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

INTRACARE NORTH HOSPITAL 1120 CYPRESS STATION DR HOUSTON, TX Jan. 30, 2013
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of facility policies, procedures, and contracts, tour of the facility, patient records, and staff interviews, the governing body failed to exercise its responsibility for the facility as contracted services were not provided in a safe manner, medications were unlabeled and not stored securely, there were infection control hazards and a risk for cross contamination in patient care areas, there were expired patient supplies and patient food, patient menus were not being followed, and the facility was in need of cleaning.

Findings were:

Review of facility contract for cleaning services, a tour of the facility, and staff interviews revealed that the governing body failed to ensure that cleaning services were performed as there was dust on high and low horizontal surfaces, floors and carpeted areas were in need of cleaning, and walls were in need of cleaning in patient care areas. Cross refer CFR 482.12(e).

Review of facility documentation, tour of the facility and staff interview revealed that the facility failed to store medication properly in accordance with accepted professional standards, as evidenced by several unlabeled medications found in a medication room. Cross refer: CFR 482.23(c) and 482.25(a)

Review of facility policies, tour of the facility, and staff interviews revealed the facility failed to provide a safe setting for patients, as there were areas in need of cleaning, expired patient supplies and food items, live and dead insects, contaminated cooking utensils and environment used in the preparation of patient meals. Cross refer: CFR 482.13(c)(2)

Review of facility policies and procedures, tour of the facility, and staff interviews revealed the facility failed to ensure responsibility for the daily management of the dietary services of the PHP as there was expired food, contaminated equipment and food cooking utensils, and no oversight of dietary services. Cross refer: CFR 482.28(a)(1)

Review of facility documentation, patient orders, tour of the facility, and staff interview revealed the facility failed to ensure that the menus met the needs of the patients, as the food service supervisor did not follow the facility menus, and there were no documented menu options for patients with food allergies. Cross refer: CFR 482.28(b)

Review of facility policies, tour of the facility, and staff interviews revealed the facility failed to provide a sanitary environment for patients, as there were areas in need of cleaning, expired patient supplies, medications, and food items, live and dead insects, contaminated cooking utensils and environment. Cross refer: CFR 482.42
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on a review of facility contract, tour of the facility, and staff interviews, the governing body failed to ensure that services performed under contract were provided in a safe and effective manner, as there was dust on high and low horizontal surfaces, floors and carpeted areas were in need to cleaning, and walls were in need of cleaning.

Findings were:

The facility's contract for janitorial services dated 10/25/2008, stated in part, "Proposal for janitorial services...Now therefore, in consideration of the mutual agreement herein contained, the parties hereto agree as follows:

General Areas: Offices, restrooms, lobbies, stairways, elevators, lunchrooms/warehouse office, etc...

OBJECTIVE: To maintain your building in like new condition...

Nightly Services

1) Vacuum all carpeted area, spot clean as needed...

5) Dust all desk tops, file cabinets, furniture, and equipment.

Facility environmental services policy entitled, "Scope of Care" stated in part, "Cleaning duties include by (sic) may not be limited to sweeping, dusting, waxing, and polishing floors, cleaning restrooms and fixtures, washing walls and furniture, cleaning stairways and elevators and shampooing and cleaning carpeted surfaces."

On 1/29/13 at 10:30 a.m. an initial tour of the Partial hospitalization Program (PHP) located at 5500 Guhn Road, Houston, Texas.

In the patient care/use areas, accompanied by the PHP Infection Control Supervisor (ID# 8) and the Director of Special Projects (ID# 6) the morning of 1/29/13, the following was observed:

In the physician exam room:

- The door threshold was loose and the carpet was torn, creating a tripping hazard and prevented effective cleaning of disinfection. There was dust, dirt, and debris in the doorway.

-There was partially deteriorated black tape across the door threshold (a weather strip); there was dirty, black, sticky tape residue on the floor of the threshold.

-Dust was visible on shelves and desk top areas, indicating a lack of cleaning and disinfection.

In the Individual Therapy Room:

-Dirt, debris, and a leaf were observed on the carpet, indication a lack of cleaning.

In the PHP Group Room Hallway:

-The floor tiles were chipped and there was debris and dirt in the chipped area.

-There as a dirty black and white "checkerboard" design tape across the floor which was partially deteriorated leaving a dirty, sticky tape residue on the floor.

-There was a 3 x 3 inch "design" on the wall in the same hallway made out of a pink, dried, semi-hardened, sticky substance, which appeared to be previously chewed chewing gum stuck on the wall. A staff member walked by as this was being observed by the surveyor; the staff member stated the substance on the wall was "chewing gum," and stated, "It's been there a long time; I've been seeing it every day when we walk right past it." The above was confirmed in an interview with Staff #8 during the tour the morning of 1/29/13.

In the "Large Group Room" at the back of the building:

-A sealed grate was observed in the floor with dirt and debris present in the grate holes.

-10 ants were observed on the floor beneath a desk and crawling on top of the desk.

-There was external light visible for approximately 8 inches under the exterior door, which allows for the entry of dust, insect, and vermin. There was raised dirt, debris and a cigarette butt inside the door in the room, indicating a lack of cleaning.

-Two black metal Television stands were noted with heavy dust on the flat surfaces.

-A filling cabinet and a folding table were also observed with heavy dust residue on horizontal surfaces.

In the #2 Intensive Outpatient room next to the large group room:

-The carpet was in need of cleaning with stains and shredded paper

The above was confirmed in interview during a tour of the PHP facility the morning of 1/29/13 with PHP Infection Control Supervisor, Staff #8 and Director of Special Projects, Staff #6.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on a review of facility policies, tour of the facility, and staff interviews, the facility failed to provide a safe setting for patients, as there were areas in need of cleaning, expired patient supplies, and food items, live and dead insects, contaminated cooking utensils and environment used in the preparation of patient meals.

Findings were:

On 1/29/13 at 10:30 a.m. an initial tour of the Partial Hospital Program located at 5500 Guhn Road, Houston, Texas.

During a tour of the patient care/use areas in the PHP the morning of 1/29/13, accompanied by the PHP Infection Control Supervisor, Staff #8 and the Director of Special Projects, Staff # 6, the following was observed:

In the physician exam room:
? The door threshold was loose and the carpet was torn, creating a tripping hazard and prevented effective cleaning or disinfection. There was dust, dirt, and debris in the doorway.

? There was partially deteriorated black tape across the door threshold (a weather strip); there was dirty, black, sticky tape residue on the floor of the threshold.

? Dust was visible on shelves and desk top areas, indicating a lack of cleaning and disinfection.

