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Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its patients and staff. This deficient practice had the potential to affect all patients.

Findings included:

During a tour of the facility the afternoon of 6/6/16 accompanied by Staff #2, the following was observed:

There was a thick layer of dust on the horizontal surfaces of the crash cart in the Cardiac Rehab department. There was also a thick layer of dust on high and low horizontal surfaces in the Respiratory patient supplies storage room. This presents a risk for cross contamination.

There were five corrugated external shipping boxes in Central Supply on the shelving units above and next to supplies available for patient use, including baby powder, bed pans, steri-strips, gloves, and other items. There were also external shipping boxes in the OR storage, next to and above nasal cannulas and ice packs. In the storage closet on the kitchen, a corrugated box of paper towels was stored on the floor. Storing patient use items in contact with a contaminated external shipping box/container, makes cross contamination likely.

The double external doors to Central Supply had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building. The lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.

The emergency call light in the Cardiac Rehab patient bathroom was observed knotted around the handicap grab bar, rendering it ineffective for a patient experiencing a fall on the floor to summon help in an emergency. There was no call light available for patient in the Pre-op/post-op patient bathroom, creating a risk that a patient could not summon assistance in an emergency.


In the Patient Nourishment room, the following was observed:
1. Oralyte, 1 liter container was opened and partially full, with no label to indicate date opened.
2. Osmolite, 8 ounce containers, expired 5/1/16/, quantity of 5.
3. Glucerna, 8 ounce containers, expired 1/2016, quantity of 1.
4. A sticky one gallon container of Molasses was in the cabinet above the sink, partially empty, which expired 2/18/12. There were drips of molasses on the container and on the shelf.

The vinyl pad on the OR table in OR-1 had tears on 3 out of 4 corners. The portable chair scale in the storage area, used in patient care had tears and punctures in the vinyl and the arms on the chair were broken and taped. The 3 x 6 foot table pad in Radiology had a 4 inch slice and tears and approximately 5 feet of the side of the pad was covered in tape due to a tear. The tears on the vinyl exposed the porous material beneath the vinyl covering. This porous material cannot be adequately cleaned between patients, and could harbor pathogens.

There was a 500 ml IV bag of 0.9% NaCl which expired 5/16 in the crash cart in the Cardiac Rehab department. In addition, there was no means to determine whether the larnygoscope blades in the crash cart had been sterilized or high level disinfected as the laryngoscope blades were in a zipper baggie and not in a peel pack.

Review of facility policy, Laryngoscope Blades and Handles Cleaning and Disinfection, Policy 1990280, stated, in part, "Laryngoscope Blades will be processed as follows: 1. via either sterlization (sic) or high level disinfection in Steris ...4. Packaged in peel pack (Long -term)."

Review of facility policy, Patient Nourishment and Floor Stock, Policy 2064170, stated, in part, " Opened multiple-use containers (such as peanut butter) MUST be dated the DAY the container is opened. "

The above findings were confirmed the afternoon of 6/4/16 with Staff #2 during the tour.

Based on observation, interview and record review the Governing Body failed to:

1) Identify areas for potential transmission of infections as the Dietary Department failed to provide a sanitary environment for the preparation, service and storage of food, and failed to ensure sanitary practices were followed in kitchen cleaning and sanitization. Kitchen staff were not trained in safe food handling practices. These deficient practices had the potential to cause a food-borne illness to all patients, staff, and visitors served food prepared at Comanche County Medical Center. There were also areas of dust in the facility, contaminated items stored with patient supplies, torn vinyl on patient care equipment which could not be disinfected and other infection control issues.
Cross refer C0270 Provision of Service

2) Ensure the Quality Assessment Performance Improvement program included all departments as evidenced by the lack of representation of the Dietary Department in the QAPI program.
Cross refer C0330 Periodic Evaluation and Quality Assurance Review

3) Develop, implement, maintain and approve a written, effective, ongoing, organization-wide, data-driven Patient Safety Program; and failed to ensure that staff were provided with job specific orientation and training, job descriptions, and performance evaluations to safely and effectively perform their job duties.
Cross refer C0241 Governing Body Responsible

Based on review of documents, interviews, and state requirements for patient safety programs, the governing body failed to develop, implement, maintain and approve a written, effective, ongoing, organization-wide, data-driven Patient Safety Program; and failed to ensure that staff were provided with job specific orientation and training, job descriptions, and performance evaluations to safely and effectively perform their job duties.

Findings included:

Review of 25 Texas Administrative Code (TAC) 133.48(a)(2) stated, in part:
The hospital must develop, implement and maintain an effective, ongoing, organization-wide, data-driven Patient Safety Program (PSP).
(A) The governing body must ensure that the PSP reflects the complexity of the hospital's organization and services, including those services furnished under contract or arrangement, and focuses on the prevention and reduction of medical errors and adverse events.
(B) The PSP must be in writing, approved by the governing body and made available for review by the department. It must include the following components:
(i) the definition of medical errors, adverse events and reportable events;
(ii) the process for internal reporting of medical errors, adverse events and reportable events;
(iii) a list of events and occurrences which staff are required to report internally;
(iv) time frames for internal reporting of medical errors, adverse events and reportable events;
(v) consequences for failing to report events in accordance with hospital policy;
(vi) mechanisms for preservation and collection of event data;
(vii) the process for conducting root cause analysis;
(viii) the process for communicating action plans; and
(ix) the process for feedback to staff regarding the root cause analysis and action plan.

Review of 25 TAC 133.48(a)(3) stated, in part:
The hospital must provide patient safety education and training to staff who have responsibilities related to the implementation, development, supervision or evaluation of the PSP. Training must include all PSP components as set out in paragraph (2)(B) of this subsection.

Findings included:

In an interview with the Chief Nursing Officer the afternoon of 6/9/16, a request was made by the surveyor to review the hospital Patient Safety Program. The regulation, 25 TAC, Chapter 133.48 was reviewed with the Chief Nursing Officer, who stated that the facility had most of the components, but did not have a Patient Safety Program in writing, approved by the governing body; there was no documented evidence of a Patient Safety Program provided to the surveyor.

