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Based on review of facility policies and procedures, job descriptions, personnel files (PF), observational tours, and interviews with staff (EMP) it was determined that the facility failed to ensure that Dietary Services is under the full time direction of a person who is trained and experienced in food services administration and dietary management.

Findings include:

Review on March 13, 2017, of the policy, "Department Roles", dated 06/15, revealed, "Department ... Food Service ... Department Actions ... Follows local and state regulatory requirements for food establishments."

Review of facility document, "Cancer Center Treatment of America Job Description, Executive Chef", on March 15, 2017, revealed, "Section A ... Job Overview ... The Executive Chef plans and directs all activities of the production area with the highest standards of nutritional excellence and service to all CTCA patients and employees. Works with the Director of Nutrition, Sous Chef, Service Supervisor to insure compliance with all Health Department, Joint Commission and ERMC/CTCA policies and procedures ... Section B ... Job Accountabilities ... 3. Supervises and provides training to maintain high standards of sanitation as directed by regulatory agencies and CTCA standards ... 6. Has developed an overall safety plan to improve/maintain department goals."

Observation of the facilities Dietary Department, on March 13, 2017, between 10:11 A.M. and 11:20 A.M., with EMP2, revealed, that no temperature monitoring logs were visibly displayed for any refrigeration unit within the department. EMP2 confirmed that no refrigeration temperature monitoring logs were visibly displayed. EMP2 further confirmed that she was not aware of the department/facility policy on refrigeration temperature monitoring or where refrigeration temperature monitoring logs were maintained for the department. There were two dishwashing units located within the department. No water temperature monitoring logs were visibly displayed for these dishwashing units. EMP2 confirmed that no water temperature monitoring logs were visibly displayed. EMP2 further confirmed that she was not aware of the department/facility policy on monitoring dishwashing units water temperature or where water temperature monitoring logs for dishwashing units were maintained for the department. EMP2 could not confirm how the department was being cleaned and maintained to ensure a sanitary environment. EMP2 could not provide any documented evidence that the department was being cleaned, routinely. EMP2 could not confirm the facility/department policy/procedure for routine cleaning of the department. EMP2 could not provide any documented evidence that the Dietary Department staff received education/training on general cleaning and mold/fungal growth prevention measures.

Observation of the facilities Dietary Department, on March 15, 2017, between 1:15 P.M. and 2:00 P.M., with EMP2, revealed on inspection, that there was no evidence of current air quality monitoring in place, within the Dietary Department, where personnel are physically working. EMP2 confirmed that she was not aware of any current air quality monitoring being performed for the Dietary Department. On further inspection there was no evidence of additional air filtration units, within the Dietary Department, where personnel are physically working. EMP2 confirmed that she was not aware of any additional air filtration units within the Dietary Department. On further inspection there was no evidence of PPE (respiratory masks) within the Dietary Department. EMP2 confirmed she did not know where masks were stored within the Dietary Department. EMP2 confirmed that the department did have an emergency eye wash station. There was no documented evidence of monitoring logs for the eye wash station on inspection of the area. EMP2 confirmed there was no documented evidence of eye wash monitoring logs within the department. EMP2 confirmed that she was not aware of the facility or department policy on monitoring eye wash stations.

Interview with EMP2, on March 13, 2017, between 10:11 A.M. and 11:20 A.M., confirmed that she "took over" the Dietary Department in "December of 2016". EMP2 further confirmed that she does not have a professional background or previous experience in managing a dietary department. EMP2 confirmed that she was in charge of Environmental Services and that she was assigned the Dietary Department because the former director was "let go". EMP2 confirmed that there is no documented evidence that Dietary Department personnel received any written notification, from the facility, about mold/fungal growth within the Dietary Department in 2016 or 2017. EMP2 confirmed that there is no documented evidence that Dietary Department personnel received any written notification, from the facilities Employee Health Department, about mold within the Dietary Department in 2016 or 2017. EMP2 confirmed that there is no documented evidence of any staff meetings held with the Dietary Department personnel in 2016 or 2017. EMP2 confirmed that she meets with the staff "weekly" and utilizes a "communication board" to discuss issues/concerns with the Dietary Department personnel. EMP2 confirmed that there is no documented evidence that the Dietary Department personnel were provided any education/training/in-services related to mold/fungal growth prevention/detection measures in 2016 or 2017. EMP2 confirmed that there is no documented evidence of Dietary Department personnel receiving any annual, on-going training/education/in-services/competencies on cleaning/sanitation standards and responsibilities in 2016 or 2017. EMP2 confirmed that she was not aware of the facilities or department's policy/procedure on cleaning/sanitation standards and responsibilities. EMP2 confirmed that she was not aware of the facilities or department's policy/procedure for monitoring refrigeration unit temperatures or dishwashing unit's water temperatures. EMP2 confirmed that she was not aware of how temperature monitoring logs were maintained within the Dietary Department.

