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Based on interview, and record review, the hospital's quality assurance and performance improvement program failed to implement fully the plan of correction (POC) for improvement as it related to deficient practices identified on the 9/28/12 Federal recertification survey when continued and repeat deficient practices were observed.

Findings:

Review of the Department Quality Improvement Program on 11/10/12 at 3:30 p.m., including Director of Nutrition and Food Service (DNFS), Director of Support Services, Registered Dietician 2 (RD2), and Director of Quality and Safety showed there were plans for quality measures and data collection that included the Infection Control Department and the Quality Department to address the deficient food service finding in food safety practices, cool down, patient weight tracking, monitoring of label and dating, handwashing and dishwashing identified during the recertification survey.

The Director of Quality stated in the meeting that they had a late start and had identified the need for more staff and surveillance but the complete Quality Program for the Dietary Department was not fully in place. She acknowledged the findings during this survey reflected the need for the Quality Department to establish performance indicator based on findings and to prioritize and investigate root causes to have an effective data driven program.

Based on observation, interview, and document review, the hospital failed to ensure that Food and Nutrition Services met the needs of all patients as evidenced by the failure to:

1. Provide organized and effective food and dietetic services (cross-reference A619).

2. Ensure the Food and Dietetic Service Director develops and monitors written procedures according to standards of practice for operational processes at the hospital. Ensures policies and procedures and staff training are implemented in a timely manner and ensure staff are monitored to ensure compliance to policies (cross-reference A620).

3. Ensure the nutritional needs of patients were met in accordance with recognized dietary practices. The menus were not analyzed to ensure they met the Recommended Daily Dietary (RDA) allowance or the Dietary Reference Intake (DRI) adopted by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences (cross-reference A630).

4. Ensure implementation of an effective Infection Prevention program for identifying unsafe food handling practices that involved cool down of potentially hazardous food, safe food storage practices of perishable fruit juice, ice machines maintained in sanitary condition and cleaned as specified by the manufacturer, hand hygiene practices for patient tray delivery, and staff wearing hair coverings in the food service area (cross-reference A749).

5. Failed to fully implement a comprehensive quality appraisal and performance improvement program to correct deficient practices cited 9/28/12 (cross-reference A620 and A297).

The cumulative effect of these systemic problems resulted in the inability for the hospital's food and nutrition service to direct and staff in such a manner to ensure that the nutritional needs of the patients were met in accordance with practitioners orders and acceptable standards of practice.

Based on food storage, production and service observations, staff interviews, and dietary document review, the hospital failed to ensure the food and dietetic services department was effectively organized. The lack of organization, supervision, and oversight of the dietary department resulted in continuing deficient practices in multiple areas related to safe food practice, service, sanitation and storage (cross-reference A749, A620, and A297).

Findings:

During several interviews with the Director of Nutrition and Food Service (DNFS) from 12/10 to 12/11/12, discussed were the observations of continued deficient practices identified in the previous survey on 9/28/12 and reflected the lack of oversight of food service operations and implementation of the Plan of Correction dated 11/29/12.

The DFNS stated she was still responsible for food service operation. She managed the day-to-day food service operation through the Food Service Manager (FSM) and clinical nutritional services was now planned to be through a clinical manager position but that was pending hiring a clinical manager.

On 12/10/12 at 3:30 p.m., the interview included the DFNS, Registered Dietitician 2 (RD 2), and Director of Support Services and review of in-service documentation submitted for the Federal Recertification Survey Plan of Correction (POC) dated 11/29/12. The following are examples of incomplete in-services that affected the correction of deficient practices:

1. The Grooming policy in-service was to address the wearing of hairnets in the food service department and had a POC completion date of 11/21/12. The in-service sign in sheet showed only 35 percent of the dietary staff had attended on 11/12/12. The DFNS had noted "need another in service." She stated they did not have a system to ensure all dietary staff received the in-service. During interview with the FSM on 12/10/12 at 4:00 p.m., he stated that he had not done the additional in-service.

2. The Dish Machine in-service was to address the dishwashing temperatures and had a POC completion date of 10/9/12. Dishwashing procedures in-service was dated 10/2 and 10/4/12 had 46 percent of dietary employees attending. There were five employees identified assigned to the dish machine who had not signed the attendance form and had not received the training. On 12/10/12 at 4:00 p.m., the FSM stated he had not completed in-service for the essential staff assigned to the dish machine duties.