Review of the personnel records for 26 out of 26 hospital staff (Staff #3, 4, 5, and 12 - 34) revealed no documented evidence of Patient Safety Program training.

The above findings were confirmed in an interview the afternoon of 6/9/16 with Chief Nursing Officer in the hospital conference room.

Based on observation, interview and record review the governing body failed to:

1) Identify areas for potential transmission of infections as there were areas of dust in the facility, contaminated items stored with patient supplies, and torn vinyl on patient care equipment which could not be disinfected. The Dietary Department failed to provide a sanitary environment for the preparation, service and storage of food, and failed to ensure sanitary practices were followed in kitchen cleaning and sanitization. These deficient practices had the potential for cross contamination.
Cross refer C0278

2) Ensure that dietary services were provided in accordance with recognized dietary standards to provide a sanitary environment for the preparation, service and storage of food, and failed to ensure sanitary practices were followed kitchen cleaning and sanitization. Kitchen staff were not trained in safe food handling practices. These deficient practices had the potential to cause a food-borne illness to all patients, staff, and visitors served food at Comanche County Medical Center.
Cross refer C0279

Based on observation, interview, and document review, the facility failed to identify areas for potential transmission of infections as the Dietary Department failed to provide a sanitary environment for the preparation, service and storage of food, and failed to ensure sanitary practices were followed in kitchen cleaning and sanitization. Kitchen staff were not trained in safe food handling practices. These deficient practices had the potential to cause a food-borne illness to all patients, staff, and visitors served food prepared at Comanche County Medical Center. There were also areas of dust in the facility, contaminated items stored with patient supplies, and torn vinyl on patient care equipment which could not be disinfected.

Findings included:

In an interview with the Infection Control Director the morning of 6/8/16, she stated that she only swabbed the food preparation areas and did not include the kitchen area of the hospital in environment of care rounds. Review of the Infection Control Assessment provided by the Infection Control Director revealed that Environmental Hygiene item, "Food Safety Failure" was assessed as a "Rare" probability, with current systems rated as "Good". Review of documentation and interview revealed that the Infection Control Director did not have a system for monitoring, identifying and/or reporting of all areas of the hospital for potential infections identified during the facility tours documented below.

A tour was conducted of the Comanche County Medical Center Hospital Kitchen and food service area the afternoon of 6/6/16 accompanied by the Kitchen Manager. The following items and areas were observed in need of cleaning and available for use in food preparation, presenting a risk for cross contamination and a risk for food-borne illness:
1. The floor in the kitchen was in need of cleaning as there was raised debris, dried food-like substances, and a greasy layer in and around stoves, refrigerators, sinks, and other kitchen equipment.
2. The tops of containers, plastic lids, shelving units, food containers and boxes had a greasy substance throughout the kitchen; there was a greasy substance on horizontal surfaces in the kitchen, indicating a need for cleaning.
3. There was a large industrial mixer on a stand which was in need of cleaning as there was a dried, raised substance which appeared to be food on the mixer directly above the bowl; in addition, there was excessive amount of rust on the mount where the paddles attach directly above the bowl. When the surveyor touched the mount with a paper towel, pieces of rust and dried food fell into the bowl.
4. There was an industrial manual can opener mounted to a food prep table, which was dirty with a thick brown/black substance and rust on the blade, the handle, the shaft, and the mount, increasing the risk of food contamination.
5. The kitchen ice machine was in need of cleaning as there was a black substance on the inside of the compartment containing the ice. The black substance was readily wiped off by the surveyor onto a clean white paper towel. There were drips on the front of the ice machine.
6. There was 1 large tray used in food preparation which had a greasy substance on it.
7. There was a stack of bowls which were stored in the upright position with an oily coating in the bowls.
8. There were 3 large muffin tins with a thick carbon build-up, rust, and what appeared to be dried food. The carbon build-up does not allow the pans to be cleaned properly causing possible food-borne illness.
9. There were 3 large sheet pans which had a thick carbon build-up and what appeared to be dried food and a greasy film. The carbon build-up was raised and flaking off on the inside of the pans.
10. There were 2 large muffin tin with a thick carbon build-up and what appeared to be dried food in the muffin container.
11. There was a cake pan with dried food adhered to the inside.
12. There were 3 pans which were stacked together which had not dried before stacking and were wet. This creates a risk for cross contamination in a moist environment.
13. There was a shelving unit containing clean plates, cups, and bowls, available for patient use, which was in need of cleaning as there was a greasy substance on the shelves. On the bottom shelf there was a large plate which was covered with a greasy substance, dust, and what appeared to be dried food particles.
14. There were 3 hand operated small can openers which were rusted.
15. There were 8 ladles hanging on the side of a rack with the bowl side up. There were dust and dried particles in the bowl of the ladles.
16. There were approximately 14 spice bottles, 13-16 ounces each, which were on a shelf over the food prep table. All the containers were covered with a sticky substance and were visibly dirty. There was a bottle of pumpkin pie spice which was dated 2013, a bottle of sage which was dated 2013, and a bottle of thyme which was dated 2014.
17. The bulk flour container was partially full of flour and a large scoop stored in the bin with the handle of the scoop touching the food product which creates a risk for cross contamination. The bin was not labeled with the date or the contents. There were 4 drips down the inside of the container touching the flour.
18. The bulk sugar container was partially full of sugar and a large scoop stored in the bin with the handle of the scoop touching the food product. The bin was not labeled with the date or the contents. There were 3 drips down the inside of the container touching the sugar.
19. There was a large plastic bin containing bread crumbs with a large scoop stored in the bin with the handle of the scoop touching the food product. There was a greasy substance on lid of the container. There was no date to determine the age or expiration date of the bread crumbs.
20. The Kitchen Manager was unable to provide a process for how the bulk flour, sugar, and bread crumb bins were cleaned, and was unable to determine how old the food product was. The Kitchen Manager stated during the observation that she was unaware that scoops could not be stored in the bins.
21. There were office supplies, including a pen, a Sharpie marker, and a roll of tape stored in a drawer of the food prep table with scoops, can openers, spoons, and other utensils used in food preparation. Cooking utensils should not be stored in the same drawer as office supplies.
22. The front of the refrigerators were in need of cleaning as there were drips down the front of the refrigerators.
23. The exterior of the ovens were dirty with a greasy film.
24. There was a 4 foot by 2 inch tear and scrape in the wall near the refrigerators including an area approximately 18 inches long where the sheetrock was exposed. Holes in the porous sheetrock cannot be disinfected.
25. There were 3 handwashing sinks in the kitchen. There was only 1 large plastic trash can near one of the sinks which had a lid on it. The surveyor observed food service staff wash and dry their hands, and there was no means to throw away paper towels used to dry hands except to touch the [contaminated] lid on the trash can.
26. In the storage closet on the kitchen, a corrugated box of paper towels was stored on the floor. Storing boxes on the floor presents a risk for contamination by dirt, dust, or insects, or during cleaning of the floors.