In the patient restroom:
? A ceiling tile was observed to be bowed outward, creating an entry for dust and insects
? The light bulb in the bathroom was uncovered.
In the Individual Therapy Room:
? Dirt, debris, and a leaf were observed on the carpet, indicating a lack of cleaning.
? There were ceiling tiles which were askew leaving an opened area for the entry of dirt, dust and insects.
In the PHP group room hallway:
? The floor tiles were chipped and there was debris and dirt in the chipped areas.
? There was dirty black and white " checkerboard " design tape across the floor which was partially deteriorated leaving a dirty, sticky tape residue on the floor.
? There was a 3 x 3 inch " design " on the wall in the same hallway made out of a pink, dried, semi-hardened, sticky substance, which appeared to be previously chewed chewing gum stuck on the wall. A staff member walked by as this was being observed by the surveyor; the staff member stated the substance on the wall was " chewing gum, " and stated, " It ' s been there a long time; I ' ve been seeing it every day when we walk right past it. " The above was confirmed in an interview with Staff #8 during the tour the morning of 1/29/13.
? There were ceiling tiles which were askew leaving an opened area for the entry of dirt, dust and insects.
In the Room M Technicians office:
? A fabric upholstered chair was observed with a 3 X2 inch stain visible to the seat, indicating lack of proper cleaning and disinfection.
? There was a 2 inch by ? inch hole in the wall, which prevented effective cleaning and disinfection of the room. The cloth chairs in the room were stained and there was a hole in the arm of a vinyl covered chair.
? A 67.6 fluid ounce of Hand Sanitizer was ? full. Markings on the bottle stated the Sanitizer expired October 2011.
? Record review of monthly audits titled " Environmental Rounds / Audit " dated December 2012 revealed the following statement " Checked hand sanitizer dispensers to see if empty. All are usable. Since hand sanitizer dispensers are being utilized by patients and staff regularly; will need to monitor routinely ... "
In the Group Room A:
? A total of 13 chairs were observed in the room and 11 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Three of the chairs had tears in the plastic exposing stained fabric beneath the plastic.
? The walls had paint peeling off where the back of the chairs were rubbing against the walls, preventing effective cleaning/disinfection.
In the hallway by Group Room A, an office room was noted with a sign that read "Employees Only Room." Three floor tiles were missing in front of the office door in the patient access hallway.

In the Group Room B:
? A total of 15 chairs were observed in the room and 14 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Five of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic.
? The walls had paint peeling off where the back of the chairs were rubbing against the walls and there were holes in the sheetrock that prevented effective cleaning or disinfection.
In the Group Room C:
? A total of 15 chairs were observed in the room and 11 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Two of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic.
? The walls had paint peeling off where the back of the chairs were rubbing against the walls and there were holes in the sheetrock that prevented effective cleaning or disinfection.
In the Group Room D:
? A total of 12 chairs were observed in the room and 8 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Four of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic.
? There were 4 partial tiles missing close to the baseboard, leaving an opening for dust or insects.
In the Group Room E:
? A total of 13 chairs were observed in the room and 9 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Two of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic.
In the Group Room:
? One water damages ceiling tile and heavily rusted grid structure for the ceiling tiles holding the tiles in place. The wet environment creates a risk for bacterial growth.
In the Group Room K:
? A total of 16 fabric chairs were observed in the room and 9 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Six of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic. Three of the chairs without the plastic covering had stains.
? The Infection Control Nurse at this time stated the staff use disinfectant wipes to clean the fabric chairs.
In the Group Room L:
? A total of 14 fabric chairs were observed in the room and 12 of those chairs had a thin layer of white plastic covering the seats of the chairs. Four of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic.
? A high back vinyl rolling office chair was also observed with a large tear noted in the seat cushion.
? The walls had paint peeling off where the back of the chairs were rubbing against the walls.
? Food wrappers and what appeared to be a cheese puff were observed on the floor, indicating inadequate cleaning.
? There were 6 holes in the sheetrock, which prevented effective cleaning or disinfection.
In the Vital sign room #1, there were 4 fabric-covered chairs. 3 of the 4 chairs were covered in a thin, white, opaque plastic covering, with stains on the fabric underneath.

Interview 1/30/13 at 1:55 p.m. with the Environmental Manager (ID# 15) revealed they were not aware that the offsite partial hospital program was placing a thin layer of white plastic to cover stained fabric chairs in the Group rooms.

In the "Large Group Room" at the back of the building:
? A sealed grate was observed in the floor with dirt and debris present in the grate holes.
? 10 ants were observed on the floor beneath a desk and crawling on top of the desk.
? There was a ceiling tile with a 1 x 1 foot area of water damage, which increases the risk of contamination in a moist environment.
? There was external light visible for approximately 8 inches under the exterior door, which allows for the entry of dust, insects and vermin. There was raised dirt, debris and a cigarette butt inside the door in the room, indicating a lack of cleaning.
? There were holes in the sheetrock throughout the building, including the "Great Room" which prevented effective cleaning.
? Two black metal Television stands were noted with heavy dust on the flat surfaces.
? A filling cabinet and a folding table were also observed with heavy dust residue on horizontal surfaces.
In the 2 IOP room next to the "Large Group Room":
? The carpet was in need of cleaning with stains and was shredded
? The wall plate was unscrewed from the wall and wires were exposed and extending into the room, creating a hazard and an entry for dust and insects.
In the back hallway next to the "Large Group Room":
? There was a built in ladder extending from the floor into the attic in the back hallway. There was a large space (approximately 5 x 3 feet) which was open to the attic, which would allow contamination by dust and allow the entry of insects or vermin.
Review of the facility's "Environmental Rounds/Audit" for the months of October, November, and December 2012 revealed no documented evidence of any of the above.

Record review of "Partial hospitalization Weekly Logs" for October 2012; November 2012; December 2012; and January 2013 revealed "Furniture in good working order." The logs further stated "No signs of pests."

-Individual Therapy office observed with dirty carpet in need of vacuuming.

Record review of monthly documents titled "Environmental Rounds/Audit" dated October 29, 2012; November 2012; and December 2012 revealed the following statement in each report "checked ceiling titles for leaks and mold. Ceiling tiles in good condition with no signs of water leak."

The above was confirmed in interview during a tour of the PHP facility the morning of 1/29/13 with the PHP Infection Control Supervisor, Staff #8 and the Director of Special Projects, Staff # 6.

