Solving the Survey Puzzle for F371

1. Solving the Survey Puzzlefor F371 Sara Gosnell, RD, CD

2. Objectives • Describe the relationship between the regulation and the interpretive guidance • Describe how to use the investigative protocol • Describe and apply components of the investigative protocol • Identify areas of noncompliance with the sanitary conditions regulation • Appropriately categorize the scope and severity of noncompliance

3. F371 Revisions • F370 merged into F371 • Regulatory language was kept the same • Revisions now provide: • 13 new definitions • Education • Explanations • Examples for surveyors to reference

4. Defined by Federal Regulation • The facility must • 483.35(i) (1) Procure food from sources approved or considered satisfactory by Federal, Stated, or local authorities • 483.35(i) (2) Store, prepare, distribute and serve food under sanitary conditions

5. Intent • Facility obtains food for resident consumption from sources approved or considered satisfactory by federal, state, or local authorities • Follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness; beginning with the vendor through the facility’s food handling processes.

6. Cross contamination Danger zone Dry storage Food contamination Food preparation Food service/distribution Foodborne illness Highly susceptible population Pathogen PHF Ready-to-eat food Storage Toxins Definitions

7. Cross Contamination • The transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils that are not cleaned after touching raw food, and then touch ready-to-eat foods. This may also occur if raw food touches or drips onto cooked or ready-to-eat food.

8. Danger Zone • Used for PHF • Temps between 41°-135° F* that allow rapid growth of pathogenic microorganisms that can cause foodborne illness • >4 hours during preparation • >6 hours for items cooked and cooled *the temps are based on the food code which are the most stringent

9. Dry Storage • Storing and maintaining dry foods (e.g., canned goods, flour, sugar) and supplies (disposable dishware, napkins, and kitchen cleaning supplies) • Examples: ensuring paper goods are open from the right end and plastic bags of silverware are sealed and not left open

10. Storage • The retention of food (before and after prep) and associated dry goods • Example: NOT keeping scoops in flour or sugar bins even if the handle is up

11. Food Contamination • The unintended presence of potentially harmful substances, including but not limited to microorganisms, chemicals or physical objects in food. • Example: fake fingernail in food

12. Food Preparation • The series for operational processes involved in getting foods ready for serving, such as: washing, thawing, mixing ingredients, cutting, slicing, diluting, concentrates, cooking, pureeing, cooling and reheating. • Example: not washing fruit; rinsing a knife, not washing it and using it again

13. Foodborne Illness • Illness caused by the ingestion of contaminated food or beverages ►Foodborne outbreak • 2 or more unrelated people that ate a similar meal

14. Food Service/Distribution • The processes of getting food to the resident • Holding foods hot on the steam table or under refrigeration for cold temp control • Dispensing food portions for individual residents • Family style and dining room service • Delivering trays to residents’ rooms or units

15. Highly Susceptible Population • Persons who are more likely than the general population to experience foodborne illness because of their susceptibility to becoming ill if they ingest microorganisms or toxins (e.g., immunocompromised, chronic disease and advanced age)

16. Pathogen • An organism capable of causing a disease (e.g., pathogenic bacteria or viruses) • Norovirus

17. Potentially Hazardous Food (PHF or TCS) • Food that requires time-temp control for safety to limit the growth of pathogens or toxin formation ٭TCS- time/temp control for safety

18. Ready-to-Eat Food • Food that is edible with little or no prep to achieve food safety • Includes foods requiring minimal preparation for palatability or culinary purposes, such as mixing with other ingredients (e.g., tuna, chicken or egg salad) • Examples include deli items and raw fruits and vegetables

19. Toxins • Poisonous substances that are produced by living cells or organisms (e.g., pathogenic bacteria) that cause foodborne illness when ingested

20. Overview • The risk for foodborne illness (FBI) • Importance of effective food safety systems • Identify hazards and critical control points (CCPs) • Operational steps to eliminate hazards

21. Types of Food Contamination • Biological • Chemical • Physical

22. Biological Contamination

23. Biological Contamination • Most common types of disease producing organisms • Bacteria • Viruses • Toxins • Spores • Parasites

24. Factors Influencing Bacterial Growth • Food • Acidity • Time • Temp • Oxygen • Moisture

25. Chemical Contamination Monitor to ensure spray cleaners are not within proximity to food prep area to prevent food from being sprayed Ensure bottles are properly labeled • Soap should not be stored in an unlabeled styrofoam container • Powder cleaners could be mistaken for a cooking product

26. Physical Contamination • Foreign objects in food • Hair • Fingernails • Metal shavings • Jewelry • Do NOT use: • a glass as an ice scooper • A steel scouring pad to clean

