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Based on record review and interview, the hospital performance improvement program (PIP) failed to assess performance improvement (PI) activities for 1 of 1 hospital services (dietary services). The Dietary department was not being monitored for quality assurance(QA) or PI activities.

Findings include:

The Administrative Policies and Procedures titled, "Performance Improvement Plan", revised 07/09, requires, "Q. The Performance Improvement program encompasses services provided by patient care, ancillary/support departments/services, and contract services..."

In the Performance Improvement (PI) Committee Notes, dated 06/03/10, there was no evidence of monitoring or evaluating QA or PI activities regarding the Dietary Department.

In the Quality/Risk Management Report, dated Quarter 1, 2010, there was no evidence of monitoring or evaluating QA or PI activities regarding the Dietary Department.

In an interview the afternoon of 06/17/10, the Director of Quality and Risk Management (Personnel #3) was asked if the PI Program monitored activities for evaluating if QA or PI activities were being performed for Dietary Services. She stated, " No. "

In an interview on the afternoon of 06/17/10, the Director of Dietary (Personnel #6) was asked if the PI Program monitored activities for monitoring or evaluating if QA or PI activities are being performed for Dietary Services. He stated, " No. "

Based on record review and interviews, the hospital failed to designate a qualified infection control professional as required by the hospital Infection Prevention & Control Plan for 8 of 8 months (November 2009 until June 2010).

Findings:

The policy entitled, "Infection Prevention & Control Plan", revised date 01/01/2009, "14. Oversight of the Infection Prevention & Control Program. A qualified individual implements the Infection Prevention & Control program. A full time certified Infection Preventionist and the Medical Director of the Infection Prevention & Control Committee oversee the Infection Prevention & Control program."

The Administrative Policy and Procedure entitled, "Infection Control Program", Revised date 02/07, "Responsibilities: A. The Infection Control Practitioner is responsible for administering the Infection Control Program."

In an interview with RN #3 on the morning of 06/17/10, she was asked if the hospital had a designated full time certified infection control professional. She stated, "No, our Director of Med-Surg (RN #8) has been doing the infection control since November of last year (2009) when our previous infection control person left."

In an interview with RN #8 on the morning of 06/17/10, she was asked if she was in charge of the infection control program. She stated, "Yes, I was asked in November 2009 to cover the infection control program when the previous infection control nurse left. I am also the Director of Medical Surgical unit, education and employee health nurse." She was then asked if she had any training or certification in Infection Control. She stated, "No."

Staff job description for Infection Prevention & Occupation Health, revised 01/2009, requires, "Position Summary: Responsible for oversight and coordination of the infection control practices for an acute hospital environment and acts as an Infection Preventionist...Qualifications: Experience Required:..5+ years Infection Control experience preferred...Special Skills & Qualifications: Certification in Infection Control."

The employee file of RN #8 did not contain a current job description, training or certification for infection control.