Interview with EMP1, on March 15, 2017, at 10:15 A.M., confirmed that the "Executive Chef" was "in-charge" of the Dietary Department, until the position was eliminated in "December of 2016" due to a "RIF" (Reduction in Force). EMP1 further confirmed that the Director of Environmental Services/Culinary Services in now responsible for the Dietary Department. EMP1 confirmed that there is not a current job description for this position.

Review of PF3, on March 15, 2017, revealed, the employee was the Director of Environmental Services and Culinary Services. PF3 revealed there was no job description for this position. PF3 further revealed no documented evidence that the employee had any previous experience or training in food services administration and dietary management. Further review of PF3 revealed, no documented evidence of any annual, on-going training/education/in-services/competencies for dietary services including on: instruction in personal hygiene; in the proper inspection, handling, preparation, and serving of food; and in the proper cleaning and the safe operation of equipment, in 2016 or 2017.

Based on review of facility policies and procedures, personnel files (PF), observational tours, and interviews with staff (EMP) it was determined that the facility failed to ensure that Dietary Department administrative and technical personnel were competent in their respective duties.

Findings include:

Review on March 13, 2017, of the policy, "Department Roles", dated 06/15, revealed, "Department ... Food Service ... Measures to Reduce Risk Between/Among Staff/Patients ... Department Actions ... Follows local and state regulatory requirements for food establishments."

Review on March 13, 2017, of the policy, "Orientation and Continuing Education Policy", dated 03/17, revealed, "Policy ... It is the policy of Eastern Regional Medical Center that each employee with patient contact is an integral member of the Infection prevention and Control Program and will implement performances to continuously improve the quality of patient care and employee wellness ... Objective ... To provide an educational program of a basic understanding of the potential hazards and safeguards to prevent the spread of infection to patients, visitors and staff ... Procedure ... Methodology ... B. Each employee shall be oriented to specific areas of infection prevention, personal protective equipment storage areas, policies and procedures of the department and appropriate disinfecting products used in cleaning equipment."

Review on March 15, 2017, of the facility policy, "Cleaning of Reach-in Refrigerator", dated 12/5/14, revealed, "Policy Statement ... To follow local and state sanitation polices ... Purpose ... To ensure sanitation and cleanliness on a daily basis."
Review on March 15, 2017, of the facility policy, "Competency", dated 12/5/14, revealed, "Purpose ... The purpose of this plan is to ensure that all food service employees are competent for the job they are performing and situations they may encounter in the course and scope of the position ... Procedure ... 2. On-going on the job training ... 3. In-services ... 4. Visual inspections ... 5. Monthly meeting with staff."
Review on March 15, 2017, of the facility policy, "Departmental Education Program", dated 12/5, revealed, "Purpose ... To ensure all departmental staff are properly trained and provided ongoing and appropriate continuing education ... Procedure ... 4. All food services staff will be given the following training ... b. In-service training during year ... b.4. Proper use and cleaning equipment ... b.5. Safety procedures and policies ... b.7. Sanitation ... b.8. Safety."
Review on March 15, 2017, of the facility policy, "Department Safety", dated 12/5/14, revealed, "Purpose ... To ensure a safe and healthy work environment ... Procedure ... 3. In-service education department in-service meetings, a minimum of one per year will address safety topics."
Review on March 15, 2017, of the facility policy, "Mission Statement of the Food Service Department", dated 12/5/14, revealed, "The food service department of CTCA in Philadelphia is committed to providing superior quality food service by maintaining the highest standards in food quality, food presentation and sanitation."
Review of facility document, "Cancer Center Treatment of America Job Description, Executive Chef", on March 15, 2017, revealed, "Section A ... Job Overview ... The Executive Chef plans and directs all activities of the production area with the highest standards of nutritional excellence and service to all CTCA patients and employees. Works with the Director of Nutrition, Sous Chef, Service Supervisor to insure compliance with all Health Department, Joint Commission and ERMC/CTCA policies and procedures ... Section B ... Job Accountabilities ... 3. Supervises and provides training to maintain high standards of sanitation as directed by regulatory agencies and CTCA standards ... 6. Has developed an overall safety plan to improve/maintain department goals."

