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Based on observation, staff interview and document review the hospital failed to have a governing body which took full legal responsibility for developing and monitoring policies and procedures when the governing body failed to ensure:

1. Services furnished under contract for the Food and Dietetics Department met the Medicare Conditions of Participation when the Governing Body did not assess the services furnished under contract, did not identify quality and performance problems, and did not ensure appropriate corrective or improvement activities were implemented or monitored. (Reference A083)

2. An effective ongoing quality appraisal and performance improvement program for the Food and Dietetic Service when performance improvement plans were not analyzed and monitored for implementation or effectiveness. (Reference A273)

3. An effective system to ensure food safety program. (Reference A747).

4. There was a fulltime Director of Food and Nutrition services who was responsible for the daily management of the department and who assured policies and procedures were maintained. (Reference A618, A620, A630).

The cumulative effects of these systemic problems resulted in the Hospitals' inability to ensure the provision of quality health care in a safe environment.







28531

Based on interview and document review the hospital failed to ensure the services furnished under contract for the Food and Dietetics Department met the Medicare Conditions of Participation when the Governing Body did not assess the services furnished under contract, did not identify quality and performance problems, and did not ensure appropriate corrective or improvement activities were implemented or monitored.

Failure to implement the plan of correction and implement effective management resulted in the potential for problems with the contracted services to continue.

Findings:

On 2/4/15 at 10:00 a.m., during an interview with the Governing Board and Hospital Administration, including the President, the operation of the contracted Food Service was discussed. The President stated the Clinical Nutrition Manager (CNM) was to be the fulltime Director responsible for the Food Service operation. The President acknowledged that there had been no oversight by Administration or the Governing Board to ensure the Food Service operation was following the plan of correction submitted and to ensure the management structure they had planned was functional.

The job description for the General Manager (Director of Food and Environmental Services - DFEVS) was reviewed. It indicated the DFEVS was an administrator over Food Services and Environmental Services.

On 2/4/15 at 1:30 p.m., during an interview, the Clinical Nutrition Manager (CNM)stated she was responsible for the clinical patient care including room service call center, tray line, and tray delivery areas. CNM stated that she was not responsible for the production part of the food service operation.

Review of the revised job description for the Clinical Nutrition Manager (CNM)(undated) indicated the CNM plans and coordinates and manages all patient nutrition care activities and food service department complying with standards established by [contract service] and regulatory agencies and client. The CNM job description included the daily management of the service.

During an interview on 2/4/15 at 8:30 a.m., the Food Production Manager (FPM) stated that she was managing the production area and employees in the food service operation. FPM stated that she was responsible for the contract service and hospital food service reports and personnel. FPM stated that she reported to the DFEVS and not the Clinical Nutrition Manager. FPM stated that her time card and time off requests were approved by the DFEVS. FPM stated when she needed something she requested these from the DFEVS.

The organizational structure outlined by the CNM and the FPM are not the organizational structure represented in the CNM job description as the fulltime food service manager responsible for directing the Food Service Department.





28991

Based on staff interview and document review the hospital failed to have an effective ongoing quality appraisal and performance improvement program for the Food and Dietetic Service when performance improvement plans were not analyzed and monitored for implementation or effectiveness.

This failure resulted in the potential for the hospital to be unable to measure, analyze, and track improvement of the services and operations within the Food and Dietetic Department.

Findings:

During an interview with the Governing Board and Hospital Administration including the President on 2/4/15 at 10:00 a.m., the operation of the contracted Food Service was discussed. The President stated that the Clinical Nutrition Manager (CNM) was to be the fulltime Director responsible for the Food Service operation. The President acknowledged that there had been no oversight by Administration or the Governing Board to ensure the Food Service operation was following the plan of correction submitted and to ensure the management structure they had planned was functional.





