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§Food and Dietetic Services

Condition Statement - A-0618 Food and Dietetic Services

Based on observation, staff interview, and administrative document review, the hospital failed to ensure the food and dietetic service was organized, including the contracted services, and to meet the Conditions of Participation for §482.28 when the hospital DID NOT:

a. Ensure the Food and Nutrition Services department was managed effectively, organized effectively and implemented policies and procedures that reflected acceptable standards of practice (Cross Reference A-619).
b. Ensure comprehensive and effective oversight of foodservice operations by the contracted foodservice vendor (Cross Reference A-0620);
c. Ensure review and approval of the patient menu by the Registered Dietitian prior to implementation (Cross Reference A-0621).
d. Ensure dietary staff were competent and properly trained to store, prepare and cool foods in accordance with food safety standards (Cross Reference A-0622).

The cumulative effect of these systemic problems resulted in the inability of the hospital's food and nutrition services to direct staff in such a manner to ensure the nutritional needs of patients were met in a safe and effective manner and in accordance with 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 deficient practices in multiple areas related to safe food practice, sanitation, storage, and staff training (Cross-reference A-0620, A-0621 and A-0622).

Findings:

Review of the hospital document titled "Master Services Agreement for Food Services" executed on 1/21/21 described the agreement, effective 2/1/21 between the Vendor and the hospital. The description of the agreement was listed as the purchase of food services and related services. The agreement also listed a section titled "Vendor Warranties" indicating services performed by the Vendor shall be performed consistent with the best practices in the industry and in compliance with federal and state laws.

In an administrative interview on 11/22/21 beginning at 2:15 PM, the Quality Director (QD) confirmed beginning in July 2021 the Vendor assumed the leadership role of dietetic services, beginning with the transition process. The process included implementing the Vendors administrative functions including elements such as software and purchasing implementation. During the interview QD indicated the Vendor recently hired an Area Director of Food and Nutrition Services. Currently on site there was an Area Patient Food Services Manager (APFSM) and an Area Interim Chef (AIC). The QD also confirmed the Registered Dietitians remained hospital employees.

During several interviews with the AIC on 11/22/21 between the hours of 2:25 PM and 4:30 PM, and on 11/23/21 between the hours of 10:10 AM and 4:30 PM, discussed were the observations of deficient practices identified which reflected the lack of oversight of food service operations and lack of staff training.

In an interview on 11/23/21 beginning at 2:20 PM, the AIC indicated he was assigned to this location and he anticipated this would be a permanent appointment, however it was unclear if he would assume the role of Executive Chef or Patient Services Manager. AIC confirmed there were several Vendor employees which have been involved in the transition to the contracted foodservice. The surveyor asked if there were any documents that might indicate what previous staff were working on or any guidance that may contribute to establishing continuity during the transition. AIC stated he wasn't aware of any, however would look through the files.

In an interview on 11/23/21 at 3:50 PM, the Ministry Admin (MA) indicated the hospital was in a "3-month steady state" which was described as the period between September and December 2021. It was intended that this period would include evaluation of the operational needs of the department by the Vendor. MA indicated the Vendor sent an interim Director of Food and Nutrition Services (DFNS) to begin the transition process which consisted of establishing the electronic systems for menus, food ordering and affiliated software needs to support the transition. MA indicated current staff whether hospital or temporary staff should have been trained by the Vendor staff. Additionally, MA indicated the Lead Registered Dietitian (LRD) was the position that would be responsible for foodservice oversight.

MA indicated to date the Vendor had not provided any formal reports, however there were some "rocky areas." MA did not describe the nature of the rocky areas.

Hospital document titled "Master Services Agreement for Food Services" executed on 1/21/21 indicated the contract included what was termed a "discovery period." It was noted while the discovery period was intended to validate the financial and operational information, this period appeared to focus on the financial costs of the contract to the Vendor.

In an interview on 11/30/21 at 8:30 AM, the LRD indicated her position description was changed to have a peer relationship with the APSM and AEC. LRD began to integrate into food and nutrition services when the interim DFNS left. At that point the LRD indicated there were too many changes with the respect to the transition along with the implementation of a new electronic health record and was not able to provide the required level of food service oversight. The LRD confirmed transition activities included the loss of a significant number of permanent dietetic services staff, the use of temporary food production staff, the implementation of a new software program for menus, a new menu system in conjunction with new recipes, transition of the types of supplies, and Vendor staff that have been rotating through the account since July. The LRD indicated she has not been involved in the development of foodservice staff training during the transition. The LRD confirmed that this position was also responsible for foodservice oversight of a separately licensed, affiliated hospital.

