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Based upon observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

A-0701 - Failure to maintain the hospital environment to assure the health and safety of all patients
A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based upon observation and interview the facility failed to maintain the hospital environment to assure the health and safety of the current census of 321 patients and its staff resulting the potential for less than optimal outcomes. Findings include:

On 5/6/19 during a dietary tour of the kitchen between 11:30 AM- 2:49 PM the following observations took place:

1. On 5/6/19 at 12:09 PM a goose-neck style hose sprayer was observed wrapped over top of fire suppression sprinkler heads above the free standing "Bain Marie" unit underneath the exhaust ventilation hood within the kitchen's main cook line. At this time the surveyor queried the staff regarding the current state of the sprayer to which Patient services coordinator, staff CC, replied, "the spring is broken so it won't hold itself back, if it's not looped it falls inside of it and we don't have the separation". The surveyor then inquired if a work order had been placed for this concern to which staff CC responded, "if not, it will be". This finding was confirmed with Food service manager, staff W, and Dietitian, staff BB, at the time of discovery.

2. On 5/6/19 between the hours of 1:54 PM- 2:47 PM equipment seals and gaskets were found damaged, loose and hanging on food service equipment such as the main cook line's microwave, two doors on one of the plating/ meal assembly line's reach-in coolers, and the "true" self-serve reach-in cooler in the cafeteria. On 5/6/19 at 2:50 PM upon interview with the Supervisor of plant operations, Staff AA, regarding if they were aware of the current state of the equipment seals, to which they stated, "I have written them all down and they will be taken care of". These findings were confirmed with the Food service manager, staff W, Dietitian, staff BB, Patient services coordinator, staff CC, and Clinical team leader, staff X at the time of discovery.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated May 8, 2019.
K-0223
K-0343
K-0351
K-0928
K-0923

Based on observation, interview and record review, the facility failed to ensure a sanitary environment resulting in the increased potential for cross contamination of food, foodborne illness and transmission of infectious agents for all 321 patients served by the facility. See specific tags:

See specific A tag:

A-0749 Failure to ensure proper cooling procedures take place, to monitor and maintain proper hand hygiene techniques, to confirm food items are legibly labeled and properly dated, and to ensure the adequate sanitization of items occurs.

Based on observation, interview and record review the facility failed to ensure sanitary conditions in the kitchen, resulting in the increased potential for cross contamination of food, foodborne illness and transmission of infectious agents to all patients receiving oral foods. Findings include:

On 5/6/19 during a dietary tour of the kitchen between 11:30 AM- 2:49 PM, the following observations and interviews took place:

1. Upon evaluation of the cold holding units of the facility, the Food service manager, staff W, stated that the facility holds ready to eat potentially hazardous foods (PHF) for no more than seven days before they are discarded, however some items are dated for fewer days attributed to the quality of the finished product being served. On 5/6/19 between 12:18 PM - 2:11 PM, multiple products were observed with illegible labeling and date marking. This finding was confirmed with the Food service manager, staff W, Dietitian, staff BB, Patient services coordinator, staff CC, and Clinical team leader, staff X, in several walk-in freezers and coolers as numerous attempts to accurately identify products were required by staff to verify food product labeling and associated discard dates. On 5/6/19 at 12:27 PM, the surveyor queried the staff on their expectations when comes to being able to easily identify food items to their contents and discard of items as needed to which staff BB replied, "we know this is not exactly the best system right now. We have a new labeling system that we will be starting soon to replace the need hand write our own labels to eliminate this from happening in the future". Staff W then commented, "we also started using a sticker labeling gun for dates on some things to help reduce errors".

2. On 5/6/19 at 12:36 PM, four mid-size containers of "sloppy Joe" were observed in the primary thawing walk in cooler with start dates of "4-17-19" and discard dates of "10-17-19". Additionally, two containers with the same identifying label were observed with start dates of "2-5-19" and discard dates of "8-5-19" and one unlabeled container of what Patient services coordinator, staff CC, stated to be, "probably the same" were observed. At this time the surveyor inquired with staff on the meaning of the dates listed on the products to which staff CC replied, "they are supposed to use pull stickers. They were probably taken out to thaw a day or two ago". The surveyor then queried the staff if they could identify what date the items were taken out of the freezer to thaw as it corresponds with their policy of holding ready to eat potentially hazardous foods (PHF) for no more than seven days before they are discarded, however, on 5/6/19 at 12:39 PM no staff member was able to verify if the food items were or were not allowed to be consumed per their date marking policy.

On 5/7/19 at 4:36 PM, record review of a policy entitled, "Tier 3: Henry Ford Macomb Culinary Wellness Department Storage", dated 9/2018, noted: "All prepared food items stored in the refrigerators are covered, labeled and dated on the day they were made with a seven (7) day shelf life. Items are discarded once they become outdated."