3. Two other in-services titled, "Temperature Control of Sandwich Preparation" (attendance was 82 percent) dated Oct 31 and Nov 2, and Storage Labeling, and Dating (attendance was 80 percent) dated 11/21, 11/28, and 11/30/12, had notes at the bottom by the DFNS stating, "Need to have another in-service." There were no documented additional in-services.

The Director of Quality and Safety stated concurrently during this meeting that in-service attendance was to be 90 to 100 percent.

As a result of this continued management organizational structure, the DNFS was not able to fully implement corrective actions and resulted in continued observations of deficient practices. There was not oversight and supervision of the food service staff that resulted in continuing deficient food safety practices. For example, although there was a cool down procedure (safe practice to ensure minimal growth of pathogenic microorganism in food prepared ahead of service or to be reserved after heating) there was no consistent monitoring of the process to ensure food was prepared and maintained in a safe manner. Review of food storage practices revealed deficient practices such as expired produces maintained for service to patients and lack of knowledge of product expiration and following manufacturers' directions for perishable products to ensure the product was maintained safe for patient service (cross-reference A0749).

Based on food storage, food production, and service observations, staff interview, and document review, the hospital failed to ensure the Food and Dietetic Service Director developed and monitored written procedures, staff practices, and knowledge according to standards of practice for operational processes at the hospital. The Department did not demonstrate a Quality Assessment Performance Improvement program (QAPI) that addressed a data driven analysis of the high risk high volume food service operation. Director of Food and Dietetic Services failed to ensure the corrective actions outlined in the Plan of Correction dated 11/29/12 were implemented.

Findings:

During several interviews with the Director of Nutrition and Food Services (DNFS), from 12/10/12 to 12/11/12, and observations which reflected lack of oversight of food service operations, she indicated while she bore the ultimate responsibility of food service operations, she managed the day-to-day food service operations through the use of a food service manager (FSM). She stated she was also responsible for the management of the Clinical Dietitian staff.

As a result of this management organizational structure, the DNFS was not fully aware of the issues affecting safe food handling practices. For example, although there was a cool down procedure (safe practice to ensure minimal growth of pathogenic microorganism in food prepared ahead of service or to be reserved after heating) there was no consistent monitoring of the process to ensure food was prepared and maintained in a safe manner. Food storage practices revealed deficient practices such as expired produces maintained for service to patients and lack of knowledge of product expiration, and following manufacturers' directions for perishable products (cross-reference A0749).

1. Review of the Department Quality Improvement Program on 11/10/12 at 3:30 p.m., including the DNFS, Director of Support Services, Registered Dietician 2 (RD 2), and Director of Quality and Safety, showed there were quality measures and data collection that included the Infection Control Department and the Quality Department to address the deficient food service finding in food safety practices, cool down, patient weight tracking, monitoring of label and dating, handwashing, and dishwashing.

The Director of Quality stated in the meeting that they had a late start and had identified the need for more staff and surveillance but the complete Quality Program for the Dietary Department was not fully in place. She acknowledged the findings during this survey reflected the need for the Quality Department to establish performance indicator based on findings and to prioritize and investigate root causes to have an effective data driven program.

2. Starting on 12/10/12 at 9:30 a.m., the following were observations with concurrent staff interviews:

a. The egg salad, tuna salad, and humus temperature logs did not accurately document cool down. The policy titled, "Hazard Analysis & Critical Control Points" dated 11/2012 Section 8. Cooling Temperature did not address the Food Code 2009 standard for cooling ambient temperature food production from 70 degrees Fahrenheit (F) to 41 degrees F in 4 hours. Review of the log showed on 11/28 the egg salad temperature was 68 degrees F at 8:40 a.m. and 39 degrees F at 3:30 p.m. This is a 6 hour cooling time and in excess of the required 4 hours. This is a potential for growth of microorganisms (potential for causing food borne illness). There was no documentation on the form of corrective action or if the product was served in an unsafe state. During interview with the FSM on 12/10/12 at 4:00 p.m. he stated he did look at the logs and did not document any corrective actions.