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

1. Ensure there was a fulltime Director of Food and Nutrition services who was responsible for the daily management of the department and who assured policies and procedures were maintained. (Refer to A620)

2. Ensure safe and effective food storage and production practices. (Refer to A620 and A749)

3. Ensure diets were provided to patients as ordered by the physician (Refer to A630)

4. Ensure equipment was maintained in good working order and according to manufacturer guidelines. (Refer to A724)

5. Ensure chemicals were not stored with the disaster food supplies. (Refer to A701)

6. Ensure timely inservice training was provided to all relevant hospital staff on topics indicated in the plan of correction. (Refer to A620)

The cumulative effect of these systemic problems resulted in the inability of the hospitals' food and nutrition services to meet the nutritional needs of patients in accordance with practitioners orders and acceptable standards of practice to prevent foodborne illness.

Based on observation, interviews, and document review, the hospital failed to ensure there was a full-time Director of Food and Nutrition services who was responsible for the daily management of the department and who assured policies and procedures were maintained when:

1. The Director of Food and Nutrition services was also, concurrently, the Director of Environmental services;

2. There were deficiencies found in safe food storage, handling, refrigeration and sanitation practices; (refer to A749)

3. The room service meal ordering system used by the hospital did not ensure patients' receiving carbohydrate controlled diets received the diet ordered by their physician.

4. In-service training was not provided to all relevant staff, not all topics were covered, staff competency was not evaluated, and handouts/agendas were not provided as indicated in the plan of correction.

The Hospitals' failure to ensure there was a full-time Director of Food and Nutrition services to provide adequate oversight resulted in the potential for growth of microorganisms (germs) in food and the inability to meet the nutritional needs of patients.

Findings:

1. The job description for the General Manager (Director of Food and environmental Services - DFEVS) of the contracted services was reviewed. It indicated the DFEVS was an administrator over Food Services and Environmental Services.

On 2/4/15 at 8:30 a.m., during an interview, the Food Production Manager (FPM) stated that she was managing the production area and employees in the food service operation. FPM stated that she was responsible for the contract service and hospital food service reports and personnel. FPM stated that she reported to the DFEVS and not the Clinical Nutrition Manager. FPM stated that her time card and time off requests were approved by the DFEVS. FPM stated when she needed something she requested these from the DFEVS.

Review of the revised job description for the Clinical Nutrition Manager (CNM), undated, indicated the CNM plans, coordinates, and manages all patient nutrition care activities and the food service department, complying with standards established by [contract service] and regulatory agencies and client. The CNM job description included the position was responsible for the daily management of the service.

On 2/4/15 at 1:30 p.m., during an interview, the Clinical Nutrition Manager (CNM) stated she was responsible for the clinical patient care including room service call center, tray line, and tray delivery staff. CNM stated she was not responsible for the production part of the food service operation.

The organizational structure outlined by the CNM and the FPM are not the organizational structure represented in the CNM job description as the fulltime food service manager responsible for directing the Food Service Department.

2. On 2/3/15 at 8:30 a.m., during the initial tour of the kitchen in the presence of the Food Production Manager (FPM) and Clinical Nutrition Manager (CNM), the following items were observed:
a. In walk-in freezer 1, one pizza shell in an opened package that was not sealed or dated, and a bag of opened, unsealed Alaska pollock (fish). In walk-in freezer 2, four bags of unlabeled and undated cooked ground meat, and five bags of unlabeled and undated roast meat (FPM stated the meat was turkey). In walk-in refrigerator 5, two packages of corn tortillas removed from their original container with no received or use-by date.

During a concurrent interview, FPM stated these items should have been sealed and dated, and the items removed from original packages should be dated. The storeroom clerk stated he did not know when the tortillas came in. He said, "I should have put a date on them, they are old inventory, and were removed from their original case."

A review of the hospital document dated 10/13/14 entitled "How to Label a Food Item" indicated, all refrigerated/frozen food should be labeled after opening, preparing, cooking, and cooling.

