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Based on observation, interview and document review, the hospital failed to ensure the Condition of Participation, CFR 482.28 Food and Dietetic Services was met when:

1. Based on interview and document review, the hospital failed to follow their job description for one of one Nutrition Service Manager (NSM) when NSM did not have the required education.

2. The hospital failed to ensure the Nutrition Service Manager (NSM) was effective in the daily management of the dietary services during an emergency water advisory to not use the city water when the emergency supplied water for the dish washing had the potential to be contaminated. (Cross Reference A-0620)

3. The hospital failed to ensure the Nutrition Service Manager (NSM) was effective in the daily management of the dietary services when Nutrition Service Aide (NSA) 1 did not receive unit orientation, competency validation and neither NSA 1 nor Cook completed a safe food handling course. (Cross Reference A-0620, A-0622)

The cumulative effect of these systemic problems resulted in the inability of the hospital's food and nutrition services to ensure there was a qualified NSM to direct daily operations and staff in such a manner to ensure the nutritional needs of patients were met in accordance with acceptable standards of practice and safety of the emergency water used for the the needs of the patients was met as required by the mandated Condition of Participation for Food and Dietetic Services. This had the potential to affect the hospital census of 69 highly susceptible patients.

According to the FDA (Food and Drug Administration) Food Code 2022, "A "Highly susceptible population" means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; ... or older adults; and (2) Obtaining food at a facility that provides services such as...health care...hospital."


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Based on observation, interview and document review, the hospital failed to ensure the Condition of Participation, CFR 482.42 for Infection Prevention Control Antibiotic Stewardship was met when:

1. The hospital failed to have an Infection Preventionist (IP), who was qualified by education and training to monitor facility infection control practices during a "DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]" issued by the city on 6/4/24. (Cross Reference A-0748)

2. The hospital failed to implement infection control practices in food and nutrition services. (Cross Reference A-0750)

The cumulative effect of these systemic problems resulted in the inability of the hospital's IP to effectively provide infection control surveillance of the food and nutrition services in such a manner to ensure safety of the emergency water used for the the needs of the patients, visitors, and staff were met in accordance with acceptable standards of practice as required by the mandated Condition of Participation for Infection Control Surveillance. This had the potential to affect the hospital census of 69, visitors, and staff.

Based on interview and document review, the facility failed to ensure one of one Nutrition Service Manager (NSM) who had been granted the authority and delegated responsibility by the hospital for the operation of the daily management of dietary services met the state's education qualification requirements according to California Title 22 (70275(b)) and Health & Safety Code (H & SC 1265.4). This failure had the potential to result in a lack of oversight of dietary services.

Findings:

During an interview on 6/7/24 at 10:38 a.m. with Nutrition Service Manager (NSM), NSM stated he managed the day-to-day operations in the kitchen. NSM stated he had a food handler certificate (food safety) and nothing else.

During an interview on 6/7/24 at 11:48 a.m. with Director of Quality/Risk Management (DQRM), DQRM stated Dietary (Food & Nutrition Services) Director and Dietary Manager position titles were considered the same positions and the Dietary Manager for the facility was the NSM.

During a review of California Code of Regulations (CCR), Title 22, Division 5, Chapter 1, Section 70271 defines Dietetic service as providing safe, satisfying and nutritionally adequate food for patients with appropriate staff, space, equipment and supplies.

During a review of CCR, Title 22, Division 5, Chapter 1, Section 70275 (b) If a registered dietitian is not employed full-time, a full-time person who meets the training requirements to be a dietetic services supervisor specified in section 1265.4(b) of the Health and Safety Code shall be employed to be responsible for the operation of the food service.

During a concurrent interview and record review on 6/7/24 at 2:45 p.m. with NSM and Chief Nursing Officer (CNO), in the presence of QRM, Nurse Manager (NM), Director of Human Resources (DHR), Regional Director of Quality Risk Management (RDQRM), Chief Executive Officer (CEO), Clinical Dietitian (CD), California Code, Health and Safety Code 1265.4 (HSC) was reviewed. H & SC 1265.4 indicated, "(a) A licensed health facility, as defined in subdivision (a), (b), (c), (d), (f), or (k) of Section 1250, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. The dietetic services supervisor shall have completed at least one of the following educational requirements:"...and proceeded to list seven different educational requirements pathways that would meet the state's criteria for NSM to be the designated authorized responsible person for the day-to-day management of the foodservice operation. NSM stated, he did not meet any of the listed educational requirements numbered one through six in the H & SC 1265.4, but he did have years of experience in foodservice as he was a cook in the military for number seven. H & SC 1265.4 # [number]7) indicated, "Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6)."