Review of Vendor position description titled "Executive Chef" dated 1/2006 indicated it was the responsibility of this position to oversee kitchen operations while maintaining a safe and sanitary work environment. In addition, this position is responsible to train kitchen staff in food preparation and food safety based on corporate and regulatory standards. Similarly, the position description of the "Patient Services Manager" dated 1/10, indicated this position was also responsible to supervise the operation of patient food services including training patient foodservice personnel. The hospital's position description for the "Manager, Nutrition Services" dated 10/13 also indicated the position was responsible for food safety and training in accordance with statutory regulations.


38335

Based on dietetic services observations, dietary management and dietary staff interview and departmental document review the hospital failed to ensure comprehensive oversight by the Director of Food Services, a contracted service, to ensure food safety in accordance with standards of practice when there was lack of 1) accurate labeling/dating of thawing meats; 2) cooldown monitoring of potentially hazardous foods; 3) staff training; and 4) lack of review of operational processes, related to food safety, within food and nutrition services.


Findings:

1. Accurate labeling and dating of stored food items are important components of overall food safety. The Food and Drug Administration (FDA) has developed recommendations for short, safe time limits to help keep refrigerated foods safe. It is recommended that thawed raw ground meats such as hamburger, turkey veal or pork as well as chicken is prepared within 1-2 days once thawed. Similarly, fresh whole meats such as beef, and pork be prepared within 3-5 days of thawing. Thawing must be monitored and controlled to ensure thoroughness. Time and/or temperature abuse can cause spoilage or growth of pathogens (FDA Food Code Annex, 2017). United States Department of Agriculture (USDA) suggests it may take 4-6 hours or longer, in a household refrigerator, to thaw 1 pound of meat, depending on the cut and density of the meat.

During an initial tour of the kitchens on 11/16/21 at 9:35 a.m., when entering the café kitchen, a sign located over the kitchen entrance indicated "hair nets required prior to entering the kitchen." No hair nets were located at the entry door. Met with the Interim Dietary Manager who was asked if there were any hair nets available, she located one. The handwashing sink located inside the café kitchen area was stocked with soap and paper towels, but no hair nets.

Entered the main kitchen area, floors and food prep tables appeared to be clean. Temperature logs located on the outside of the refrigerators/freezers were dated for October 2021, four to five temperature entries were observed on each log. When asking the Interim Dietary Manager how often the refrigerator/freezer logs are monitored, she stated the temperatures should be monitored two times a day. When questioning why the log sheets say October, she stated the logs should be changed the 1st of every month, we should have November logs posted.

Returning to the Café kitchen on 11/16/21 at 11:30 a.m., the walk-in freezer located in the café kitchen contained boxes of meat and fish. The inside freezer thermometer read 20 degrees F, the freezer temperature felt warm, and the boxes of meat felt soft. One open box of meat (not labeled, dated or closed securely), contained ground beef that was soft and sticky (photos attached). When questioning the Registered Dietician (RD), she did not know why the box of ground beef was in the freezer and not frozen. She mentioned, she had not been in this part of the kitchen for a while. There was no electronic temperature panel located outside of the walk-in freezer or a freezer temperature monitoring sheet. When questioning the Interim Dietary Manager if there were any problems with the walk-in freezer temperatures, she stated this was her 4th day and she was not aware of any problems.

During a continued food storage observation of the café kitchen on 11/16/21 at 11:35 a.m., the floors in the café kitchen were grimy with food particles. When asking the Interim Dietary Manager how often the floors were cleaned, she stated every day/evening. The café kitchen was cluttered with boxes and pans stocked on the counters.

The walk-in Refrigerator used for thawing meats contained several bins of thawing meat and boxes of pre-cooked chicken. One bin contained thawed pork in a bag sitting in meat juices, the label on the bin indicated "Thaw to use Pork" dated, 11/8/21 good through 11/12/21. A second bin contained several chubs of thawed Pork, dated, 11/11/21 good thru 11/15/21. Two bins located on a rack contained 2 packages of thawing ground meat and 1 large chunk of thawed ground meat wrapped in Saran wrap (photos attached), the bin was not labeled or dated. A second bin contained thawing pieces of Turkey, not labeled, or dated. A box on the same rack contained a brick of thawing ground meat, not labeled, or dated (photos attached). When questioning the Interim Dietary Manager about labeling and dating of meats she stated the dietary staff pull meat to thaw based on the menu for the week.

