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Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to conform to all applicable State Laws.

The facility was found to be non-compliant with the following State law:

Select Specialty Hospital Pittsburgh was not in compliance with the following State law related to Act 52 of July 20, 2007, Medical Care Availability And Reduction Of Error (MCCARE) Act - Reduction And Prevention Of Health Care-Associated Infection And Long-Term Care Nursing Facilities ...Section 403. Infection control plan. ... (1) A multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility: (i) Medical staff that could include the chief medical officer or the nursing home medical director. (ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator. (III) Laboratory personnel (iv) Nursing staff that could include a director of nursing or a nursing supervisor. (v) Pharmacy staff that could include the chief of pharmacy (vi) Physical plant personnel."

This is not met as evidenced by:

Based on review of facility documentation and staff interview (EMP), it was determined that the facility failed to ensure a multidisciplinary committee.

Findings include:

Review of facility documentation "Infection Control Policy and Procedure Manual Infection Control Plan" dated July 2015, revealed "Committee structure: ... For larger Hospitals or Hospitals with state mandates to have separate IC (Infection Control) Committee, the IC function can be reported quarterly by the DQM (Director of Quality Management), CNO(Chief Nursing Officer) and Director of Pharmacy. For Hospitals in Pennsylvania additional members will include a community representative not affiliated with the hospital and a representative from the microbiology lab. This committee will meet as required by the state, but no less than quarterly."

Review of facility documentation "Infection Control Committee Meeting" dated August 20, 2015, July 16, 2015, June 18, 2015, May 21, 2015, and April 16, 2015, failed to include Laboratory staff and physical plant."

Interview with EMP1 on October 13, 2015, at approximately 9:20 PM confirmed the above findings and revealed "No I don't see them [Laboratory staff and physical plant]."

Based on tour of the facility and review of facility documents and staff interviews (EMP), it was determined that the facility failed to maintain a sanitary environment.

Findings include:

Review of facility policy and procedure "Cleaning Patient Room after Discharge" revised July 2013, revealed "..... The approach will be as if the patient had an MDRO (multi drug resistant organism) and "terminal cleaning" is required... Privacy-cubicle curtains will be changed between every patient. ... E. Proceed with bathroom cleaning: ... Wipe down the shower tile, shower fixtures and curtain....."

Review of facility policy and procedure "Cleaning Procedure: General Patient Room" revised October 2013, revealed "..... Bathroom cleaning ... with the hospital approved disinfectant, wash mirror, basin and commode to include all fixtures, exposed pipes underneath basin and behind commode......"

Review of facility policy and procedure "Isolation Room Cleaning Procedure" revised October 2013, revealed ".......Daily Cleaning ... clean room and bathroom. ... Discharge (Terminal) Cleaning.... use same procedure for cleaning room with these additional steps... thoroughly clean bathroom....."

Interview with EMP2 on September 21, 2015, at approximately 11:20 AM revealed a laminated cleaning guide. "This hangs on every cleaning cart, they [environmental services] are supposed to using it as a cleaning guide. ..... The restrooms are to be cleaned every day."

1) Tours of the facility on September 21, 2015, at 8:30 AM revealed the following environmental observations:

Room 841 revealed a black substance on the bottom of the shower curtain, bottom of the shower walls, and hard black substance around the drain area. Further observation revealed the shower light did not work.

Room 847 revealed a black substance on the bottom of the shower curtain and hard black substance around the drain area. Further observation revealed the shower light did not work.

Room 851 revealed a hard black substance around the drain and a large amount of hair. Further observation revealed the shower light did not work.

During an interview at the time of the tour EMP2 confirmed the above findings.


2) Observation on October 9, 2015 at approximately 1:15PM of room S846 discharge cleaning revealed the cubicle curtains was not removed and replaced. Review of facility documentation revealed the patient was in contact precautions for VRE.

Interview with EMP8 on October 9, 2015, at approximately 1:15 PM confirmed the above findings and revealed "We only remove them when a patient has C-diff."

Interview with EMP3 on October 9, 2015, at approximately 1:30 PM revealed "They [privacy curtains] should be changed between every patient."

Based on a tour of the facility and review of facility documentation and staff interview (EMP), it was determined that the facility failed to ensure appropriate medical and nursing isolation techniques were followed.

Findings include:

Review of facility policy "Contact/Contact Enteric Precautions" revised April 2013, revealed "... A sign reading 'Contact Precautions' will be posted on the door and on the patient's chart. ... PPE (Personal Protective Equipment) will be available at the entrance to the room. 3. Gowns should be worn when soiling will be likely to occur or when contact with the patient or environmental surfaces that have been contaminated will occur. ... 6. Non-sterile gloves are to be worn by persons having direct contact with the patient and the environment....."

1. During a tour of the facility on September 21, 2015, at approximately 8:30 AM the surveyor observed EMP17 in room 846 and 851 at the patient's bedside with no gown and gloves. The patients were in contact isolation.

2. During a tour of the facility on September 21, 2015, at approximately 11:40 AM the surveyor observed EMP5 exiting room 841 wearing a mask but not wearing a gown and gloves. EMP5 explained that the mask was worn to clean the bathroom in room 841. The patient was in isolation.

3. During a tour of the facility on September 21, 2015, at approximately 1:00 PM the surveyor observed EMP15 in patient isolation room 846 not wearing a gown and gloves. Further tour revealed EMP7 in room 843 not wearing a gown and gloves. The patients were in contact isolation.

During the tour EMP2 confirmed the above findings and that appropriate isolation techniques were not followed.