replaced the lid, and proceeded to the food preparation area. EMP5 confirmed EMP9 did not remove their gloves, wash their hands and replace the gloves. EMP5 confirmed EMP9's gloves were considered contaminated when touching the trash can lid.

Observation of EMP10 on April 9, 2018, revealed the employee was distributing food for patient consumption. With gloved hands, EMP10 adjusted their hair that was not contained in the hair net. EMP10 then continued distributing food on the tray line for patient consumption.

Interview with EMP5 on April 9, 2018, at the time of the observation confirmed EMP10 was distributing food for patient consumption and with gloved hands adjusted their hair that was not contained in the hair net. EMP5 confirmed EMP10's gloves were considered contaminated when touching hair.

3) Review on April 9, 2018, of the facility's "Monthly Cleaning Assignment Dietary Custodial Workers" form, no review date, revealed "... Clean Freezer Floors .... (Quarterly) ..."

Observation on April 9, 2018, of the facility's two walk-in freezers revealed an accumulation of torn paper and plastic debris, pieces of packaging material debris, cardboard debris, and dried frozen food debris on the floor of each of these freezers.

Interview with EMP4 and EMP5 on April 9, 2018, at the time of the observation confirmed the accumulation of torn paper and plastic debris, pieces of packaging material debris, cardboard debris, and dried frozen food debris on the floor of each of these walk-in freezers.

4) Review on April 9, 2018, of the facility's "Sanitation / Safety Inspection Record" form, no review date, revealed "General Inspection Criteria ... 2. Food is stored properly: 6" off floor, away from walls / good air circulation around it; separate of chemicals, at proper temperature ..."

Observation on April 9, 2018, of the facility's Dietary Department revealed a cart with a pail containing white suds. Interview with EMP5 revealed this pail contained soapy water for cleaning. On the cart, there was also a container of celery and a container of carrots.

Interview with EMP4 and EMP5 on April 9, 2018, at the time of the observation confirmed the pail of soapy water for cleaning and the containers of celery and carrots. EMP5 confirmed food should not be stored near cleaning solutions.

5) A request was made of EMP4 and EMP5 for a facility policy, procedure or guideline for cleaning the light fixtures above the soup kettle area. No policy was provided.

Observation on April 9, 2018, of the facility's Dietary Department revealed 12 light fixtures above the soup kettle area. These lights had a thick accumulation of dust and grease on all the horizontal surfaces of the outer light fixtures.

Interview with EMP4 and EMP5 on April 9, 2018, at the time of the observation confirmed the 12 light fixtures above the soup kettle area and these lights had a thick accumulation of dust and grease on all the horizontal surfaces of the outer light fixtures.

Observation of EMP13 on April 9, 2018, revealed the employee removed a food thermometer protected by a plastic sheath from the uniform pocket, placed the thermometer and plastic sheath in their mouth, bit down on the sheath, removed the thermometer, and begin to obtain the temperature of the food.

Interview with EMP5 on April 9, 2018, at the time of the observation confirmed EMP13 removed a food thermometer protected by a plastic sheath from their uniform pocket, placed the thermometer and plastic sheath in their mouth, bit down on the sheath, removed the thermometer, and begin to obtain the temperature of the food. EMP5 revealed this was not appropriate and did not follow proper infection control.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure the electrical cables and ligature points were not accessible to patients on the patient care units (310, 311 and 211).

Findings include:

Review on April 9, 2018, of the facility's "Consumer Safety" policy, last reviewed February 2018, revealed "Purpose: To maintain a hospital wide consumer safety program to reduce risk to consumers. Policy: Danville State Hospital (DHS) will maintain an ongoing, pro-active and reactive program for the identification and management of risks to consumer safety. Definition: Ligature Risk - A ligature risk (point) is defined as anything which could be used to attach a rope, cord, or other material for the purpose of hanging or strangulation. Ligature points include rails, coat racks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures. ..."