Two boxes of sweet potatoes dated October 12th on the packing label located in the walk-in refrigerator were observed to have mold on the potatoes in each box (photos attached). When asking the Interim Dietary Manager when the potatoes were delivered, she stated, "November 15th."

During continued food storage and kitchen observations in the Main kitchen on 11/16/21 at 12:00 p.m., the RD was asked to assist in taking temperatures of foods. When questioning the RD and Interim Dietary Manager how often the kitchen thermometers are calibrated. The RD stated they are checked weekly. The Interim Dietary Manager was asked if the temperatures are documented she stated there is a log, but she did not know where it was. The RD proceeded to calibrate a thermometer by putting ice and water in a cup; the thermometer would not reach 32 degrees F (the required temperature for calibrating the thermometer). The Interim Dietary Manager suggested the RD use less water, she attempted to calibrate two additional thermometers that would not calibrate to the required temperature. The RD stated she had new thermometers and would try one.

Further kitchen observations on 11/16/21 at 12:30 p.m., showed the RD attempting to check the temperatures of refrigerated foods, (e.g., refrigerated cheese was 37.2 degrees F). The RD was asked if the kitchen prepares cold salads, she stated, egg, tuna, and chicken salads are prepared two times a week. The tuna salad container was prepared and labeled 11/14/21 to use by 11/17/21. A temp was taken of the Tuna salad and was 36.5 F. When questioning the RD if a cool down log is used to record temperatures she stated, "Yes there is one." The Interim Dietary Manager showed the cool down log that contained temperatures of cooked meats from 9/8/21, no temperatures of any salads were listed on the logs. There were no cooling logs with current temperatures of salads for October or November. The Interim Dietary Manager stated she has a cool down log, but did not know where it was. Temperatures of meat in the Café walk-in freezer were attempted but the thermometer was fluctuating and not accurate. When questioning the RD about the accuracy of the thermometer, she stated, she was not sure.

During a kitchen observation and concurrent interview on 11/17/2021 at 09:30 a.m., the cafe and main kitchens in the facility were observed. The walk-in freezer temperature was -7 and boxes of meat remained soft to touch. The thawing refrigerators contained the same bins of meats and thawed pork lying in meat juices. No changes were observed from the prior day.

During food storage observations on 11/22/21 beginning at 2:25 PM, in the walk-in refrigerator (referred by hospital staff as the thawing refrigerator) there were multiple bins of raw meat, all of which were dated 11/22/21. One bin contained 2 unlabeled, 10-pound packages of fully thawed ground turkey; a second bin contained 2 unlabeled packages, approximately 5 pounds each, of partially thawed ground meat identified by the Interim Executive Chef (IEC) as ground sausage; 2 fully thawed pork loins, greater than 5 pounds each; and 2 fully frozen packages of chicken, weighing approximately 5 pounds each.

In a concurrent interview with Interim Support Manager (ISM) she stated the labeling date was intended to demonstrate the date the item was thawed. ISM was unable to explain why some items dated 11/22/21 were fully thawed, while others remained frozen. The surveyor also inquired whether the facility had a defined schedule of when to pull frozen foods for thawing. ISM indicated they did not as the cooks generally looked ahead on the menu and determined what needed to begin thawing.

In a follow-up observation on 11/22/21 beginning at 2:45 PM in the main kitchen walk-in freezer there was a fully thawed piece of meat weighing greater than 5 pounds, identified by IEC, as an eye of round dated 11/18/21 and was fully thawed. There was no use-by date indicated.

In a follow up interview on 11/22/21 at 3:18 PM, ISM demonstrated the intended use of orange colored dating/labeling stickers for thawing. As an example, when thawing beef dietary staff should have printed a label identifying the meat as "beef" as well as the current and "good thru" date.

In an interview on 11/23/21 beginning at 11:15 AM with Dietary Staff (DS) 5, the position responsible for receiving items, DS 5 confirmed he was the receiving clerk for food deliveries. DS 5 indicated when items are received, he placed a sticker on either the packaging box or the individual items, indicating the receipt date. He also stated he utilized a first-in-first-out method, meaning newer items are placed behind existing items. DS 5 also indicated it would not be his responsibility to label thawing items.

