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SUN BEHAVIORAL HEALTH 820 DOLWICK DRIVE ERLANGER, KY 41018 Jan. 22, 2015
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on observation, interview, review of the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration (FDA) Food Code and review of the facility's policies, it was determined the facility failed to ensure implementation of a policy addressing safe practices for food handling as evidenced by observations of dietary staff serving food without wearing hair restraints such as hats, hair coverings or hairnets, and observations of patients' food improperly stored in the refrigerator on the inpatient unit.

The findings include:

1. Review of the "U.S. Department of Health and Human Services, Public Health Services", FDA Food Code", 2005, Section 2-402.11 revealed food employees should wear restraints such as hats, hair coverings or hairnets, beard restraints, and clothing which covered body hair, which were designed and worn to effectively to keep their hair from contacting exposed food.

Observation, on 01/21/15 at 12:05 PM, revealed three (3) dietary staff members behind the serving line in the cafeteria with no hair covering in place, while preparing patients' trays and serving patients going through the cafeteria serving line.

Observation, on 01/21/15 at 2:15 PM, revealed three (3) dietary staff members in the kitchen area with no hair covering in place preparing food. Upon entering the kitchen area, the Surveyor requested a hairnet and was informed by the Director of Quality Improvement, staff did not normally wear hairnets in the kitchen area.

Interview with the Nutrition Services Aide (NSA), on 01/22/15 at 9:35 AM, revealed she had worked at the facility for two (2) years and had not worn a hairnet during that entire time. The NSA stated the County Health Inspector had told the dietary staff to only be sure to have their hair pulled back.

Interview with the Dietitian/Manager of Food Services, on 01/22/15 at 10:25 AM, revealed she had worked in the facility for over four (4) years and had not ever required the dietary staff to wear hair coverings during food preparation and serving.

Interview with the Director of Quality Improvement, on 01/22/15 at 10:30 AM, revealed her expectations would be for staff to follow federal and state regulations, and she would expect dietary staff to wear hair coverings as required by the regulations.

2. Review of the facility's policy titled, "Dietary/Nutrition/Nursing Policy & Procedure D045 N054", revised 06/03/13, related to "management of meals sent to the units", revealed all meals sent to the patient units were to be served immediately or stored properly to prevent food being served at inadequate temperatures. The Policy revealed patients' trays were to be labeled with the patient's name when sent to the unit and must be served within seven (7) minutes of delivery. Per the Policy, patients' meal trays should not be left longer than seven (7) minutes unless refrigerated and reheated to proper temperatures.

Review of the facility's policy titled, "Storage Refrigerators" revealed food was to be covered when stored and labeled with date and contents.

Observation, on 01/22/15 at 08:55 AM, revealed two (2) unlabeled Styrofoam containers in the patient's refrigerator on Unit B on the inpatient unit of the facility.

Interview with Registered Nurse (RN) #2, on 01/22/15 at 9:00 AM, revealed the two unlabeled Styrofoam containers were brought up from the kitchen for two (2) patients who were still sleeping. RN #2 revealed no knowledge of having to label patient food items when stored in the patient's refrigerator (even though the facility's Policy indicates this was to be done).

Continued interview with the NSA, on 01/22/15 at 9:35 AM, revealed food items sent up to the inpatient unit should be dated due to possible spoilage if left stored undated in the refrigerator. The NSA stated if the food item was undated, someone would not be able to determine when the item was placed in the refrigerator.

Continued interview with the Dietitian/Manager of Food Services, on 01/22/15 at 10:25 AM, revealed dietary staff had not dated meals when sending the meals to the unit on the facility's "dumbwaiter" system. Per interview, meals sent on the "dumbwaiter" system should be served immediately and not stored in the refrigerator.

Continued interview with the Director of Quality Improvement, on 01/22/15 at 10:30 AM, revealed her expectations would be for staff to follow the facility's policies, related to dietary services and to label and date food stored in the refrigerators.