During a tour of the kitchen area on 01/29/13 at 1050, the following infection control issues were observed:
? 1 out of 2 microwaves was visibly soiled, with a discolored stain on the turntable approximately 2 X 3 inches in size. Visible splatters were observed inside this microwave. The exterior of both kitchen microwaves had a visible layer of greasy dust. These issues inadequate cleaning and disinfection of this equipment and present a risk for cross contamination.
? 1 sheet pan on a storage shelf was observed, with what appeared to be, a piece of rice adhered to the handle, which indicated inadequate cleaning. 19 metal serving pans and 6 sheet pans were stored stacked together upside down, not allowing for complete drying post washing. This presents a risk for the growth of bacteria and creates a risk of contamination. The top pans in these stacks had a greasy residue present.
? 3 out of 5 square plastic bins were observed with stickers and sticker residue present on the containers. The sticker residue cannot be properly disinfected and provides a risk for cross contamination.
? In the refrigerator the following food items were found open with no open date noted to indicate when it was opened or when it would it expire: 1 container of Chicken Base and 1 bottle of Real Lemon Juice.
? On the top of the refrigerator a brown, greasy, dusty residue was noted, indicating inadequate cleaning.
? Under the food preparation table the following items were found inside a large plastic bin: 1 large open container of Pace picante sauce with no date indicating when opened. The container directed to " refrigerate after opening " , this item was not being stored in the refrigerator, presenting a risk of food borne illness. Containers of Zataran ' s Shrimp and Crab Boil, 1 bottle of Red Hot Buffalo Sandwich Sauce, 1 bottle of White Vinegar, and 1 bottle of A-1 Sauce were open and not dated to indicate when the item was opened or when it would expire. The plastic bin containing these bottles had a piece of cardboard that covered the bottom which had a discolored grease spot 7 X 7 inches with visible debris, dust, and a dried bean present in the bin, indicating inadequate cleaning.
? One large metal strainer on the clean dishes shelf had what appeared to be food particles present in the holes of the strainer, indicating inadequate cleaning.
? A large plastic bin on the clean dishes shelf contained 16 visibly dirty utensils, indicating inadequate cleaning and disinfection. A discolored piece of paper towel was observed at the bottom of this bin.
? The rolling coffee cart was dirty and in need of cleaning as there was a layer of brown greasy residue on the horizontal surfaces of the cart.
? The lid to a Rubbermaid container storing crackers was dirty, with dust, dried food, and a piece of string on the lid.
? The plastic bin which stored mustard packets was dirty inside and there was a brown greasy residue on the lid of the tub.
? The handle of the plastic bin which stored mayonnaise and pasta had a thick, yellow, greasy substance on the handle and there was a dried substance, which appeared to be old food on the top of the lid.
? The plastic bin which stored jelly, picante sauce, and chocolate milk packets had a dried substance, which appeared to be old food on the lid. One of the dried food particles was approximately ? inch in length.
? There was dirt and chunks of dried food debris in a 22 quart container which stored knives and cooking utensils, available for use in food preparation. In this container were 5 knives with dirty handles which were stained black, a large knife with dried food on the blade, a long serrated knife with dried food on the blade, 3 potato peelers that were dirty with dried food on the blades and the handles, and a meat tenderizer which had 3 pieces of a dried reddish substance adhered which appeared to be meat.There were 2 dirty pot holder mitts on top of a "clean" food strainer and a cooking pot which were available for use in food preparation.
? There was a man's ball cap sitting with the pots and pans on the clean cooking equipment shelf, creating a risk for contamination.
The above was confirmed in an interview during a tour of the kitchen the morning of 1/29/13, by the PHP Food Service Supervisor, Staff #9, and the PHP Infection Control Supervisor, Staff # 8.

The following was observed on the shelving unit in the kitchen:
? 4 of 4 lids to the large bins storing disposable packets of plastic eating utensils, bowls, and other patient eating supplies was covered in a brown greasy residue with dirt and dried food particles.

? 9 large bottles of spices used in patient food preparation which were covered in a brown greasy residue.

? 15 midsized bottles of spices used in patient food preparation which were covered in a brown greasy residue.

? 2 cans of bread crumbs, 15 ounces, which expired 7/14/2012

? Hunt ' s tomato paste, 12 ounces, best by 12/13/12

? The shelves upon which the above was stored were covered with a layer of greasy dust; there was debris in the corners of the shelves, which appeared to be old, dried food.

? There were 3 dirty aprons, with a dried substance adhered which appeared to be food and dust, were hanging on the shelf with food products and eating utensils available for patient use.

The above was confirmed in an interview during a tour of the kitchen the morning of 1/29/13, by the PHP Food Service Supervisor, Staff #9, and the PHP Infection Control Supervisor, Staff # 8.

During a tour of the kitchen the morning of 1/29/13, accompanied by the PHP Food Service Supervisor, Staff #9, and the PHP Infection Control Supervisor, Staff # 8, the survey team observed a large scoop stored in the ice machine in the ice. This was confirmed in an interview with Staff #9 and Staff #8.

During a revisit to the kitchen the morning of 1/30/13, the large scoop was observed by the surveyor in the ice machine in the ice again the morning of 1/30/13 and was confirmed by the PHP Food Service Supervisor, Staff #9. Staff #9 stated that the large scoop was kept in the ice in the ice machine as a Houston inspector told him the ice scoop should be kept in the ice. Storing the ice scoop in the ice is an infection control risk as the handle of the ice scoop, after hand contact, could contaminate the ice and spread bacteria.

The Centers for Disease Control and Prevention (CDC) article entitled, "Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee" (2003), found at: <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm>, states, "Do not store the ice scoop in the ice bin." in the section entitled, "IX. Ice Machines and Ice."

In an interview on 01/30/13, when asked who is responsible for cleaning the PHP kitchen, staff member # 15 stated, " (Staff member #9) and his group are responsible for cleaning the kitchen there (at the PHP)."

In an interview 1/30/13 at 10 a.m. with the Infection Control Nurse (ID# 8) assigned to the Partial hospitalization program, she stated she does not make environmental rounds inside the kitchen area.

In an interview 1/30/13 at 1:55 pm, when asked who is responsible for cleaning the PHP kitchen, staff member # 15 stated, "Cleaning the kitchen falls into dietary. Housekeeping cleans the bathroom and helps mopping the office. Dietary is in charge of cleaning the kitchen at the hospital. (Staff member #9) and his group are responsible for cleaning the kitchen there (at the PHP)."

During a tour of the PHP facility the morning of 1/29/13, accompanied by the PHP Infection Control Supervisor, Staff #8 and the Director of Special Projects, Staff # 6, the following was observed in the laboratory area:

? Debris and discarded items were observed on the floor. 7 plastic caps to needles and 3 used alcohol pads were observed on the floor.
? In the refrigerator, there was a urine specimen container which was half filled with an amber colored liquid. The liquid was cold and appeared to be urine. The urine specimen container had no identifying information on the label or on the specimen cup to indicate name, time, date, or other information.

? The refrigerator temperature log had not been completed on the following dates: 1/21/13, 1/22/13, 1/23/13, 1/24/13, 1/25/13, 1/26/13, 1/27/13, and 1/28/13. The refrigerator log had a hand-written date of "January 2013" stated on the form, "Directions: [1] Read and record temperature daily: use a dot in the appropriate column/date. Connect dots."

? There was a thick layer of dust on high and low horizontal surfaces, including the refrigerator, the centrifuge, and the table and other furniture in the room.
? There was a dead ant in a plastic lab supply bin.

