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Based on observations, record review, and interviews, the hospital failed to ensure its Quality Assurance program took actions aimed at performance improvement and monitored to ensure improvements were accomplished and maintained in problems identified in the Food and Dietetic Services. This deficient practice was evidenced by problems identified in food and dietary services, provided by Contractor "A" in the hospital's onsite kitchen, with no corrective actions developed, implemented and monitored for improvement.

Findings:

Review of patient grievances from 01/2020 through 07/2020, related to dietary services, revealed 10 of 11 grievances related to dietary services involved food being served cold that should have been served hot. Grievances also included complaints of raw food (chicken), small portions, and the menus not varied. Further review of the grievance responses revealed acknowledgment of receipt of the complaints, and indications that careful attention was given to the issues stated. Additional review of the response letters revealed the food production manager had corrective actions in place, to include assurances that food would be served within acceptable ranges at safe temperatures. The letter further noted that the reader should expect to see improvement in the meal service provision.


Review of kitchen inspection reports by hospital dieticians in the Nutritional Services revealed, in part, the following:

04/29/2020- "No" to the following indicators: Endpoint/serving line temperatures are recorded; log available, food is protected from cross contamination during tray prep, refrigerators cleaned and organized; prevent contamination, Tray verification acknowledged by Kitchen Supervisor (signature).

General comments noted by the staff dietician inspecting included, "temps taken after prompted; log not easily assessable by staff or they didn't attempt to locate it, opened/empty juice containers were on the shelves with deli meat that wasn't wrapped.
05/06/2020- "No" to the following indicators: refrigerators cleaned and organized; prevent contamination. Under cleaning and sanitation: Chlorine (50-100ppm); records maintained and available and Quat (200-400ppm) [in reference to 3-part sink]; records maintained and available were checked as N/A [the kitchen uses a 3-part sink].

General comments were noted as, "Special trays prepared and sitting on counter upon arrival (12+ trays) possibly waiting on verification and signature."

05/20/2020- "No" answered to these indicators: Food is protected from cross contamination during tray prep, Chlorine (50-100ppm); records maintained and available, Quat (200-400ppm); records maintained and available.

General comments: "Tray prep still needs some improvement- some food spilled into other trays/pans ...All refrigeration and sanitation, temps not always individually recorded."

06/24/2020- "No" to these indicators: End point/serving line temperatures are recorded; log available, Sample trays prepared and dated; Wiping cloths are stored in sanitizing solution between uses, Chlorine (50-100ppm); records maintained and available, Quat (200-400ppm); records maintained and available, tray verification acknowledged by Kitchen Supervisor(signature).
General comments: "Hot box/Warmer showing 145 degrees F, Test Tray: Oatmeal- 118.5 degrees F, Chopped ham and gravey-112.2 degrees F, Eggs 103.6 F." [Food temps not within acceptable range]

07/08/2020-"No" to the following indicators: End point/serving line temperatures are recorded; log available, Sample trays prepared and dated, Wiping cloths are stored in sanitizing solution between uses, Food contact surfaces clean to sight and touch, refrigerators cleaned and organized; prevent contamination ("sneeze guards filthy pictures taken, most foods not wrapped properly in pans"), food contact surfaces clean to sight and touch, refrigerators cleaned and organized; prevent contamination, Chlorine (50-100ppm); records maintained and available, Quat (200-400ppm); records maintained and available, tray verification acknowledged by Kitchen Supervisor(signature).

Written comments included, "Regular trays: meal didn't match menu, noted some patients didn't receive ration of kcals (two ½ c scoops for grits= 1 cup, only got ½ cup serving), Wrapped trays not in warmer; ...Floor is so dirty/sticky my shoes squeaked all the way back to my office. Pictures of refrigerator/cooler taken-completely out of compliance. Also note: gumbo from day prior looks completely unappealing- filled with imitation crab meat."

07/14/2020- "No" to the following: ABHR available for serving line staff ("varies by line, using the pt.'s wall unit"), End point/serving line temperatures are recorded; log available, food is protected from cross contamination during tray prep ("also varies by line"), sample trays prepared and dated ("sneeze guards need to be cleaned; throwing trash on floor during tray prep to be cleaned after meal service"), wiping cloths are stored in sanitizing solution between uses, work surfaces are cleaned and sanitized between uses, Chlorine (50-100ppm); records maintained and available, Quat (200-400ppm); records maintained and available.

A written note for last section of inspection noted, "Did not get to complete observation as we were working the lines and preparing the trays for delivery."

General comments were noted as, "Yesterday we helped deliver meals to the units. The food processor stopped working and texture modified meals weren't ready until 3:00 p.m. Today we literally worked the serving lines after (Contractor "A") staff threatened to go on strike. While assisting them it was apparent that many of them need additional training. * Tickets [meal tickets] not referenced often; * Don't all know appropriate food group substitutions-provided extra roll and didn't see need to give additional vegetables as outlined on the ticket; ** Also realized for additional Kcal diets (and some regular menu items) adequate portions will not fit in Styrofoam box. * Some food items were prepared randomly- if a patient needed a different vegetable than the rest of the ward, - delayed delivery of meals for the unit, * When accurate portions are served the lines ran out of menu items before all trays prepared, *some servers drag scoop/spoon of good across the whole serving line while fixing frays lined on the top (definitely cross contaminating as food/liquid spills into other wells/pans; *had to prompt them to get deli paper in an effort to not put bread and cookie (and meal ticket) directly on entrée'-chicken pot pie; * said they often have limited supply."


Review of emails between S1CEO and Contractor "A", provided by S1CEO, revealed an email dated 02/24/2020 which noted the attached corrective actions of Contractor "A" did not appear to be any different from what the contractor was doing at that time. The email further noted that the corrective action plan was not accepted by ELMHS.


Review of a corrective action plan from Contractor "A" revealed a plan to resolve problems and issues, with the status of proposed corrective actions as of 02/28/2020, and through 08/10/2020 that included, in part, areas of cleanliness/sanitation, accuracy of diet, and hot holding equipment on the delivery vehicles not adequate to hold temps. At the time of survey, 08/12/2020-08/14/2020, observations were made of unsanitary food storage, kitchen, food prep areas, and transportation vehicles, and no hot or cold holding equipment used in transportation of patient food from the kitchen to other patient locations.