In a follow-up group interview on 11/23/21 beginning at 12:20 PM with the Quality Director (QD), Director of Plant Operations (DOP), IEC and LRD the surveyor asked the team to describe leadership staffing of the department. They indicated at the time the contract was implemented the contracted vendor sent a leadership position to begin developing the internal structure of the department in preparation of the transition. This development included the set-up of the required technology such as the menu and food ordering system as well as food related patient care systems. The IEC also indicted there were several leadership staff from the vendor to provide support. The QD indicated food production staff were a combination of temporary employees hired through an employment agency and permanent hospital staff. The surveyor inquired whether interim staff from the Vendor provided a method of communication, with respect to areas of concern or transitional progress, as leadership positions transitioned in and out of the department. IEC stated he wasn't sure but would check.

Departmental document titled "Avoiding Food Contamination" dated 11/3/20, indicated food in thawing state must be labeled with a use through or expiration date as well as a pull date indicating when the item was relocated in the refrigerator from the freezer.

Review of food vendor invoice dated 11/15/21 did not list any ground turkey. Similarly, the invoice listed only pork and turkey sausage links. There was no ground sausage listed. Vendor invoice dated 11/22/21 did list receipt of a case of 10-pound packages of ground turkey, which were delivered frozen.

2. Close attention must be paid to control of biological hazards when a food establishment cooks raw animal foods using a process in which the food is partially cooked then cooled with the expectation of fully cooking the food later or time. USDA Food Code (2017) requires that establishments wishing to use a non-continuous process for the cooking of raw animal foods establish and follow a written plan that ensures each stage of the process is completed within time and temperature parameters that adequately prevent pathogen survival and growth. USDA Food Code also requires that establishments take special precautions to ensure that raw animal foods that have only been initially heated to temperatures that are not lethal to the pathogens of concern are clearly identified so that they will not be inadvertently sold or served to the consumer in a partially cooked state. To ensure the food does not dwell for extended periods within temperature ranges that favor pathogen growth, the USDA Food Code establishes limits on the time permitted to initially heat the food (initial "come-up" time) and the time permitted to cool the product to temperatures that are safe for refrigerated storage. Together, these limits should prevent food from remaining at temperatures at which pathogen growth to harmful levels may occur (USDA Food Code Annex, 2017).

a. During food storage observations on 11/22/21 at 2:40 PM, of the walk-in refrigerator in the main kitchen, there were 2 large unlabeled sheet pans of chicken breasts with grill marks. It was noted the chicken did not appear fully cooked. The internal temperature, taken by the surveyor, was 56 degrees F (Fahrenheit-a unit of measure). In a concurrent interview with Dietary Staff (DS) 1 the surveyor asked her to describe the process. DS 1 stated the item would be used for dinner. DS 1 confirmed the chicken was not fully cooked, rather was pre-grilled and would be fully cooked later. DS 1 also indicated there was no temperature monitoring during or after the non-continuous cooking stage. DS 1 also stated in addition to chicken there were occasions where pork chops and pork loin were also pre-grilled. DS 1 described the process for grilling pork loin. She stated the pork would be cut in slices, grilled off and left to "cool a bit" at room temperature to the "right temperature." The surveyor asked what right temperature was, to which DS 1 replied "under 100 degrees" at which time the meat would be put in the refrigerator. DS 1 indicated there was no temperature monitoring of the pork during the cooling or storage process. The surveyor asked how the facility ensured meats were cooked to the proper final temperatures for food safety. DS 1 stated final temperatures were taken prior to meal distribution (tray- line).

Review of departmental document titled "Temperature Log and Checklist" dated 11/22/21 indicated the log was not intended to determine final adequate cooking temperatures, rather was intended to document minimum holding temperatures. It was noted the minimum meal distribution temperature was listed as greater or equal to 140 degrees F, with an optimal temperature of 155 degrees F. While this would be within the standard of practice for hot food holding, this temperature would not be adequate for food safety of cooked meats.