Review of the dishwasher temperature log for the first 6 days in June 2016 revealed the following out or range temperatures, below the 120 degree minimum temperature for washing dishes:
· June 1 AM: 60
· June 1 PM: 85
· June 2 AM: 70
· June 2 PM: 80
· June 3 AM: 60
· June 6 AM: 60
· Review of the logs for the previous months revealed the following:
· January 2016: 13 temperatures were documented below 120 degrees, and 4 cycles were not documented and were left blank.
· February 2016: 22 temperatures were documented below 120 degrees and 1 cycle was not documented and was left blank.
· March 2016: 29 temperatures were documented below 120 degrees.
· April 2016: 32 temperatures were documented below 120 degrees and 5 cycles were not documented and left blank.
· May 2016: 35 temperatures were documented below 120 degrees and 1 cycle was not documented and left blank.

There was no documented evidence that the low temperatures were reported or reviewed. When asked about the out of range/below normal dishwasher temperatures, the Kitchen Manager stated, " Oh, they don ' t know how to do it right " referring to the food service workers.

The Dishwasher Temperature log form did not state the safe temperature ranges. The form also did not provide instructions outlining the steps to be taken if the temperature was out of range. In addition, there was no log or documentation to determine that the right concentration of chemical sanitizing agent was being used in the dishwasher. This presents a risk that dishes and utensils may not be cleaned or sanitized before use.

A document entitled, " Ware Washing Machines & Dish Room Best Practices " provided to the surveyor by the Kitchen Manager during the tour stated, " 1. A Chemical Sanitizing Agent, typically Chlorine, (Sodium Hypochlorite) at a minimum concentration of 50 PPM, is mixed in with the Final Rinse Water and sprayed on to the Ware during the Final Rinse Cycle. 2. Typically, the Temperature of the water & Chlorine Sanitizer mixture delivered / sprayed onto the Ware ' s during Final Rinse must be maintained at a temperature no lower than 120 [degrees]. 3. Low Temperature, Chemical Sanitizing Dish Machines, require that the Wash Water be maintained at a minimum Temperature of 120 [degrees] F. "

A second tour was conducted of the Kitchen Area the morning of 6/8/2016 accompanied by the Infection Control Director. The following items and areas were observed in need of cleaning and available for use in food preparation, presenting a risk for cross contamination and a risk for food-borne illness:

At the 3-sink dishwashing area in use, only two out of three commercial sinks were in use for manually washing, rinsing, sanitizing dishware, equipment and utensils. The Kitchen Manager stated that the sink on the left contained sanitizing solution, however this sink contained what appeared to be soapsuds and foam bubbles, with dirty yellow streaks in the foam; there were also black specs throughout the foam. The Kitchen Manager confirmed that the sanitizing solution should be clear, without foam, bubbles, streaks, or black specs. The Kitchen Manager stated that this was the way the sanitizing solution appeared after using the automatic sanitizer dispenser and also stated that the water was " greasy " and left a ring of grease in the sink when the sink was drained after "sanitizing" the dishes. The Kitchen Manager stated that " I washed the dishes yesterday and it was that way yesterday, too. " The Kitchen Manager stated that the sanitizer water had been contaminated in this manner every day for " a few months. " When asked by the surveyor, the Kitchen Manager confirmed that this " sanitizing solution " , containing white and dirty yellow foam suds and black specs throughout, was used by the staff in washing the dishware used in food preparation for patient meals. The Kitchen Manager confirmed that the obviously contaminated solution had been used to " sanitize " the dishes for " a few months " . When asked if the contaminated sanitizer issue had been reported to her manager or to the vendor for the sanitizer dispensing equipment, the Kitchen Manager stated that the issue had not been reported. There was another 3-sink dishwashing area on the other side of the kitchen which was not in use.

Per the current standard found in 25 Texas Administrative Code §228.107 (b)(1), "Except as specified in paragraph (3) of this subsection, a sink with at least three compartments shall be provided for manually washing, rinsing, and sanitizing equipment and utensils.
(2) Sink compartments shall be large enough to accommodate immersion of the largest equipment and utensils. If equipment or utensils are too large for the warewashing sink, a warewashing machine or alternative equipment as specified in paragraph (3) of this subsection shall be used.
(3) Alternative manual warewashing equipment may be used when there are special cleaning needs or constraints and its use is approved."

When asked for a log demonstrating that the sanitizing solution used in washing dishware, equipment and utensils had been tested, the Kitchen Manager stated that a log was not maintained. Verification of proper sanitizer concentration is done by using sanitizer test strips and maintaining a log of the results.