Review of Quality Council meeting minutes for 2019, provided by S5QAPI, revealed in part that the following notations:

04/11/2019- under PI reports, "12) Private provider for food services: Raw chicken issue ongoing"

06/27/2019- 12) Raw chicken issue ongoing


Review of Quality Council/Utilization Review Meeting minutes, dated January 23, 2020 and provided by S5QAPI as the only formal meeting of the Quality Council for 2020, revealed the note, "new charter with monitoring plan for Nutritional Services." Further review revealed a proposed PI pan titled, "Modified Textured Diet Meal Delivery Process" which would collect and analyze data related to preparation, temps, and delivery of Modified Texture Diets (modified trays). Further review of quality meeting minutes revealed no other PI projects or problems identified or addressed related to food and dietary services.


In an interview on 08/13/2020 at 10:00 a.m. S4Dietary confirmed she was the hospital's Dietary Manager and was responsible for the Nutritional Services for the hospital. The dietician reported that Contractor "A" ordered, prepared, and delivered food to patients at all locations of the hospital (separate buildings). She reported that the hospital's staff of dieticians help monitor the contracted meal company's services. When surveyor observations of the kitchen, food service, and food transportation were discussed with S4Dietary, she confirmed the sanitary conditions, food safety concerns, correct food and diets served to the patients, transportation of the food, and dietary staff practices had been ongoing problems.

Patient grievances submitted throughout this year (2020), related to cold food served which should have been hot, undercooked food, and portion sizes too small, were reviewed. S4Dietary confirmed the only action to correct these identified problems was the contracted company's submitted corrective action plan from the beginning of the year. She further confirmed that plan was not implemented as described, as evidenced by continued patient complaints and kitchen monitoring by the hospital's dietary staff. When asked if the hospital had put anything into place to correct the problems of services provided for and to their patients, S4Dietary reported they had ongoing email correspondence with the company throughout the year, but confirmed no other actions had been addressed in the hospital's quality program.

S4Dietary confirmed the hospital had not documented identified food and dietary service problems, developed any plan of action, or acted to resolve the food and dietary problems in their quality program.

Based on record review, observation, and interview, the hospital failed to meet the Condition of Participation for Food and Dietetic Services as evidenced by:

Failure to ensure the supervisor of food and dietetic services ensured the daily management of the contracted dietary services, provided onsite in the hospital's kitchen and food service area, was provided according to policies and procedures and FDA guidelines. This deficient practice was evidenced by:

a) failure to ensure food storage, kitchen, preparation areas, and practices were implemented and maintained to ensure the quality and safety of food provided to patients;

b) failure to ensure the 3-compartment sink was being tested to ensure temperatures and disinfecting liquids were within acceptable range; and

c) failure to ensure food was monitored to ensure proper food temperatures and sanitary conditions were maintained from preparation, through transportation, to delivery to the patients.

(see findings at A-0620)

Based on observations, record reviews, and interviews, the hospital failed to ensure the supervisor of food and dietetic services ensured the daily management of the contracted dietary services, provided onsite in the hospital's kitchen and food service area, was provided according to policies and procedures and FDA guidelines. This deficient practice was evidenced by:

1) failure to ensure food storage, kitchen, preparation areas, and practices were implemented and maintained to ensure the quality and safety of food provided to patients;

2) failure to ensure the 3-compartment sink was being tested to ensure temperatures and disinfecting liquids were within acceptable range; and

3) failure to ensure food was monitored to ensure proper food temperatures and sanitary conditions were maintained from preparation, through transportation, to delivery to the patients.


Findings:

Review of the hospital's contract with Contractor "A" revealed the food and dietary services would be provided by Contractor "A" within the hospital's kitchen and dietary facility onsite. Further review revealed Contractor "A" would be responsible, in part, for the procurement, correct storage, preparation, labeling, and transport of food, including providing dietary meals, snacks, and supplements to hospital patients.


Review of the contracted food company's policy and procedures, provided as dietary polices adopted by the hospital, revealed the following, in part:

Section 1.3 Monitoring and Recording: Food: Team members must monitor and record food temperatures to prevent foodborne illness.

For hot foods: if the temperature is found to be below 135 degrees F but the previous temperature taken within the last 2 hours was above 135 degrees F, then reheat the food to 165 degrees F for 15 seconds using an appropriate heating method. If the temperature was below 135 degrees F for more than 2 hours, or for an unknown amount of time, then discard food.
For cold foods: if the temperature is found to be above 41 degrees F but the previous temperature taken within the last 2 hours was below 41 degrees F, then rapidly chill the food using an appropriate cooling method. If the temperature was above 41 degrees F for more than 2 hours, or for an unknown amount of time, or if it reaches 71 degrees F for any amount of time, then discard food.


Section 3.4 Storing Food and Equipment: Team members must store food in a manner that ensures quality, freshness, and safeguards against foodborne illness. Food temperatures: Monitor temperatures for TCS food- food requiring time and temperature control for safety based on the type of food: Store TCS food at a temperature of 41 degrees F or below.
Store items away from walls and at least 6 inches off of the floor.

Container: Cover, label and date all leftovers. Clean cover and label food bins.

Scoops may be used for flour, sugar, cereal, and other grain products. Store scoops in a covered area next to the container and not in food containers.


Sanitize: Keep all storage areas clean and dry; Clean floors, walls, and shelving in refrigerators, freezers, dry storage area, and heated holding cabinets on a regular basis; Clean up spills and leaks promptly;
Clean dollies, carts, transporters, and trays often; and Keep refrigerator and freezer coils and fans free of dust, mold, frost, and condensation.

Section 3.5 Labeling: Ensure all items are properly labeled. Procedure: Items to label: Ensure all food items are labeled. Be especially cautious to label all food items that are: not kept in original containers, including condiments (salad dressing, ketchup, etcetera). TCS food (food requiring time and temperature control for safety) prepared onsite.

Label information: Each label must contain the following information: product name/identifying description, use by date, date the product was prepared or opened, time prepared and team member initials where applicable, date frozen, if applicable, date thawed if applicable.