Further review of the temperature log showed entry dated 12/5 egg salad starting at 8:30 a.m., and cooling to 38 degrees F at 2:20 a.m., a 6 hour time and in excess of the 4 hours required to maintain safe food time temperature requirements. Again, there was no documentation of the review of action to ensure the product was maintained safe.

The POC dated 11/29/12 did not address the implementation of the Food Code 2009 to ensure there was a policy and staff knowledge of food cooled from ambient temperature to 41 degrees F met the 4 hour or less requirement.

b. Walk in refrigerator 5 stocked cases of individual size thawed fruit juice which were delivered frozen. The FSM stated these juices were used for patient tray line and nourishments. The manufacturer document titled "shelf life matrix" stated the Food Service Juice and drinks must be used once thawed in 14 days. There were thawed cases with a delivery date of 11/16/12 that were maintained for service to the patient and in excess of the 14 days the manufacturer stated was safe to serve.

The FSM provided the Matrix and stated the document gave a 2 months serving time line. Review of the Matrix showed the "2 months" were for frozen juice storage and the 14 days was for thawed produce.

The DNFS confirmed there was not a system to ensure the thawed fruit juice was used within the 14 days.

The hospital's Federal Recertification Survey POC dated 11/29/12 stated the policy for label, dating and storage was to be updated and the facility would start weekly inspections of food storage areas. The FSM was responsible for the ongoing compliance.

c. Identified were 1? packages of hot dog buns labeled 12/8/12. Food Service Worker 8 (FSW 8) working in the Valley Cafe stated she used whatever was in the cabinet. She did not look at the date or know what this date label meant.

The DSM stated the date on the label was the use by date. He discarded the product.

The POC dated 11/29/12 stated that there were weekly inspections and the FSM was responsible for ongoing compliance.

d. Many items were identified for consumption in Valley Cafe without expiration dates or used past expiration dates. Examples included:
1. One case FUZE raspberry ice tea in dispensed machine with a use by date of 12/5/12.
2. One case of root beer had a use by date of 11/14/12.
3. One case of individual Thousand Islands dressing had no expiration date.
4. Butter pats open with no label, date opened or expiration date.
5. Quaker oatmeal packages had no expiration dates.

The DSM stated during the observation that they did not have a system to ensure the products were monitored for expiration dates. He acknowledged the staff were not knowledgeable of manufacturer's codes to ensure products were not served after they expired.

d. One cafeteria electric vent fan was observed on 12/11/12 at 11:00 a.m., with an accumulation of dust on all grill surfaces. The FSM stated that this was an exhaust fan and was not concerned that is was not clean in the food service area and was not cleaned on a regular basis. The COE stated this would be cleaned immediately.

They hospital did not have a system to ensure the fan was maintained clean.

6. On 12/10/12 at 9:30 a.m., there was one blue cloth on the nourishment area cart. FSW 1 identified the rag as just used to wipe a spill. She stated she should have put the used rag in the laundry tub but instead had just placed it on the cart. The FSM stated this was not the place to put contaminated rags and they should be discarded.

A similar finding was observed during the 9/28/12 Federal Recertification Survey and there was no POC-directed correction of the deficient practice.

7. On 12/10/12 at staring at 9:00 a.m. the following were observed:
a. Enteral nourishment distribution area had one case of Ensure (nourishment product) which had dented cans in the sealed package. The DNFS stated the dented cans are discarded when the package is opened. Three dented cans of Jevity 1.5 (nourishment product) and two dented cans of high nitrogen supplement were on the shelf and available for patient use.

During interview FSW 9 stated the staff separate dented cans when the case is labeled and place them in a plain box on the shelf. There was no area or box labeled dented cans observed to identify product that was not to be used. There was no system to ensure the dented cans were separated from usable product to ensure they are not served to patients.

b. There were three dented #10 cans (commercial size) of tomato sauce, peppers, and apple rings, on storeroom shelf or can rack and available for service.

Cook 4 stated the cooks knew not to use the dented cans and the cans are discarded. He stated there was no system to separate the dented cans or prevent them from being used.

Cans on shelves have a potential to be used for patient meal preparation when not separated from undented cans. Dented cans can be a source of food poisoning (Food Coded 2009).

