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Based on observation, review of facility provided documentation, interviews with staff and review of the facility's policy and procedures, the facility failed to ensure their contracted food service provider was organized and maintained in a safe and sanitary manner. The facility failed to ensure food safety when they allowed their immune-suppressed patients to be served potentially hazardous foods which were delivered in an un-clean vehicle and in broken, un-sanitized transportation carts. Their patients were served hot and cold foods that were held in the temperature danger zone between 41 -135 degrees F (cold foods above 41 degrees F and hot foods below 135 degrees F)and no documentation could be located that the food temperatures were monitored before each meal service. The facility failed to ensure the physician ordered therapeutic diets were followed as written. They failed to develop a policy and procedure for providing their patients with the necessary nutrients in the case of an emergency/disaster and they failed to educate and train the dietary staff on how to prepare and serve food in an emergency/disaster situation. The Condition of Participation for Food and Dietetic Services was not met when the facility failed to ensure their contracted food service provider followed safe and sanitary techniques which created the potential for negative outcome in the form of food borne illness, cross contamination, further decline in patients health status, and the potential for infectious disease to spread throughout their population.

The findings include:

1. Observation of the main kitchen at a separate facility at 9:50 am on 3/3/10 revealed the driver/host had prepared individual lunch meal trays to be delivered to the offsite facility (Specialty Hospital). He stated the offsite facility census was approximately 60 and this main facility prepared and transported three meals each day to the offsite facility which was approximately 3 miles away.

Observation of the meal service and the transportation procedure on 3/3/10 at 9:50 am revealed the cold foods were holding at room temperature and the transportation vehicle and insulated transportation carts were un-clean, un-sanitized and not maintained in good condition.

Observation of the three insulated transportation carts revealed the doors on the inside were covered with food debris and felt sticky and wet when touched. One of the carts had broken front handles which allowed the doors to fly open, exposing the food twice during the transportation process on 3/3/10.

The driver/host prepared the individual meal trays with condiments, rolls, and eating utensils and placed the trays in the un-clean transportation carts. Observed on top of the carts, and holding at room temperature, were cold foods in white lunch bags which were prepared at 7:00 am (per staff) and were intended as snacks for the patients at the offsite facility. There were 28 bagged snacks that contained cheese, crackers, chicken salad sandwiches, milk, yogurt, fruit, and cottage cheese.

Interview with the driver/host on 3/3/10 at 10:00 am revealed the bagged snacks and cold foods which were placed on top of the transportation carts were to be delivered to the offsite facility at 10:45 am. He stated he was the person who filled the meal trays, loaded the carts, drove the truck, and passed out the individual trays to the patient rooms at the offsite facility. When interviewed about when the temperature of the hot and cold foods would be taken, he stated he was unsure. He stated he did not take the food temperatures either before he left the main facility or once he arrived at the offsite facility.

Review of the temperature logs revealed the cold food temperatures had not been recorded before being placed in the un-clean transportation carts.

Observation of the transport vehicle on 3/3/10 at 11:20 am revealed it was paneled with wood inside and was covered with light colored particles which resembled dust or dirt.

Interview with the driver/host at 11:22 am on 3/3/10 confirmed he had not cleaned or sanitized the truck. He stated because it was paneled with wood, he could not clean the inside of the vehicle with water.

Review of the transportation policy and procedure dated 2/23/10 revealed the transportation vehicle was to be swept, mopped and sanitized daily to ensure the food could be delivered in a sanitary fashion.

2. Observation of the meal service at the offsite facility (Specialty Hospital) revealed the food temperatures had not been taken or recorded until surveyor intervention. Interview with the offsite facility staff at 11:30 am on 3/3/10 confirmed it was not their practice to take or record food temperatures before the meals were delivered to their patients.

The food temperatures were taken at 11:35 am on 3/3/10, approximately 1 1/2 hours after the meal trays were being prepared in the main kitchen. Each of the foods recorded were holding in the danger zone (cold foods above 41 degrees F and hot foods below 135 degrees F). The following temperatures were recorded:

a. Puree beef was holding at 110 degrees F
b. Mechanically altered beef was holding at 110 degrees F.
c. Pudding was holding at 51 degrees F.
d. Two chicken salad sandwiches were recorded and one was holding at 58 degrees F and the other was holding at 50 degrees F.

After the temperatures were recorded, the driver/host and the employees at the offsite facility delivered the individual trays to their patients. The food was not heated or cooled to ensure food safety before delivery.