Section 4.2: TCS Food: Temperature: when preparing TCS food, team members must protect food from cross contamination and/or time/ temperature abuse. Temperature: Take 2 internal temperatures in different areas of each TCS food at various stages of preparation.

Holding TCS foods: Hold TCS foods at the correct temperature: 41 degrees F or below for cold foods and 135 degrees F or above for hot foods. Foods cannot be in the danger zone (between 41 degrees F and 135 degrees F) for more than 4 hours.


Section 7.1 Cleaning and Sanitizing: All food service departments must have an effective cleaning program that includes a cleaning schedule.


Section 7.3 Cleaning and Sanitizing: Team members must maintain the food service operation in a clean and sanitary manner. Procedure: Sanitize: Clean surfaces: non-contact surfaces must be cleaned and rinsed including walls, floors, storage shelves, equipment exteriors, and garbage containers as necessary.

Food contact surfaces: Must be cleaned rinsed and sanitized for example; knives, cutting boards, pots and pan, prep tables, and other equipment that touches food. When: after use, before working with a different type of food, anytime a food handler s interrupted during a task and the equipment items may have been contaminated, after 4 hours if in constant use.


Section 7.5: General equipment cleaning and sanitizing: follow these steps for cleaning and sanitizing stationary equipment: scrape food from the equipment surfaces. Wash surfaces using a cleaning solution prepared with an approved cleaner.


Review of the FDA Food Code guidelines revealed the following, in part:

Dry Storage Area: the dry storage area should be adjacent to the food preparation area. Adequate ventilation must be provided. Temperatures between 50 degrees Fahrenheit and 70 degrees Fahrenheit are recommended. All food storage should be 6 inches above the floor. Approved food containers with tight fitting covers and dollies should be used for storing bulk foods such a flour, cornmeal, sugar, dried beans, rice and similar foods. Scoops are needed for each food storage container in use.


Equipment/utensil storage: cleaned equipment and utensils shall be stored in a clean, dry location where they are not exposed to splash, dust, or other contamination.


Handwashing facilities: handwashing sinks shall be located within 25 feet of a work station. Splashguard protection is suggested if adequate spacing to adjoining food, food prep, food contact surfaces and utensil washing area surfaces (drain boards) is insufficient. Splash from a hand wash sink may not contaminate food, equipment, or utensils. A baffle or barrier may be needed if the hand sink abuts a food preparation or service surface.


1) Failure to ensure food storage, kitchen, preparation areas practices were maintained to ensure the quality and safety of food:

On 08/12/2020 from 1:30 p.m. - 3:00 p.m. observations were conducted in the hospital's kitchen area, accompanied by S5QAPI, S14Administration, S6ContDietaryMgt, and S12ContDietary. The following breaches in food quality and safety were observed:


Dry Storage Room:

*A fabric "scrub" top, wadded up and lying on the floor upon entry into the dry storage room to the right.


Metal shelving units where dry food was stored revealed the following:

* 2 - open boxes of grits noted, one not covered with no date of opening and one covered with saran wrap with no date of opening on the box.

*Loose grits were observed on 3 shelves of the metal shelving unit and grits were also observed on the tops of the soup cans on another shelf.

*Opened gravy mix package wrapped with clear plastic wrap with no date of opening

*Opened plastic bag wrapped, with a yellowish flour like substance observed. There was no label identifying the substance and no date indicating when it was opened. S6ContDietaryMgt, present during the observation, indicated the bag contained gravy mix.

* 32-ounce bag of walnuts, wrapped with clear plastic wrap, opened, and not dated.

*One gallon of Apple Cider Vinegar, opened, with no date of opening on the container.

*13-ounce container of Gumbo filet, ¾ of contents used, opened and not labeled with date of opening.

*7-ounce container of Dill weed, opened, with no cap and no date of opening.

*20-ounce container of chili powder opened, no date of opening on container.

*20-ounce container of Smoked Bittersweet Paprika, ¾ of contents used, opened and not labeled with date of opening.

*18- ounces of Ground Cinnamon, ½ of contents used, opened and not labeled with date of opening.

Air conditioner mounted in the wall of the dry storage room, opposite of the entry door, and with food storage shelves to either immediate side, was noted to being on and running, with a thick layer of dark grayish brown dust on all intake and output vents, as well as on the bottom intake vent. This AC unit was noted to be between food storage shelving. the air temperature was measured as 83 degrees F by maintenance at the time of the observation.

* numerous plastic jars of spices opened, with no labeling as to date opened, and snap top plastic tops were unable to be closed due to spices clogging the tops, leaving them partially open.

* 2 large plastic containers of rice, identified as 100 pound containers by S6ContDietaryMgt, sitting directly on floor with no evidence of a scoop to use for rice removal; S6ContDietaryMgt, reported she did not know what process was used to remove the rice from the large containers, but verified there were no implements observed for that purpose.

*2 -35 lb. cardboard containers labeled as soybean oil, unopened, lying on their side, were noted on the bottom shelf of a large metal shelving unit. Both boxes were observed to be darkened on the bottom portion of the boxes, indicating a leak within the box. Further observation revealed a clear, thick liquid pooling and standing on the floor next to the boxes under an inverted plastic milk crate. The shelves appeared to be slightly leaning away from the wall. (During an interview 08/13/2020 at 1:25 p.m. S7ContDietaryMgt with Contractor "A" confirmed the inverted milk crate was supporting the shelving unit, and reported that a new shelving unit was needed.)

*Large areas of plaster were noted missing from the walls in several areas, with peeling paint at the edges of the holes, making the walls unable to be cleaned and disinfected adequately.

* No PPE or hand sanitizer observed in the dry storage area.


Vestibule area between the dry storage area, kitchen entry and walk in cooler entry:

*Large industrial sized orange fan observed covered in a thick coating of dust, blowing into the vestibule area where pans/pots and cooking utensils were stored on shelving units.

*2-wheeled metal transport carts observed to have large dented areas on the top shelf that were sloping to the center with sharp metal edges at a cut area in the top shelf- unable to be properly disinfected (later observed to be used for transporting food pans for delivery to units).