During a tour of the PHP facility the morning of 1/29/13, accompanied by the PHP Infection Control Supervisor, Staff #8 and the Director of Special Projects, Staff # 6, the following was observed in the patient laboratory drawing room:

? 7 ammonia packets which expired 8/2010, a tiger top lab tube which expired 3/2011, a purple top lab tube which expired 12/2012, and adult blood culture collection kit which expired 11/30/2012
? There was a layer of dust on high horizontal surfaces.
The facility based contract for janitorial services with Clean U.S.A. dated 10/25/2008, stated in part, "Proposal for janitorial services ...Now therefore, in consideration of the mutual agreement herein contained, the parties hereto agree as follows:

General Areas: Offices, restrooms, lobbies, stairways, elevators, lunchrooms/warehouse office, etc ...

OBJECTIVE: To maintain your building in like new condition ...

Nightly Services
1. Vacuum all carpeted area, spot clean as needed ...

5. Dust all desk tops, file cabinets, furniture, and equipment. (No correspondence will be moved.)"

Facility environmental services policy entitled, "Scope of Care" stated in part, "Cleaning duties include by (sic) may not be limited to sweeping, dusting, waxing, and polishing floors, cleaning restrooms and fixtures, washing walls and furniture, cleaning stairways and elevators and shampooing and cleaning carpeted surfaces."

Facility environmental services policy entitled, "Service Specifications" stated in part,

"A GENERAL CLEANING FOR NON-PATIENT AREAS:..

4. Dust all desks, counters, tables, and related surfaces

(Note: Housekeeper will not move papers or articles left on surfaces.)
5. Dust all areas with-in high hand reach, including all chairs, desks, tables, cabinets,
furniture, window sills low ledges, picture frames, etc.

C. GENERAL CLEANING FOR PATIENT AREAS:

1. General cleaning Same as 'A-1 through A-10'.

Facility environmental services policy entitled, "Cleaning of Day Rooms" stated in part, "To provide an aesthetically clean, sanitary area for patients and staff.

PROCEDURES:

Daily: (Monday through Friday) ...
3. Wash, and rinse all unobstructed shelves, counters and table tops with germicidal cleaning agent.

4. Spot clean walls, light switches, doors, door facings, outside of cabinets and inside windows.

5. Damp wipe chairs; inspect upholstered furniture for spot removal and/or necessary scheduling of extraction shampoo cleaning. "

Facility environmental services policy entitled, "Cleaning of Classrooms" stated in part, "To maintain clean, sanitary, attractive classrooms for the patients and instructor ...

4. All furniture shall be damp cleaned using germicidal detergent solution and clean cloths. Damp clean furniture, then wipe it with a cleaning cloth. Only unobstructed desk, table tops, and book shelves will be cleaned."

Facility environmental services policy entitled, "Office Cleaning" stated in part,
"4. Damp wipe unobstructed desks, counter tops, tables and shelves, then wipe dry to prevent streaking ...
8. Vacuum carpeted floors daily spot clean carpets as needed. Bonnet clean or extraction cleaning of carpets is done as needed.

Facility environmental services policy entitled, "Cleaning of Pharmacy" stated in part, "3. Surfaces containing papers or other items, both personal and hospital property will not be cleaned by Housekeeping Services. Cleaning of these surfaces is the responsibility of the Pharmacy Department."

Facility environmental services policy entitled, "Furniture Cleaning" stated in part, "6. Upholstered Furniture: Upholstered furniture should not be allowed to become badly soiled. Spot cleaning of upholstered surfaces should be done each time a surface becomes soiled so stains do not set. Always refer to manufacturer's directions for cleaning procedures and proper products when cleaning any furniture surfaces."

Facility environmental services policy entitled, "Cleaning of Stainless Steel Surfaces" stated in part, "1. Disinfect the surface by damp wiping the stainless steel surface with a cloth saturated in properly diluted germicidal cleansing solution or spray the surface with pre-diluted germicidal solution, wipe with a damp cloth, and the (sic) wipe surface with a clean soft cloth."

The above was confirmed in an interview the afternoon of 1/31/2013 in the conference room with administrative staff.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on a tour of the facility, review of documentation, and interview, the facility failed to ensure that medication was properly stored in accordance with accepted professional standards, as evidenced by several unlabeled medications found in a medication room at the partial hospitalization program located at 5500 Guhn Road, Houston, Texas.

Findings were:

During tour of the Partial hospitalization Program on 1/29/13 at 11:45 a.m., the following issues were noted:

-Medication Room #2 contained an unlocked drawer near the Medication Aide's desk that contained an unlabed, amber-colored, plastic bottle containing 44 peach, scored, oblong tablets. The tablets were labeled "500" on one side. The other side was scored and a "G" was to the left of the score and "32" was to the right of the score. The tablets were identified through drugs. com as being Naprosyn, available by prescription only. In an interview with Staff #10 on 1/29/13 at 11:45 a.m., she stated that no stock medications were kept in the medication rooms and that any medications came from an external pharmacy and were prescribed for a specific patient.

-Medication Room #2 contained a desk with office supplies in a plastic bin on top of the desk. Inside the plastic bin were 5 light blue oblong tablets. The tablets were not scored. the tablets were labeled "Pfizer" on one side. The other side was labeled "CHX1.0". The tablets were identified through drugs. com as being Chantix, available by prescription only. In an interview with Staff #10 on 1/29/13 at 11:45 a.m. she stated that no stock medications were kept in the medication rooms and that any medications came from an external pharmacy and were prescribed for a specific patient.

-Medication Room #2: The following unlabeled medications were found loose in the bottom of the metal drug storage cabinet door: 1 small orange tablet labeled "TL/211" on one side, 2 white capsules labeled IP101 on each half of the capsule and 1 small peach tablet labeled TEVA on one side and 2083/(empty). These medications were identified as 1 tablet of Flexeril 5mg, 2 capsules of Neurotin 100mg, and 1 tablet of Hydrochlorothiazide 25mg. These medications were identified via www.drugs.com (source http://www.drugs.com/pill-identification. html).

Staff ID# 10 working in the medication room acknowledged 1/29/13 at 11:45 a.m. that the pharmacist of the hospital does not make rounds to the medication room at the off-site partial hospitalization program.

Facility policy MM03.01.01(b) titled "Storage and Security of Medications" states, in part, "The Director of Nursing or delegate shall be responsible for the supervision and proper storage and security of all patient medications and related patient care supplies to maintain medication stability, integrity, effectiveness and availability within the medication management process ...Controlled medications shall be stored under a second lock, inside a designated narcotic locked cabinet. Controlled substance counts shall be verified each morning by two staff ...Monthly medication room audits shall be performed by the Director of Nursing or delegated Nursing staff to assure proper patient safety with respect to medication integrity."

