HospitalInspections.org

Based on observation, staff interview and document review it was determined that the facility failed to maintain the kitchen in a manner consistent with food safety and sanitation standards. Failure to maintain a sanitary environment has the potential to impact the safety and well-being of patients and staff.

Findings:

On 1/5/16 the kitchen inspection began at approximately 1:00 PM.

During the inspection, the solution in sanitizer buckets observed by the surveyor appeared dirty. The surveyor used strips approved for testing the sanitizer concentration to test the solution in the buckets at four locations where food was being prepared. Three of the four buckets did not meet the required concentration. Two of the four buckets of solution tested showed no color change (no sanitizer) on the indicating test strip. One of the buckets of solution showed between 0-100ppm (insufficient concentration). Review of facility policy indicated the required concentration is 150-400 parts per million.

Facility policy "HACCP / Food Safety Program Food Safety Standards and Requirements", (Document # 1.1.4, Issued 1/27/2012, revised 3/13/2015) indicated the required concentration for the quaternary sanitizer Oasis 146, which was being used, is 150-400 parts per million. The solutions used to clean the food preparation surfaces were below the concentration required to assure that the areas are properly sanitized.

At approximately 2:00 PM, the Executive Chef stated testing strips to measure the effectiveness of the sanitizing solution were stored in his office. Testing strips were not readily available for staff use. Additionally, upon interview at approximately 2:10 PM food preparation staff lacked knowledge of the testing requirements.

The above findings were confirmed by the Executive Chef and the Director of Food and Housekeeping Services at the time of inspection.

Additional findings during the kitchen inspection :

A wall in the dry food storage area, and a wall in the kitchen next to the spice rack were damaged at the bottom, and were missing sections of the cove base. As a result the surfaces were not able to be cleaned and were harborage areas for insects and pests.

The floor of the walk in freezer was soiled with food debris and the refrigerator labeled "Jell-O" was soiled with spilled Jell-O. Interview with staff at approximately 1:30 PM indicated that when the cart holding the Jell-O is wheeled into the refrigerator, there is a slight incline, and the Jell-O frequently spills.

The floor between the steam kettles and the food preparation line was soiled with grease in a pile more than two inches high.

The inside of the microwave used to heat puree food was soiled with food debris.

Disposable utensils, including knives, forks and spoons were stored unprotected in several areas throughout the kitchen, including, on shelves in the dry storage room, on work tables in the kitchen, and in a closet that had damaged brick walls and also contained cleaning products. All of these areas have potential for contamination of these utensils.

There was damage to the walls in the food cart return area, making the surface non-cleanable. Walls were missing sections of the rubber bumpers installed to protect the walls from damage.

Sections of the floor in the food cart return area, and the dish room had pieces of the floor surface missing creating a non-cleanable surface.

The floor in the dish room was littered with food debris, and had standing water, creating an area beneficial to bacterial growth, and a slippery surface.

Drain flies were present in the dish room and in the area of the food preparation sink adjacent to the dish room. A review of the facility's pest control reports for 2015 showed that this has been a persistent problem, demonstrating the pest control program was ineffective.

The dishwasher had damage to the metal at the end where the dishes are loaded, with a jagged piece of metal sticking out creating a non-cleanable surface.

The rollers on the conveyor belt in the dishwasher were caked with food debris. The food catch basin was full and was in need of emptying and cleaning.

These findings were confirmed by the Executive Chef, the Director of Food and Housekeeping Services, and the Operations Manager at the time of inspection.

Based on document review and interview, the facility failed to include specific required provisions in its contract with the Organ Procurement Organization (OPO).
Findings:
On 1/5/16, at approximately 9:30 AM, review of " The Agreement Between Center for Donation & Transplant of Albany, New York and St. Peter ' s Hospital " , dated 1/22/15, indicated that there were no provisions for the following:
1) A regularly scheduled access for the Center for Donation & Transplant of Albany (CDT)
to view the hospital ' s death records;
2) Mitigation of the hospital ' s responsibility for credentialing or providing privileges to
members of the organ recovery team;
3) A policy or policies designating the interventions the hospital will utilize to maintain
potential organ donor patients so that organs remain viable.
On 1/5/16, in a morning interview, the hospital ' s Organ Procurement representative noted that the provisions were not present in the contract.