Review of departmental policy titled "Avoiding Food Contamination" dated 11/3/20 guided staff to fully cook chicken to an internal temperature of 165 degrees F. There was no procedure for ensuring food safety for non-continuous cooking methods.

b. Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. While it is possible to utilize water to thaw foods, this process requires specific time and temperature controls. The item must be completely submerged under running water; at a water temperature of 70 degrees F; with sufficient water velocity to agitate and float off loose particles in an overflow, and for a period that does not allow thawed portions of ready to eat foods to rise above 41 degrees F (USDA Food Code, 2017).

Departmental policy titled "Avoiding Food Contamination" dated 11/3/21 instructed staff that "frozen foods are thawed in a refrigerator ...Frozen foods can also be thawed under cold running water ..." The policy also included a section titled "critical control points" that described temperature parameters for hot and cold holding temperatures. The policy did not include any food safety parameters for thawing foods using water in accordance with standards of practice.

During the observation on 11/22/21 at 2:40 PM, it was also noted there was a pre-cooked beef pot roast, weighing greater than 10 pounds, with a thaw date of 11/22/21, intended to be used on 11/24/21. In concurrent interview DS 1 stated she took the roast to the café kitchen at approximately 2 PM at which point she put it in the sink with water for about 30 minutes to thaw, then brought it back into the walk-in refrigerator. DS 1 then indicated the roast would be sliced, weighed then heated up for meal service on 11/24/21. The surveyor asked if there was any time or temperature monitoring during or after the thawing process. DS 1 indicated there was not.

In an interview on 11/22/21 at 2:45 PM, IAC indicated there was no system for temperature monitoring for foods thawed using water.

Review of invoice dated 11/22/21 indicated the facility ordered multiple frozen beef pot roasts all of which weighed greater than 12 pounds.

c. Foods that require Temperature Control for food Safety (TCS) are defined as those foods capable of supporting bacterial growth associated with foodborne illness. Common TCS foods include eggs; cooked meats, poultry, seafood; cream-based bakery products; raw cut tomatoes and cantaloupe; cooked beans, potatoes, and pasta (USDA Food Code, 2017).

During general kitchen observation on 11/23/21 at 11:20 AM, it was noted DS 3 was placing a pork loin in the oven. In a concurrent interview DS 3 stated the meat was intended for lunch the following day (11/24/21). DS 3 stated once the meat was cooked, it would be placed in the refrigerator, sliced, and heated the following day. The surveyor asked if there was any monitoring of temperatures after cooking once the item was placed in the refrigerator. DS 3 replied there was not, temperature monitoring would be completed when the item was reheated the following day. DS 3 also indicated pork loin was prepared on a weekly basis. Additionally, DS 3 indicated turkey breast was another item cooked the day prior to serving.

Review on 11/23/21 at 11:30 AM, of facility document titled "TCS* [temperature controlled for safety] Food Cooking and Cooling Log" dated 11/16/21, noted the only items entered on the log was cinnamon apples and blueberries. In a concurrent interview, with AIC the surveyor asked if there were any other cooldown logs. AIC stated he wasn't sure but would check. In a concurrent interview the surveyor asked ISM to describe the use of the cooling log. ISM indicated she was unfamiliar with the log and was unsure of its origin as it wasn't an approved Vendor form. In an interview on 11/23/21 at 11:40 AM, Hospital Staff 13, the former Dietary Supervisor, stated when the Vendor assumed operational responsibilities, they put in place new forms, however the forms were not presented to the hospital for review and/or approval.

The cooling log guided staff to begin monitoring the cooldown process when the item reaches 140 degrees F; at 2 hours the temperature must read 70 degrees F or below and at 6 hours the final temp must read at or below 40 degrees F.

d. Food safety practices would include time/temperature monitoring for ready to eat foods that may have been prepared at temperatures greater than 41 degrees F. Additionally, the food safety indicates that TCS foods shall be cooled within 4 hours to 41 degrees F if ingredients reach ambient temperatures. This would include reconstituted such as canned tuna (USDA Food Code, 2017).

During kitchen observations on 11/16/21 at 12:30 p.m., the RD attempted to check the temperatures of refrigerated foods, (e.g., refrigerated cheese temp 37.2 F). The RD was asked if the kitchen prepares cold salads, she stated, egg, tuna, and chicken salads are prepared two times a week. The tuna salad container was prepared and labeled 11/14/21 to use by 11/17/21. A temp was taken of the Tuna salad and was 36.5 F. When questioning the RD if a cool down log is used to record temperatures of the salads when prepared she stated, "Yes there is one." The Interim Dietary Manager showed a cool down log that contained temperatures of meats from 9/8/21, no temperatures of any salads were listed on the logs. There were no cool down logs with current temperatures of salads for October or November. The Interim Dietary Manager stated she has one but did not know where it was. Temperatures of meat in the Café walk-in freezer were attempted but the thermometer was fluctuating and not accurate.