Facility policy MM03.01.01(a) titled "Medication Storage" states, in part, "3. There shall be a separate, securely locked (double-locked) drawer in the medication room for the storage of the patient ' s controlled medications ...6. The Director of Nursing or delegated nursing staff shall make monthly inspections of the unit medication rooms to assure that the medications are properly stored."

Based on a review of documentation and an interview with Staff #8 on 1-29-13, the facility was unable to provide evidence that monthly audits of the medication rooms were being performed.

Based on a review of documentation, the facility was unable to provide evidence that the controlled substance counts were being verified each morning by two staff. In an interview with Staff #10 on 1-29-13, she stated that the controlled substances in the medication rooms were randomly audited by Staff #8.
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on a review of facility policies and procedures, tour of the facility, and staff interviews, the facility failed to ensure responsibility for the daily management of the dietary services of the PHP, a contracted dietary service, as there was expired food, contaminated equipment and food cooking utensils, and no oversight of dietary services.
Findings were:
In an interview with Staff #1 the afternoon of 1/28/2013, he stated that the facility provides monitoring of dietary services, a contracted service, for [the accrediting organization] and the Texas Department of Health, including infection control and risk management.
During a tour of the kitchen the morning of 1/29/13, accompanied by the PHP Food Service Supervisor, Staff #9, and the PHP Infection Control Supervisor, Staff # 8, the following was observed on the shelving unit in the kitchen:
? 4 of 4 lids to the large bins storing disposable packets of plastic eating utensils, bowls, and other patient eating supplies was covered in a brown greasy residue with dirt and dried food particles.

? 9 large bottles of spices used in patient food preparation which were covered in a brown greasy residue.

? 15 midsized bottles of spices used in patient food preparation which were covered in a brown greasy residue.

? 2 cans of bread crumbs, 15 ounces, which expired 7/14/2012

? Hunt ' s tomato paste, 12 ounces, best by 12/13/12

? The shelves upon which the above was stored were covered with a layer of greasy dust; there was debris in the corners of the shelves, which appeared to be old, dried food.

? There were 3 dirty aprons, with a dried substance which appeared to be food and dust which were hanging on the shelf with food products and eating utensils available for patient use.
During a tour of the kitchen the morning of 1/29/13, accompanied by the PHP Food Service Supervisor, Staff #9, and the PHP Infection Control Supervisor, Staff # 8, the following was observed:
? The rolling coffee cart was dirty and in need of cleaning as there was a layer of brown greasy residue on the horizontal surfaces of the cart.

? The lid to a Rubbermaid container storing crackers was dirty, with dust, dried food, and a piece of string on the lid.

? The plastic bin which stored mustard packets was dirty inside and there was a brown greasy residue on the lid of the tub.

? The handle of the plastic bin which stored mayonnaise and pasta had a thick, yellow, greasy substance on the handle and there was a dried substance, which appeared to be old food on the top of the lid.

? The plastic bin which stored jelly, picante sauce, and chocolate milk packets had a dried substance, which appeared to be old food on the lid. One of the dried food particles was approximately ? inch in length.

? There was dirt and chunks of dried food debris in a 22 quart container which stored knives and cooking utensils, available for use in food preparation. In this container were 5 knives with dirty handles which were stained black, a large knife with dried food on the blade, a long serrated knife with dried food on the blade, 3 potato peelers that were dirty with dried food on the blades and the handles, and a meat tenderizer which had 3 pieces of a dried reddish substance adhered which appeared to be meat." food strainer and a cooking pot which were available for use in food preparation.

? There was a man ' s ball cap sitting with the pots and pans on the clean cooking equipment shelf, creating a risk for contamination.

During a tour of the kitchen the morning of 1/29/13, accompanied by the PHP Food Service Supervisor, Staff #9, and the PHP Infection Control Supervisor, Staff # 8, the survey team observed a large scoop stored in the ice machine in the ice. This was confirmed in an interview with Staff #9 and Staff #8.
During a revisit to the kitchen the morning of 1/30/13, the large scoop was observed by the surveyor in the ice machine in the ice again the morning of 1/30/13 and was confirmed by the PHP Food Service Supervisor, Staff #9. Staff #9 stated that the large scoop was kept in the ice in the ice machine as a Houston Health inspector told him the ice scoop should be kept in the ice. Storing the ice scoop in the ice is an infection control risk as the handle of the ice scoop, after hand contact, could contaminate the ice and spread bacteria.
The Centers for Disease Control and Prevention (CDC) article entitled, "Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee" (2003), found at: <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm>, states, "Do not store the ice scoop in the ice bin." in the section entitled, "IX. Ice Machines and Ice."

The above findings were confirmed during the tour the morning of 1/29/13 with the PHP Food Service Supervisor, Staff #9, and the PHP Infection Control Supervisor, Staff # 8.

A contracted Food Service Supervisor (Staff# 9) at the Partial hospitalization Program stated 1/30/13 at 9:30 a.m. that he currently uses (5) menu cycles. The Food Service Supervisor (FSS) stated that he is currently using menu cycle "Four." The FSS acknowledged that he does not always follow the menus because the census changes daily and he may not have enough of one food grouping. The Food Service Supervisor stated that today for lunch he is preparing Blackened Tilapia. The cycle four menu called for "Catfish and Boiled Shrimp" on Wednesday. The FSS stated that the outpatient program no longer serves Shrimp because it is too expensive. The cycle four menu called for "Jumbo Wing Ding" (fried chicken) on Thursday. The Food Service supervisor stated that the program no longer serves "Jumbo Wing Ding" because the facility no longer serves fried food.
Observation 1/29/13 at 12 noon revealed that patients were being served Meatball sandwiches with chips. The cycle four menu for Tuesday called for Beef tip hoagie, macaroni salad, and sliced yellow peaches. No macaroni, vegetables or peaches were served at lunch on 1/29/13, chips were substituted.

Interview 1/30/13 at 1:55 p.m. with the Dietary Manager (ID# 15) responsible for the hospital and contracted kitchen at the offsite location revealed that she has only been to the offsite Partial hospitalization Program twice in November 2012, stating, "I am supposed to make rounds. But I didn ' t get to go all the time. I went twice in November. I didn't get to go back because I ' ve been so busy here." When asked what is done during these rounds at the kitchen in the PHP, staff member #15 replied, "I check the refrigerator temperature, that everything is labeled, put away. I make sure he is following the menus that are posted ...That they are following the cleaning schedule there." The Dietary Manager acknowledged that she was not aware that the Food Service Supervisor at the offsite Partial hospitalization Program was not following the approved menus. The Dietary Manger further stated that she was not aware that the offsite outpatient program no longer served Shrimp or Fried Chicken as prescribed by the menus.