Interview with EMP2, on March 13, 2017, between 10:11 A.M. and 11:20 A.M., confirmed that she "took over" the Dietary Department in "December of 2016". EMP2 further confirmed that she does not have a professional background or previous experience in managing a dietary department. EMP2 confirmed that she was in charge of Environmental Services and that she was assigned the Dietary Department because the former director was "let go". EMP2 confirmed that there is no documented evidence of any staff meetings held with the Dietary Department personnel in 2016 or 2017. EMP2 confirmed that she meets with the staff "weekly" and utilizes a "communication board" to discuss issues/concerns with the Dietary Department personnel. EMP2 confirmed that there is no documented evidence of Dietary Department personnel receiving any annual, on-going training/education/in-services/competencies on instruction in personal hygiene; in the proper inspection, handling, preparation, and serving of food; and in the proper cleaning and the safe operation of equipment in 2016 or 2017.

Interview with EMP1, on March 15, 2017, at 10:15 A.M., confirmed that the "Executive Chef" was "in-charge" of the Dietary Department, until the position was eliminated in "December of 2016" due to a "RIF" (Reduction in Force). EMP1 further confirmed that the Director of Environmental Services/Culinary Services in now responsible for the Dietary Department. EMP1 confirmed that there is not a current job description for this position.

Review of PF3, on March 15, 2017, revealed, the employee was the Director of Environmental Services and Culinary Services. PF3 revealed there was no job description for this position. PF3 further revealed no documented evidence that the employee had any previous experience or training in food services administration and dietary management. Further review of PF3 revealed, no documented evidence of any annual, on-going training/education/in-services/competencies for dietary services including on: instruction in personal hygiene; in the proper inspection, handling, preparation, and serving of food; and in the proper cleaning and the safe operation of equipment, in 2016 or 2017.

Review on March 15, 2017, of PF9, revealed, no documented evidence of any annual, on-going training/education/in-services/competencies on instruction in personal hygiene; in the proper inspection, handling, preparation, and serving of food; and in the proper cleaning and the safe operation of equipment in 2016 or 2017.

Review on March 15, 2017, of PF10, revealed, no documented evidence of any annual, on-going training/education/in-services/competencies on instruction in personal hygiene; in the proper inspection, handling, preparation, and serving of food; and in the proper cleaning and the safe operation of equipment in 2016 or 2017.

Based on review of facility policies and procedures, job descriptions, personnel files (PF), observational tours, and interviews with staff (EMP) it was determined that the facility failed to ensure that the infection control officer or officers developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel, as related to mold/fungal growth, in the Dietary Department.

Findings include:

Review on March 13, 2017, of the policy, "Infection Control Program", dated, 06/15, revealed, "Policy ... The Governing Body, Medical Staff and Administration of Eastern Regional Medical Center authorize an Infection control program to establish a mechanism for the surveillance, prevention and control of infection among patients, healthcare workers, and others. The infection Control program activities will ensure compliance with local, state, and federal regulators ... Objectives ... To reduce the risk of hospital acquired infections, both endemic and epidemic, through surveillance methodology and identification of risk factors in patients and health care workers ... To analyze data, identify trends of infection, and implement a plan of resolution ... To determine the required needs of the hospital in providing appropriate staff for surveillance, policy revision, education, consultation and compliance with regulatory standards ... To prevent the spread of infection by implementing Standard precautions, hand hygiene methodology and use of protective barriers when appropriate ... Scope ... All direct patient care and support service departments shall participate in the Infection Control Program ... 1. Structure ... A. Governing Board ... The Governing Board has ultimate authority for implementation of the infection Control Program ... B. Infection Control Committee ... The Infection Control Committee will review aggregate data gathered and determine actions needed to reduce the risk of the transmission and incidence of healthcare acquired infections ... 1. Committee Membership ... b. Infection Preventionist ... The Committee will assign the Infection Preventionist the task of gathering data and preparing data in a reporting modality for analysis ... m. Representatives from Materials Management, Food Service, and other departmental directors will participate as needed when the committee deals with issues related to their respective areas ... 2. Functions of the committee will include ... 1. Mechanisms for effective healthcare acquired infection surveillance ... Mechanisms for obtaining and distributing information to the medical staff ... 3. Determination of effectiveness of policies and procedures related to process or staff performance and compliance, and clinical outcomes ... 5. Reporting ... The findings, conclusions, recommendations, actions taken, follow-up plans to reassess the actions and evaluation of actions taken will be documented in the minutes of the Committee and summarized in quarterly reports. The Committee will forward copies of the minutes and data reports to the Medical Executive Staff, Nursing Executive and safety Commitment at least four times a year. Governing Body will receive quarterly reports ... C. Responsibilities ... The Infection Control Practitioner shall be responsible for ... d. Coordinating educational programs for hospital staff."

