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Based on observation, documentation review and interviews the hospital failed to ensure established policies and procedures were enforced to maintain safe food handling when many foods in the deli cart were not labeled or dated and protein salads dates were beyond the allowed date range after being prepared. Required food service certification for the dietary management was not followed according to the hospital policy. Findings include:

The hospital has a contracted food service company, Sodexo, with established policies, procedures and requirements to manage the kitchen and dietary department. Observations on January 24, 2014 at 3:45 p.m. with dietary lead-G and quality director-B revealed white rice, dated January 21, 2014. Dietary lead-G said the rice should have been discarded on January 21, 2014 due to poor quality. Cooked chicken for fajitas, January 24, 2014, was in an open plastic bag. The dietary lead secured the bag of chicken.Observations in the kitchen with nutrition manager-C and quality director-B on January 28, 2014 at 8:45 a.m. revealed and verified tuna salad and taco pasta salad, dated 1/24/2014, was in the walk-in cooler one day past the three day guideline for food shelf life. Observations of the kitchen deli case with the nutrition manager-C and quality director-B on January 28, 2014 at 8:58 a.m. revealed:
1. Tuna salad (mayonnaise based), dated January 24, 2014 was one day past the three day guideline for food shelf life.
2. Egg salad (mayonnaise based), dated January 23, 2014 was two days past the three day guideline for food shelf life.
3. Chicken salad (mayonnaise based), dated January 24, 2014 was one day past the three day guideline for food shelf life.
4. Yogurt open and out of the original container, dated January 22, 2014 was past the three day guideline for food shelf life.
5. Sliced hard boiled eggs were not dated.
6. Sugar free pudding was not labeled or dated.
7. Open packages of lunch meat, including roast beef, turkey, and ham were not dated.
8. Bacon was not dated.
9. A nearly empty bottle of balsamic vinegar dressing was not dated.
10. Two pans of gelatin were not dated.
11. A pan of cottage cheese was not dated.
Review of the Food Safety Product Labeling and Dating Guide-U.S., dated 1/27/2012 revealed " Food safety product labeling and dating requirements for Sodexo operations. Storing Prepared Food: Applies to: Food prepared in Sodexo operation: Product storage label: Name of product (unless clearly identifiable). Date of preparation and/or use-by date. Applies to: Purchased, ready to eat food removed from original container: Sodexo standard: Food left over after meal service: Use within 2 days (for quality reasons). Advance production (food prepared for later use): Use within 5 days (for food safety reasons), if held at 40 degrees Fahrenheit or below and if clearly marked with " use by date " (day or date product must be consumed, sold or discarded).

Review of the Sodexo Food Product Shelf Life Guideline, revised 11/22/2010, established:
1. Salad dressings-refrigerator storage 3 days
2. Puddings refrigerate 24 to 48 hours
3. Gelatin refrigerate 3 to 4 days
4. Cold foods left over after meal period: refrigerate 24 to 48 hours
5. Cottage cheese: refrigerate 1 weekReview of the Sodexo Requirements for the nutrition director/manager and manager/chef food service certification, last revised on 5/31/2012, noted, " All managers, dieticians and supervisors involved in foodservice must be trained and certified in the Sodexo-approved food safety certification program ....Recertification is required every three years .... Review of the food service certification for the manager/chef revealed certification expired August 16, 2013. An interview was conducted with quality director-B on January 24, 2014 at 12:05 p.m. who stated the nutrition director and chef are employed through the contracted food service company, Sodexo, and are responsible for the oversight of the dietary department and department staff. A second interview on January 29, 2014 at 8:30 a.m. verified safe food handling concerns in the kitchen noted during the kitchen tour. Quality director-B stated there has been no known negative outcome related to foods prepared or served.

An interview with the nutrition manager-C on January 28, 2014 at 8:45 a.m. verified observation of foods beyond the guidelines for food shelf life which should have been discarded. Foods observed in the deli case with no date should have been discarded since there was no way to know that the foods were not beyond the guideline for food shelf life.

Interviews were conducted on January 29, 2014 at 11:00 a.m. with district manager of Sodexo Foods-D, on January 29, 2014 at 11:25 a.m. with nutrition manager-C, and on January 29, 2014 at 1:50 p.m. with executive chef-E . All three verified the manager/chef 's food service certification was last completed on August 16, 2010, beyond the 3 years allowed for recertification according to the Sodexo and hospital requirements.An interview was conducted with nutrition manager-C on January 29, 2014 at 11:25 a.m. and he verified he is responsible for the nutrition services department at the hospital. He also verified protein salads are to be held for not more than three days. Foods are to be labeled and dated. Any foods out of date are to be discarded. These were concerns observed.