In an interview on 11/22/21 beginning at 3:18 PM, the surveyor asked DS 2 to describe the process for preparing ready to eat TCS foods. DS 2 indicated Deli items such as tuna, egg and chicken salad were produced approximately every 3 days. DS 2 indicated since ingredients are ready to eat, they may be pre-chilled prior to preparation. The items are then prepared by mixing additional ingredients such as mayonnaise or herbs and spices. DS 2 stated once the item was prepared it is labeled/dated and placed in the refrigerator. While ingredients may have been chilled prior to combining ingredients DS 2 indicated there was no post-production temperature monitoring or any temperature monitoring once the item was refrigerated, rather the temperature would be taken prior to use. There was no system in place to ensure the ready to eat items did not reach ambient room temperature during or shortly after combining ingredients.

Review of departmental document titled "TCS* Food Cooking and Cooling Log" dated 11/16/21 revealed the time/temperature monitoring was limited to hot foods. There was no mechanism to ensure food safety of ready to eat deli items with multiple ingredients.

e. In an interview on 11/23/21 at 10:10 AM, with the Infection Control Practitioner (ICP), the ICP indicated evaluation of dietetic services was done on a routine basis using a checklist. The ICP stated she has been with the hospital for 3 months, however based on the files left by the previous ICP the last ICP evaluation was completed in 2015. The ICP also indicated on 11/18/21, during the survey, she completed an evaluation of the department. The ICP indicated there were no identified issues with freezer temperatures, labeling/dating or how foods were placed in the refrigerators/freezer. It was also noted while the hospital completed environment of care rounds in nutrition services on 5/4 and 11/1/21 the evaluation was specific to life safety concerns such as electrical and fire safety.

In a follow up interview on 11/23/21 at 11:50 AM, IEC stated he was unable to locate any prior cooldown monitoring logs.

In an interview on 11/23/21 beginning at 11:10 AM, IEC was asked to describe how food safety was evaluated. IEC indicated managers spent time in the kitchen daily. IEC also indicated there should be monthly and quarterly sanitation audits completed by leadership staff, however he was unsure if any were performed.

Review of Infection Prevention Committee Minutes dated 5/21/21 and 7/22/21 as well as the Infection Prevention Committee Agenda dated 9/23/21 did not include surveillance or standing reports from Food and Nutrition Services.


38335

Based on dietary management staff, Registered Dietitian interview, and dietary document review, the hospital failed to ensure the hospital's Registered Dietitian reviewed and approved the patient menu prior to implementation.

Findings:

On 11/22/21 beginning at 3:45 PM the menu was reviewed with the Interim Support Manager (ISM). The ISM indicated, due to staffing issues, the current menu is a non-select menu (a meal system where patients are given pre-designated items based on their physician ordered diet). The ISM indicated beginning mid-September the menu was changed to the Vendor's standardized menu. The ISM also indicated the Heart Healthy diet was the same as the regular and Carbohydrate Consistent diets (a carbohydrate consistent diet is used to treat diabetes). The ISM also stated the regular no added salt diet would include all food items except for the brownie on 11/22/21. The surveyor inquired why the menu eliminated the brownie, the ISM indicated because it contained salt. Additionally, the ISM also indicated the renal and dialysis diets were the same.

One of the roles of the Registered Dietitian is to supervise the nutritional aspects of patient care. Responsibilities of the Registered Dietitian include but are not limited to review and approval of patient menus (Center for Medicare/Medicaid Services, State Operations Manual, Appendix A).

In an interview on 11/30/21 at 8:30 AM, the Lead Registered Dietitian (LRD) indicated her position description was changed to have a peer relationship with the Area Patient Services Manager and Area Executive Chef. LRD began to integrate into food and nutrition services when the interim Director of Food and Nutrition Services left. At that point the LRD indicated there were too many changes with the respect to the transition along with the implementation of a new electronic health record and was not able to provide the required level of food service oversight. The LRD confirmed transition activities the implementation of new menus, and a new menu system. The LRD indicated while the Registered Dietitians had access to the nutritional analysis of the menus, she was not asked to review or approve the menus prior to implementation.