According to the FDA Food Code 2013 (3-302.11 and 3-302.12) opened items must be protected from contamination by either resealing or placing them in a sealed container, and items removed from their original packaging must be labeled with their common name.

b. On 2/3/15 at 8:30 a.m., during kitchen observations, there was a large amount of ice accumulated along the bottom of the freezer 2 door and storage shelves located next to the door.

During a concurrent interview, FPM validated the observation and stated a work order had been provided to the hospital maintenance department, but there was no permanent resolution.

c. On 2/3/15 at 8:55 a.m., in the dry storage area of the kitchen, a quart sized container with a hand pump of antiseptic hand gel (product used to kill germs) was observed on the handwashing sink. Food Service Worker 2 (FSW 2) stated he was using it because, "I have a cold."

During a concurrent interview, FPM stated the antiseptic hand gel was used by office staff, and should not have been located in the kitchen area.

A review of the hospital policy number NS-702 dated 8/12 entitled "Infection Control Guidelines" indicated under Section III. A. 4. Guidelines, "Handwashing is the single most important infection control measure. It should be done at least during these times: b. After sneezing, coughing, or touching the face or hair." It further indicated under Section III. B. 2., "Personnel with any....or other respiratory illness,...shall not work.

d. On 2/3/15 at 3 p.m., Food Service Worker 1 (FSW 1) was observed taking a large wheeled trash container over-filled with garbage bags so the lid would not close tightly through the kitchen food preparation area and dry storage areas.

During a concurrent interview, FPM stated the trash container lid should be tightly closed and taken through the dishwashing area and not the food preparation/dry storage areas.

According to the FDA Federal Food Code 2013 (5-501.113) trash receptacles shall be kept covered inside the food establishment if the receptacles and units are not in continuous use; or after they are filled; and with tight-fitting lids.

e. On 2/3/15 at 3:05 p.m., during review of disaster food storage, a chemical cleaning compound was stored on a wheeled cart directly adjacent to the food.

During a concurrent interview, the Director of Food and Environmental Services (DFEVS) and FPM stated cleaning chemicals should not be stored with the food.

Review of in-service training documents indicated the hospital provided the following "safety talk" training sessions to staff on 12/18/14, "Food and drinks in areas where there are chemicals" and "Chemicals not stored next to disaster food."

f. On 2/4/15 at 8 a.m., during tour of the Campus 2 kitchen, with FPM, the following were observed:
A. The hot water temperature at the food preparation sinks did not exceed 97 degrees Fahrenheit (F) (a unit of measurement) after five minutes of continuous running.
B. Expired fountain drink syrups attached to the dispensing unit, Mountain Dew (brand name) 11/3/14, sweetened tea 10/13/14, and unsweetened tea 11/5/14.
C. Three bottles of Dr. Pepper (brand) soda 1/15/15 and four bottles of Squirt (brand) soda 1/26/15.
D. Two installed soda dispenser filters dated 11/10/11. The manufacturer's label indicated the filters should be replaced six-months after installation.
E. A bag of unlabeled and undated breaded patties in the freezer.
F. In the freezer, two trays containing various pre-portioned desserts such as cake and pie with no dates.

During a concurrent interview FPM stated the soda vendor was responsible for maintaining the soda dispenser (syrups and filters). She further stated she did not have time to validate the vendor was performing according to contract to ensure the syrups and bottled drinks were not being used/stored beyond their expiration dates and the filters were changed as indicated by the manufacturer.

The FPM stated the stored items in the freezer should have been labeled and dated.

3. Review of the hospital plan of correction indicated the following examples of in-service training topics that would be provided to all relevant staff:
A. " In-service completed with all cooks on proper procedure to reinforce the hot food and cool down procedure by 10/13/14."

Review of documentation provided by the hospital indicated an in-service was provided on 10/14/14 entitled "Proper placement of probe thermometer and chill down on tuna and egg salad in blast chiller." The document was a sign-in sheet and hand-out and contained one employee signature. There was no indication of competency testing (no post-test or other means of determining comprehension/competency).