*Food crumbs and food residue noted on 3 of 3 carts located next to shelves containing clean cook ware and cooking utensils;

* 3 mobile warming cabinets, empty of food at the time of observation were observed to have dark brown build up, in a run pattern, like old oil or grease that baked on the glass fronts and interiors. 1 of the 3 upright mobile warming cabinets had a thin white sheet of plastic adhered to one outer side, with grime and debris noted, especially at peeling edges, with some of the plastic sheet shredded and peeling off in strips.


Walk in cooler:

*Tile floor in the cooler was observed to have dirt and orange stains on the surface.

*Large container of boiled eggs, stored in water and citric acid solution, not sealed/opened to air and able to see contents of container, not dated with opening date.

*Block of butter opened on shelf, not covered and not labeled with date of opening.

*Partially used block of processed cheese product opened, wrapped with clear plastic wrap, approximately ½ of block used, no date of opening noted.

*Plastic milk crates stacked on top of each, directly on floor, not elevated 6 inches off of floor.

*Puddles of white, milk -like substance noted on floor of cooler near the milk storage area.

*Vents on 5 air circulators in the walk in cooler covered with dust.

*Large pan of 30 uncooked cinnamon rolls, on rack in cooler, uncovered and located where dusty air vents were blowing (risk of dust from air vents landing on them/contamination).

*3 large uninsulated plastic tubs with cracked sides and no covers filled with Styrofoam boxes and 1 cardboard box of Styrofoam boxes, observed to be sandwich meals (cold cuts, cheese, and condiment packets), were noted to be stacked on top of each other in the walk in cooler. No labeling or dates of preparation were noted on the boxed meals and they were not sealed to prevent opening in transit, only closed with the tab on the box. Openings between the edges of the Styrofoam boxes of food were observed, leaving the meals vulnerable to possible contamination/inability to maintain safe temperatures for cold foods. S6ContDietaryMgt for the hospital's contracted meal service, present during the observation, reported the sandwich box meals were prepared as alternate meals in the kitchen at Facility "A" (4 miles away) and transported to this cooler for distribution to the patient units.

*A metal beam across the center of the cooler was observed to be rusted with droplets of condensation noted to be collected on the beam. The condensation was observed to be dripping on the Styrofoam boxes of sandwiches. Some of the boxes were not completely sealed and were observed to have cracks between the edges/openings.


Walk in freezer:

*Opened pack of frozen biscuits, unwrapped and no label as to when they were opened.

*large pan of pork chops covered with clear plastic wrap with a notation that read, "use by 08/09/2020".

S6ContDietaryMgt, present with surveyor, confirmed the observation and acknowledged today's date was 4 days past the documented "use by" date.

*Base tiles on either side of freezer door, to the inside of the freezer were cracked and pulled away from the wall, making it unable to be cleaned and disinfected adequately.


Kitchen Food prep area:

*2 large grease vats, filled with grease, noted to have with baskets for frying food in them. S6ContDietaryMgt, present during the observation, was asked how often the grease in the fryers was changed and she indicated she was not sure, it depended on how often food was fried. She was not sure exactly when the grease had last been changed but thought it was changed approximately a week ago. She indicated she did not have documentation of when they were cleaned or the grease was changed.

* Puddles of grease noted under the fryers.

* Brownish-black grease residue noted on warming ovens. A strip of clear plastic food wrap was observed tied around the handles of one warming oven. S6ContDietaryMgt reported it was broken and not being used. She verified no signage was attached to the equipment to indicate it was out of order.

*Hood over large tilt skillets was noted to have strips of disintegrating gray electrical tape (adhesive residue and strings of the tape - 4 feet in length) dangling above the tilt skillet. Staff was observed removing pasta from the tilt skillet, located directly below the adhesive tape remnant strings and air current was observed blowing the strings - potential for contaminating the pasta if blown into food.

* Upright food warmer observed to have a groove at the bottom that had food crumbs collected and crusted in it.

* Warmer was observed to have dark areas of baked on liquid in run patterns on the front and sides of the warmer.

* A large steel wool type scrub pad was noted in the window sill above the right of the 3 compartment sink.

* The window sill, air conditioning unit, the clear thick plastic taped between the side of the air conditioner and window sill, and window itself were noted to be very dirty with debris, spots of off-white, light brown, and grayish substances. The piece of plastic installed to enclose the area between the window sill and the side of the air conditioner was noted to be pushed out at the bottom corner closest to the air conditioning unit, with an opening to the outside approximately 6 inches wide. The air conditioner was observed to have a thick coat of dust on the unit and the air intake and output vents.

*The paper towel holder mounted on the wall next to the only handwashing sink was empty, with a paper wrapped package of folded paper towels sitting on the food prep table next to the sink, unprotected from splash contamination from the sink. S7ContDietaryMgt confirmed and reported they had been unable to get the correct paper towels for the dispenser for a couple of weeks. She confirmed that the paper towels sitting open on the counter were not protected from contamination.

*Walls in food cooking and prep area were dirty, with splatters of substances on them.

*large multi-burner stove was noted to have areas of crumbs, old thickened cooked on grease; S6ContDietaryMgrt confirmed and reported the stove should be cleaned daily.

*Two upright rolling food tray racks were noted to have thick substances in spill patterns, crumbs in the side rails to hold the food trays, and one had a very thick dried substance around a side rail approximately 1 inch by ¾ inch.

*Hole in side wall of large open doorway between kitchen and serving area, with missing plaster approximately 7 inches by 3 ½ inches, with metal rod exposed inside the wall, then on the same corner of the wall an area about 6 inches by 3 inches of missing plaster, presenting an area that could not be cleaned and disinfected appropriately.


All of the above referenced observations in the hospital's kitchen, dry storage areas, walk in cooler, and food prep/serving lines/dining rooms were verified by S5QAPI, S6ContDietaryMgt, and S7ContDietaryMgt, who were present with the surveyor during the observations.


An observation on 08/13/2020 at 1:00 p.m. in dietary services area with S1CEO, S18EOC, and S7ContDietaryMgt, revealed 20 contracted employees working on cleaning dry storage area, kitchen, and hot food line/serving area. Further observation revealed the prep table next to handwashing sink (approximately 3-4 inches between sink and prep table, with no barrier between the two) contained 3 large bags of grated yellow cheese with one opened bag of grated cheese immediately next to handwashing sink. A paper towel holder was observed mounted on the wall to the left of the sink directly over bags of cheese, including the opened one (could be contaminated with water dripping when reaching over food for paper towels). S7ContDietaryMgt verified this food was potentially contaminated by any handwashing that may have been done while it was open on the table. She further verified this is the only handwashing sink in the kitchen/food department. The contracted dietary supervisor confirmed the only other installed ABHR dispenser was in the dining area.



