Inadequate Emergency Food Supply Inventory
Penalty
Summary
The facility failed to implement its facility-wide assessment to ensure an adequate inventory of resources, specifically sustenance, food, and beverages, in the event of an emergency or disaster. The facility assessment dated January 22, 2025, indicated that the facility was responsible for maintaining a documented inventory of resources necessary for emergencies. However, upon review, it was found that the facility did not adhere to this requirement as outlined in their emergency preparedness plan. The emergency preparedness plan required the facility to ensure adequate sustenance needs for residents and staff during emergencies. Additionally, the facility's "Food and Nutrition Disaster Plan," last reviewed on March 8, 2024, outlined procedures for preparedness, including maintaining an inventory of both perishable and non-perishable food supplies. This inventory was supposed to cover all current service points and additional staff and visitors. During an observation in the kitchen on February 11, 2025, and a review of facility documentation, it was revealed that the required number of food items listed in the facility's par listing were not available. Interviews with the general manager of the dietary department and the Administrator confirmed that the facility did not have the necessary food and beverage supplies on hand as per the facility assessment, emergency preparedness plan, and dietary policy and procedure.
Plan Of Correction
A 4-day disaster menu will be maintained. All food items needed to implement the emergency menu will be kept in the food storage areas. The facility always keeps 7-days of food in house in the main kitchen. Additionally, a 3-day emergency stock specific to the emergency menu is kept in designated areas of the food storage. All foods required to feed staff and residents of the facility for 3 days is available on premises at all times. A food inventory sheet with required par level/ portions will be updated weekly as stock is rotated and ordered by the Head Chef or designee. Each week the inventory sheets will be signed, dated and retained by the Dining Service Director. The Dining Service Director will be responsible to assure emergency food supplies are always adequate for the facility staff and residents. Training will be provided to the Food and nutrition general services manager, head chef, dining services managers and other key managers regarding the emergency supplies requirements and process. Each month the inventory levels will be reported to the QAPI team for the next six months. A compliance book will be created and will hold: - 4-day Emergency Menu - Emergency Food Inventory- Weekly - Training for key administrative staff on emergency supplies - Report for monthly QAPI meeting reflecting ongoing compliance