8. On 12/10/12 starting at 2:30 p.m., FSW 8 was not able to demonstrate the use of the test strip for the sanitizing concentration. She could not find the test strip and stated they did not document the daily testing of the sanitizer concentration. The FSM went to the main kitchen and brought back test strips.

The FSW 8 demonstrated the test strip by immersing in the sanitizer for 21 seconds and the reading was 400 ppm (part for million). This did not demonstrate the manufacturer's posted instructions which read to immerse the test strip for 10 seconds.

The FSM asked FSW 8 to re-test. He did not have knowledge of the correct immersion of the test strips. In a subsequent interview on 12/11/12 at approximately 11:00 a.m. FSW 8 stated the immersion was 15 seconds.

The policy titled, "Three Compartment Sink" was reviewed and did not state the time a test strip was to be immersed in the sanitizer. There was a separate page with the manufacturer's directions but this was not part of the policy approval. The policy as written did not include all essential information.

In addition, the policy titled Three Compartment Sink did not include directions for the staff to document the sanitizer concentration.

9. The Valley cafe observation noted one case of burritos in refrigerator. The box stated to "keep frozen." The burritos were not stored in accordance with the manufacturer's directions.

The 9/28/12 survey previously identified products that were stored in the refrigerator and not frozen as required. There was no corrective action established at that time to ensure the products with direction to "store frozen" were maintained frozen.

Based on staff interview and document review the hospital failed to ensure the nutritional needs of patients were met in accordance with recognized dietary practices, when;

1. All menus were not analyzed to ensure they met the Recommended Daily Dietary Allowances (RDA) or the Dietary Reference Intake (DRI) adopted by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. Lack of nutrient analysis of patient menus could potentially place patients at risk of not receiving required nutrients thereby compromising medical care.

2. Emergency menus were not analyzed to ensure they met the RDA or DRI guidelines.

Findings:

1. On 12/11/12, at 11:00 a.m., the Director of Nutrition and Food Services (DNFS) provided copies of the nutrient analysis of a sampling of menus by age and gender categories using their database. There was no analysis for all diets provided by the hospital, no analysis of all age and gender categories outlined in the RDA, no analysis of how the menus met the diet requirement as outlined in the diet manual, and the analysis did not contain all of the nutrients provided in the RDA.

Review of the nutrient analysis provided showed the hospital only provided a print out of the one-week cycle menu for Regular Diet, Soft Diet, and an incomplete Cardiac Diet (missing days six, seven, and summary page). The analysis did not include consideration for their pediatric and maternity population. Diets not provided included diabetic, renal, sodium restriction, puree, altered mechanical, vegetarian, maternity, and pediatric.

The nutrient analysis was missing analysis for the following nutrients: Iodine, Fluoride, Chromium, Molybdenum, Chloride, Biotin, and Pantothenic Acid. During a concurrent interview, the RD 2 stated the database used by the hospital did not include all these nutrients.

The Regular Diet menu analysis for 12/10/12 was inaccurate. The meal observed on trayline specified one cup of spaghetti noodles, and whole wheat spaghetti noodles were served. The nutrient analysis indicated 1/2 cup spaghetti noodles, and whole wheat noodles were not specified. The DNFS and RD 2 were not able to provide a reason for the discrepancy or how all nutrient analysis data was verified for accuracy.

The weekly average nutrient analysis for the regular diet indicated it did not contain the recommended amount of fiber for each of the analyzed age and gender types. There was no analysis conducted or plan to modify the menu or notify medical staff of the potential inadequacy of the menus served.

2. Emergency menus did not contain all the required nutrients. The nutrient analysis was missing analysis for the following nutrients: Iodine, Fluoride, Chromium, Molybdenum, Chloride, Biotin, and Pantothenic Acid.

The analysis indicated some days were inadequate in some nutrients, for example calories, fiber, and calcium. During a concurrent interview, the DNFS and RD 2 acknowledged there was no plan to modify the menu or notify the medical staff of these inadequacies.

The Federal Recertification Survey Plan of Correction (POC) dated 9/28/12 indicated, "Hospital menus have been analyzed for age and gender." However, during the revisit on 12/10/12, review of documents provided show they were incomplete as specified above.