Review on March 13, 2017, of the policy, "Hospital Acquired Infection Surveillance Process", dated 06/15, revealed, "Objective ... To outline the methods of surveillance at Eastern Regional Medical Center to limit the spread of infectious organisms and the development of hospital acquired infections (HAI) ... Policy ... Microbiologic Surveillance of the Environment and Personnel ... Patient-care practices are the most important factors influencing the preventable hospital-acquired infections since they usually involve direct personal contact between patients and staff. Still, the patients and staff, the animate environment, are in continuous contact with inanimate environment, thus facilitating the exchange of microorganisms between these two environments. Microorganisms which contaminate the inanimate environment have been associated with sporadic cases of infection and hospital-acquired outbreaks. The inanimate environment must be given proper attention without under-or-overestimating its contribution to infection. A true understanding of the role of the environment in disease transmission is essential to allow the hospital to concentrate personnel and financial resources on areas of greatest importance ... In order to limit unnecessary culturing of the environment or of personnel, such culturing is to be directed and guided by the Infection Control Committee or the Infection Preventionist and should follow a written plan of action".

Review on March 13, 2017, of the policy, "Infection Control Committee Authority Statement", dated 6/15, revealed, "The infection Prevention and Control Committee at Eastern Regional Medical Center has the ultimate responsibility for giving direction and monitoring outcomes as they relate to the prevention and control of infection within the hospital ... It is the policy at Eastern Regional Medical Center that the Infection Prevention and Control Committee, through its Chairperson or a designated physician member, has the ultimate authority to evoke immediate collaborative action by involving the appropriate representatives from the Medical Staff, Nursing, Infection Control, and hospital Administration and to institute any appropriate control measures or studies in situations where there is as potential risk of infection in patients or personnel. This includes danger of person-to-person transmission, as well as conditions present in the hospital environment predisposing to infection."

Review on March 13, 2017, of the policy, "Department Roles", dated 06/15, revealed, "Department ... Food Service ... Measures to Reduce Risk Between/Among Staff/Patients ... Department Actions ... Follows hospital IC P/P as well as department P/P related to IC ... Follows local and state regulatory requirements for food establishments ... Member of Infection Control Committee."

Review on March 13, 2017, of the policy, "Orientation and Continuing Education Policy", dated 03/17, revealed, "Policy ... It is the policy of Eastern Regional Medical Center that each employee with patient contact is an integral member of the Infection prevention and Control Program and will implement performances to continuously improve the quality of patient care and employee wellness ... Objective ... To provide an educational program of a basic understanding of the potential hazards and safeguards to prevent the spread of infection to patients, visitors and staff ... Procedure ... Methodology ... B. Each employee shall be oriented to specific areas of infection prevention, personal protective equipment storage areas, policies and procedures of the department and appropriate disinfecting products used in cleaning equipment ... C. 2. Infection prevention and control in-service programs on specific topics may be requested."

Review on March 13, 2017, of the policy, "Risk Assessment for Construction and Renovation Projects", dated 06/15, revealed, "Policy ... Eastern Regional Medical Center makes certain that appropriate measures are implemented during any demolition, construction, renovation or major utility replacement work to ensure the safety and wellbeing of all patients, visitors and staff ... Objective ... To proactively address the impact of demolition, renovation, new construction or major utility replacement activities have on the following ... Air quality ... Infection Prevention and Control ... D. Procedure ...2. Quality Control ... Eastern ' s Infection Control, Safety, Facilities and Security Departments will monitor areas affected by construction projects regularly ... 4. Infection Control Procedures ... F. Eastern ' s Infection Control, Safety, Facility Services and Security Departments will monitor areas affected by construction projects regularly to ensure compliance with requirements ... 6. Environmental Considerations and Monitoring ... C. Eastern ' s Infection Control, Safety, Facility Services and Security Departments will monitor areas affected by construction projects regularly to ensure compliance ... E. The Infection Control Practitioner will monitor air quality throughout project as needed."