During a concurrent interview and record review on 6/7/24 at 2:45 p.m. with NSM, NSM reviewed H & SC 1265.4 (2), (3), and (6). H & SC 1265.4 indicated "(2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association, and (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision", and NSM stated he did not meet any of the educational requirements of (2), (3) or (6) as listed in #(7). NSM stated the facility provided the survey team the only educational certificate NSM had, which was titled "In recognition for completing Food Handler Training California Version." NSM stated, "I did not see that listed in the Health & Safety Code 1265.4 as meeting qualifications." NSM verified he did not meet any of the seven available educational requirements that was required by state law to be qualified to be responsible for the operation of the food service.

During a concurrent interview and record review on 6/7/24 at 2:45 p.m. NSM stated the hospital's full-time Registered Dietitian (RD) recently went out on family medical leave act. NSM stated the majority of the RD's duties were clinical nutrition, acting as liaison with medical and nursing staff, overseeing menus and therapeutic diets, meeting with patients and family for therapeutic diet counseling, providing periodic in-services to himself and dietary staff, and completed audits within the foodservice operation. NSM stated he was responsible for the day-to-day foodservice operations. NSM description of the full time RD role would satisfy the component of H & S Code 1265.4 that required "the dietetic services supervisor [the person delegated authority to be responsible for the day-to-day foodservice operation] shall receive frequently scheduled consultation from a qualified dietitian" and would meet CCR "70275 (a). A registered dietitian shall be employed on a full-time, part-time or consulting basis. Part-time or consultant services shall be provided on the premises at appropriate times on a regularly scheduled basis and of sufficient duration and frequency to provide continuing liaison with medical and nursing staffs, advice to the administrator, patient counseling, guidance to the supervisor and staff of the dietetic service, approval of all menus and participation in development or revision of dietetic policies and procedures and in planning and conducting in-service education programs." However, the interview verified the full time RD was not responsible for the operation of the food service, and therefor the hospital needed to have a full-time dietary services supervisor (role of NSM) to have met one of the educational pathways as listed in H & S Code 1265.4, as indicated in Title 22 "70275(b) If a registered dietitian is not employed full-time, a full-time person who meets the training requirements to be a dietetic services supervisor specified in section 1265.4(b) of the Health and Safety Code shall be employed to be responsible for the operation of the food service." NSM and CNO stated they did not have any further questions or any further information they wanted to submit to the survey team for review.

During a review of facility's job description (JD) for Nutrition Services Manager, the JD indicated, "Position Purpose: The Nutrition Services Manager plans, directs, and coordinates the activities of the Nutrition Services Department to provide nutritional services to patients ... The position establishes policies and procedures to provide administrative direction for cafeteria management, food preparation, distribution, service, budgeting, purchasing, sanitation standards, safety practices, staffing and staff development. In addition, the Manager may assist Dietitian with nutrition assessments if qualified. The Nutrition Services Manager creates an environment and culture that enables the hospital to fulfill its mission by providing patient safety and patient-centered treatment. . .License or Certification: CDM [Certified Dietary Manager] or Dietetic Technician registration with Academy of Nutrition and dietetics if required by State ...Current member of Academy of Nutrition and Dietetics if required by State or other regulatory agency."

During a review of facility's job description (JD) for Dietitian, the JD indicated, "Position Purpose: The Dietitian plans therapeutic diets and confers with patients, doctors, nursing staff and patient family members concerning these diets. The position monitors Nutrition Services provided to patients to ensure that standard of care are met in accordance with all associated regulatory agencies and the administrative policies of the hospital. The Dietitian instructs patients in diets for home use prior to discharge and as outpatients. The Dietitian monitors past and present nutritional status and makes recommendations to the health care team based on available data. To ensure the accuracy of food production as related to modified diets, the Dietitian acts in a supervisory capacity, as needed and performs other project assignments."