2) Failure to ensure the 3-compartment sink was being tested to ensure temperatures and disinfecting liquids were within acceptable range.

Review of the contracted food company's policy and procedures, reported by S1CEO as adopted by the hospital revealed the following, in part: Section 7.7 Three Compartment Sink: Set up sink preparation using the following guidelines: Sink one: Fill 1st sink with detergent and water which is maintained at 110 degrees F. Sink 2: with clean, warm water. Sink 3: fill the 3rd sink with water and sanitizer to the correct concentration per manufacturer's recommendations - Contact time: Chlorine greater than or equal to 7 seconds and iodine & Quats greater than or equal to 30 seconds.

Post signage for the amount of time the equipment should be in the water and the correct sanitizing solution concentration. Provide a clock with a second hand for team members to know how long items have been in sanitizer.

Record: Check and record wash temperature and final rinse on the 3 compartment sink temperature log prior to doing dishes. Maintain records for at least one year.


An observation on 08/12/2020 at 2:35 p.m. was made of a 3 compartment sink in the kitchen. The first compartment had soapy water in it, the second compartment had clear water in it, and the 3rd compartment was empty. The sink was observed to be connected to a commercial dispensing mechanism for disinfecting liquids. Nothing was being washed at the time of observation. A small plastic dispenser containing of a roll of thin colored paper was observed in the window sill above the sink. No thermometer for checking the temperature of the wash water was observed.


In an interview on 08/12/2020 at 2:35 p.m. S8ContDietary reported he was assigned to dishwashing that day. He reported the kitchen did not have an automatic dishwasher, and that the 3 compartment sink was used. He explained that his process was to put hot soapy water in the first sink, clean rinse water in the 2nd sink and use the dispensing mechanism to dispense the disinfectant in the 3rd sink. The dietary aide was asked if he checked the temperature of the water and the strength or quality of the disinfectant in the 3rd sink. He responded that sometimes he does. He reported he thinks the last time he checked was maybe last week. He reported he did not always log the results. When asked to review the log for the quality indicators for the 3 compartment sink, he said he was not sure where it was, but it should be in a drawer near the sink. No log was located in the sink, and he was not able to locate one.


In an interview on 08/13/2020 at 8:40 a.m. S7ContDietaryMgt reported that they could not provide a log for the 3 compartment sink, and that those quality checks had not been done. She confirmed she could not provide any log for the 3 compartment sink



3) Failure to ensure food was monitored to ensure proper food temperatures and sanitary conditions were maintained from preparation, through transportation, to delivery to the patients.

Review of the contracted food company's policy and procedures, provided to surveyors as dietary policies adopted by the hospital, revealed the following, in part:

Food Safety: Reheat/Re-cool. Continue heating or chilling food if the proper temperature is not reached. If the internal temperature of hot food cools to below 135°F, then upon delivery reheat the food to 165°F for 15 seconds using a proper heating procedure. If the internal temperature of cold food warms above 41°F, then upon delivery cool it to 41°F or below using a proper cooling procedure. Discard foods held in the danger zone (between 41°F to 135°F) for more than four hours.

Sanitize: Ensure offsite transportation equipment (examples: heat keepers, insulated food containers, ice chests) is cleaned and sanitized and in good repair. Regularly clean the inside of the delivery vehicles.

Section 5.5: Delivering Offsite: Team members must transport (or ensure food is transported) in a manner that maintains its quality and safety.

Procedure: Temperature: Use appropriate containers and/or equipment to hold food at the correct temperature. Equipment must comply with local and state requirements.

Label: Label food with use-by date and time, and cooking/reheating and service instructions for staff at offsite locations.
Prepare Containers and pack food in insulated food containers. Use only food grade containers so that food does not mix, leak or spill. Ensure that all transport equipment complies with local food code.

Food Safety: Reheat/Re-cool. Continue heating or chilling food if the proper temperature is not reached.

If the internal temperature of hot food cools to below 135°F, then upon delivery reheat the food to 165°F for 15 seconds using a proper heating procedure.

If the internal temperature of cold food warms above 41°F, then upon delivery cool it to 41°F or below using a proper cooling procedure.

Discard foods held in the danger zone (between 41°F to 135°F) for more than four hours.
Sanitize: Ensure offsite transportation equipment (examples: heat keepers, insulated food containers, ice chests) is cleaned and sanitized and in good repair. Regularly clean the inside of the delivery vehicles.


On 08/12/2020 at 2:43 p.m. an observation was made of a panel truck being loaded to transport food from the kitchen to the patient care units, located in separate buildings. Further observation revealed the panel truck had walls made of thin plywood and a large gaping hole was noted in the top, upper right corner of the truck leaving the interior of the truck exposed to the elements. The sky could easily be seen through the hole at the front right corner of the cargo area, while standing at the back door. The floor of the truck was metal, and the surface was scraped and stained. There was no type of insulation noted in the truck.
Additional observation of the truck revealed there was a large, uninsulated blue plastic bin placed directly on the bed of the truck. The bin contained numerous Styrofoam boxes that were stacked on top of each other. The boxes were not sealed except for the small Styrofoam tab on the box and cracks were observed between the top and bottom of the containers. The boxes contained bread, cold cuts, cheese and condiment packages. There was no lid on the plastic bin, no cold packs, and no other type of thermal material to keep the contents cold. The outdoor temperature at the time of the observation was above 90 degrees F.


On 08/12/2020 at 2:45 p.m. an observation was made of a panel van that was also used to transport patient meals. Further observation revealed the bed of the van was metal and the surface was scraped and stained. A large puddle of a thick, oily black substance that smelled strongly of motor oil was observed on the floor of the van.


S6ContDietaryMgt, present at the time of the observation, confirmed the truck and van referenced above were used to transport patient meals. She confirmed the above referenced observations related to the food transport vehicles. The manager confirmed food was not transported in any insulated or climate controlled devices within the vehicle.