The above findings were confirmed in an interview with administrative staff in the conference room the afternoon of 1/30/13.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on a review of facility policies, tour of the facility, and staff interviews, the facility failed to provide a sanitary environment for patients, as there were areas in need of cleaning, expired patient supplies and food items, live and dead insects, contaminated cooking utensils and environment.

Findings were:

On 1/29/13 at 10:30 a.m. an initial tour of the Partial Hospital Program located at 5500 Guhn Road, Houston, Texas.

During a tour of the medication storage areas in the PHP the morning of 1/29/13, accompanied by the PHP Infection Control Supervisor, Staff #8 and the Director of Special Projects, Staff # 6, the following was observed:

In the PHP 1 & 2 med room:
? There was a thick layer of raised brown dirt and fuzz on the shelf for the water which was provided to patients for taking their medications
? There was a thick layer of dust on top of the refrigerator, and there was dust observed on the shelves and the floor of the medication storage cabinet
? In a drawer stored with sanitary napkins available for patient use was a dirty plastic drinking glass with a lid and straw which had dried reddish drips, presenting a risk for contamination of patient supplies
? There was a bottle of glucometer control solution which expired 05/2012
? In another drawer with patient prescriptions was an opened package of chocolate doughnuts
In the Pharmacy medication storage room:
? Four large metal cabinets full of patient medication bottles. Heavy dust was observed on the bottom shelf of each cabinet and heavy dust was also noted on the top of the cabinets. Inside the door of one cabinet four loose pills (two tablets and two capsules) were observed caught inside the bottom lip of the metal door. At this time a pharmacy staff member (ID# 10) stated that the medication room staff was responsible for keeping the medication storage room clean.
? Four blue pills were observed on top of a desk inside a plastic container containing office supplies. The pills were not inside in medication bottle.
The above was confirmed in an interview with the Director of Special Projects, Staff #6.

In the patient care/use areas, accompanied by the PHP Infection Control Supervisor, Staff #8 and the Director of Special Projects, Staff # 6 the morning of 1/29/13, the following was observed:

In the physician exam room:
? The door threshold was loose and the carpet was torn, creating a tripping hazard and prevented effective cleaning or disinfection. There was dust, dirt, and debris in the doorway.

? There was partially deteriorated black tape across the door threshold (a weather strip); there was dirty, black, sticky tape residue on the floor of the threshold.
? Dust was visible on shelves and desk top areas, indicating a lack of cleaning and disinfection.

In the patient restroom:
? A ceiling tile was observed to be bowed outward, creating an entry for dust and insects
? The light bulb in the bathroom was uncovered.
In the Individual Therapy Room:
? Dirt, debris, and a leaf were observed on the carpet, indicating a lack of cleaning.
? There were ceiling tiles which were askew leaving an opened area for the entry of dirt, dust and insects.
In the PHP group room hallway:
? The floor tiles were chipped and there was debris and dirt in the chipped areas.
? There was dirty black and white "checkerboard" design tape across the floor which was partially deteriorated leaving a dirty, sticky tape residue on the floor.
? There was a 3 x 3 inch "design" on the wall in the same hallway made out of a pink, dried, semi-hardened, sticky substance, which appeared to be previously chewed chewing gum stuck on the wall. A staff member walked by as this was being observed by the surveyor; the staff member stated the substance on the wall was "chewing gum," and stated, "It's been there a long time; I've been seeing it every day when we walk right past it." The above was confirmed in an interview with Staff #8 during the tour the morning of 1/29/13.
? There were ceiling tiles which were askew leaving an opened area for the entry of dirt, dust and insects.
In the Room M Technicians office:
? A fabric upholstered chair was observed with a 3 X 2 inch stain visible to the seat, indicating lack of proper cleaning and disinfection.
? There was a 2 inch by ? inch hole in the wall, which prevented effective cleaning and disinfection of the room. The cloth chairs in the room were stained and there was a hole in the arm of a vinyl covered chair.
? A 67.6 fluid ounce of Hand Sanitizer was ? full. Markings on the bottle stated the Sanitizer expired October 2011.
? Record review of monthly audits titled "Environmental Rounds / Audit" dated December 2012 revealed the following statement "Checked hand sanitizer dispensers to see if empty. All are usable. Since hand sanitizer dispensers are being utilized by patients and staff regularly; will need to monitor routinely ... "
In the Group Room A:
? A total of 13 chairs were observed in the room and 11 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Three of the chairs had tears in the plastic exposing stained fabric beneath the plastic.
? The walls had paint peeling off where the back of the chairs were rubbing against the walls, preventing effective cleaning/disinfection.
In the hallway by Group Room A, an office room was noted with a sign that read "Employees Only Room." Three floor tiles were missing in front of the office door in the patient access hallway.

In the Group Room B:
? A total of 15 chairs were observed in the room and 14 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Five of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic.
? The walls had paint peeling off where the back of the chairs were rubbing against the walls and there were holes in the sheetrock that prevented effective cleaning or disinfection.
In the Group Room C:
? A total of 15 chairs were observed in the room and 11 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Two of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic.
? The walls had paint peeling off where the back of the chairs were rubbing against the walls and there were holes in the sheetrock that prevented effective cleaning or disinfection.
In the Group Room D:
? A total of 12 chairs were observed in the room and 8 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Four of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic.
? There were 4 partial tiles missing close to the baseboard, leaving an opening for dust or insects.
In the Group Room E:
? A total of 13 chairs were observed in the room and 9 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Two of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic.
In the Group Room:
? One water damages ceiling tile and heavily rusted grid structure for the ceiling tiles holding the tiles in place. The wet environment creates a risk for bacterial growth.
In the Group Room K:
? A total of 16 fabric chairs were observed in the room and 9 of those chairs had a thin layer of white plastic covering the fabric seats of the chairs. Six of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic. Three of the chairs without the plastic covering had stains.
? The Infection Control Nurse at this time stated the staff use disinfectant wipes to clean the fabric chairs.
In the Group Room L:
? A total of 14 fabric chairs were observed in the room and 12 of those chairs had a thin layer of white plastic covering the seats of the chairs. Four of the chairs with plastic covers had tears in the plastic exposing stained fabric beneath the plastic.
? A high back vinyl rolling office chair was also observed with a large tear noted in the seat cushion.
? The walls had paint peeling off where the back of the chairs were rubbing against the walls.
? Food wrappers and what appeared to be a cheese puff were observed on the floor, indicating inadequate cleaning.
? There were 6 holes in the sheetrock, which prevented effective cleaning or disinfection.
In the Vital sign room #1, there were 4 fabric-covered chairs. 3 of the 4 chairs were covered in a thin, white, opaque plastic covering, with stains on the fabric underneath.

Interview 1/30/13 at 1:55 p.m. with the Environmental Manager (ID# 15) revealed they were not aware that the offsite partial hospital program was placing a thin layer of white plastic to cover stained fabric chairs in the Group rooms.