3. On 5/6/19 at 12:53 PM, five large six-inch deep plastic containers of pre-cooked noodles were observed covered with visible condensation coating the interior of the containers. Upon observation Dietitian, staff BB stated, "this isn't right" and Patient services coordinator, staff CC, acknowledged, "we'll need to redo them". At this time staff BB was unsure why these products were cooled in this manner instead of following the facility's policy of rapidly cooling items for later use with an ice bath and with cooling wands. At this time Food service manager, staff W confirmed this was not the correct cooling procedure to be used for this type of product and instructed an unidentified dietary aide to, "throw these away, we need to make new ones". When queried by the surveyor if the facility kept cooling logs to verify proper cooling was conducted of these items, staff W replied, "nope".

4. On 5/6/19 at 12:10 PM, the lack of proper glove was observed as Cook, staff DD, was observed not washing their hands between donning gloves while continuing with food preparation, plating and serving food. On 5/6/19 at 12:13 PM upon observation by Patient services coordinator, staff CC, staff DD, was instructed to, "take your gloves off and wash your hands" and assured the surveyor that this was not the facility's correct procedure to follow. On 5/6/19 at 1:10 PM and at 1:18 PM, staff DD was observed repeating the same practice of not washing their hands between donning gloves while plating and serving food. On 5/6/19 at 1:20 PM, staff DD was observed not changing gloves after handling raw beef hamburger patties prior to handling clean plates and utensils.

On 5/6/19 at 12:29 PM, Cook, staff EE, was observed assembling and plating cook-to-order meals with the same pair of gloves after wiping their gloved hands on a cloth towel utilized for cleaning the counter tops and cutting boards. On 5/6/19 at 1:21 PM, staff EE was observed not washing their hands between donning gloves while continuing with food preparation.

On 5/6/19 at 1:19 PM, Dietary aide, staff FF, was observed not washing their hands between donning gloves while continuing with food preparation. On 5/6/19 at 1:36 PM, staff FF was observed adjusting their hair net and touching their face while continuing food preparation activities without changing gloves or performing any form of hand hygiene. On 5/6/19 at 1:38 PM, upon observation by Food service manager, staff W, education was observed being provided to staff FF. At this time a hand hygiene policy was requested by the surveyor to review.
On 5/7/19 at 4:54 PM, record review of a policy entitled, "Tier 1: Hand Hygiene and Hand Care", dated 7/2018, revealed that the policy does not include handwashing instructions for foodervice workers when changing gloves.
5. On 5/6/19 between 11:50 AM - 2:11 PM Food service manager, staff W, Cook, staff EE, Dietary aide, staff FF, and an unidentified dishwasher were observed re-contaminating their hands after conducting hand washing due to the lack of a hand barrier being used to turn the faucet off. During this time frame, surveyor review of a policy identifying proper handwashing procedures to follow including the use of a hand barrier (paper towel) to shut off the faucet when hand washing has been completed was observed posted above each designated hand washing sink in the kitchen. On 5/6/19 at 1:51 PM, upon observation of this practice by staff FF, staff W confirmed this was not correct procedure and was observed providing education to staff FF.
On 5/7/19 at 4:55 PM, record review of a policy entitled, "Tier 1: Hand Hygiene and Hand Care", dated 7/2018, noted: "paper towel should be used to turn off the water faucet when applicable".

6. On 5/6/19 at 2:19 PM, improper sanitizing of items was observed as the three-compartment sink was found with a chemical concentration of zero in its sanitizing compartment (verified through a test strip test conducted twice by Patient services coordinator, staff CC) while it was actively in use. At this time staff CC, stated, "I'll dump this out and make a new one" and the Dietitian, staff BB commented, "to save time we could run what was just cleaned through the dish machine". On 5/6/19 at 2:21 PM, the surveyor observed a sign posted on the wall above the 3-compartment sink next to an automatic chemical dispensing system which displayed temperature and chemical concentration parameters for adequate sanitizing to occur. Upon observation the surveyor queried staff BB if this was a facility policy to be followed to which they replied, "we got this from our supplier, we have our own policy which I can get you a copy of".

On 5/7/19 at 5:22 PM, record review of a policy entitled, "Tier 3: Henry Ford Macomb Culinary Wellness Department Pot and Pan Washing", dated 9/2018, noted: "4. Fill sink #3. Turn on water/sanitizer dispenser (water 65-75 degrees) to fill line. Use test strips to verify sanitization concentration is correct (200-400 PPM)" and "9. Sink #3 with sanitizer should be tested three times a day and recorded on the Quaternary Test Sheet in parts per million with employees initials. The quaternary test tape should read minimum 200 ppm. Any deviation should be reported immediately to management. (Anything less than 200 ppm will not kill bacteria.)"