On 08/13/2020 at 10:40 a.m. a tour of the hospital kitchen revealed the following:
S9ContDietary, driver, placed 4 large steam table serving pans covered with aluminum foil directly on the dirty, torn black mat in the rear of the commercial transport van. Two pans were noted to have ventilation holes in the aluminum foil and multiple flies were noted landing on the trays and van. The van was noted to not to be running with both back doors open for approximately 10 minutes.


In an interview on 08/13/2020 at 10:51 a.m. S7ContDietaryMgt verified the above findings and confirmed the process was not correct.


Review of kitchen inspection reports by hospital employed dieticians in the Nutritional Services department revealed, in part, the following:

04/29/2020- "No" to the following indicators: Endpoint/serving line temperatures are recorded; log available, food is protected from cross contamination during tray prep, refrigerators cleaned and organized; prevent contamination, Tray verification acknowledged by Kitchen Supervisor (signature).

General comments noted by the staff dietician inspecting included, "temps taken after prompted; log not easily assessable by staff or they didn't attempt to locate it, opened/empty juice containers were on the shelves with deli meat that wasn't wrapped."
05/06/2020- "No" to the following indicators: refrigerators cleaned and organized; prevent contamination. Under Cleaning and Sanitation: Chlorine (50-100ppm); records maintained and available and Quat (200-400ppm) [ in reference to 3-compartment sink]; records maintained and available were checked as N/A [the kitchen uses a 3-part sink].

General comments were noted as, "Special trays prepared and sitting on counter upon arrival (12+ trays) possibly waiting on verification and signature."

05/20/2020- "No" answered to these indicators: Food is protected from cross contamination during tray prep, Chlorine (50-100ppm); records maintained and available, Quat (200-400ppm); records maintained and available.

General comments: "Tray prep still needs some improvement- some food spilled into other trays/pans ...All refrigeration and sanitation, temps not always individually recorded."

06/24/2020- "No" to these indicators: End point/serving line temperatures are recorded; log available, Sample trays prepared and dated; Wiping cloths are stored in sanitizing solution between uses, Chlorine (50-100ppm); records maintained and available, Quat (200-400ppm); records maintained and available, tray verification acknowledged by Kitchen Supervisor(signature).

General comments: "Hot box/Warmer showing 145 degrees F, Test Tray: Oatmeal- 118.5 degrees F, Chopped ham and gravey-112.2 degrees F, Eggs 103.6 F. " [Food temps not within acceptable range]

07/08/2020-"No" to the following indicators: End point/serving line temperatures are recorded; log available, Sample trays prepared and dated, Wiping cloths are stored in sanitizing solution between uses, Food contact surfaces clean to sight and touch, refrigerators cleaned and organized; prevent contamination ("sneeze guards filthy pictures taken, most foods not wrapped properly in pans"), food contact surfaces clean to sight and touch, refrigerators cleaned and organized; prevent contamination, Chlorine (50-100ppm); records maintained and available, Quat (200-400ppm); records maintained and available, tray verification acknowledged by Kitchen Supervisor(signature).

Written comments included, "Regular trays: meal didn't match menu, noted some patients didn't receive ration of kcals (two ½ c scoops for grits= 1 cup, only got ½ cup serving), Wrapped trays not in warmer; ...Floor is so dirty/sticky my shoes squeaked all the way back to my office. Pictures of refrigerator/cooler taken-completely out of compliance. Also note: gumbo from day prior looks completely unappealing- filled with imitation crab meat."

07/14/2020- "No" to the following: ABHR available for serving line staff ("varies by line, using the pt.'s wall unit"), End point/serving line temperatures are recorded; log available, food is protected from cross contamination during tray prep ("also varies by line"), sample trays prepared and dated ("sneeze guards need to be cleaned; throwing trash on floor during tray prep to be cleaned after meal service"), wiping cloths are stored in sanitizing solution between uses, work surfaces are cleaned and sanitized between uses, Chlorine (50-100ppm); records maintained and available, Quat (200-400ppm); records maintained and available.

A written note for last section of inspection noted, "Did not get to complete observation as we were working the lines and preparing the trays for delivery."

General comments were noted as, "Yesterday we helped deliver meals to the units. The food processor stopped working and texture modified meals weren't ready until 3:00 p.m. Today we literally worked the serving lines after (Contractor "A") staff threatened to go on strike. While assisting them it was apparent that many of them need additional training. * Tickets [meal tickets] not referenced often; * Don't all know appropriate food group substitutions-provided extra roll and didn't see need to give additional vegetables as outlined on the ticket; ** Also realized for additional Kcal diets (and some regular menu items) adequate portions will not fit in Styrofoam box. * Some food items were prepared randomly- if a patient needed a different vegetable than the rest of the ward, - delayed delivery of meals for the unit, * When accurate portions are served the lines ran out of menu items before all trays prepared, *some servers drag scoop/spoon of good across the whole serving line while fixing frays lined on the top (definitely cross contaminating as food/liquid spills into other wells/pans; *had to prompt them to get deli paper in an effort to not put bread and cookie (and meal ticket) directly on entrée'-chicken pot pie; * said they often have limited supply."


Review of emails between S1CEO and Contractor "A", provided by S1CEO, revealed an email dated 02/24/2020 which noted the attached corrective actions of Contractor "A" did not appear to be any different from what t

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Based on observation, interview, and record review, the hospital failed to ensure the condition of the physical plant and overall kitchen environment was maintained in a manner that provided an acceptable level of safety and quality. This deficient practice was evidenced by multiple breaches in quality and safety in the hospital's kitchen, kitchen Food prep area, serving line area, dry storage room, walk in cooler, and freezer.

Findings:

Review of the contracted food company's policy titled, "3.4 Storing Food and Equipment" revealed the following, in part: Team members must store food in a manner that ensures quality. Store items away from walls and at least 6 inches off of the floor.

Sanitize: Keep all storage areas clean and dry; Clean floors, walls, and shelving in refrigerators, freezers, dry storage area, and heated holding cabinets on a regular basis; Clean up spills and leaks promptly;

Clean dollies, carts, transporters and trays often; and Keep refrigerator and freezer coils and fans free of dust, mold, frost and condensation.