Review on March 13, 2017, of the policy, "Remediation of Fungal Growth", dated 05/17, revealed, " Policy ... To define a remediation procedure to identify and decontaminate areas within the facility found to harbor mold/fungus ... Objectives ... Prevent exposure to staff/patients/visitors ... Define a systematic approach for remediation of fungal growth identified as a result of unexpected moisture/water sources ... Limit and control moisture production by monitoring plumbing and HVAC systems for condensation ... Procedure ... Administration will be notified by the Infection Preventionist as to the scope of the project, the plan of remediation as well as the plan for protecting staff/patients/visitors in the immediate area ... Designation of who will perform the remediation (internal or external) will be identified. If an outside contractor is used, Infection Control/Facilities Management will do education as to how the process will be performed to protect the contractor ' s employees, ERMC employees and ERMC patients ... General Guidelines ... Remediation should be performed immediately within 24-48 hr., thoroughly cleaned and dried. To prevent further mold growth, relative humidity should be maintained at levels below 60% ... Remediation should proceed without delay ... Occupational Health may request Bulk or surface samples be collected to identify specific fungal contaminants as part of a medical evaluation if personnel are experiencing symptoms which may be related to fungal exposure ... The Infection Preventionist will meet with the Department head and the staff to inform them as to the situation, and the process for remediation ... Process ... Remediation includes containment of the area with rigid and impervious barriers from floor to ceiling to prevent generation or spread of spores and dust. Hepa Filters will be placed in the immediate area as well as adjacent area for source containment and particle capture ... Use of appropriate Personal Protective Equipment (PPE) is defined by the size of the area for clean up per OSHA recommendations ... Recommendations for smaller areas of cleanup include use of N-95 Masks, PPE including gloves and eye protection ... Infection Preventionist will document events and report to Infection Control Committee and the Safety Committee."

Review on March 15, 2017, of the facility policy, "Mission Statement of the Food Service Department", dated 12/5/14, revealed, "The food service department of CTCA in Philadelphia is committed to providing superior quality food service by maintaining the highest standards in food quality, food presentation and sanitation."
Review of the facility document, "Cancer Treatment Centers of America at Eastern Regional Medical Center Infection Prevention and Control Program Plan 2016-17", on March 15, 2017, revealed, "Scope ... The Cancer Treatment Centers of America supports the establishment of an effective, facility wide Infection Prevention and Control Program encompassing all patient service areas, diagnostic departments and support services. The Program ' s processes and activities are based on sound epidemiological principles and are designed to promote a safe patient care and work environment. The program is managed directly by the Infection Preventionist ... Administrative guidance is provided by the Director of Quality and Regulatory Affairs. It is the responsibility of the department manager to ensure department participation in the Infection Prevention and Control Program and ensure compliance with all infection control policies and procedures. Each department has an individual responsibility in the program ... Risk Assessment ... Infection Control Committee ... The Infection Control Committee shall be responsible to perform the following functions ... Establishing and operating a surveillance system for identifying and analyzing infections and infectious risks among patients caregivers and stakeholders ... Development and implementation of strategies designed to decrease or eliminate risks of infection ... Identifying, managing and controlling any outbreaks of infection ... Assess the effectiveness of implemented strategies and make adjustments if necessary ... Communicate all activities of the committee to appropriate adjustments if necessary ... The Infection Preventionist shall be responsible for investigating any potential outbreak or cluster of infection reported via stakeholders ... The Infection Preventionist will work with the Chairperson of the Infection Control Committee, Director of Quality, Clinical Laboratory, Nursing and any other appropriate hospital department to both collect data and to implement corrective actions ... The Infection Preventionist will communicate all relevant findings to the administration, medical staff, appropriate hospital departments and public health authorities when indicated ... At the conclusion of the investigation, the Infection Preventionist shall prepare a written final report of the investigation. This report shall outline all findings, conclusions, corrective actions and follow-up to assess effectiveness of actions. This report shall be made available to the Infection Control Committee, appropriate medical and nursing staff, ancillary departments and Administration ... Surveillance of the Environment and Stakeholders ... Patient-care practices are the most important factors influencing the preventable hospital-acquired infections since they usually involve direct personal contact between patients and staff. Still, the patients and staff, the animate environment, are in continuous contact with inanimate environment, thus facilitating the exchange of microorganisms between these two environments. Microorganisms which contaminate the inanimate environment have been associated with sporadic cases of infection and hospital-acquired outbreaks. The inanimate environment must be given proper attention without under-or-overestimating its contribution to infection. A true understanding of the role of the environment in disease transmission is essential to allow the hospital to concentrate personnel and financial resources on areas of greatest importance."

