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Based on document review and interview the Food Service Supervisor failed to insure the dietary department participated in Quality Assessment Process Improvement (QAPI).

On 8/28/2012 the Food Service Supervisor (FSS) was interviewed and revealed the following topics were repeatedly submitted for quality review:
- the dietary department was monitoring temperatures in the kitchen (No problems noted for 6 months)
- the dietary department was reviewing the satisfaction reports

A review of the QAPI for the kitchen for the past 12 months revealed no mention of Quality Assessment Process Improvement was mentioned other than meal satisfaction reports.

The FSS was asked if any other QAPI was followed or submitted to the QAPI committee and the the replay was "no"

Based on document review and interview the facility failed to show evidence the qualified dietician was an employee of the facility in one of one dieticians reviewed.

On 8/29/2012, review of the employment record for the registered dietician (RD) revealed the dietician was an employee of a sister facility and all documents including the employment application had the letter head and contact information of the sister facility.

On 8/38/2012 the Food Service Supervisor (FSS) confirmed the RD was an employee for a sister facility.

On 8/30/2012 the Director of Human resources confirmed the RD had come from a sister facility and worked at their facility 1 day a week. She also confirmed all the employee documents had been copied from the sister facility and sent to them.

On 8/30/2012 an interview with the administrator confirmed the RD was not on contract with his facility for services but was part of the larger health care system. The Governing Body and Medical Staff had not reviewed the RD application or approved the RD.

There was no document indicating the RD was an employee of the hospital.

Based on observation and interview the facility failed to maintain a sanitary environment in 4 of 4 item found during a tour of the dietary department.

On 8/29/2012 at 10:30 AM during a tour of the kitchen the following items were observed in an unsanitary environment:

- pre-made hamburger patties in a tray, beneath the grill, were observed open to air without a "date opened" or "use by" date on the open wrapper.
- a large bag of frozen fish fillets was open to air with no "date opened" or "use by" date on the open bag.
- a carton of egg beaters was observed, on a refrigerator shelf, with the top open to air and no "date opened" or "use by " date on the label.
- frozen cooked turkey quarters were observed on a tray in the freezer exposed to air with tin foil loosely sitting in the meat.

During the tour the Food Service Supervisor (FSS) confirmed the "date opened" and "use by dates" were absent and also confirmed the above items were not properly sealed from exposure to the air, while in storage.