On 08/12/2020 from 1:30 p.m. - 3:00 p.m. observations were conducted in the hospital's kitchen area, accompanied by S5QAPI, S6ContDietaryMgt and S7ContDietaryMgt. The following breaches in quality and safety were observed:


Dry Storage Room:

- Entry door observed to have peeling paint and peeling paint also observed on the wall beside the door.

- Ceiling between fluorescent light fixtures was observed to have large bubbles in the surface and had peeling paint and holes in paint.

- Ceiling above window unit air conditioner (located in the back wall of the dry storage area) was observed to have large bubbles in the surface and had peeling paint. A piece of plywood was observed on the ceiling with a hole noted in the plywood, through which daylight could be seen (could potentially allow pests to enter the dry storage area).

- 1-fluorescent light fixture with yellowish beige water stains.

- 2-fluorescent light fixtures observed to have both live and dead insects in them.

- Window unit air conditioner (located in the back wall of the dry storage area) was observed to have a thick greyish coating of dust covering the vents. Multiple orange colored drip marks were noted on the wood frame below the air conditioning unit. There was a crack noted around the air conditioner unit (area around insertion was not sealed) and daylight could be seen through the crack which could potentially allow pests to enter the dry storage area.

The air coming out of the air conditioner was not cold and the air temperature in the dry storage area was measured at 83 degrees F by maintenance staff.

- Cardboard boxes containing paper goods and Styrofoam food boxes were stored on the top shelf of metal shelving units and they were partially blocking an air vent to the hall outside.


Review of the FDA Food Code guidelines for dry storage revealed the dry storage area should be adjacent to the food preparation area. Adequate ventilation must be provided. Temperatures between 50 degrees Fahrenheit and 70 degrees Fahrenheit are recommended.

- Large industrial sized orange fan observed covered in a thick coating of dust, blowing into the vestibule area where pans/pots were stored on shelving units.

- 2-wheeled metal transport carts observed to have large dented areas on the top shelf that were sloping to the center with unprotected sharp metal edges at "cut" like separation in top shelf (later observed to be used for transporting food pans for delivery to units).


Review of the FDA Food Code guidelines revealed cleaned equipment and utensils shall be stored in a clean, dry location where they are not exposed to splash, dust, or other contamination.

Walk in cooler:

- Tile floor in the cooler was observed to have dirt and orange stains on the surface.

- Vents on 5 air circulators in the walk in cooler covered with dust.

- A metal beam across the center of the cooler was observed to be rusted with droplets of condensation noted to be collected on the beam. The condensation was observed to be dripping on the patient meal Styrofoam boxes of sandwiches and surveyors.


Walk in freezer:

- Outside wall of walk in freezer noted to be dented and a congealed yellowish substance noted in the groove where the wall was dented, near the floor.

- Floor tile under shelving unit in back corner of walk in freezer noted to have tile missing


Kitchen Food prep area:

- Brownish-black grease residue noted on warming ovens. A strip of clear plastic wrap was observed tied around the handles of the warming oven, reported to be broken by S6ContDietaryMgt who was present for the observation;

- Hood over large tilt skillets was noted to have strips of disintegrating gray electrical tape (adhesive residue and strings of the tape 4 feet in length) dangling above the tilt skillet.

- Edge of the wall leading to the dining room/serving line (located off of the kitchen) was noted to have a large chunk of plaster missing and was noted to have another area of crumbling plaster with flaking paint that was collecting on the floor. A metal bar within the wall was exposed in the area of the missing plaster.


Secondary dining room off of serving line room:

- Ceiling tiles (2) located in the far corner of the room were observed to have brown stains

- 3 ceiling tiles noted to be drooping and separating from the metal frames.


All of the above referenced observations in the kitchen, dry storage areas, walk in cooler, and food prep/serving lines/dining rooms were verified by S5QAPI, who was present with the surveyor during the observations.

Based on record review and interview, the hospital failed to ensure the infection control officer ensured the hospital's policies and procedures for preventing and controlling the transmission of infections within the hospital were implemented and monitored for adherence. This deficient practice was evidenced by:

1) failure to ensure policies and procedures for hand hygiene and PPE were implemented by contracted staff in the dietary department;

2) failure to ensure correct use of PPE and hand hygiene after glove use was implemented by hospital staff on the isolation and observation units of Building "a", the designated COVID building.

Findings:

1) Failure to ensure policies and procedures for hand hygiene and PPE were implemented by contracted staff in the dietary department.

Review of the contracted food service policies and procedures, provided as dietary policies adopted by the hospital, revealed a policy on mask use titled," Easy Guidelines for Mask Use. Further review revealed the following, in part:

Properly Put On/Take Off Masks. In addition, masks are only helpful if they are properly put on and removed. To do so, take the following steps:

First, clean hands with alcohol-based hand sanitizer or soap and water.

Cover mouth and nose with mask. Make sure there are no gaps between your face and the mask.

Don't touch the mask while using it; if you do, clean your hands with alcohol-based hand sanitizer or soap and water.


Review of policy #5.1, Serving: Basic revealed in part under Food safety that Service Staff must follow the guidelines when serving food. Further review revealed the following guidelines, in part: -Avoid bare-handed contact with ready to eat food, wear single use gloves whenever handling ready to eat food


On 08/12/2020 at 2:25 p.m. a contracted kitchen staff member was observed taking a pan of pasta from the food warmer bare handed. S12ContDietary observed the staff member and she instructed him to put on gloves.


On 08/12/2020 at 2:30 p.m. two of six contracted dietary employees observed on the serving line were wearing their masks below their noses. S6ContDietaryMgt, present during the observation, confirmed the staff were not wearing their masks over their mouth and nose as required.


On 08/13/2020 at 10:51 a.m. two contracted dietary aides were observed serving food with their masks below their noses.


In an interview on 08/13/2020 at 10:56 a.m. S13QAPI verified the above referenced breaches in proper mask usage.



2) Failure to ensure correct use of PPE and hand hygiene after glove use was implemented by hospital staff on the isolation and observation units.

Review of current CDC recommendations for PPE use for healthcare personnel (HCP) during the COVID-19 pandemic (as of 07/15/2020), revealed the following, in part:

Eye Protection: Put on eye protection (i.e. goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. Remove eye protection after leaving the patient room or care area, unless implementing extended use. Reusable eye protection (e.g. goggles, face shields) must be properly cleaned, decontaminated, and maintained after and between uses. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse.