Review on April 9, 2018, of the facility's "Improving Safety by Reducing Ligature Risks" training, no review date, revealed "In psychiatric hospitals, the most frequent method of suicide is hanging, and 75% of inpatient suicides occur in the patient's bathroom, bedroom, or closet. The patient's bathroom is the one area where a patient can be assured of some privacy for a certain amount of time. ... A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include rails, coat racks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures. ... The most common ligature points and ligatures are doors, hooks/handles, windows, and belts or sheets/towels. The use of shoelaces, doors, and windows have increased over time. ... The presence of ligature risks in the physical environment of a psychiatric patients compromises the patient's safety. This is particularly an issue for a patient with suicidal ideation. Our consumers have the right to receive care in a safe setting. Safety risks in a psychiatric setting include but are not limited to furniture that can be easily moved or be thrown; sharp objects accessible by patients; areas out of view of staff; access to plastic bags (for suffocation); oxygen tubing; equipment used for vital signs or IV [intravenous] fluid administration; breakable windows; access to medications; access to harmful medications; accessible light fixtures; non-tamper proof screws; etc. ..."

Patient unit 310:

1) Observation on April 9, 2018, of patient care unit 310 revealed electric beds in patient rooms 2211, 2212, 2213, 2215, 2226, 2227, 2238, 2240, 2241 and 2242. These beds had electrical cords extending from under the bed to the wall electrical outlet.

Interview with EMP2 and EMP 4 on April 9, 2018, at the time of the observation confirmed the electric beds in patient rooms 2211, 2212, 2213, 2215, 2226, 2227, 2228, 2238, 2240, 2241 and 2242, and these beds had electrical cords extending from under the bed to the wall electrical outlet. EMP4 revealed these electrical cords measured approximately 8 feet long. Interview with EMP2 confirmed these electrical cords posed a risk to patients with suicidal thoughts.

2) Observation on April 9, 2018, of the visitor room on patient care unit 310 revealed a wall mounted TV. There was an electrical cable and cable wire coming from behind the TV to the cable and electrical outlet behind the TV. These wires were easily accessible to patients.

Interview with EMP2 on April 9, 2018, at the time of the observation confirmed the wall mounted TV in the visitor room; the electrical cable and cable wire coming from behind the TV to the cable and electrical outlet behind the TV; and these wires were easily accessible to patients. EMP2 and EMP4 confirmed the cable and electrical wires posed a safety risk to patients with suicidal thoughts.

3) Observation on April 9, 2018, of the patient bathrooms on patient care unit 310 revealed these bathroom doors were unlocked and the area accessible to both ambulatory and wheelchair patients. Further observation of these patient bathrooms revealed a locked door in these bathrooms. These door handles were lever door handles on the outside of the door.

Interview with EMP2 on April 9, 2018, at the time of the observation confirmed the patient bathrooms doors on patient care unit 310 were unlocked; the area was accessible to both ambulatory and wheelchair patients; these patient bathrooms had a locked door in these bathrooms and these door handles were lever door handles on the outside of the door. EMP2 confirmed lever door handles were ligature risks and posed a safety risk to patients with suicidal thoughts.

Patient unit 311:

1) Observation on April 9, 2018, of patient care unit 311 revealed electric beds in patient rooms 1113, 1114, 1118, 1130, 1131 and 1132. These beds had electrical cords extending from under the bed to the wall electrical outlet.

Interview with EMP2 and EMP 4 on April 9, 2018, at the time of the observation confirmed the electric beds in patient rooms 1113, 1114, 1118, 1130, 1131 and 1132, and these beds had electrical cords extending from under the bed to the wall electrical outlet. EMP4 revealed these electrical cords measured approximately 8 feet long. Interview with EMP2 confirmed these electrical cords posed a risk to patients with suicidal thoughts.

2) Observation on April 9, 2018, of the visitor room on patient care unit 311 revealed a wall mounted TV. There was an electrical cable and cable wire coming from behind the TV to the cable and electrical outlet behind the TV. These wires were easily accessible to patients.

Interview with EMP2 on April 9, 2018, at the time of the observation confirmed the wall mounted TV in the visitor room; the electrical cable and cable wire coming from behind the TV to the cable and electrical outlet behind the TV; and these wires were easily accessible to patients. EMP2 and EMP4 confirmed the cable and electrical wires posed a safety risk to patients with suicidal thoughts.

Patient unit 211:

Observation on April 9, 2018, of patient care unit 211 revealed an electric bed in patient room 2046. The bed had an electrical cord extending from under the bed to the wall electrical outlet.

Interview with EMP14 on April 9, 2018, at the time of the observation confirmed the electric bed in patient room 2046 with an electrical cord extending from under the bed to the wall electrical outlet. EMP14 confirmed the electrical cord posed a risk to patients with suicidal thoughts.