Review of an in-service document dated 10/14/14 entitled "Proper way to cool down product in blast chiller" included six employee signatures and a hand-out. There was no indication of competency testing.

B. "In-service conducted with all staff on proper procedure for holding cold food and documentation of temperatures including all cold serving units are to kept closed when not in use by 10/14/14."

No documentation was provided to indicate training on this topic was provided to staff.

C. "In-service staff of proper cleaning of can opener by 10/16/14."

Review of an in-service document titled "Can opener cleaning," dated 10/15/14, indicated the training was only provided to staff working at the Campus 2 kitchen and not to all staff. There was no indication of competency testing.

During an interview with FPM on 2/4/15 at 8:35 a.m., she verified she had not completed all the in-services indicated in the plan of correction and that not all staff who had relevant responsibilities had been trained. She stated some of the topics were discussed during staff "huddles" (informal discussions), however, these sessions were not documented. She validated that staff who attended the sessions were not given competency testing to determine comprehension.
















28773

Based on observation, staff interview, and clinical record review, the hospital failed to ensure the nutritional needs of one of 30 patients (Patient 8) was met when the diabetic diet (carbohydrate, starch, controlled) was not served as ordered by the physician.

This failure resulted in the potential for compromising Patient 8's medical status.

Findings:

Patient 8 was admitted 2/1/15 with Dyspnea (shortness of breath) and hypoxia (inadequate oxygen in blood or tissues). Other medical conditions included Type 2 Diabetes Mellitus (high blood sugar) and hypertension (high blood pressure). Diet order was Diabetic Diet and the tray tickets stated ADA (American Dietetic Association) Cal 16.

On 2/3/15 at 9:00 a.m., the room service (patient calls in meal request) breakfast meal for Patient 8 was observed. Patient 8's meal ticket stated 1 package sugar substitute, one package brown sugar, ½ cup oatmeal, and ½ cup scrambled eggs. The Clinical Nutrition Manager (CNM) concurrently confirmed this meal as served had 2 carbohydrate (starch) servings and not the required 4 per the physician order.

Review of the Carbohydrate patterns stated a 1500 calorie diet was to receive 4 carbohydrates (starch) servings at breakfast and an equivalent 60 grams carbohydrate.

CNM stated on 2/4/15 at 1:30 p.m. that the patient had also received another tray at breakfast but the system did not provide documentation regarding additional room service orders. CNM confirmed that there was no system in place to monitor and ensure the patient ordered room service meals met the physician diet orders.

Concurrent review of the 2014/2015 competencies for diet aides and hospital staff specific for correct selection of nourishment/meal on ADA, Renal, Puree and non-purees diets, the CNM acknowledged the call center staff had not been evaluated on these competencies and evaluating the staff competencies had not been initiated.





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Based on observation, interview, and document review, the hospital failed to ensure the hospital environment was maintained in a manner to ensure patient safety when chemicals were stored with the disaster food supply.

This failure resulted in the potential for the hospital not being able to ensure the safety and well-being of patients during an emergency.

Findings:

On 2/3/15 at 3:05 p.m., during a concurrent observation and interview, a one-gallon container of a cleaning chemical was stored on a cart directly adjacent to the disaster food supplies. The Director of Food and Environmental Services (DFEVS) and the Food Production Manager (FPM), both stated the chemical should not be stored with the food supplies. They further stated the hospital had provided in-service training on this subject to staff.

Review of the hospital policy number NS-702, titled "Infection Control Guidelines," dated 8/12, indicated under Section III. J. 6. "Cleaning tools and supplies are stored in an area away from food."

Review of hospital in-service training, dated 12/18/14, indicated topics discussed included, "Food and drinks in areas where there are chemicals" and "Chemicals not stored next to disaster food."

