Volume 2024 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
24.01.09 Lighting, ventilation, and temperature control Overview of the requirement:
Tips for compliance:
Just as unit-based medication remains the responsibility of the pharmacy, unit based food products are the responsibility of nutrition services.
Ventilation, airflow, and temperature where food products are stored and prepared must meet relevant guidelines. Light sources provide adequate illumination and are protected. Compliance with this standard is assessed through observation and interview. Most citations noted temperatures outside of acceptable range monitoring issues.
n Assign responsibility for daily temperature logging of unit-based refrigerators and freezers, identify acceptable range and train on what to do when a temperature falls out of range. n Avoid comingling patient-assigned food, staff food, and medications.
Comment on deficiencies:
Frequency of citation:
35%
24.01.08 Physical Environment Overview of the requirement:
Examples of surveyor findings:
n Three grab-and-go open-front coolers holding dairy, deli meat sandwiches, salads with protein, and sushi, and a sandwich station holding eggs, cheese, and deli meat that is prepped the evening before for next-day service, are not monitored for temperature every four hours as required by the state’s Food Code when the area is closed overnight. n The main kitchen freezer temperature log for [date] noted for the freezer “+25°” and maintenance was called. There was no documentation of how the food was handled while out of range and there was no documentation of a temperature recheck. Per policy, temperature should be followed-up within one hour when the device falls out of range. n The main kitchen refrigerator temperature log for [six dates in one month] noted a temperature of 41°F with no recheck documented. Per policy any temperature greater than 40° F requires action and a recheck in one hour. n During the tour of the dish room, it was noted that the temperature conversion tapes were marked “Must exceed 160°.” The dish machine is a heat sterilization unit. ANSI standards require final rinse of 180°. Based on temperature log review, the final rinse was meeting the 180° requirement. n During the tour of the cafeteria, a significant build-up of grease was found on the exhaust hood and fire suppression system over the short order grill. n A significant buildup of grease, dust, and lint was observed on the fire suppression pipes in the exhaust hood over the cooking area. The primary drain under the large dish machine was observed to be partially occluded by debris and in need of cleaning. Several locations in the main kitchen and the dry storage room had fluorescent light lenses that were “rippled” and not resting on the ceiling grid. n Record temperatures of all refrigerators and freezers used for food products, and dish machines, and document corrective action when they fall out of range. n Add observation of vent hoods to environmental rounding and schedule regular cleaning and maintenance. n Routinely inspect food preparation areas for cleanliness. n Educate staff to observe and report grease buildup on exhaust hoods and pipes.
Food services maintains a sanitary environment that minimizes infection risks and risk of product contamination. Compliance with this standard is assessed through observation and document review. Most deficiencies cited equipment cleanliness and maintenance issues.
Comment on deficiencies:
Frequency of citation:
27%
Examples of surveyor findings:
n Condensation was observed below the window in the door of the walk-in freezer. Gaskets were in good repair, but the plastic curtains designed to maintain temperature were broken, allowing cold air to make the door cold enough to cause ambient humidity to condense. n The patient refrigerators were unusable, needed defrosting. n The door gasket on the cook’s walk-in freezer was noted to be damaged. It was not attached at the bottom of the door and appeared to be covered with mold. n Employee food and personal items were observed in areas designated for patient food. n Refrigerators in patient nutrition rooms on several units contained individual- use condiments with no use-by dates. n Labeled food past its expiration date was found in refrigerators (pastas). Opened, but unlabeled items were noted in refrigerators and freezers (chicken stock, waffle fries, hash browns). n Include kitchen areas in environmental rounding for assessment of cleanliness and properly working equipment. n Assess refrigerators located outside the nutrition department for cleanliness and state of repair. n Educate staff to report equipment maintenance issues. n Label food items to capture “opened/prepared on” and “use by/discard on” dates. n Conduct periodic surveillance to identify and remove expired food items. n Audit food inventory and discard expired items.
Tips for compliance:
Tips for compliance:
achc.org | (855) 937-2242 | 17
16
Made with FlippingBook - PDF hosting