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Based on observation, document review, and staff interview, the hospital failed to ensure the data collected from its Dish Machine Temperature Log was accurate. By not reporting to the hospital's Performance Improvement Committee that the Dish Machine Temperature Log was filled out incorrectly by the Dietary Manager, problems with dish machine operation and documentation were not brought to the attention of hospital leaders. The findings are:

A. On 08/07/13 at 1:30 pm, during surveyor tour of the hospital kitchen, the facility's Dish Machine Temperature Log, completed by the Dietary Manager, revealed the documentation of the machine's wash temperature to be 120 degrees Fahrenheit (F). The rinse temperature was also documented as 120 degrees F. The sanitizer was documented at the 50 part per million level. The same data was documented for the period 08/01/13-08/07/13. This was the same information for the days the hospital had patients for May 2013, June 2013, and July 2013.

B. On 08/07/13 at 1:30 pm, during surveyor observation of the functioning of the dish machine, the Assistant Administrator ran the dish machine through a wash and rinse cycle and periodically checked the temperature. The rinse gauge on the dishwasher rose to 165 degrees F.

C. The dishwasher specifications from the manufacturer were reviewed on 08/09/13. The machine was produced by Fagor Commercial, Incorporated. The facility's machine, Model FI-120W, provides high temperature sanitation. The wash temperature is specified to be 150 degrees F. and the rinse temperature 190 degrees F. by Fagor.

D. On 08/07/13 at 4:14 pm the Assistant Administrator was asked if he read the instructions for use of the dishwashing machine and knew the required operating temperatures for the machine. He stated that before today he had not read the instructions. He stated that he was reviewing the log, but did not know that the log was incorrect.

E. On 08/09/13 at 9:00 am, during telephone interview, the Assistant Administrator was questioned about the data documented on the Dish Machine Temperature Log. He replied that the Dietary Manager was documenting the minimum acceptable temperature for a cold water machine. He agreed that this documentation was incorrect because the dish machine was a hot water, not a cold water, machine. The Assistant Administrator said that the dietary manager was not present to address the question and that he did not know why she was not documenting actual temperatures for the hot water machine that was currently in use at the hospital.

F. Review of the hospital's 2013 Quality Improvement Plan revealed no requirement for monitoring and reporting dish machine temperatures.

Based on record review and interview, the hospital failed to ensure that references of competence were required to be submitted as part of the credentials application process for 3 of 4 sampled doctors (#2, 3, and 4). This deficient practice precluded the hospital from fully assessing the practitioner's competence to perform the tasks that he/she was requesting in his/her request for privileges. The findings are:

A. Review of Paragraph 4.1.1 of the hospital's Medical Staff Bylaws, approved on 10/21/10 by the hospital's governing board, revealed the statement, "Application for appointment to the medical staff shall be presented in writing on the prescribed form and shall state the qualifications, references, and physical and mental health of the applicant."

B. Review of the credentials for Doctor #2 revealed no letters of recommendation were provided with this physician's credentials application packets.

C. Review of the credentials for Doctor #3 revealed no letters of recommendation were provided with this physician's credentials application packets.

D. Review of the credentials for Doctor #4 revealed no letters of recommendation were provided with this physician's credentials application packets.

E. Review of the hospital's Credentialing Checklist (undated), displayed no requirement for letters of recommendation to be included in the credentials packet.

F. Review of paragraph 5.2 of the above-referenced bylaws disclosed the statement, "Every initial application for appointment and every application for reappointment must contain a request for the specific clinical privileges desired by the applicant. The evaluation of such requests shall be based upon the applicant's education, training, experience, demonstrated competence, references, physical and mental health, and other relevant information, including information obtained from the results of quality assurance activities."

G. On 08/06/13 at 11:20 am, during interview, the hospital's Director of Human Resources and credentials clerk stated, "No letters of recommendation are required for credentialing physicians."

Based on document review and interview, the facility failed to ensure that the Dietary Services Supervisor was qualified to perform the duties required of the position. This deficient practice could result in substandard dietary services provided to hospital patients. The findings are:

A. Review of the Dietary Service's Policy and Procedure Manual, signed by the hospital dietary manager and dietitian on 02/15/13, revealed, in a policy titled, "Dietary Supervisor," the qualifications of the Dietary Manager. These include the requirement that the Dietary Manager is "a graduate of, or enrolled in, a dietary supervisor correspondence course approved by the Dietary Manager's Association or has training and experience in food service supervision in a military service that is state approved."

B. Review of the Dietary Manager's personnel file revealed neither documentation of completion of a correspondence course such as that described in paragraph A above nor documentation of prior military service.

C. On 08/07/13 at 3:00 pm, during interview, the hospital Dietary Manager stated that she had been working at the hospital for approximately 5 years and that she had never received training except for the quarterly training that she receives from the contract dietitian.

D. On 08/08/13 at 08:30 am, during telephone interview, the Assistant Administrator stated that the Dietary Supervisor was hired on 04/10/09. He also verified that she has no military experience.

