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Based on review of records and interview, the facility failed to ensure that the policies pertaining to a critical access hospital (CAH) were reviewed and subsequently scheduled to be reviewed every two years by members of the hospital's professional healthcare staff, including one or more Doctor of Medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists on staff. Reviews of 3 of 3 infection control policies showed that the policies had not been updated in the last 7 years.

Findings included:

The following 3 policies were provided by the facility as current policies in use:

POLICY #1
Title: Infection Control Monitoring the Process
Department: Hospital Wide
Originated date: May 31, 1999
Revised date: March 1, 2006

POLICY # 2
Title: Antibiotic Stewardship Program
Department: Pharmacy
Date Revised: September 17th, 2016

Policy # 3
Title: W.J. Mangold Memorial Hospital and Clinics Hand and Fingernail Hygiene Policy
Department: Hospital Wide
Originated date: 12/25/05
Reviewed: 2/1/2013
Revised: 11/03/2016
Revised: 2/26/2018

During an interview, on the morning of 9/30/2025 Staff #1, #2, and #3 verified these findings.

Based on observation, interview, and record review, the facility failed to maintain and meet the standards at Texas Administrative Code, Title 26 section 505.41 (d)(1)(A), when the facility's Dietary Manager failed to have current Food Service Manager certification.

Findings include:

Review of the Texas Administrative Code, Title 26 section 505.41 (d)(1)(A) reflects the following: "(A) The hospital shall have a full-time employee who is qualified by experience or training to serve as director of the food and dietetic service and be responsible for the daily management of the dietary services."


Review of the facility policy "Dietary Manager Job Description" last revised 3/28/25 reflected the following "... The Dietary Manager must have graduated from an approved Dietary Manager's course and have taken their Servsafe Manager's course and passed the exam ..."

Review of the Staff #24's, Dietary Manager, Servsafe Certification reflected an expiration of 4/17/2022.

During an interview, on the morning of 9/30/25 Staff #24 reported that she had not been able to pass the test.

During an interview, on the afternoon of 9/30/25 Staff #1 reported that he was unaware of this issue.