Based on observation, interview, and document review, the hospital failed to maintain the food service equipment in a manner to ensure an acceptable level of safety and quality when:

1. The condenser covers were not clean for the refrigerator on Campus 2

2. A refrigerator located in the cafeteria was not maintained to the temperature of 40 degrees Fahrenheit or below.

3. The freezer was observed to have ice buildup and not maintained.

These failures resulted in the potential for the growth of infectious organisms (germs) in food not maintained at the proper temperature and a fall risk due to ice build-up on the floor.

Findings:

1. On 2/4/15 at 8:80 a.m., the three condenser covers in the walk-in freezer were observed with dust and black grime on the surfaces. In concurrent interview the Food Production Manager (FPM) stated that she did not know when engineering would clean this equipment.

Review of a work order number 235926 dated 6/9/14, showed service to work on cooling system and walk in refrigerator.

Interview on 2/4/15 at 2:00 p.m. the Facilities Director (FD) stated this was probable the work order and last time work was done on the Dominican kitchen freezer. FD acknowledged that there was no scheduled maintenance on to clean the condenser covers.

2. On 2/3/15 at 3:30 p.m., during an observation and concurrent interview with the Food Production Manager (FPM), the Café ' s open front refrigerator contained one egg salad sandwich with a temperature measured at 49.6 degrees Fahrenheit (F). The egg salad sandwich was in the front of the 4th shelf down. The merchandise refrigerator also contained 2 to 3 dozen pint milk cartons on the top shelf and approximately 15 yogurt parfaits on the second shelf down. There were approximately 8 to 10 sandwiches on the 4th shelf.

Review of the Time/Temperature Control for Safety Food Cold Holding (TCS) log showed the temperature of the egg sandwich taken on 2/3/15 at 11:30 a.m. was measured at 39.6 degrees F.

Concurrent interview with the Food Production Manager (FPM) stated the plan was to monitor food temperatures of two foods every two hours in the open front refrigerator.

Review of the TCS logs showed the following recorded temperatures in degrees F with dates and comments. No times were recorded.

12/12/14 Jello, 46F, removed closed shade
12/12/14 Pudding, 45F, Discard product
12/15/14 yogurt parfait and pudding, not holding remove put in walk-in
12/16/14 Strawberry & cream, 42F, did not hold temp
12.16.14 Chocolate pudding, 46F, did not hold temperature
12/18/14 Chocolate pudding, 47.5F pulled and put in walk in refrigerator
12/18/14 Yogurt parfait, 47.5F, pulled put in walk in refrigerator
12/19/14 no grab and go temperature monitoring documented
1/14/15 Yogurt parfait and pudding, not holding put in walk in
1/16/15 pudding, 42F, not holding temperature- put in walk in
2/2/15 chocolate pudding, 42.8F, put in walk-in 8:35 a.m.

Review of the Policy titled "Food Storage" indicated " ...All readily perishable food or beverages capable of supporting rapid and progressive growth of microorganisms which cause food borne infections and food intoxication (poisoning) shall be maintained at temperatures of 40 degrees F or below."

3. On 2/3/15 at 8:30 a.m., during kitchen observation with the Food Production Manager (FPM) and Clinical Nutrition Manager (CNM), there was a large amount of ice and frost build-up along the bottom of the Freezer 2 door and storage shelves located directly adjacent to the door.

During a concurrent interview, FPM and CNM validated the observation and stated a work order had been submitted to the maintenance department, but there was no resolution.

On 2/4/15 at 1:30 p.m., during a subsequent interview with the Facilities Director (FD) and Facilities Supervisor (FS) they stated they had an outside refrigeration vendor conduct an assessment of the freezer door to determine the cause of the ice accumulation. They replaced the heating coil located along the edge of the door that kept the ice defrosted, but that didn't resolve the problem. FD stated that recently they noticed a ripped gasket (seal) along the bottom edge of the freezer door, which they thought might be causing the leakage. He further stated they had not replaced the gasket.

According to the FDA Federal Food Code 2013 (4-501.11 Annex), "Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations...that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding potentially hazardous (time/temperature control for safety) foods at safe temperatures."