In the "Large Group Room" at the back of the building:
? A sealed grate was observed in the floor with dirt and debris present in the grate holes.
? 10 ants were observed on the floor beneath a desk and crawling on top of the desk.
? There was a ceiling tile with a 1 x 1 foot area of water damage, which increases the risk of contamination in a moist environment.
? There was external light visible for approximately 8 inches under the exterior door, which allows for the entry of dust, insects and vermin. There was raised dirt, debris and a cigarette butt inside the door in the room, indicating a lack of cleaning.
? There were holes in the sheetrock throughout the building, including the "Great Room" which prevented effective cleaning.
? Two black metal Television stands were noted with heavy dust on the flat surfaces.
? A filling cabinet and a folding table were also observed with heavy dust residue on horizontal surfaces.
In the 2 IOP room next to the "Large Group Room":
? The carpet was in need of cleaning with stains and was shredded
? The wall plate was unscrewed from the wall and wires were exposed and extending into the room, creating a hazard and an entry for dust and insects.
In the back hallway next to the "Large Group Room":
? There was a built in ladder extending from the floor into the attic in the back hallway. There was a large space (approximately 5 x 3 feet) which was open to the attic, which would allow contamination by dust and allow the entry of insects or vermin.
Review of the facility's "Environmental Rounds/Audit" for the months of October, November, and December 2012 revealed no documented evidence of any of the above.

Record review of "Partial hospitalization Weekly Logs" for October 2012; November 2012; December 2012; and January 2013 revealed "Furniture in good working order." The logs further stated "No signs of pests."

Record review of monthly documents titled "Environmental Rounds/Audit" dated October 29, 2012; November 2012; and December 2012 revealed the following statement in each report "checked ceiling titles for leaks and mold. Ceiling tiles in good condition with no signs of water leak."

The above was confirmed in interview during a tour of the PHP facility the morning of 1/29/13 with the PHP Infection Control Supervisor, Staff #8 and the Director of Special Projects, Staff # 6.

During a tour of the kitchen area on 01/29/13 at 1050, the following infection control issues were observed:
? 1 out of 2 microwaves was visibly soiled, with a discolored stain on the turntable approximately 2 X 3 inches in size. Visible splatters were observed inside this microwave. The exterior of both kitchen microwaves had a visible layer of greasy dust. These issues inadequate cleaning and disinfection of this equipment and present a risk for cross contamination..
? 1 sheet pan on a storage shelf was observed, with what appeared to be, a piece of rice adhered to the handle, which indicated inadequate cleaning. 19 metal serving pans and 6 sheet pans were stored stacked together upside down, not allowing for complete drying post washing. This presents a risk for the growth of bacteria and creates a risk of contamination. The top pans in these stacks had a greasy residue present.
? 3 out of 5 square plastic bins were observed with stickers and sticker residue present on the containers. The sticker residue cannot be properly disinfected and provides a risk for cross contamination.
? In the refrigerator the following food items were found open with no open date noted to indicate when it was opened or when it would it expire: 1 container of Chicken Base and 1 bottle of Real Lemon Juice.
? On the top of the refrigerator a brown, greasy, dusty residue was noted, indicating inadequate cleaning.
? Under the food preparation table the following items were found inside a large plastic bin: 1 large open container of Pace picante sauce with no date indicating when opened. The container directed to "refrigerate after opening", this item was not being stored in the refrigerator, presenting a risk of food borne illness. Containers of Zataran ' s Shrimp and Crab Boil, 1 bottle of Red Hot Buffalo Sandwich Sauce, 1 bottle of White Vinegar, and 1 bottle of A-1 Sauce were open and not dated to indicate when the item was opened or when it would expire. The plastic bin containing these bottles had a piece of cardboard that covered the bottom which had a discolored grease spot 7 X 7 inches with visible debris, dust, and a dried bean present in the bin, indicating inadequate cleaning.
? One large metal strainer on the clean dishes shelf had what appeared to be food particles present in the holes of the strainer, indicating inadequate cleaning.
? A large plastic bin on the clean dishes shelf contained 16 visibly dirty utensils, indicating inadequate cleaning and disinfection. A discolored piece of paper towel was observed at the bottom of this bin.
? The rolling coffee cart was dirty and in need of cleaning as there was a layer of brown greasy residue on the horizontal surfaces of the cart.
? The lid to a Rubbermaid container storing crackers was dirty, with dust, dried food, and a piece of string on the lid.
? The plastic bin which stored mustard packets was dirty inside and there was a brown greasy residue on the lid of the tub.
? The handle of the plastic bin which stored mayonnaise and pasta had a thick, yellow, greasy substance on the handle and there was a dried substance, which appeared to be old food on the top of the lid.
? The plastic bin which stored jelly, picante sauce, and chocolate milk packets had a dried substance, which appeared to be old food on the lid. One of the dried food particles was approximately ? inch in length.
? There was dirt and chunks of dried food debris in a 22 quart container which stored knives and cooking utensils, available for use in food preparation. In this container were 5 knives with dirty handles which were stained black, a large knife with dried food on the blade, a long serrated knife with dried food on the blade, 3 potato peelers that were dirty with dried food on the blades and the handles, and a meat tenderizer which had 3 pieces of a dried reddish substance adhered which appeared to be meat. There were 2 dirty pot holder mitts on top of a "clean" food strainer and a cooking pot which were available for use in food preparation.
? There was a man's ball cap sitting with the pots and pans on the clean cooking equipment shelf, creating a risk for contamination.
The above was confirmed in an interview during a tour of the kitchen the morning of 1/29/13, by the PHP Food Service Supervisor, Staff #9, and the PHP Infection Control Supervisor, Staff # 8.

The following was observed on the shelving unit in the kitchen:
? 4 of 4 lids to the large bins storing disposable packets of plastic eating utensils, bowls, and other patient eating supplies was covered in a brown greasy residue with dirt and dried food particles.

? 9 large bottles of spices used in patient food preparation which were covered in a brown greasy residue.

? 15 midsize bottles of spices used in patient food preparation which were covered in a brown greasy residue.

? 2 cans of bread crumbs, 15 ounces, which expired 7/14/2012

? Hunt ' s tomato paste, 12 ounces, best by 12/13/12

? The shelves upon which the above was stored were covered with a layer of greasy dust; there was debris in the corners of the shelves, which appeared to be old, dried food.

? There were 3 dirty aprons, with a dried substance adhered which appeared to be food and dust, were hanging on the shelf with food products and eating utensils available for patient use.

The above was confirmed in an interview during a tour of the kitchen the morning of 1/29/13, by the PHP Food Service Supervisor, Staff #9, and the PHP Infection Control Supervisor, Staff # 8.

During a tour of the kitchen the morning of 1/29/13, accompanied by the PHP Food Service Supervisor, Staff #9, and the PHP Infection Control Supervisor, Staff # 8, the survey team observed a large scoop stored in the ice machine in the ice. This was confirmed in an interview with Staff #9 and Staff #8.