Based on interview and document review, the hospital failed to follow their job description for one of one Nutrition Service Manager (NSM) as evidenced by:
1. NSM did not have the required education.
2. NSM permitted potentially contaminated water to be used to wash kitchen wares (cookware, utensils and appliances for use in a kitchen).
3. NSM did not ensure a Sanitizer log was maintained for one of one 3 - compartment sink.
4. NSM did not orient or ensure competencies for One of one dietary staff (Nutrition Service Aide - NSA) 1.

These failures resulted in a lack of oversight of Dietary Services and had the potential to result in food borne illness to patients, staff, and visitors.

Findings:

1. During an interview on 6/7/24 at 10:38 a.m. with Nutrition Service Manager (NSM), NSM stated he managed the day-to-day operations in the kitchen. NSM stated he had a food handler certificate and nothing else.

During an interview on 6/7/24 at 11:48 a.m. with Director of Quality/Risk Management (DQRM), DQRM stated Dietary (Food & Nutrition Services) Director and Dietary Manager position titles were considered the same position and the Dietary Manager for the facility was the NSM.

During a review of NSM's Job Description (JD) Approval 2019, dated review period 01/01/2019 - 12/31/2019, the JD Approval indicated NSM signed the JD Approval on 5/3/2019. The JD Approval indicated under Job Description: "Maintains sanitation and proper temperature as well as correct food handling techniques in department to ensure compliance with all regulatory agencies ...Ensures that in-service education meetings are held and courses are completed as required by ...Meets position requirements and performs essential functions. Completes mandatory training and courses by completion date ...Maintains current licensure and/or certifications, if applicable."

During a review of facility's job JD for Nutrition Services Manager, the JD indicated, "Position Purpose: The Nutrition Services Manager plans, directs, and coordinates the activities of the Nutrition Services Department to provide nutritional services to patients. . .The position establishes policies and procedures to provide administrative direction for cafeteria management, food preparation, distribution, service, budgeting, purchasing, sanitation standards, safety practices, staffing and staff development ...The Nutrition Services Manager creates an environment and culture that enables the hospital to fulfill its mission by providing patient safety and patient-centered treatment. . .License or Certification: CDM [Certified Dietary Manager] or Dietetic Technician registration with Academy of Nutrition and dietetics if required by State ...Current member of Academy of Nutrition and Dietetics if required by State or other regulatory agency ..."

2. During a review of "City of [name] Water System. . . DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]" dated 6/4/24. The "Advisory" indicated, "City of [name] Water System customers. . . are advised to not drink nor use their tap water until further notice. . .Failure to follow this advisory could result in illness. . .oil from a private customer's property backflowed into the water distribution system. . .DO NO USE YOUR TAP WATER-USE ONLY BOTTLED WATER. Bottled water should be used for all drinking. . .brushing teeth, washing hands, washing dishes, making ice, and preparing food."

During an observation on 6/6/24 at 10:39 a.m. outside, by the entrance to the kitchen, a large white tank was approximately half full of liquid with an opening on top. The intake inlet opening was partially open to the environment. A red colored hose was curled up on top of the tank.

During an interview on 6/6/24 at 4:40 p.m. with DFO, DFO stated on 6/5/24 he observed the 500 gallon tank's inlet opening, which supplied water for the 3-compartment dish wash sinks with gray tape partially covering the water inlet opening. The opening exposed the water to potential contamination. DFO stated the opening in the water inlet was why the kitchen was shut down on 6/5/24 by the city.

During a concurrent observation and interview on 6/7/24 with Director of Facility Operations (DFO) and Infection Preventionist (IP), outside by the entrance to the kitchen, the white water tank did not indicate what it contained or if it was potable. IP stated there were no markings on the tank which indicated what it contained or if it was potable. IP stated the DFO obtained the tank for use in the kitchen. IP stated she visually inspected the tank when it arrived. DFO stated the tape used to partially cover the opening was not ideal and they did not have a way to monitor or secure the water tank to ensure contamination did not occur.