28531

Based on observation, interview, and document review, the hospital failed to develop effective systems for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel in accordance with Hospital policy and nationally recognized infection control guidelines when:

1. An employee (Food Service Worker 2 - FSW 2) with a respiratory infection reported for duty in the dietary department contrary to personnel guidelines. FSW 2 used hand gel in the dietary department (instead of washing hands) contrary to policy and procedure.

2. Unsafe storage temperatures of food in the cafeteria refrigerator were identified and no system was in place to protect patients and other individuals from the hazards of consuming foods stored at unsafe temperatures.

3. Hot water temperatures were not maintained at 120 degrees Fahrenheit (F - a measure of temperature) in the kitchen area for Campus 2 as required by county health department regulation.

4. Two dietary staff were observed with hair uncovered in the food preparation and food serving area of the kitchen contrary to policy and procedure.

5. Cross contamination was observed when Cook 11 placed patients ' paper tray tickets back on the food tray after they had fallen to the kitchen floor.

6. Wash cloths used to clean and sanitize food preparation work surfaces were placed in the food preparation sink instead of a bucket containing sanitizing solution when not in use.

These failures resulted in the hospital's inability to provide infection control services and care in a safe and effective manner.

Findings:

1. On 2/3/15 at 8:55 a.m., in the dry storage area of the kitchen, a quart sized container with a hand pump of antiseptic hand gel (product used to kill germs) was observed on the hand washing sink. Food Service Worker 2 (FSW 2) stated he was using it because, "I have a cold."

During a concurrent interview, the Food Production Manager (FPM) stated the antiseptic hand gel was used by office staff, and should not have been located in the kitchen area.

On 2/4/15 at 1:10 p.m., during an interview with the Infection Control Officer (ICO) and CNM, the ICO stated FSW 2 should not have come to work. She further stated the hospital uses an "honor system" whereby employees are not to report to work when they are sick. The hospital has a "health nurse" available for employees to consult with if they are unsure if they should be at work.

A review of the hospital policy number NS-702 dated 8/12 entitled "Infection Control Guidelines" indicated under Section III. A. 4. Guidelines, "Handwashing is the single most important infection control measure. It should be done at least during these times: b. After sneezing, coughing, or touching the face or hair ..." The policy indicated under Section III. B. 2., " ...Personnel with any....or other respiratory illness,...shall not work ... "

2. On 2/3/15 at 3:30 p.m., during an observation and concurrent interview with the Food Production Manager (FPM), the Café ' s open front refrigerator contained one egg salad sandwich with a temperature measured at 49.6 degrees Fahrenheit (F). The egg salad sandwich was in the front of the 4th shelf down. The merchandise refrigerator also contained 2 to 3 dozen pint milk cartons on the top shelf and approximately 15 yogurt parfaits on the second shelf down. There were approximately 8 to 10 sandwiches on the 4th shelf.

Review of the Time/Temperature Control for Safety Food Cold Holding (TCS) log showed the temperature of the egg sandwich taken on 2/3/15 at 11:30 a.m. was measured at 39.6 degrees F.

Concurrent interview with the Food Production Manager (FPM) stated the plan was to monitor food temperatures of two foods every two hours in the open front refrigerator.
Review of the TCS logs showed the following recorded temperatures in degrees F with dates and comments. No times were recorded.

12/12/14 Jello 46 removed closed shade
12/12/14 Pudding 45 Discard product
12/15/14 yogurt parfait and pudding not holding remove put in walk-in
12/16/14 Strawberry & cream 42 did not hold temp
12.16.14 Chocolate pudding 46 did not hold temperature
12/18/14 Chocolate pudding 47.5 pulled and put in walk in refrigerator
12/18/14 Yogurt parfait 47.5 pulled put in walk in refrigerator
12/19/14 no grab and go temperature monitoring documented
1/14/15 Yogurt parfait and pudding not holding put in walk in
1/16/15 pudding 42 not holding temperature- put in walk in
2/2/15 chocolate pudding 42.8 put in walk-in 8:35 a.m.