Other findings during the tour on 6/8/16 accompanied by the Infection Control Director included the following:

1. The Dry Food Storage room was excessively humid with a humidity of 70%, per a humidity instrument in the Dry Storage room. There were several round unopened cardboard boxes of oatmeal which had become warped due to the excessive humidity.
2. The floor in the dry food storage room was sticky and visibly splotchy and appeared to be greasy. In an interview with the Kitchen Manager, she stated that the staff had spilled a bottle of ginger ale the previous day and had only mopped it with water and had not cleaned the floor.
3. None of the food in the dry food storage room was labeled to determine expiration dates or to process food by the first in, first out method of rotation. When asked if and how the food stock was rotated, the Kitchen Manager did not have a response. There was no means to determine how long food had been in the facility or if the "first in, first out" method was being followed.
4. There was an open insect trap on the floor in the dry food storage room with approximately 5 dead insects. There were 3 dead insects on the floor underneath the food shelving unit. There was other trash and raised debris on the floor underneath the food shelving units.
5. The Kitchen Manager stated that the ice machine had been cleaned the previous day. The surveyor wiped a clean white paper towel inside the ice machine compartment and a black substance was again observed on the paper towel, indicating the ice machine was still in need of cleaning.
6. The industrial can opener had been cleaned on the previous day, per the Kitchen Manager, however the metal paint was chipped and the can opener was rusted near the blade, presenting a risk that paint chips or rust could flake off into food.
7. The industrial mixer had been cleaned of dried food from 6/6/16, however the mount for the paddles over the bowl was still coated with rust which rubbed off when touched with a paper towel. This presents a risk that rust particles could contaminate food prepared in the mixer.

The above findings were confirmed during the tour the morning of 6/8/16 with the Infection Control Director in the hospital kitchen.

Review of the personnel folder for 3 out of 3 kitchen food service workers (Staff #16, 17, and 18) revealed no documented evidence of orientation or training related to kitchen duties or safe food handling. In an interview with the Kitchen Manager on 6/6/16, she stated that food service workers were provided orientation training " on the computer " . There was no documented evidence of an orientation or training program for the food service workers provided. In an interview with Staff #18 (date of hire 2007) the afternoon of 6/8/16 in the kitchen area, when asked about the training she had received during her employment, she stated, " not much. " In an interview with Staff #16 (date of hire 11/16/15), she stated that there was no training except for general orientation and computer training. Staff #2 confirmed that the computer training that Staff #16 received was not training in food handling and safe practices, but was emergency and disaster response training.

During a tour of the facility the afternoon of 6/6/16 accompanied by Staff #2, the following was observed:

There was a thick layer of dust on the horizontal surfaces of the crash cart in the Cardiac Rehab department. There was also a thick layer of dust on high and low horizontal surfaces in the Respiratory patient supplies storage room. This presents a risk for cross contamination.

There were five corrugated external shipping boxes in Central supply on the shelving units above and next to supplies available for patient use, including baby powder, bed pans, steri-strips, gloves, and other items. There were also external shipping boxes in the OR storage, next to and above nasal cannulas and ice packs. In the storage closet on the kitchen, a corrugated box of paper towels was stored on the floor. Storing patient use and food preparation items in contact with a contaminated external shipping box/container, makes cross contamination likely. Storing boxes on the floor presents a risk for contamination by dirt, dust, or insects, or during cleaning of the floors.

The double external doors to Central Supply had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building. The lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.

The vinyl pad on the OR table in OR-1 had tears on 3 out of 4 corners. The portable chair scale in the storage area, used in patient care had tears and punctures in the vinyl and the arms on the chair were broken and taped. The 3 x 6 foot table pad in Radiology had a 4 inch slice and tears and approximately 5 feet of the side of the pad was covered in tape due to a tear. The tears on the vinyl exposed the porous material beneath the vinyl covering. This porous material cannot be adequately cleaned between patients, and could harbor pathogens.

There was a 500 ml IV bag of 0.9% NaCl which expired 5/16 in the crash cart in the Cardiac Rehab department. In addition, there was no means to determine whether the laryngoscope blades in the crash cart had been sterilized or high level disinfected as the laryngoscope blades were in a zipper baggie and not in a peel pack.

Review of facility policy, Laryngoscope Blades and Handles Cleaning and Disinfection, Policy 1990280, stated, in part, "Laryngoscope Blades will be processed as follows: 1. via either sterlization (sic) or high level disinfection in Steris ...4. Packaged in peel pack (Long -term)."

The tour findings above were confirmed the afternoon of 6/6/16 with Staff #2 during the tour.

All of the above findings were reviewed and confirmed with the Infection Control Director the afternoon of 6/9/16 in the hospital conference room.

Based on observation, interview, and document review, the facility failed to ensure that dietary services were provided in accordance with recognized dietary standards to provide a sanitary environment for the preparation, service and storage of food, and failed to ensure sanitary practices were followed in kitchen cleaning and sanitization. Kitchen staff were not trained in safe food handling practices. These deficient practices had the potential to cause a food-borne illness to all patients, staff, and visitors served food prepared at Comanche County Medical Center.

Findings included:

A tour was conducted of the Comanche County Medical Center Hospital Kitchen and food service area the afternoon of 6/6/16 accompanied by the Kitchen Manager. The following items and areas were observed in need of cleaning and available for use in food preparation, presenting a risk for cross contamination and a risk for food-borne illness:
1. The floor in the kitchen was in need of cleaning as there was raised debris, dried food-like substances, and a greasy layer in and around stoves, refrigerators, sinks, and other kitchen equipment.
2. The tops of containers, plastic lids, shelving units, food containers and boxes had a greasy substance throughout the kitchen; there was a greasy substance on horizontal surfaces in the kitchen, indicating a need for cleaning.
3. There was a large industrial mixer on a stand which was in need of cleaning as there was a dried, raised substance which appeared to be food on the mixer directly above the bowl; in addition, there was excessive amount of rust on the mount where the paddles attach directly above the bowl. When the surveyor touched the mount with a paper towel, pieces of rust and dried food fell into the bowl.
4. There was an industrial manual can opener mounted to a food prep table, which was dirty with a thick brown/black substance and rust on the blade, the handle, the shaft, and the mount, increasing the risk of food contamination.
5. The kitchen ice machine was in need of cleaning as there was a black substance on the inside of the compartment containing the ice. The black substance was readily wiped off by the surveyor onto a clean white paper towel. There were drips on the front of the ice machine.
6. There was 1 large tray used in food preparation which had a greasy substance on it.
7. There was a stack of bowls which were stored in the upright position with an oily coating in the bowls.
8. There were 3 large muffin tins with a thick carbon build-up, rust, and what appeared to be dried food. The carbon build-up does not allow the pans to be cleaned properly causing possible food-borne illness.
9. There were 3 large sheet pans which had a thick carbon build-up and what appeared to be dried food and a greasy film. The carbon build-up was raised and flaking off on the inside of the pans.
10. There were 2 large muffin tin with a thick carbon build-up and what appeared to be dried food in the muffin container.
11. There was a cake pan with dried food adhered to the inside.
12. There were 3 pans which were stacked together which had not dried before stacking and were wet. This creates a risk for cross contamination in a moist environment.
13. There was a shelving unit containing clean plates, cups, and bowls, available for patient use, which was in need of cleaning as there was a greasy substance on the shelves. On the bottom shelf there was a large plate which was covered with a greasy substance, dust, and what appeared to be dried food particles.
14. There were 3 hand operated small can openers which were rusted.
15. There were 8 ladles hanging on the side of a rack with the bowl side up. There were dust and dried particles in the bowl of the ladles.
16. There were approximately 14 spice bottles, 13-16 ounces each, which were on a shelf over the food prep table. All the containers were covered with a sticky substance and were visibly dirty. There was a bottle of pumpkin pie spice which was dated 2013, a bottle of sage which was dated 2013, and a bottle of thyme which was dated 2014.
17. The bulk flour container was partially full of flour and a large scoop stored in the bin with the handle of the scoop touching the food product which creates a risk for cross contamination. The bin was not labeled with the date or the contents. There were 4 drips down the inside of the container touching the flour.
18. The bulk sugar container was partially full of sugar and a large scoop stored in the bin with the handle of the scoop touching the food product. The bin was not labeled with the date or the contents. There were 3 drips down the inside of the container touching the sugar.
19. There was a large plastic bin containing bread crumbs with a large scoop stored in the bin with the handle of the scoop touching the food product. There was a greasy substance on lid of the container. There was no date to determine the age or expiration date of the bread crumbs.
20. The Kitchen Manager was unable to provide a process for how the bulk flour, sugar, and bread crumb bins were cleaned, and was unable to determine how old the food product was. The Kitchen Manager stated during the observation that she was unaware that scoops could not be stored in the bins.
21. There were office supplies, including a pen, a Sharpie marker, and a roll of tape stored in a drawer of the food prep table with scoops, can openers, spoons, and other utensils used in food preparation. Cooking utensils should not be stored in the same drawer as office supplies.
22. The front of the refrigerators were in need of cleaning as there were drips down the front of the refrigerators.
23. The exterior of the ovens were dirty with a greasy film.
24. There was a 4 foot by 2 inch tear and scrape in the wall near the refrigerators including an area approximately 18 inches long where the sheetrock was exposed. Holes in the porous sheetrock cannot be disinfected.
25. There were 3 handwashing sinks in the kitchen. There was only 1 large plastic trash can near one of the sinks which had a lid on it. The surveyor observed food service staff wash and dry their hands, and there was no means to throw away paper towels used to dry hands except to touch the [contaminated] lid on the trash can.
26. In the storage closet on the kitchen, a corrugated box of paper towels was stored on the floor. Storing boxes on the floor presents a risk for contamination by dirt, dust, or insects, or during cleaning of the floors.

In the free standing refrigerators, the following was observed:
1. A bottle of orange juice was observed opened and partially empty and was not labeled with date opened.
2. A large Cool Whip container which had been opened without a label containing date or contents. The Kitchen Manager opened the container and stated that there was " fruit salad " in the unlabeled container.
3. A plastic container which contained sliced meat which appeared to be ham. The container was not labeled with date or contents and no means to determine when the meat was placed in the refrigerator.
4. A quart bottle of lime juice which had been opened with a manufacturer ' s " use by " date of 6/4/16. There was no label to indicate when the bottle had originally been opened.

Review of the dishwasher temperature log for the first 6 days in June 2016 revealed the following out or range temperatures, below the 120 degree minimum temperature for washing dishes:
· June 1 AM: 60
· June 1 PM: 85
· June 2 AM: 70
· June 2 PM: 80
· June 3 AM: 60
· June 6 AM: 60
· Review of the logs for the previous months revealed the following:
· January 2016: 13 temperatures were documented below 120 degrees, and 4 cycles were not documented and were left blank.
· February 2016: 22 temperatures were documented below 120 degrees and 1 cycle was not documented and were left blank.
· March 2016: 29 temperatures were documented below 120 degrees.
· April 2016: 32 temperatures were documented below 120 degrees and 5 cycles were not documented and left blank.
· May 2016: 35 temperatures were documented below 120 degrees and 1 cycle was not documented and left blank.

There was no documented evidence that the low temperatures were reported or reviewed. When asked about the out of range/below normal dishwasher temperatures, the Kitchen Manager stated, " Oh, they don ' t know how to do it right " referring to the food service workers.

The Dishwasher Temperature log form did not state the safe temperature ranges. The form also did not provide instructions outlining the steps to be taken if the temperature was out of range. In addition, there was no log or documentation to determine that the right concentration of chemical sanitizing agent was being used in the dishwasher. This presents a risk that dishes and utensils may not be cleaned or sanitized before use.

A document entitled, " Ware Washing Machines & Dish Room Best Practices " provided to the surveyor by the Kitchen Manager during the tour stated, " 1. A Chemical Sanitizing Agent, typically Chlorine, (Sodium Hypochlorite) at a minimum concentration of 50 PPM, is mixed in with the Final Rinse Water and sprayed on to the Ware during the Final Rinse Cycle. 2. Typically, the Temperature of the water & Chlorine Sanitizer mixture delivered / sprayed onto the Ware ' s during Final Rinse must be maintained at a temperature no lower than 120 [degrees]. 3. Low Temperature, Chemical Sanitizing Dish Machines, require that the Wash Water be maintained at a minimum Temperature of 120 [degrees] F. "

All of the above findings were confirmed during the tour the afternoon of 6/6/2016 in the kitchen with the Kitchen Manager.