The facility was unable to provide documentation the red hose used to transfer water from the tank to other containers to the kitchen was food-grade.

During a review of the Food and Drug Administration Food Code 2022 (FDAFC), the FDAFC indicated many pathogens transmitted through food are also spread through water.

During a review of the FDAFC dated 2022, the FDAFC indicated the person in charge of the day to day foodservice operations is expected "to have knowledge to include identifying the source of water used and measures taken to ensure that it remains protected from contamination", as it relates to foodborne disease prevention. (FDA Food Code 2022; 2-102 Knowledge)

During a review of the FDAA dated 2022, the FDAA indicated, "Some tanks are designed with an access opening to facilitate the cleaning and servicing of the water tank. The access must be constructed to prevent the opening from becoming a source of contamination of the water." (FDA Food Code 2022 Annex,
5-302.12)

3. During an interview on 6/6/24 at 12:18 p.m. with Cook 1, Cook 1 stated on 6/5/24, he and Surveyor 1 observed NSA 1 place the quaternary ammonium test strip into the sanitizer and water solution in the third sink (of the 3-compartment sink) for 25-30 seconds which was an incorrect length of time. Cook 1 stated NSA 1 should have left the quaternary ammonium test strip in the sanitizer and water solution for 10 seconds not 25-30 seconds.

During an interview on 6/6/24 at 3:56 p.m. with NSA 1, NSA 1 stated on 6/5/24 he took a piece of a quaternary ammonium test strip and placed it in the third compartment of the 3-compartment dish wash sink which contained the sanitizer and water solution as Surveyor 1 observed. NSA 1 stated he held the quaternary ammonium test strip in the water and sanitizer solution for approximately 25-30 seconds until it turned blue. NSA 1 stated when the quaternary ammonium test strip turned blue the sanitizer solution was okay to use for the dishes.

During a review of "QT-10 HYDRION" container instructions, the instructions indicated, "for testing n-alkl dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride (sanitizer agents) IMMERSE FOR 10 SECONDS COMPARE WHEN WET."

During a review of the FDAFC, the FDAFC indicated a chemical sanitizer will not sanitize a dirty dish.

During a review of the FDAFC, dated 2022, the FDAFC indicated concentration of the sanitizing solution shall be accurately determined by using a test kit in accordance with the manufacturer's label.

4. During an interview on 6/6/24 at 4:41 p.m. with Nutrition Service Manager (NSM), NSM reviewed NSA 1's personnel file. NSM stated he was unable to provide documentation NSA 1 completed orientation to the dietary/kitchen department, had his competencies evaluated or had a ServSafe California Food Handler Certificate of Achievement (completed a food safety course).

Based on observation, interview, and record review the facility failed to ensure competent staff when:

1. One of one Nutrition Services Aide (NSA) 1 did not receive dietary department specific orientation or validated competencies. This failure resulted in NSA 1's incorrect process to verify sanitizer concentration in the pots and pans sink (sink three) which put patients at risk for food borne illnesses.

2. Two of three nutrition service staff (NSA 1 and Cook 2) did not obtain their ServSafe California Food Handler Certificate of Achievement (a food safety course). This failure put patients, staff, and visitors at risk for food borne illnesses.

Findings:

1. During an interview on 6/6/24 at 12:18 p.m. with Cook 1, Cook 1 stated on 6/5/24, he and Surveyor 1 observed NSA 1 place the quaternary ammonium (sanitizer) test strip into the sanitizer and water solution in the third sink for 25-30 seconds. Cook 1 stated NSA 1 should have left the quaternary ammonium test strip in the sanitizer and water solution for 10 seconds not 25-30 seconds. Cook 1 stated if sanitizer levels are not correct bacteria can remain on dishes.

During a concurrent interview and record review on 6/6/24 at 3:04 p.m. with Director of Human Resources (DHR), NSA 1's employee personnel record (EPR) undated, was reviewed. The EPR indicated, NSA 1 was hired as a Nutritional Service Aide on 3/14/23. DHR stated there was no record of NSA 1's nutrition services department orientation or unit specific competencies available. DHR stated NSA 1 should have received unit specific orientation and competency verification.