3. Observation of the kitchen at the offsite facility (Specialty Hospital) on 3/5/10 at 4:00 pm, revealed their kitchen was not equipped to prepare meals for their patients. Interview with staff at that time confirmed their food service was contracted out and the dinner meal would arrive via truck at approximately 4:30 or 4:45 pm that evening.

Interview with the kitchen staff and the registered dietitian (RD) on 3/5/10 at 4:15pm revealed they did not know where to find an emergency/disaster food service meal plan or how they would feed their patients in the case of an unplanned emergency.

Review of the facility provided documentation, the "Comprehensive Emergency Management Plan", revealed the plan had not been reviewed or revised since June 2009. It was dated June 2008-2009 and did not contain an emergency food service plan or menu. The "Plan" stated only that the facility would have adequate supplies and manpower to provide meals to an estimated 170 people at this facility for 72 hours. It went on to say that "Food, supplies, paper goods, and refrigerated storage needs will be met through various established service contract agreements".

Interview with the Chief Executive Officer, the Chief Nursing Officer, and the Director of Nursing Operations (DON) at 4:20 pm on 3/5/10 confirmed that was the only written emergency food service plan. They were unsure what the facility would do if the "contracted agreements" could not provide the meal service to their patients during an unplanned emergency or disaster.

4. Observation of the meal service at the offsite facility (Specialty Hospital) on 3/5/10 at 5:30 pm revealed the food had been delivered via truck and was 45 minutes late. The meals arrived at 5:30pm and the following temperatures were taken and recorded:

a. Puree turkey was holding at 90 degrees F.
b. Ground turkey was holding at 80 degrees F.
c. Mixed vegetables were holding at 90 degrees F.
d. Milk was holding at 60 degrees F.
e. Cornbread stuffing was holding at 102 degrees F.
f. Applesauce was holding at 60 degrees F.
h. Roast Beef sandwiches were holding at 65 degrees F.

There were five covered plates on top of the transportation cart which were "extra" per interview with the driver/host at 5:40 pm on 3/5/10. The food temperatures of the extra plates were recorded and the cornbread stuffing and the ground turkey were holding at 110 degrees F. (Danger zones, cold foods above 41 degrees F and hot foods below 135 degrees F)

Observation of the puree foods revealed they were runny, had a yellow film on the top and holding at an un-safe temperature. The puree foods were placed in separate bowls and not placed on a heated palate during the transportation process.

Interview with the RD at 6:20 pm on 3/5/10 confirmed the puree foods were runny and out of temperature control. The temperature of the food was tested in each of the three transportation carts. Five meal trays in the first cart and one meal tray in the remaining two carts were tested. All of the foods tested were holding in the danger zone between 41-135 degrees F.

Observation of the insulated transportation carts at 6:30 pm on 3/5/10 revealed the inside and outside remained food covered and un-clean. The inside doors were covered with food debris and the sides and bottoms of all three carts had spilled and dried on food.

The facility census was 70 on 3/5/10 at 6:30 pm, per interview with the DON. Each patient who could eat their meals by mouth had to have their meals reheated by the nursing unit microwave; one meal at a time. The cold foods had to be discarded. At 7:00 pm the meal service still continued.

5. Review of the facility provided documentation the list of "Current Diets" revealed there were many patients who had physician ordered therapeutic diets. The following information was confirmed from the diet list:

a. There was 1 patient who was ordered a 1600 calorie diet.
b. There were 11 patients who were ordered an 1800 calorie diet.
c. There was 1 patient who was ordered a 2000 calorie diet.
d. There were 2 patients who were ordered a 2200 calorie diet. e. There was 1 patient who was ordered a 2400 calorie diet
f. There was 1 patient who was ordered a 2600 calorie diet
g. There were 2 patients who were ordered a Potassium restricted diet.
h. There was 1 patient who was ordered a no added salt (NAS) diet.

Observation of the meals delivered to the facility on 3/5/10 at 5:30pm revealed all the plates had the same amount of food. There was no differentiation between the different caloric levels. Interview with the RD at that time revealed the "regular" diets were approximately 2000 calories.

Review of the daily menu and the diet spreadsheet revealed there was a column for "Calorie" diets; however, it did not differentiate between the different caloric levels. The spreadsheet did not contain a potassium restricted diet or a NAS diet. It also did not contain appropriate serving sizes.

When interviewed at 6:30 pm on 3/5/10 the RD was unsure how the staff at this facility would be able to evaluate if their patients had received the correct physician ordered therapeutic diets or what would be an appropriate food substitute if the spreadsheet did not contain the different types of therapeutic diets or included the appropriate serving sizes.