Review of facility document, "Cancer Treatment Centers of America Eastern Regional Medical Center Performance Improvement Plan CY2017", on March 15, 2017, revealed, "Purpose ... This plan provides a framework for monitoring and improving the quality of patient care throughout the organization, to insure that patients are provided high quality care in a safe environment ... Program Objectives ... The Performance Improvement Plan provides a structure and systematic process to assure the following ... That there is integration of all departments and services into the organization-wide effort to improve patient care services and safety for all age groups and populations served ... Processes that are problem prone, involve risks, are hazardous, and may result in sentinel events, are measured, assessed, and targeted areas are identified for further study ... The findings, conclusion, root-cause assessments, recommendations for improvement, actions taken, and the evaluation of the results of those actions, is communicated through established channels to appropriate leaders, departments, and service ... Patient Safety ... Care or services that involve risk or may result in sentinel events ... Care or services provided to high risk populations ... Intensive analysis is performed for the following ... Hazardous conditions ... The organization considers evaluation of the following ... Infection Control ... Leaders are responsible for the following activities ... Implementation and effective use of the continuous Performance Improvement Program ... Ensure that processes that affect patient safety are measured, assessed, and variation is managed ... The leaders set priorities for organization-wide performance improvement activities that are designed to improve patient outcomes, safety and identifies how the hospital adjust priorities in response to unusual or urgent events ... Prioritization of Performance Improvement activities that consider processes that affect a large percent of patients, place the patients at risk, or processes that may likely be problem prone, and address needs to improve ... Assigning and define in writing the actions and recommendations of Performance Improvement activities ... Assessing the effectiveness of the actions taken, and taking new actions when the initial actions do not achieve the desired goal ... Developing communication systems in which Performance Improvement information is shared on all levels ... That clinical practice guidelines are used, leaders evaluate the outcomes related to the use of the guidelines and determine refinements to improve processes ... make recommendations to the Governing Body for actions to be taken with regard to the quality process ... Safety Committee ... The Safety Committee is a multi-disciplinary committee, appointed by the Chief Executive Officer, which reviews the non-clinical aspects of patients, staff and visitor safety. It includes representatives from administration, clinical services and support services ... Infection Control Committee ... The Infection Control Committee is a multidisciplinary committee. It establishes and directs a hospital-wide infection control program. The Infection Control Committee meets at least six times per year, and their responsibilities include ... Approval of actions to prevent or control infections based on evaluation of the surveillance reports of infections, and of the infection potential among patients and hospital personnel ... Reviews and approves all policies and procedures related to the infection surveillance, prevention and control program for a department and/or service ... Quality Management ... The Director of Quality in conjunction with the Quality Improvement Coordinator is responsible for ... Overseeing an ongoing, systematic process to track the evaluation of quality and appropriateness of care ... Developing and establishing standardized formats for reporting ... Communicating the results of the monitoring and evaluation process to the relevant individuals, departments or services, and committees ... Advising committees about the date, information and support available to aid with the required monitoring and evaluation activities ... Maintaining appropriate documentation of improvement activities including cumulative profiles of findings."