During an interview on 6/6/24 at 3:56 p.m. with NSA 1, NSA 1 stated on 6/5/24 he took a piece of a quaternary ammonium test strip and placed it in the third compartment of the 3-compartment sink which contained the sanitizer and water solution as Surveyor 1 observed. NSA 1 stated he held the quaternary ammonium test strip in the water and sanitizer solution for approximately 25-30 seconds until it turned blue. NSA 1 stated when the quaternary ammonium test strip turned blue the sanitizer solution was okay to use for the dishes.

During a review of "QT-10 HYDRION" container instructions. The instructions indicated, "for testing n-alkl dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride (sanitizer agents) IMMERSE FOR 10 SECONDS COMPARE WHEN WET."

During a review of Food and Drug Administration Food Code 2022 (FDAFC), the FDAFC indicated concentration of the sanitizing solution shall be accurately determined by using a test kit in accordance with the manufacturer's label.

2. During a concurrent interview and record review on 6/6/24 at 3:04 p.m. with DHR, NSA 1 and Cook 2's employee EPR undated, were reviewed. DHR stated there was no record of NSA 1's or Cook 2's ServSafe California Food Handler Certificate of Achievement.

During a review of the facility's policy and procedure (P&P) titled, "New Employee Orientation," dated 12/22/2023, the P&P indicated, "All new staff members will participate in a formal orientation program to learn the fundamental workings of the facility. The formal orientation program will consist of two phases: 1) General Orientation and, 2) Department Orientation. . .2. Department Orientation is the responsibility of the Department Director/Manager. . .Once completed a copy of the orientation checklist will be forwarded to the Human Resources Department to be placed in the individual employee file."

During a review of "JOB DESCRIPTION [JB]. . .Nutritional Service Aide,"undated," the "JB" indicated, "The Nutrition Services Aide assists in preparing. . .diets for patients as well as preparing meals for employees, visitors and special functions. The Nutrition Services Aide assists in maintaining inventory, serviceware and sanitary conditions within the department. . .Cleans and sanitizes all assigned areas. . .Completes mandatory training and courses required by completion date. . .POSITION REQUIREMENTS License or Certification: Food handlers permit. . .Machines, Equipment Used. . .dish washer. . .may be required to perform other duties as assigned by supervisor."

Based on interview and record review, the facility failed to ensure the fire suppression sprinkler system was safe and a fire watch was implemented when a do not drink and do not use advisory due to city water system contamination was in effect. This failure put the patients, staff, and visitors at risk for exposure to unsafe water in the event of an activation of the fire suppression sprinklers.

Findings:

During a review of "City of [name] Water System. . . DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]" dated 6/4/24. The "Advisory" indicated, "City of [name] Water System customers. . . are advised to not drink nor use their tap water until further notice. . .Failure to follow this advisory could result in illness. . .oil from a private customer's property backflowed into the water distribution system. . .DO NO USE YOUR TAP WATER-USE ONLY BOTTLED WATER. Bottled water should be used for all drinking. . .brushing teeth, washing hands, washing dishes, making ice, and preparing food."

During an interview on 6/6/24 at 9:40 a.m. with the Director of Facility Operations (DFO), DFO stated the facility did not request verification the fire suppression sprinkler system was safe to use during the do not use the city water system advisory the facility received on 6/4/24. DFO stated the fire suppression sprinkler system had a supply of water but once exhausted the city water would be used. DFO stated the water in the sprinkler system would only last about one hour, and then city water would be flowing into the sprinkler system. DFO stated the facility did not implement a fire watch when the city water system do not use advisory was received on 6/4/24.

Based on observation and interview, the facility failed to ensure one of one Infection Preventionist (IP) was qualified by education and training to monitor facility infection control practices during a "DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]" issued by the city on 6/4/24. This failure had the potential to expose staff, patients and visitors to hazards from contaminated water.

Findings:

a. During a review of "City of [name] Water System. . . DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]" dated 6/4/24. The "Advisory" indicated, "City of [name] Water System customers. . . are advised to not drink nor use their tap water until further notice. . .Failure to follow this advisory could result in illness. . .oil from a private customer's property back flowed into the water distribution system. . .DO NO USE YOUR TAP WATER-USE ONLY BOTTLED WATER. Bottled water should be used for all drinking. . .brushing teeth, washing hands, washing dishes, making ice, and preparing food."