Review of the Policy titled Food Storage indicated " ...All readily perishable food or beverages capable of supporting rapid and progressive growth of microorganisms which cause food borne infections and food intoxication (poisoning) shall be maintained at temperatures of 40 degrees F or below."

On 2/4/15 at 1:10 p.m., during an interview with the Infection control practitioner (IC), she stated she rounded monthly (with food preparation staff). The IC declined to comment on the open front merchandise refrigerator, the food items observed out of the safety temperature range and the TCS Log temperatures and comments.

This food had the potential to cause food borne illness.

The random temperature monitoring did not identify all of the potentially hazardous food (requires time/temperature control for safety to limit pathogenic microorganisms (germs) growth or toxin (poison) formation) held in the case. There was no way to ensure all of the food was held under the required cold temperatures and anyone purchasing sandwiches, yogurt, milk or pudding were at risk of food borne illness.

There was no effective monitoring in place to ensure food was held in an acceptable safe temperature even after food was found repeatedly in the danger zone.

Review of the Food Code published by the Food and Drug Administration (FDA) preface on page 1 indicated the following: Foodborne illness in the United States is a major cause of personnel distress, preventable death, and avoidable economic burden. Food borne illness is a serious outcome in the elderly, children, and immune compromised individuals. Epidemiological outbreaks repeatedly identify major risks that contribute to food borne illness that include improper holding temperatures.

3. On 2/4/15 at 8:30 a.m., water temperatures at 3 food preparation sinks at Campus 2 measured 94 to 97 degrees Fahrenheit (F).

Review of the (local county) Department of Public Health Division of Environmental Health report dated 8/6/14 cited the hospital Campus 2 for hot water at food preparation sinks not at required 120 degrees F minimum.

Review of the domestic hot water monitoring form for Campus 2 for the dates 8/12/14, 10/16/14, 10/31/14, and 12/5/14 showed temperatures from 108 degrees F to 119 degrees F.

On 2/4/15 at 2 p.m., during an interview with the Facilities Director (FD), he stated there was no monitoring of the water temperatures in the kitchen food preparation sinks. FD stated since there was one boiler supplying Campus 2 hot water and this would represent the water temperature in the whole facility. FD acknowledged that the water temperature was not maintained at 120 degrees F or above as required by the county Health Department.

4. On 2/3/15 at 8:30 a.m., the Clinical Nutrition Manager (CNM) was observed in production kitchen with bangs not covered by hair constraint. The Director of Food and Environmental Services (DFEVS) stated it was not correct to have hair outside of the hair restraint.

On 2/2/15 at 9:00 a.m., Food Service Worker 12 was observed with hair restraint not covering the front and back of the hair. DFEVS stated it was not correct to have hair outside of the hair restraint.

"Food employees shall wear hair restraints, such as hats, hair coverings or nets that are designed and worn to effectively keep their hair from contaminating exposed food, clean equipment, utensils and ..." ( FDA Food Code 9 2-402.11)

5. On 2/3/15 at 11:30 a.m., during an observation in the food preparation area of the kitchen, approximately 20 to 30 paper tray tickets were observed printing and then fell onto the floor at the cook's production area. Cook 11 picked up the tickets and placed the paper meal ticket under the patient plate for assemble onto the tray.

On 2/4/15 at 1:10 p.m., during an interview, the Infection Control Officer (IC) stated she did rounding monthly and had not observed the tickets falling onto the floor. IC stated this would be a problem with contaminating the tickets and she did not know why the cook used the contaminated tickets.

6. On 2/3/15 at 2:45 p.m., 3 wet rags were observed in the food preparation sink next to the sanitizing bucket. Cook 10 stated that she was cleaning.

Review of policy titled wiping cloths, dated 2/18/213, stated " ... to store wet cloths in a bucket of detergent or sanitizer solution."










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