Review of facility document, "Cancer Treatment Centers of America Eastern Regional Medical Center Performance Improvement Plan CY2016", on March 15, 2017, revealed, "Purpose ... This plan provides a framework for monitoring and improving the quality of patient care throughout the organization, to insure that patients are provided high quality care in a safe environment ... Program Objectives ... The Performance Improvement Plan provides a structure and systematic process to assure the following ... That there is integration of all departments and services into the organization-wide effort to improve patient care services and safety for all age groups and populations served ... Processes that are problem prone, involve risks, are hazardous, and may result in sentinel events, are measured, assessed, and targeted areas are identified for further study ... The findings, conclusion, root-cause assessments, recommendations for improvement, actions taken, and the evaluation of the results of those actions, is communicated through established channels to appropriate leaders, departments, and service ... Patient Safety ... Care or services that involve risk or may result in sentinel events ... Care or services provided to high risk populations ... Intensive analysis is performed for the following ... Hazardous conditions ... The organization considers evaluation of the following ... Infection Control ... Leaders are responsible for the following activities ... Implementation and effective use of the continuous Performance Improvement Program ... Ensure that processes that affect patient safety are measured, assessed, and variation is managed ... The leaders set priorities for organization-wide performance improvement activities that are designed to improve patient outcomes, safety and identifies how the hospital adjust priorities in response to unusual or urgent events ... Prioritization of Performance Improvement activities that consider processes that affect a large percent of patients, place the patients at risk, or processes that may likely be problem prone, and address needs to improve ... Assigning and define in writing the actions and recommendations of Performance Improvement activities ... Assessing the effectiveness of the actions taken, and taking new actions when the initial actions do not achieve the desired goal ... Developing communication systems in which Performance Improvement information is shared on all levels ... That clinical practice guidelines are used, leaders evaluate the outcomes related to the use of the guidelines and determine refinements to improve processes ... make recommendations to the Governing Body for actions to be taken with regard to the quality process ... Safety Committee ... The Safety Committee is a multi-disciplinary committee, appointed by the Chief Executive Officer, which reviews the non-clinical aspects of patients, staff and visitor safety. It includes representatives from administration, clinical services and support services ... Infection Control Committee ... The Infection Control Committee is a multidisciplinary committee. It establishes and directs a hospital-wide infection control program. The Infection Control Committee meets at least six times per year, and their responsibilities include ... Approval of actions to prevent or control infections based on evaluation of the surveillance reports of infections, and of the infection potential among patients and hospital personnel ... Reviews and approves all policies and procedures related to the infection surveillance, prevention and control program for a department and/or service ... Quality Management ... The Director of Quality in conjunction with the Quality Improvement Coordinator is responsible for ... Overseeing an ongoing, systematic process to track the evaluation of quality and appropriateness of care ... Developing and establishing standardized formats for reporting ... Communicating the results of the monitoring and evaluation process to the relevant individuals, departments or services, and committees ... Advising committees about the date, information and support available to aid with the required monitoring and evaluation activities ... Maintaining appropriate documentation of improvement activities including cumulative profiles of findings."

Review of facility document, "Cancer Treatment Centers of America Patient Safety Plan Calendar Year 2017", on March 15, 2017, revealed, "Purpose ... Eastern Regional Medical Center is committed to patient safety as a priority at all levels. To that end, the organization supports a systematic process for pro-active risk assessment, implementation of mechanisms to measure, analyze and manage variation in the performance of processes that affect safety, and development of a pervasive culture that emphasizes communication and collaboration with respect to error reduction strategies ... Objectives ... Establishment of a pervasive culture for assuring patient safety through ongoing education for all levels of staff and pursuit of new learning with the intent of reducing risk and promoting safety ... Support and coordination of safety event analysis through use of established root cause system analysis, failure mode effect analysis techniques, and other approaches as needed ... Application and use of recognized best practice and current industry knowledge and expertise to modify current processes to reduce risk and promote patient safety ... Promotion of staff involvement with respect to patient safety issues."

Review of facility document, "Cancer Treatment Centers of America Patient Safety Plan Calendar Year 2016", on March 15, 2017, revealed, "Purpose ... Eastern Regional Medical Center is committed to patient safety as a priority at all levels. To that end, the organization supports a systematic process for pro-active risk assessment, implementation of mechanisms to measure, analyze and manage variation in the performance of processes that affect safety, and development of a pervasive culture that emphasizes communication and collaboration with respect to error reduction strategies ... Objectives ... Establishment of a pervasive culture for assuring patient safety through ongoing education for all levels of staff and pursuit of new learning with the intent of reducing risk and promoting safety ... Support and coordination of safety event analysis through use of established root cause system analysis, failure mode effect analysis techniques, and other approaches as needed ... Application and use of recognized best practice and current industry knowledge and expertise to modify current processes to reduce risk and promote patient safety ... Promotion of staff involvement with respect to patient safety issues."

Review of facility documents, "Eastern Regional Medical Center Infection Control Committee Meeting Minutes", dated, "May 25, 2016", "July 27, 2016", "September 23, 2016", "November 23, 2016", and "January 25, 2017", revealed, no documented evidence of any discussion(s) related to mold/fungal growth in the Dietary Department and the potential impact on patient/staff safety, no active monitoring/surveillance of the mold remediation project in the Dietary Department, progress-to-date of the mold remediation project in the Dietary Department, no communication to other departments/services/committees throughout the organization of the mold remediation project, development, implementation, and assessment of strategies designed to decrease or eliminate risks of infection related to the mold remediation project, no educational plans/projects/competencies for Dietary Personnel related to the mold remediation project, no assistance in the monitoring of the employees in the Dietary Department in collaboration with the facility Employee Health Program, and no documented representation from the Dietary Department at the Infection Control Committee meetings.