During an observation on 6/6/24 at 10:39 a.m. outside, by the entrance to the kitchen, a large white tank was approximately half full of liquid with an opening on top. The intake opening was partially uncovered, and open to the environment. A red hose was coiled on the top of the tank.

During a concurrent observation and interview on 6/6/24 at 3 p.m. with Infection Preventionist, pictures of the water tank were reviewed. IP stated the kitchen staff used the water in the tank yesterday (6/5/24) to fill the 3-compartment sink in the kitchen to wash pots and pans. IP stated the partially covered opening on the water tank was a concern for infection control.

During a concurrent observation and interview on 6/7/24 at 10:50 a.m. with Director of Facility Operations (DFO) and IP, outside by the entrance to the kitchen, the white water tank did not indicate what it contained or if it was potable. IP stated the Director of Facilities (DFO) obtained the tank for use in the kitchen. IP stated she visually inspected the tank when it arrived and was aware of the tape partially covering the top. IP stated she was not involved in the water tank use. DFO stated the tape used to partially cover the opening was not ideal and they did not have a way to monitor or secure the water tank to ensure contamination did not occur.

The facility was unable to provide documentation of the red hose attached to the water tank was food grade as requested.

b. During an interview on 6/6/24 at 12:18 p.m. with Cook, Cook stated on 6/5/24, he and Surveyor 1 observed NSA 1 place the quaternary ammonium (sanitizer) test strip into the sanitizer and water solution in the third sink for 25-30 seconds. Cook stated NSA 1 should have left the quaternary ammonium test strip in the sanitizer and water solution for 10 seconds not 25-30 seconds. Cook stated if sanitizer levels are not correct bacteria can remain on dishes.

During an interview on 6/6/24 at 3:56 p.m. with NSA 1, NSA 1 stated on 6/5/24 he took a piece of a quaternary ammonium test strip and placed it in the third compartment of the 3-compartment sink which contained the sanitizer and water solution as Surveyor 1 observed. NSA 1 stated he held the quaternary ammonium test strip in the water and sanitizer solution for approximately 25-30 seconds until it turned blue. NSA 1 stated when the quaternary ammonium test strip turned blue the sanitizer solution was okay to use for the dishes.

During a review of "QT-10 HYDRION" container instructions. The instructions indicated, "for testing n-alkl dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride (sanitizer agents) IMMERSE FOR 10 SECONDS COMPARE WHEN WET."

c. During an interview with IP on 6/6/24, at 2:28 PM, IP stated she was a certified Critical Care Registered Nurse. IP stated in 2004 she took the position of Case Manager (ensure patient gets the care and equipment needed while in the facility and after discharge from the facility) and then transitioned into the infection preventionist/education role. IP stated she did not have formal training in IP but had some training from corporate and Regional Support. IP stated she attended quarterly meetings at the local Association for Professionals in Infection Control (APIC). IP stated her responsibilities included patients in isolation, provide references for staff, review cultures, tracking infections, monitoring staff hand hygiene practices

During a review of IP's Completed Training List covering 7/22/2022 through 5/27/24, IP's Completed Training List indicated the following training completed on:
8/29/2022 Quality Indicator Training - Nursing PT 1 & 2 (Live)
9/30/2022 2022 Annual Re-training - Clinical
10/25/2022 Education Plan Training for Hospital Leadership
12/8/2023 2023 Annual Re-training for Clinical Employees
4/3/2024 Job Description for Infection Preventionist/Hospital Educator
No training for Infection Prevention was indicated.