A second tour was conducted of the Kitchen Area the morning of 6/8/2016 accompanied by the Infection Control Director. The following items and areas were observed in need of cleaning and available for use in food preparation, presenting a risk for cross contamination and a risk for food-borne illness:

At the 3-sink dishwashing area in use, only two out of three commercial sinks were in use for manually washing, rinsing, sanitizing dishware, equipment and utensils. The Kitchen Manager stated that the sink on the left contained sanitizing solution, however this sink contained what appeared to be soapsuds and foam bubbles, with dirty yellow streaks in the foam; there were also black specs throughout the foam. The Kitchen Manager confirmed that the sanitizing solution should be clear, without foam, bubbles, streaks, or black specs. The Kitchen Manager stated that this was the way the sanitizing solution appeared after using the automatic sanitizer dispenser and also stated that the water was " greasy " and left a ring of grease in the sink when the sink was drained after "sanitizing" the dishes. The Kitchen Manager stated that " I washed the dishes yesterday and it was that way yesterday, too. " The Kitchen Manager stated that the sanitizer water had been contaminated in this manner every day for " a few months. " When asked by the surveyor, the Kitchen Manager confirmed that this " sanitizing solution " , containing white and dirty yellow foam suds and black specs throughout, was used by the staff in washing the dishware used in food preparation for patient meals. The Kitchen Manager confirmed that the obviously contaminated solution had been used to " sanitize " the dishes for " a few months " . When asked if the contaminated sanitizer issue had been reported to her manager or to the vendor for the sanitizer dispensing equipment, the Kitchen Manager stated that the issue had not been reported. There was another 3-sink dishwashing area on the other side of the kitchen which was not in use.

Per the current standard found in 25 Texas Administrative Code §228.107 (b)(1), "Except as specified in paragraph (3) of this subsection, a sink with at least three compartments shall be provided for manually washing, rinsing, and sanitizing equipment and utensils.
(2) Sink compartments shall be large enough to accommodate immersion of the largest equipment and utensils. If equipment or utensils are too large for the warewashing sink, a warewashing machine or alternative equipment as specified in paragraph (3) of this subsection shall be used.
(3) Alternative manual warewashing equipment may be used when there are special cleaning needs or constraints and its use is approved."

When asked for a log demonstrating that the sanitizing solution used in washing dishware, equipment and utensils had been tested, the Kitchen Manager stated that a log was not maintained. Verification of proper sanitizer concentration is done by using sanitizer test strips and maintaining a log of the results.

Other findings during the tour on 6/8/16 included the following:

1. The Dry Food Storage room was excessively humid with a humidity of 70%, per a humidity instrument in the Dry Storage room. There were several round unopened cardboard boxes of oatmeal which had become warped due to the excessive humidity.
2. The floor in the dry food storage room was sticky and visibly splotchy and appeared to be greasy. In an interview with the Kitchen Manager, she stated that the staff had spilled a bottle of ginger ale the previous day and had only mopped it with water and had not cleaned the floor.
3. None of the food in the dry food storage room was labeled to determine expiration dates or to process food by the first in, first out method of rotation. When asked if and how the food stock was rotated, the Kitchen Manager did not have a response. There was no means to determine how long food had been in the facility or if the "first in, first out" method was being followed.
4. There was an open insect trap on the floor in the dry food storage room with approximately 5 dead insects. There were 3 dead insects on the floor underneath the food shelving unit. There was other trash and raised debris on the floor underneath the food shelving units.
5. The Kitchen Manager stated that the ice machine had been cleaned the previous day. The surveyor wiped a clean white paper towel inside the ice machine compartment and a black substance was again observed on the paper towel, indicating the ice machine was still in need of cleaning.
6. The industrial can opener had been cleaned on the previous day, per the Kitchen Manager, however the metal paint was chipped and the can opener was rusted near the blade, presenting a risk that paint chips or rust could flake off into food.
7. The industrial mixer had been cleaned of dried food from 6/6/16, however the mount for the paddles over the bowl was still coated with rust which rubbed off when touched with a paper towel. This presents a risk that rust particles could contaminate food prepared in the mixer.

The above findings were confirmed during the tour the morning of 6/8/16 with the Infection Control Director in the hospital kitchen.

Review of the personnel folder for 3 out of 3 kitchen food service workers (Staff #16, 17, and 18) revealed no documented evidence of orientation or training related to kitchen duties or safe food handling. In an interview with the Kitchen Manager on 6/6/16, she stated that food service workers were provided orientation training " on the computer " . There was no documented evidence of an orientation or training program for the food service workers provided. In an interview with Staff #18 (date of hire 2007) the afternoon of 6/8/16 in the kitchen area, when asked about the training she had received during her employment, she stated, " not much. " In an interview with Staff #16 (date of hire 11/16/15), she stated that there was no training except for general orientation and computer training. Staff #2 confirmed that the computer training that Staff #16 received was not training in food handling and safe practices, but was emergency and disaster response training.

Review of facility policy, Food Preparation, Policy 1919950, stated, in part, " A.1. Environment and Equipment: a. Meet all sanitation and safety standards ...A. procedures in Food Preparation ...g. Leftovers: i. Are stored in shallow containers, tightly wrapped, labeled, and dated ...iv. Are disposed of after 48 hours ... "

Review of facility policy, General Dietary Storage Procedures, Policy 1919956, stated, in part, " F. All dishes, kitchenware, tableware, drink ware, food equipment, etc, will be stored and handled so that food and lip contact surfaces avoid contamination.
G. All eating utensils will be stored in mouth side down direction ...
Cleaning of Food Storage Areas: A. The storeroom will be kept clean, organized, dry, well-lit, and properly ventilated.
B. Staff will be observant for evidence of insects and rodents. All holes in the ceiling, walls, etc. will be sealed ...
D. Spills are to be immediately cleaned or mopped up to prevent hazards and/or injury.
Rotation System: A. The first in, first out system is used.
Food Storage: A. Food should be stored: a. In a clean, dry, secured location b. Where it is not exposed to splash, dust, drips, or other contamination ...
B. Leftovers 1 ...b. Leftovers will be used within a 48 hour period, and then properly disposed of ...
D. Labeling: 1.a. All food items will be labeled as to contents, particularly those items that have been removed from their original packages (e.g. cooking oils, flour, salt, sugar, etc.) ...
E. Storage of Scoops: Scoops left in containers will be stored with handle end UP, never touching any food. "

All of the above findings were confirmed in an interview the afternoon of 6/9/16 with the Chief Nursing Officer and Infection Control Manager in the hospital conference room.