38335

Based on food storage observations, dietary staff interview, and departmental document review, the hospital failed to ensure position specific training for foodservice personnel as evidenced by observed lapses in food safety. Failure to ensure staff are comprehensively trained may result in practices associated with foodborne illness which may result in further compromising the medical status of patients and in severe instances may result in death.

Findings:

During the survey conducted beginning on 11/16 through 11/23/21 it was noted there were multiple lapses in safe food handling practices (Cross Reference A-0620). The lapses in food safety include lack of cooldown monitoring for previously cooked foods; use of non-continuous cooking practices, without temperature monitoring of meat; the practice of thawing using water without monitoring time and/or temperature and lack of accurate date labeling of thawing, raw meats.

During an interview on 11/22/21 beginning at 1:46 PM, the Director of Quality (DOQ) confirmed the hospital provided dietetic services through a Vendor. The DOQ indicated the contract was limited to leadership personnel, consisting of several area positions. Area positions were intended to oversee operations in 2 separately licensed hospitals. The area positions included the Director of Food Services, Executive Chef, and Patient Service Manager. The Registered Dietitians as well as the remaining food and nutrition services staff, with the exception of temporary dietetic services staff, were hospital employees.

In an interview on 11/23/21 beginning at 12:50 PM, the DOQ in the presence of the Director of Plant Operations (DPO) and the Area Interim Chef (AIC), confirmed beginning in July the department began losing staff. The DOQ indicated the department currently has 14 available positions and while there has been some success in filling the positions there continues to be a significant vacancy rate. As a result, the positions were filled through the use a temporary employment agency. The surveyor inquired how the hospital ensured the temporary employees possessed the skill set necessary to safely carry out the position requirements within the department. The DPO indicated when requesting staff, they provided the agency with criteria such as a familiarity of foodservice operations. The DQ stated, when using a temporary agency, they relied on the agency to verify competency and health status prior to placing them with the hospital.

Review of Nutritional Services employee schedule from 11/21-12/4/21 it was noted there were 8 temporary employees (Dietary Staff [DS] 1, 6, 7, 8, 9, 10, 11 and 12) currently on the schedule. Review of personnel records of the 8 employees on 11/23/21 beginning at 1 PM, revealed there was no consistency in the file contents. The file for DS 1 was limited to a resume provided by the employment agency and required background checks. Five (DS 6, 8, 9, 10 and 12) of the files were limited to employee health related documents such as a Health Screening Attestation and employee physicals. Of the six files one employee (DS 10) completed a Nutrition Services Orientation Checklist that included a competency checklist. The competency included the completion of a course on Hazard Analysis Critical Control Points (a system designed to recognize and manage food safety risks).

In a concurrent interview AIEC acknowledged there was no course, rather the competency was based on review of the cooldown log. In a concurrent interview Hospital Staff 14, the former Dietary Services Supervisor, stated the competency checklist was intended as a framework for determining future training as it included a self-assessment component. It was not intended to determine comprehensive competency. The self-assessment for this employee was blank. It was also noted the remaining competency areas included skills such as demonstrating department infection control and food safety policies, proper use of equipment, food production techniques, covering/labeling/dating all of which indicated the employee successfully demonstrated full competency within 2 days and was fully qualified to function within the current job description. There was no other documentation of skills and/or experience prior to joining the hospital. Review of DS 7's competency checklist was limited to a signature page there was no self-assessment checklist included.

Review of dietetic services training dated 9/27/21 was limited to team building information. There was no documented training on skills related to safe and effective foodservice operations. Review of documented hospital dietary staff trainings provided by the Director of Plant Operations, dated 4/29/21 and 11/17/21 were limited to life safety trainings. The hospital was unable to provide documentation of consistent training, in relationship to the safe operations of dietetic services or competency evaluation for permanent or temporary dietetic services staff.

Review of the hospital document titled "Master Services Agreement for Food Services" dated 2/1/21 described the agreement between the Vendor and the corporate representation of the hospital. The description of the agreement was listed as the purchase of food services and related services from the vendor. The training section indicated the services may require additional or specialized training beyond normal operational in-service training for customers' staff. The agreement indicated this included any operational training and would be provided by the Vendor.


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