Based on observations, staff interviews and document review, the hospital's Infection Prevention Manager (IPM) failed to develop an effective system for identifying:

1. Unsafe hand hygiene practices for dietary staff delivering patient trays. Not using sanitizer between patient tray deliveries increased the potential for cross-contamination.

2. Unsafe practices for staff handwashing in the Dietary Department.

3. Unsafe practices for using designated handwashing sinks for food service activities. Using designated handwashing sinks for food service activities puts patients at risk of cross-contamination and food-borne illness.

4. Unsafe food handling practices that involved cool down of potentially hazardous food.

5. Preventative maintenance to ensure all hospital ice machines were cleaned and sanitized in accordance with the manufacturer's directions and time frames. Dietary staff did not notify IPM of a potential infection control issue when there was significant build-up of white scale inside one ice machine. Failure to sanitize and perform maintenance on ice machines in a timely manner places patients at risk of infection.

6. Staff in food storage areas not wearing hair covering.

7. Unsafe food handling practice of storing opened nonfat dry milk in its original packaging in a storage bin. Failure to protect food from the exterior packaging of opened food packages creates an increased risk of cross-contamination.

Findings:

1. On 12/10/12 at 12:30 p.m., accompanied by the Director of Nutrition and Food Service (DNFS), an observation of tray delivery to patient rooms on the Pediatrics unit was conducted. Food Service Worker 7 (FSW 7) was not using hand sanitizer gel upon entering or exiting patients' rooms and delivering food to other patient rooms. During a concurrent interview with the DNFS, she stated the procedure was for tray delivery staff to only use hand sanitizing gel if they touched something in the room.

On 12/10/12 at approximately 1:00 p.m., during an interview with the Infection Prevention Manager (IPM) regarding patient tray delivery procedures, she stated all hospital staff that entered patient rooms are expected to use hand sanitizing gel each time they enter and exit patients' rooms. The IPM reviewed the policy provided, which had not been approved by the governing body, to confirm the expected practice was to use the hand sanitizing gel each time a staff entered and left a patient's room. The policy wording was not specific to this situation, however, she later provided a clarifying version including the above requirement.

2. On 12/10/12 starting at 9:00 a.m., accompanied by the DNFS the following was observed: there was no trash receptacle near the handwash sink in the dishwashing room. Staff who washed their hands were observed opening a door between the dishwasher room and main kitchen area and going into the tray line area to dispose of used paper towels. During a concurrent interview with the DNFS about this practice, the DNFS stated she did not know why a trash receptacle was not located near the handwashing sink in the same room as the sink.

Review of the policies titled, "Hand Hygiene Guidelines" dated 10/2012, and Hand Washing Procedures dated 10/2012 did not specify how to discard the paper towel in a sanitary manner.

3. On 12/11/12 starting at 11:00 a.m. accompanied by the Food Service Manager (FSM), Food Service Worker 6 (FSW 6) was observed in the Cafeteria filling a red sanitizer bucket with food service water from the designated handwashing sink located behind the serving area. FSW 6 was then observed pouring the water into the steam table well (equipment used to maintain food serving temperatures). He then dumped the remaining unused water back into the handwashing sink. Designated handwashing sinks are to only be used for handwashing. When used for food preparation activities use of handwashing sinks pose a significant risk of cross-contamination with organisms that can cause human illness (Federal Food Code 2009).

During a concurrent interview with the FSM, he did not acknowledge the potential for cross-contamination. The FSM commented, "the FSW 6 " did not add the water to the fish which was located in the steam table." This indicated he was not able to demonstrate knowledge of FSW 6's breach in infection control practices.

Review of the food service policy "Handwashing Procedure" dated 10/20/12 indicated it did not include directions not to use handwashing sinks for food service activities.

4. On 12/10/12 starting at 9:00 a.m., accompanied by the FSM, a roast beef with a date labeled 12/12/12 was observed in the walk-in refrigerator. During a subsequent interview, the FSM stated 12/12/12 was the "use by" date and the roast was cooked on 12/09/12. A review of the cool-down log "Roast Beef Temperature Chart" indicated no roast beef was logged on 12/9/12. The FSM could not state why cooling temperatures of the roast beef identified in the refrigerator were not documented on the Temperature Chart.