27. Other Factors Involved in Foodborne Illness • Poor personal hygiene • Inadequate cooking and improper holding • Contaminated equipment • Unsafe food sources

28. Prevention of Foodborne Illness • Food handling and preparation • Employee health • Hand washing, gloves, antimicrobial gel

29. Employee Illness An employee will be restricted from working with food if they are experiencing symptoms of: • Fever • Cough/sore throat • Diarrhea • Open wound, not bandaged/covered

30. Safe Food Storage • FIFO!! • Dry food storage should be maintained in a clean and dry area • Safe refrigerator practices • Monitoring temps • Proper handling/cooling of hot foods • Separation of raw, cooked and ready-to-eat foods

31. Safe Food Preparation • Cross contamination • Thawing • Final cook temps • Modified consistency • Cooling • Reheating food • NO pooled eggs unless pasteurized

32. Thawing Foods Properly • Under cold water, < 70°F, agitating enough to get off ice • In the cooler • Microwaving; food needs cooked immediately following • Cook from frozen state

33. Final Cook Temperatures

34. Proper Cooling Techniques • Techniques • Shallow pans for smaller quantities • Ice bath • Frequent stirring • Cooling paddles • 135° F ► 70° F► within 2 hours 70 ° F► 41° F ► within 4 hours ٭Total time not to exceed 6 hours

35. Proper Reheating Procedures • Required internal temp = 165°F for 15 seconds minimum • Only for foods properly cooled • Can only reheat a food item once! ٭Facility-made pureed food cannot be reheated

36. Equipment and Utensil Cleaning and Sanitization • Machine wash and sanitize • Manual wash and sanitize • Cleaning fixed equipment √ Test strips should be at each station and used!!

37. Food Service and Distribution • Tray line, alternative meal preparation and service are • Food distribution • Snacks • Special events • Transported foods • Ice • Refrigeration

38. Wiping Cloths • Service area wiping cloths are cleaned and dried, or • Place in a chemical sanitizing solution of appropriate concentration √ test strips need used periodically as sanitizer strength decreases over time

39. Surveying Facilities That Receive Food Prepared by Off-site Kitchens When a nursing home receives food services from an off-site location, the surveyor must assess whether the facility is compliant with 42 CFR 483.35 (i) ٭Your facility should have on hand a copy of the most recent sanitation inspection from the off-site location

40. Culture Change Provisions • Family members, or other resident guests, who bring in food for the resident’s consumption are not regulated under this federal tag. ● many state regs address this • Dietary is responsible for foods cooked by recreation department, and should be trained accordingly • A cake from the bakery is ok, but bake sales to the residents should notbe done • Families/guests can bring food in for the individual but it should not be set out for others

41. Pathogenic Microorganisms and Strategies for Their Control • Commonly identified ingestible items associated with illness-producing organisms • Primary agents of concern (hazards) are organisms associated with the food source • PHF/TCS primary control strategies to minimize potential for foodborne illness outbreak

42. Investigative Protocol Sanitary Conditions Use this protocol to investigate compliance at F371 (483.35 (i) (1) and (2))

43. Objectives • To determine if the facility procured food from approved sources • To determine if the facility stores, prepares, distributes and serves food in a sanitary manner to prevent FBI • To determine if the facility has systems (e.g., policies, procedures, training, and monitoring) in place to prevent the spread of FBI and compromising of food safety • To determine if the facility utilizes safe food handling from the time the food is received from the vendor and throughout the food handling processes in the facility

44. Investigative Protocol Procedure During Survey • Observations • Interviews • Record reviews • Review of facility practices

45. Observation • Surveyors will observe • food procurement • Service of food during meals • Service after meal • Storage of food

46. Observation of Food Procurement Procedures • Observe when, where and how food is procured • Invoices (to verify sources) • Vendor records • Source verification • Temps upon arrival • Visually observe items • Are boxes wet?

47. Observation of Food Preparation Procedures • Food handling practices • Food labeling and dates • Hand washing • Handling of potential cross contamination foods • Acceptable cooking and cooling temps

48. Observation of Trayline Service • Observe staff measuring the temp of all hot and cold menu items at all points of service • Cold food should be ≤ 41° F • Hot foods should be ≥ 135° F ٭ensure staff are taking temps from the middle of the food item

49. Observation of Dish Room Procedures • Observe whether staff are properly operating dish machine and evaluate sanitization processes • Check for proper equipment and supplies to evaluate dish machine operation • Observe the 3 step process of manual pot and pan washing • What sanitizer do you use with what test strip?

50. Observation of Service After Meals • Observe store dishes, utensils, pots/pans, and equipment for evidence of soiling • Can the lowerator be splashed by dirty water? • Evaluate whether proper hand washing is occurring between handling soiled and clean dishes to prevent cross contamination of the clean dishes