Based on observation, document review, and interview, the facility failed to ensure proper operation of the kitchen dishwasher. This deficient practice has the potential to increase the risk of food-borne illness. The findings are:

A. On 08/07/13 at 1:30 pm, during surveyor tour of the hospital kitchen, the facility's Dish Machine Temperature Log, completed by the Dietary Manager, revealed the documentation of the machine's wash temperature to be 120 degrees Fahrenheit (F). The rinse temperature was also documented as 120 degrees F. The sanitizer was documented at the 50 part per million level. The same data was documented for the period 08/01/13-08/07/13. This was the same information for the days the hospital had patients for May 2013, June 2013, and July 2013.

B. The dishwasher specifications from the manufacturer were reviewed on 08/09/13. The machine was produced by Fagor Commercial, Incorporated. The facility's machine, Model FI-120W, provides high temperature sanitation. The wash temperature is specified to be 150 degrees F. and the rinse temperature 190 degrees F. by Fagor.

C. Review of the 2009 Food and Drug Administration Food Code revealed the following information:
"4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures.
? (A) Except as specified in ? (B) of this section, in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 90?C (194?F), or less than:
(1) For a stationary rack, single temperature machine, 74?C (165?F); or
(2) For all other machines, 82?C (180?F). "

D. On 08/07/13 at 1:30 pm, during surveyor observation of the functioning of the dish machine, the Assistant Administrator ran the dish machine through a wash and rinse cycle and periodically checked the temperature. The rinse gauge on the dishwasher rose to 165 degrees F.

E. On 08/07/13 at 4:00 pm, the dishwasher was observed to have two liquids flowing into it. One was a detergent and the other was noted to be a rinse agent. No sanitizer was seen to be flowing into the dish machine.

F. On 08/08/13 at 10:30 am, during telephone interview, the hospital's contract dietitian, who provides services at the hospital on a quarterly basis, stated that the dishwashing machine was not working properly and that it was suspected that the machine had a bad heating element.

G. On 08/09/13 at 9:00 am, during telephone interview, the hospital's maintenance supervisor stated that there is no maintenance contract for the dish machine. He said that a company comes to the hospital monthly to clean the dishwasher and ensure that detergent is flowing in the machine.

H. On 08/09/13 at 9:00 am, during telephone interview, the Assistant Administrator was questioned about the data that was documented on the Dish Machine Temperature Log. He replied that the Dietary Manager was documenting the minimum acceptable temperature for a cold water machine. He agreed that this documentation was incorrect because the dish machine was a hot water, not a cold water, machine. The Assistant Administrator said that the Dietary Manager was not present to address the question and that he did not know why she was not documenting actual temperatures for the hot water machine that was currently in use at the hospital.

I. On 08/12/13 at 11:00 am, during telephone interview, the Associate Administrator reported that a maintenance technician, whom the hospital had called to check the functioning of the dish machine, found that the machine had a broken heating element. The technician measured the temperature of the wash water at 140 degrees F. and the temperature of the rinse to be 160 degrees F.

Based on observation, document review, and interview, the facility failed to ensure proper maintenance of the kitchen dish machine. This deficient practice has the potential to increase the risk of food-borne illness. The findings are:

A. On 08/07/13 at 1:30 pm, during surveyor tour of the hospital kitchen, the facility's Dish Machine Temperature Log, completed by the Dietary Manager, revealed the documentation of the machine's wash temperature to be 120 degrees Fahrenheit (F). The rinse temperature was also documented as 120 degrees F. The sanitizer was documented at the 50 part per million level. The same data was documented for the period 08/01/13-08/07/13. This was the same information for the days the hospital had patients for May 2013, June 2013, and July 2013.

B. On 08/07/13 at 1:30 pm, during surveyor observation of the functioning of the dish machine, the Assistant Administrator ran the dish machine through a wash and rinse cycle and periodically checked the temperature. The rinse gauge on the dishwasher rose to 165 degrees F.

C. The dishwasher specifications from the manufacturer were reviewed on 08/09/13. The machine was produced by Fagor Commercial, Incorporated. The facility's machine, Model FI-120W, provides high temperature sanitation. The wash temperature is specified to be 150 degrees F. and the rinse temperature 190 degrees F. by Fagor.

D. Review of the 2009 Food and Drug Administration Food Code revealed the following information:
"4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures.
? (A) Except as specified in ? (B) of this section, in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 90?C (194?F), or less than:
(1) For a stationary rack, single temperature machine, 74?C (165?F); or
(2) For all other machines, 82?C (180?F). "

E. On 08/08/13 at 10:30 am, during telephone interview, the hospital's contract dietitian, who provides services at the hospital on a quarterly basis, stated that the dishwashing machine was not working properly and that it was suspected that the machine had a bad heating element.

F. On 08/09/13 at 9:00 am, during telephone interview, the hospital's maintenance supervisor stated that there is no maintenance contract for the dish machine. He said that a company comes to the hospital monthly to clean the dishwasher and ensure that detergent is flowing in the machine.

G. On 08/12/13 at 11:00 am, during telephone interview, the Associate Administrator reported that a maintenance technician, whom the hospital had called to check the functioning of the dish machine, found that the machine had a broken heating element. The technician measured the temperature of the wash water at 140 degrees F. and the temperature of the rinse to be 160 degrees F.