The cool down logs did not indicate if they were reviewed for accuracy or what corrective actions were taken (if any) when time and temperature parameters were not met.

The Federal recertification survey plan of correction (POC) dated 11/29/12 indicated the policy would be updated to include cooling procedures. Review of the Hazard Analysis and Critical Control Point (HACCP) plan indicated in "Section 8 Cooling Temperatures" address leftover foods from the cafeteria. The policy did not address the appropriate cooling and documenting of foods prepared for later service.

5. On 12/10/12 starting at 9:00 a.m., accompanied by the Food Service Manager (FSM), the bin ice machine in the kitchen had significant white scale interior of ice making unit near the ice harvester (ice cube trays where ice is formed). During a concurrent interview, the Air Conditioner Engineer (ES 2) stated he had not reported it to the IPM. ES 2 stated that the water was hard and the calcium built up in one week.

During a later interview with the IPM at approximately 1:00 p.m., she acknowledged the potential for bacteria/virus build-up in the white scale areas. She stated she had not observed the interior of all ice machines located in the hospital. She acknowledged that increased frequency of visual inspections including the interior ice making components of the machines to assure adequate removal of scale build-up was needed.

A review of the Ice Machine Preventive Maintenance log indicated the Engineering Department last cleaned the bin ice machine on 9/10/12.

A review of the Ice Machine Preventive Maintenance log indicated the Engineering Department did not clean and sanitize eight of the thirty-six ice machines located within the hospital according to the timelines specified in the manufacturer's instructions.

6. On 12/10/12 starting at 9:00 a.m., accompanied by the DSM, in the #5 refrigerator, one staff from distribution (D 1), was observed with no hair covering. The staff D 1 stated he collected the fruit juice five days a week and did not put on a hairnet.

The DSM did not correct the D 1 staff and direct him to get a hairnet when the staff was first observed.

Review of the policy titled, "Grooming" dated 10/2012 states "Wears a hairnet to confine hair in food production and service areas." The DSM stated this meant the hairnets are to be worn by all staff in the kitchen.

7. On 12/10/12 starting at 9:00 a.m., accompanied by the Director of Nutrition and Food Service (DNFS) the following was observed: one opened package of nonfat dry milk powder stored in a bin which also contained five unopened packages of nonfat dry milk powder. During a concurrent interview, the DNFS stated the nonfat dry milk powder was not removed from its original packaging after being opened because it absorbed moisture which caused it to clump. Separating bulk packaged foods from its original contaminated packaging to a clean bin or environment reduces the potential for cross-contamination (Federal Food Code 2009).

8. On 12/10/12 staring at 11:20 a.m., the patient tray assemble was observed. At 11:45 a.m., the temperature log of cold food temperatures was requested. Temperatures taken at 11:45 a.m. of fruit cocktail was 44 degrees F and egg salad sandwich was 46 degrees F. Cook 1 stated that she did not take the temperatures of the cold food being served on the trayline; only the hot food.

Interview with the FSM at this time stated he had in-serviced the cooks in September on taking the cold food temperatures when patient trays were assembled. Cook 1 stated she did not know she was to take the cold food temperatures. FSM stated he had not reviewed the temperature log to ensure the cold food temperatures were being taken. He also stated the canned fruit and the sandwiches which had temperatures of 44 and 45 degree F (taken at 11:45 a.m.) were fine to serve because they had 4 hours to be safe.

Review of the policy, "Trayline Procedure" (patient meal tray assembly) stated acceptable temperatures are: milk was to be served at less than 41 degrees F, juice at less than 41 degrees F, and salad less than 41 degrees F.

There was no direction for the canned fruit to be served at 41 degrees F. The DNFS acknowledged the canned fruit should also be served at 41 degrees F or below but was not included in the policy or on the temperature logs to ensure the temperatures were taken.

POC dated 11/29/12, stated the DNFS and IPM revised the policy titled Trayline and staff was in-serviced. The POC stated the organization will ensure the staff continues to follow the policy with monthly observations by dietary director and infection prevention.

This corrective action did not occur because there was no system implemented of the POC and documentation of cold food temperatures and ensuring cold food temperatures are served as designated.