During a review of the Job Description for Infection Preventionist/Hospital Educator, undated, the Job Description indicated "The Infection Preventionist/Hospital Educator implements and manages the Infection Control Program... The Infection Preventionist acts on behalf of hospital leadership to prevent the spread of infections throughout the hospital. The Infection Preventionist has authority to implement and monitor compliance with all policies, procedures, protocols and other requirements relating to Infection Control and Prevention. The Medical Executive Committee authorizes the IP to take any actions necessary (within the limits of standard practice) to prevent the outbreak and spread of infection. In doing so the aid to the extent possible, the Infection Preventionist shall consult with...all federal, state and local health districts that may have jurisdiction...Responsibilities and Tasks...Conducts ongoing infection and infection risk surveillance and investigation activities...Performs environmental surveillance of all patient care areas and appropriate departments during safety/risk rounds in order to monitor compliance with infection control policies and procedures...Position Requirements...Minimum Qualifications...Experience in hospital infection control practice preferred. Training in infection control and epidemiology. Certification in Infection Prevention and Control (CIC, standardized measure of the basic knowledge, skills and abilities expected of professionals working in the field of infection prevention and control) preferred..."

During a review of the Certification Board of Infection Control and Epidemiology (CBIC), IP was not listed as having a CIC certificate.

Based on observation, interview, and record review, the facility failed to implement infection control practices when:

1. One of one portable 500 gallon water tank, which supplied water for the 3 - compartment dish wash system (due to an advisory to not use the city water) had an open water intake inlet at the top of the water tank.

2. Facility did not log the chemical concentration of Quaternary Ammonium (sanitizer) test strips used in one of one three (3)-compartment sink (sink used for sanitizing clean cooking utensils, pots and pans) for April 2024, May 2024, June 1st, June 2nd, and June 3rd, 2024.

3. One of one dietary staff (Nutrition Service Aide - NSA) 1 did not test the chemical concentration in the pots and pans sink per Quaternary Ammonium test strip directions.

These failures had the potential to place patients at risk for food borne illnesses.

Findings:

1. During a review of "City of [name] Water System. . . DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]" dated 6/4/24. The "Advisory" indicated, "City of [name] Water System customers. . . are advised to not drink nor use their tap water until further notice. . .Failure to follow this advisory could result in illness. . .oil from a private customer's property backflowed into the water distribution system. . .DO NO USE YOUR TAP WATER-USE ONLY BOTTLED WATER. Bottled water should be used for all drinking. . .brushing teeth, washing hands, washing dishes, making ice, and preparing food."

During an observation on 6/6/24 at 10:39 a.m. outside, by the entrance to the kitchen, a large white tank was approximately half full of liquid with an opening on top. The intake inlet opening was two thirds covered with gray tape and one third uncovered and open to the environment. The tank did not indicate what the liquid was or the intended use. There was a red colored hose attached to the tank curled up on top.

During a concurrent observation and interview on 6/6/24 at 3 p.m. with Infection Preventionist (IP), pictures of the water tank were reviewed. IP stated the water in the tank was being used yesterday (6/5/24) to fill the 3-compartment sink in the kitchen to wash pots and pans. IP stated the partially covered opening on the water tank was a concern for infection control.

During an interview on 6/6/24 at 4:40 p.m. with DFO, DFO stated on 6/5/24 he observed the 500 gallon water tank's inlet opening, which supplied water for the 3-compartment dish wash sinks with gray tape partially covering the water inlet opening. The opening exposed the water to potential contamination. DFO stated the opening in the water inlet was why the kitchen was shut down on 6/5/24 by the city.

During a concurrent observation and interview on 6/7/24 with Director of Facility Operations (DFO) and IP, outside by the entrance to the kitchen, the white water tank did not indicate what it contained or if it was potable. IP stated there were no markings on the tank which indicated what it contained or if it was potable. IP stated the DFO obtained the tank for use in the kitchen. IP stated she visually inspected the tank when it arrived and was aware of the tape covering the top but was not involved in its use. DFO stated the tape used to partially cover the opening was not ideal and they did not have a way to monitor or secure the water tank to ensure contamination did not occur.

The facility was unable to provide documentation the red hose used to transfer water from the tank to other containers to the kitchen was food-grade.


39650


During a review of the Food and Drug Administration Food Code 2022 (FDAFC), the FDAFC indicated many pathogens transmitted through food are also spread through water. In addition, a chemical sanitizer will not sanitize a dirty dish.