Gloves: Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene.

Gowns: Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use.

Hand Hygiene HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
HCP should perform hand hygiene by using ABHR (alcohol based hand rub) with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHR.


Review of the hospital's policy for glove use, titled, "Personal Protective Equipment - Gloves", policy number G026, revealed the following, in part: Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin.

Policy Interpretation and Implementation:

1. All employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin.

2. Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed.

3.The use of gloves will vary according to the procedure involved. The use of disposable gloves is indicated:

a. When it is likely that the employee's hands will come in contact with blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin while performing the procedure;

b. When the employee has any cuts, wounds, or scrapes on his or her hands;

c. When the employee's hands are chapped or have a skin rash or skin condition;

d. When handling soiled linen or items that may be contaminated;

e.... f. When examining abraded or non-intact skin or patients with active bleeding;

g. During invasive procedures; and h. During all cleaning of blood, body fluids, and decontaminating procedures.

6.General purpose utility (rubber) gloves worn by maintenance, environmental services, laundry or other non-medical personnel may be decontaminated and reused in accordance with the manufacturer's instructions.

7.Do not use all-purpose gloves if they are peeling, cracked, or discolored, or if they have punctures, tears, or other evidence of deterioration.

8.Wash your hands after removing gloves.

10.Employees must receive training relative to the use of gloves and other protective equipment prior to being assigned tasks that involve potential exposure to blood or body fluids and when new or modified protective equipment or procedures have been introduced into the workplace.

.
Review of the hospital's policy titled, "Personal Protective Equipment- Using Gloves", procedure number G027, revealed the following:

Removing Gloves

1.Using one hand, pull the cuff down over the opposite hand turning the glove inside out.

2. Discard the glove into the designated waste receptacle inside the room.

3 With the ungloved hand, pull the cuff down over the opposite hand, turning the glove inside out.

4. Discard the glove into the designated waste receptacle inside the room.

5. Wash hands.


Review of CDC Guidance for gown use, provided by S3IC, revealed the following:

3.Gowns: Gown front and sleeves are contaminated!

If your hands get contaminated during gown removal, immediately wash your hands or use an alcohol-based hand sanitizer.

1. Unfasten gown ties, taking care that sleeves don't contact your body when reaching for ties,

2. Pull gown away from neck and shoulders, touching inside of gown only,

3. Turn gown inside out, fold or roll into a bundle and discard in a waste container

4. Wash hands or use an alcohol based-hand sanitizer immediately after removing all PPE.; and

5. Perform hand hygiene between steps if hands become contaminated.


On 08/13/2020 from 2:30 p.m. - 3:00 p.m. observations were conducted, via live feed from the security cameras, on Building "a" (designated building housing COVID-19 positive patients and those under observation for COVID signs and symptoms). S1CEO assisted with the remote observations and S3IC was present during the observations.


On 08/13/2020 at 2:30 p.m. an observation was made of two CGT (a care tech who is also a guard) staff members (identified as CGTs by S1CEO) seated at a table. One of the CGTs had on gloves and was not performing any care related tasks. No patients were observed in the area. S3IC confirmed the staff should not be wearing gloves at all times on the unit. She further confirmed wearing gloves continuously, when not performing tasks, was not part of the required PPE to be worn by staff working on the COVID unit.


On 08/13/2020 at 2:35 p.m. a CGT was observed to have gloved hands in pockets. Further observation revealed the CGT opened the door with the same gloves on. S3IC verified, during the observation, that staff should not be putting their hands in their pockets while wearing gloves. She reported gloves should be changed after providing care or performing an activity requiring gloves.


Another observation on the COVID unit in Building "a" on 08/13/2020 at 2:40 p.m. revealed a CGT came out of a patient's room who was in isolation with a gown and gloves on. The CGT was observed touching the wall with gloved hands and then touched her face with the gloves. The CGT was then observed walking to a table, touching the surface of the table, and touching a paper on the table top with the same gloves and gown on. S3IC, present during the observation, S3IC confirmed the CGT should have changed her gloves and should have performed hand hygiene after exiting the room. She confirmed the CGT should have also changed gowns after leaving the isolation patient's room.


Observation on 08/13/2020 at 2:50 p.m. revealed a housekeeper on the COVID unit (S3IC identified the staff being observed as housekeeping staff) was walking down the hall with gloves on, touching doors with her gloved hands. The housekeeper then took her face shield off and put it back on with same gloves, touched the door, and came out of the unit. The housekeeper was also observed collecting trash, not changing gloves, and then touching door handles. The above referenced observed infection control breaches were verified by S3IC who was present during the observation. S3IC confirmed the housekeeper should not have touched the face shield and should not touch multiple surfaces with the same pair of gloves. S3IC further confirmed the housekeeper was not removing gloves between tasks and was not performing hand hygiene.


In an interview on 08/14/2020 at 9:20 a.m. with S15RN, she confirmed she works on the COVID unit. She reported required PPE worn by staff was dependent upon which part of Building "a" you were assigned to. S15RN reported gowns were not worn all the time on the COVID negative unit. She indicated gowns were worn as needed for procedures on the COVID negative unit. She explained when staff was assigned to the COVID positive isolation unit gowns were worn at all times as well as N-95 masks. She reported gowns and gloves worn for close patient contact should be discarded and hand hygiene performed after removal. She confirmed a new gown should then be worn. She further confirmed gloves should not be worn at all times on the unit, when not performing tasks, no matter which unit in Building "a" you were assigned to.


In an interview on 08/14/2020 at 9:42 a.m. with S17HK, she confirmed she works on the COVID unit - Building "a" and has been the designated housekeeper on that unit since March 2020. S17HK indicated she wears a gown for her entire shift. She reported she wears gloves at all times as long as she is on the COVID unit. S17HK confirmed hand hygiene should be done after removing her gloves when she is finished with cleaning.


In an interview on 08/14/2020 at 9:57 a.m. with S16CGT, she confirmed she works on the COVID unit - Building "a". S16CGT reported she wears a gown for her entire shift. S16CGT confirmed hand hygiene should be done after removing gloves.


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