Review of facilities documents, "Eastern Regional Medical Center Patient Safety Committee Meeting Minutes", dated, "July 13, 2016", "August 10, 2016", "September 14, 2016", " October 12, 2016", "November 9, 2016", "December 14, 2016", "January 11, 2017", "February 8, 2017", and "March 8, 2017", revealed, no documented evidence of any discussion(s) related to mold/fungal growth in the Dietary Department and the potential impact on patient/staff safety, active monitoring/surveillance of the mold remediation project in the Dietary Department, progress-to-date of the mold remediation project in the Dietary Department, communication to other departments/services/committees throughout the organization of the mold remediation project, development, implementation, and assessment of strategies designed to decrease or eliminate risks of infection related to the mold remediation project, no educational plans/projects/competencies for Dietary Personnel related to the mold remediation project, no assistance in the monitoring of the employees in the Dietary Department in collaboration with the facility Employee Health Program, and no documented representation from the Dietary Department at the Patient Safety Committee meetings.

Review of facility documents, "Eastern Regional Medical Center Quality Improvement Committee Meeting Minutes", dated, "6/26/16", "8/23/16", and "10/25/16", revealed, no documented evidence of any discussion(s) related to mold/fungal growth in the Dietary Department and the potential impact on patient/staff safety, active monitoring/surveillance of the mold remediation project in the Dietary Department, progress-to-date of the mold remediation project in the Dietary Department, communication to other departments/services/committees throughout the organization of the mold remediation project, development, implementation, and assessment of strategies designed to decrease or eliminate risks of infection related to the mold remediation project, no educational plans/projects/competencies for Dietary Personnel related to the mold remediation project, no assistance in the monitoring of the employees in the Dietary Department in collaboration with the facility Employee Health Program, and no documented representation from the Dietary Department at the Quality Improvement Committee meetings. Interview with EMP1, on March 15, 2017, at 11:40 A.M. confirmed that that, "QAPI Committee is now part of the Patient Safety Committee", effective in "November 2016", due to a recent "RIF" (Reduction in Force).

Review of facility documents, "Eastern Regional Medical Center Board of Directors Meeting Minutes", dated, "June 30, 2016", "September 29, 2016", "December 1, 2016", and "February 9, 2017", revealed no documented evidence of any discussion(s) related to mold/fungal growth in the Dietary Department and the potential impact on patient/staff safety, no active monitoring/surveillance of the mold remediation project in the Dietary Department, progress-to-date of the mold remediation project in the Dietary Department, no communication to other departments/services/committees throughout the organization of the mold remediation project, no development, implementation, and assessment of strategies designed to decrease or eliminate risks of infection related to the mold remediation project, no educational plans/projects/competencies for Dietary Personnel related to the mold remediation project, and no assistance in the monitoring of the employees in the Dietary Department in collaboration with the facility Employee Health Program.

Review of facility documents, "HSC Builders and Construction Managers Meeting Minutes", dated, "8/4/16", "8/8/16", "9/15/16", "9/29/16", "10/6/16", "10/13/16", "10/27/16", "11/17/16", "12/1/16", "12/15/16", " 1/5/17", " 1/19/17", " 1/26/17", " 2/9/17", and "2/16/17", revealed, documented evidence of discussion(s) related to mold/fungal growth in the Dietary Department and progress-to-date of the mold remediation project in the Dietary Department. Further review of facility documents revealed no discussion of the potential impact on patient/staff safety of the mold remediation project in the Dietary Department, no active monitoring/surveillance of the mold remediation project in the Dietary Department, no communication to other departments/services/committees throughout the organization of the mold remediation project, no development, implementation, and assessment of strategies designed to decrease or eliminate risks of infection related to the mold remediation project, no educational plans/projects/competencies for Dietary Personnel related to the mold remediation project, and no assistance in the monitoring of the employees in the Dietary Department in collaboration with the facility Employee Health Program. Documented evidence is present of attendance by a representative from the Dietary Department as well as by the Infection Preventionist for all meeting dates listed.

Review of facility document, "Philadelphia Dept. of Health/Office of Food Protection Food Facility Inspection Report", dated, "8/18//2016", revealed, "Cancer Treatment Center of America Eastern Regional Medical Center" was "out of compliance" with cleaning and sanitizing of "food contact surfaces", "proper cold handling temperature", "adequate ventilation and lighting", and "standing water observed on the floor in the dishwashing area", which was listed as a "repeat violation". There is documented evidence of citations issued.

Review of facility document, "Philadelp