During a review of the FDA Food Code Annex 2022 (FDAA), the FDAA indicated, "Effective sanitization procedures destroy organisms of public health importance that may be present on wiping cloths, food equipment, or utensils after cleaning, or which have been introduced into the rinse solution. It is important that surfaces be clean before being sanitized to allow the sanitizer to achieve its maximum benefit." (FDA Food Code 2022 Annex; 4-701.10)

During a review of the FDAFC dated 2022, the FDAFC indicated the person in charge of the day to day foodservice operations is expected "to have knowledge to include identifying the source of water used and measures taken to ensure that it remains protected from contamination", as it relates to foodborne disease prevention. (FDA Food Code 2022; 2-102 Knowledge)

During a review of the FDAA dated 2022, the FDAA indicated, "Some tanks are designed with an access opening to facilitate the cleaning and servicing of the water tank. The access must be constructed to prevent the opening from becoming a source of contamination of the water." (FDA Food Code 2022 Annex,
5-302.12)

2. During a concurrent interview and record review on 6/6/24 at 12:18 p.m. with Cook, the QUATERNARY AMMONIUM [sanitizer] LOG [quat log]" for the 3-compartment sink (wash, rinse, sanitize), dated June 2024 was reviewed. The "quat log" indicated " INSTRUCTIONS: Test the concentration of the ammonium in the quaternary sanitizer using the proper strips. . .Ammonium reading should be at least 150-200 ppm (parts per million - unit of measure). . .or manufactures recommendation. Keep log on file in the Dietary Department for one year." Documented on June 4 and June 5 the test strip read 400 (ppm). No other tests results were documented. Cook was unable to provide quat logs for the 3-compartment sink for the months of April 2024 or May 2024. Cook stated the quat levels should be tested in the 3rd compartment of the 3-compartment sink each time they were filled. Cook stated the 3-compartment dish wash sink water and sanitizing solution was changed three times a day (breakfast, lunch, and dinner) prior to advisory to not use the city water issued on 6/4/24.

During a review of the FDAFC, dated 2022, the FDAFC indicated the person in charge of the day to day foodservice operations should ensure that employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of sanitizing solution chemical concentration. (FDA Food Code 2022, 2-103.11 Person in Charge)

3. During an interview on 6/6/24 at 12:18 p.m. with Cook 1, Cook 1 stated on 6/5/24, he and Surveyor 1 observed NSA 1 place the quaternary ammonium test strip into the sanitizer and water solution in the third sink (of the 3-compartment sink) for 25-30 seconds which was an incorrect length of time. Cook 1 stated NSA 1 should have left the quaternary ammonium test strip in the sanitizer and water solution for 10 seconds not 25-30 seconds.

During a review of "QT-10 HYDRION" container instructions, the instructions indicated, "for testing n-alkl dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride (sanitizer agents) IMMERSE FOR 10 SECONDS COMPARE WHEN WET."

During an interview on 6/6/24 at 3:56 p.m. with NSA 1, NSA 1 stated on 6/5/24 he took a piece of a quaternary ammonium test strip and placed it in the third compartment of the 3-compartment dish wash sink which contained the sanitizer and water solution as Surveyor 1 observed. NSA 1 stated he held the quaternary ammonium test strip in the water and sanitizer solution for approximately 25-30 seconds until it turned blue. NSA 1 stated when the quaternary ammonium test strip turned blue the sanitizer solution was okay to use for the dishes.

During a review of the FDAFC, dated 2022, the FDAFC indicated concentration of the sanitizing solution shall be accurately determined by using a test kit in accordance with the manufacturer's label.

During an interview on 6/6/24 at 4:41 p.m. with Nutrition Service Manager (NSM), NSM stated he was unable to provide documentation NSA 1 completed orientation to the dietary/kitchen department, had his competencies evaluated or had a ServSafe California Food Handler Certificate of Achievement (completed a food safety course).

During a review of the facility's policy and procedure (P&P) titled, "Infection Control Plan," dated 3/29/24, the P&P indicated, "Vision To promote disease prevention and the reduction of Hospital-Acquired Infections through the implementation of Infection Prevention and Control principles and practices. Mission Ensure safety, health and welfare for all customers, visitors and staff in an economically sound, effective manner. . . Integration of Infection Control and Prevention: Departmental Specific Involvement . . . 3. Dietary: A. Maintaining a controlled environment for safe aseptic preparation and serving of food for patients and staff by using Standard Precautions and policies."