Based on interview and document review the Governing Body failed to ensure the Quality Assessment Performance Improvement program included all departments as evidenced by the lack of representation of the Dietary Department in the QAPI program. There was no documented evidence that the QAPI Committee reviewed or was aware of problems with the Dietary Department as services were not provided in accordance with recognized dietary standards and sanitary practices were not followed in food storage, food preparation, cleaning and sanitization.
Cross refer C0337

Based on interview and document review the Governing Body failed to ensure the Quality Assessment Performance Improvement program included all departments as evidenced by the lack of participation of the Dietary Department in the QAPI program, specifically the Kitchen area. There was no documented evidence that the QAPI Committee reviewed or was aware of problems with the Dietary Department as food services were not provided in accordance with recognized dietary standards and sanitary practices were not followed in food storage, food preparation, kitchen cleaning and sanitization; kitchen staff were not trained in safe food handling practices. These deficient practices had the potential to cause a food-borne illness to all patients, staff, and visitors served food prepared at Comanche County Medical Center.

Findings included:

Review of facility policy, Quality Assurance Plan, Policy 526367, stated, in part, "Objectives ...5. To identify patterns or trends that have or may have jeopardized the safety of those involved, analyze the variables and institute corrective action to reduce the probability or recurrence and injury (severity) ...The Quality Assurance Plan shall apply to all departments, services, medical staff and hospital staff."

Review of facility policy, Performance Improvement Plan, Policy Area: Dietary, Policy 2061548, stated, in part, "The Dietary Department participates in a hospital wide Performance Improvement (PI) Program designed to monitor, evaluate, and improve the quality and appropriateness of clinical services through a systematic process of planning and designing, measuring, collecting data for aggregation and analysis that identifies and promotes performance improvement ...Indicators (performance measures and outcomes) will be established ...The Dietitian and Dietary Manager will establish standards for compliance with criteria for each indicator under review ...
The Dietitian and Dietary Manager will ensure that documentation is maintained and that reports are forwarded as prescribed by the hospital-wide PI plan. Documentation and reports shall include: Findings from monitoring activities, Conclusions regarding identified opportunities for improvement, Recommendations concerning potential actions, Actions taken to effect change, Outcome of action effectiveness."

Review of the "Schedule of Quality Reviews" by department revealed that Dietary was scheduled to report QAPI activities and findings quarterly.

Review of the "Quality Assurance Problem Identification Loop Closure Log Book 2016" revealed indicators with date opened and explanation of problem for all hospital departments except for Dietary. There were no active problems identified for the Dietary Department.

Review of the monthly QAPI Committee meeting minutes for November 2015, December 2015, January 2016, February 2016, March 2016, April 2016, and May 2016 revealed no documented evidence of participation or reporting by the Dietary Department in the QAPI meetings.

Review of the spreadsheet provided by the Quality Director revealed the following Dietary Indicators in the Quality Program:
· Department Cleaning,
· Temperatures on Dishwasher,
· Temps on ALL refridgerators (sic) logged daily, and
· AC Temp.
There was no documentation provided by the Dietary department on these indicators for 2016.

Review of the "Comanche County Medical Center Annual QA Review 2015" for the Dietary Department revealed the question, "What actions have you taken on negative trends? What were the results?" The documented response to this question by the Kitchen Manager was "NA".

A tour was conducted of the Comanche County Medical Center Hospital Kitchen and food service area the afternoon of 6/6/16 accompanied by the Kitchen Manager. The following items and areas were observed in need of cleaning and available for use in food preparation, presenting a risk for cross contamination and a risk for food-borne illness and dishwasher temperatures were not documented:
Review of the dishwasher temperature log for the first 6 days in June 2016 revealed the following out or range temperatures, below the 120 degree minimum temperature for washing dishes:
· June 1 AM: 60
· June 1 PM: 85
· June 2 AM: 70
· June 2 PM: 80
· June 3 AM: 60
· June 6 AM: 60
· Review of the logs for the previous months revealed the following:
· January 2016: 13 temperatures were documented below 120 degrees, and 4 cycles were not documented and were left blank.
· February 2016: 22 temperatures were documented below 120 degrees and 1 cycle was not documented and was left blank.
· March 2016: 29 temperatures were documented below 120 degrees.
· April 2016: 32 temperatures were documented below 120 degrees and 5 cycles were not documented and left blank.
· May 2016: 35 temperatures were documented below 120 degrees and 1 cycle was not documented and left blank.

There was no documented evidence that the low temperatures were reported or reviewed. When asked about the out of range/below normal dishwasher temperatures, the Kitchen Manager stated, " Oh, they don ' t know how to do it right " referring to the food service workers.

The Dishwasher Temperature log form did not state the safe temperature ranges. The form also did not provide instructions outlining the steps to be taken if the temperature was out of range. In addition, there was no log or documentation to determine that the right concentration of chemical sanitizing agent was being used in the dishwasher. This presents a risk that dishes and utensils may not be cleaned or sanitized before use.

A document entitled, " Ware Washing Machines & Dish Room Best Practices " provided to the surveyor by the Kitchen Manager during the tour stated, " 1. A Chemical Sanitizing Agent, typically Chlorine, (Sodium Hypochlorite) at a minimum concentration of 50 PPM, is mixed in with the Final Rinse Water and sprayed on to the Ware during the Final Rinse Cycle. 2. Typically, the Temperature of the water & Chlorine Sanitizer mixture delivered / sprayed onto the Ware ' s during Final Rinse must be maintained at a temperature no lower than 120 [degrees]. 3. Low Temperature, Chemical Sanitizing Dish Machines, require that the Wash Water be maintained at a minimum Temperature of 120 [degrees] F. "

All of the above findings were confirmed during the tour the afternoon of 6/6/2016 in the kitchen with the Kitchen Manager.