During a revisit to the kitchen the morning of 1/30/13, the large scoop was observed by the surveyor in the ice machine in the ice again the morning of 1/30/13 and was confirmed by the PHP Food Service Supervisor, Staff #9. Staff #9 stated that the large scoop was kept in the ice in the ice machine as a Houston inspector told him the ice scoop should be kept in the ice. Storing the ice scoop in the ice is an infection control risk as the handle of the ice scoop, after hand contact, could contaminate the ice and spread bacteria.

The Centers for Disease Control and Prevention (CDC) article entitled, "Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee" (2003), found at: <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm>, states, "Do not store the ice scoop in the ice bin. " in the section entitled, " IX. Ice Machines and Ice."

In an interview on 01/30/13, when asked who is responsible for cleaning the PHP kitchen, staff member # 15 stated, "(Staff member #9) and his group are responsible for cleaning the kitchen there (at the PHP)."

In an interview 1/30/13 at 10 a.m. with the Infection Control Nurse (ID# 8) assigned to the Partial hospitalization program, she stated she does not make environmental rounds inside the kitchen area.

In an interview 1/30/13 at 1:55 pm, when asked who is responsible for cleaning the PHP kitchen, staff member # 15 stated, "Cleaning the kitchen falls into dietary. Housekeeping cleans the bathroom and helps mopping the office. Dietary is in charge of cleaning the kitchen at the hospital. (Staff member #9) and his group are responsible for cleaning the kitchen there (at the PHP)."

During a tour of the PHP facility the morning of 1/29/13, accompanied by the PHP Infection Control Supervisor, Staff #8 and the Director of Special Projects, Staff # 6, the following was observed in the laboratory area:
? 15 gray top blood specimen test tubes were available for use with the expiration date of 12/2012.
? Debris and discarded items were observed on the floor. 7 plastic caps to needles and 3 used alcohol pads were observed on the floor.
? In the refrigerator, there was a urine specimen container which was half filled with an amber colored liquid. The liquid was cold and appeared to be urine. The urine specimen container had no identifying information on the label or on the specimen cup to indicate name, time, date, or other information.

? The refrigerator temperature log had not been completed on the following dates: 1/21/13, 1/22/13, 1/23/13, 1/24/13, 1/25/13, 1/26/13, 1/27/13, and 1/28/13. The refrigerator log had a hand-written date of "January 2013" stated on the form, "directions: [1] Read and record temperature daily: use a dot in the appropriate column/date. Connect dots."

? There was a thick layer of dust on high and low horizontal surfaces, including the refrigerator, the centrifuge, and the table and other furniture in the room.

? There was a dead ant in a plastic lab supply bin.

During a tour of the PHP facility the morning of 1/29/13, accompanied by the PHP Infection Control Supervisor, Staff #8 and the Director of Special Projects, Staff # 6, the following was observed in the patient laboratory drawing room:
? 7 ammonia packets which expired 8/2010, a tiger top lab tube which expired 3/2011, a purple top lab tube which expired 12/2012, and adult blood culture collection kit which expired 11/30/2012
? There was a layer of dust on high horizontal surfaces.
The facility based contract for janitorial services with Clean U.S.A. dated 10/25/2008, stated in part, "Proposal for janitorial services ...Now therefore, in consideration of the mutual agreement herein contained, the parties hereto agree as follows:

General Areas: Offices, restrooms, lobbies, stairways, elevators, lunchrooms/warehouse office, etc ...

OBJECTIVE: To maintain your building in like new condition ...

Nightly Services
1. Vacuum all carpeted area, spot clean as needed ...
5. Dust all desk tops, file cabinets, furniture, and equipment. (No correspondence will be moved.)"

Facility environmental services policy entitled, "Scope of Care" stated in part, "Cleaning duties include by (sic) may not be limited to sweeping, dusting, waxing, and polishing floors, cleaning restrooms and fixtures, washing walls and furniture, cleaning stairways and elevators and shampooing and cleaning carpeted surfaces."

Facility environmental services policy entitled, "Service Specifications" stated in part,
"A GENERAL CLEANING FOR NON-PATIENT AREAS:..
4. Dust all desks, counters, tables, and related surfaces
(Note: Housekeeper will not move papers or articles left on surfaces.)
5. Dust all areas with-in high hand reach, including all chairs, desks, tables, cabinets,
furniture, window sills low ledges, picture frames, etc.
C. GENERAL CLEANING FOR PATIENT AREAS:
1. General cleaning Same as 'A-1 through A-10'.

Facility environmental services policy entitled, "Cleaning of Day Rooms" stated in part, "To provide an aesthetically clean, sanitary area for patients and staff.

PROCEDURES:
Daily: (Monday through Friday) ...
3. Wash, and rinse all unobstructed shelves, counters and table tops with germicidal cleaning agent.
4. Spot clean walls, light switches, doors, door facings, outside of cabinets and inside windows.
5. Damp wipe chairs; inspect upholstered furniture for spot removal and/or necessary scheduling of extraction shampoo cleaning. "

Facility environmental services policy entitled, "Cleaning of Classrooms" stated in part, "To maintain clean, sanitary, attractive classrooms for the patients and instructor ...
4. All furniture shall be damp cleaned using germicidal detergent solution and clean cloths. Damp clean furniture, then wipe it with a cleaning cloth. Only unobstructed desk, table tops, and book shelves will be cleaned. "

Facility environmental services policy entitled, "Office Cleaning" stated in part, "4. Damp wipe unobstructed desks, counter tops, tables and shelves, then wipe dry to prevent streaking ...8. Vacuum carpeted floors daily spot clean carpets as needed. Bonnet clean or extraction cleaning of carpets is done as needed.

Facility environmental services policy entitled, "Cleaning of Pharmacy" stated in part, "3. Surfaces containing papers or other items, both personal and hospital property will not be cleaned by Housekeeping Services. Cleaning of these surfaces is the responsibility of the Pharmacy Department."

Facility environmental services policy entitled, "Furniture Cleaning" stated in part, "6. Upholstered Furniture: Upholstered furniture should not be allowed to become badly soiled. Spot cleaning of upholstered surfaces should be done each time a surface becomes soiled so stains do not set. Always refer to manufacturer's directions for cleaning procedures and proper products when cleaning any furniture surfaces."

Facility environmental services policy entitled, "Cleaning of Stainless Steel Surfaces" stated in part, "1. Disinfect the surface by damp wiping the stainless steel surface with a cloth saturated in properly diluted germicidal cleansing solution or spray the surface with pre-diluted germicidal solution, wipe with a damp cloth, and the (sic) wipe surface with a clean soft cloth."

The above was confirmed in an interview the afternoon of 1/31/2013 in the conference room with administrative staff.