Other findings in the Comanche County Medical Center Hospital Kitchen and food service area the afternoon of 6/6/16 included:
1. The floor in the kitchen was in need of cleaning as there was raised debris, dried food-like substances, and a greasy layer in and around stoves, refrigerators, sinks, and other kitchen equipment.
2. The tops of containers, plastic lids, shelving units, food containers and boxes had a greasy substance throughout the kitchen; there was a greasy substance on horizontal surfaces in the kitchen, indicating a need for cleaning.
3. There was a large industrial mixer on a stand which was in need of cleaning as there was a dried, raised substance which appeared to be food on the mixer directly above the bowl; in addition, there was excessive amount of rust on the mount where the paddles attach directly above the bowl. When the surveyor touched the mount with a paper towel, pieces of rust and dried food fell into the bowl. This presents a risk that rust and other particles could contaminate food prepared in the mixer.
4. There was an industrial manual can opener mounted to a food prep table, which was dirty with a thick brown/black substance and rust on the blade, the handle, the shaft, and the mount, increasing the risk of food contamination.
5. The kitchen ice machine was in need of cleaning as there was a black substance on the inside of the compartment containing the ice. The black substance was readily wiped off by the surveyor onto a clean white paper towel. There were drips on the front of the ice machine.
6. There was 1 large tray used in food preparation which had a greasy substance on it.
7. There was a stack of bowls which were stored in the upright position with an oily coating in the bowls.
8. There were 3 large muffin tins with a thick carbon build-up, rust, and what appeared to be dried food. The carbon build-up does not allow the pans to be cleaned properly causing possible food-borne illness.
9. There were 3 large sheet pans which had a thick carbon build-up and what appeared to be dried food and a greasy film. The carbon build-up was raised and flaking off on the inside of the pans.
10. There were 2 large muffin tin with a thick carbon build-up and what appeared to be dried food in the muffin container.
11. There was a cake pan with dried food adhered to the inside.
12. There were 3 pans which were stacked together which had not dried before stacking and were wet. This creates a risk for cross contamination in a moist environment.
13. There was a shelving unit containing clean plates, cups, and bowls, available for patient use, which was in need of cleaning as there was a greasy substance on the shelves. On the bottom shelf there was a large plate which was covered with a greasy substance, dust, and what appeared to be dried food particles.
14. There were 3 hand operated small can openers which were rusted.
15. There were 8 ladles hanging on the side of a rack with the bowl side up. There were dust and dried particles in the bowl of the ladles.
16. There were approximately 14 spice bottles, 13-16 ounces each, which were on a shelf over the food prep table. All the containers were covered with a sticky substance and were visibly dirty. There was a bottle of pumpkin pie spice which was dated 2013, a bottle of sage which was dated 2013, and a bottle of thyme which was dated 2014.
17. The bulk flour container was partially full of flour and a large scoop stored in the bin with the handle of the scoop touching the food product which creates a risk for cross contamination. The bin was not labeled with the date or the contents. There were 4 drips down the inside of the container touching the flour.
18. The bulk sugar container was partially full of sugar and a large scoop stored in the bin with the handle of the scoop touching the food product. The bin was not labeled with the date or the contents. There were 3 drips down the inside of the container touching the sugar.
19. There was a large plastic bin containing bread crumbs with a large scoop stored in the bin with the handle of the scoop touching the food product. There was a greasy substance on lid of the container. There was no date to determine the age or expiration date of the bread crumbs.
20. The Kitchen Manager was unable to provide a process for how the bulk flour, sugar, and bread crumb bins were cleaned, and was unable to determine how old the food product was. The Kitchen Manager stated during the observation that she was unaware that scoops could not be stored in the bins.
21. There were office supplies, including a pen, a Sharpie marker, and a roll of tape stored in a drawer of the food prep table with scoops, can openers, spoons, and other utensils used in food preparation. Cooking utensils should not be stored in the same drawer as office supplies.
22. The front of the refrigerators were in need of cleaning as there were drips down the front of the refrigerators.
23. The exterior of the ovens were dirty with a greasy film.
24. There was a 4 foot by 2 inch tear and scrape in the wall near the refrigerators including an area approximately 18 inches long where the sheetrock was exposed. Holes in the porous sheetrock cannot be disinfected.
25. There were 3 handwashing sinks in the kitchen. There was only 1 large plastic trash can near one of the sinks which had a lid on it. The surveyor observed food service staff wash and dry their hands, and there was no means to throw away paper towels used to dry hands except to touch the [contaminated] lid on the trash can.
26. In the storage closet on the kitchen, a corrugated box of paper towels was stored on the floor. Storing boxes on the floor presents a risk for contamination by dirt, dust, or insects, or during cleaning of the floors.

All of the above findings were confirmed during the tour the afternoon of 6/6/2016 in the kitchen with the Kitchen Manager.

Review of the personnel folder for 3 out of 3 kitchen food service workers (Staff #16, 17, and 18) revealed no documented evidence of orientation or training related to kitchen duties or safe food handling. In an interview with the Kitchen Manager on 6/6/16, she stated that food service workers were provided orientation training " on the computer " . There was no documented evidence of an orientation or training program for the food service workers provided. In an interview with Staff #18 (date of hire 2007) the afternoon of 6/8/16 in the kitchen area, when asked about the training she had received during her employment, she stated, " not much. " In an interview with Staff #16 (date of hire 11/16/15), she stated that there was no training except for general orientation and computer training. Staff #2 confirmed that the computer training that Staff #16 received was not training in food handling and safe practices, but was emergency and disaster response training.

There was no documented evidence that the above issues were reported through the QAPI Committee, or that the QAPI Committee reviewed or was aware of the above identified problems, assessed the scope and cause, established priorities for the resolution of identified problems, assured that corrective action was taken, evaluated, and sustained for the Dietary Department. There were no documented discussions, process changes, or recommendations for improvement for the above findings. In an interview the morning of 6/9/16 in the conference room, Staff #5, Quality Director confirmed that the Dietary department had not contributed to the QAPI program of the facility.