Failure to Provide Required Monthly In-Services to Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff received required monthly in-service training, as evidenced by the lack of in-services provided to food and nutrition services staff. During interviews, the Dietary Supervisor confirmed that no in-services were conducted in 2024 and only a few were held in 2023, despite facility policy requiring monthly in-services. This lapse was further highlighted when a dishwasher staff member, who had been working morning shifts for the past three months, stated they did not check the chlorine parts per million (ppm) in the dishwashing machine, did not know the purpose of chlorine in the machine, and had never checked the chlorine ppm prior to washing dishes. Observation in the kitchen revealed that the chlorine ppm was at zero, when it should have been at 100 ppm, indicating a failure in proper sanitizing practices. The Dietary Supervisor acknowledged that without regular in-services, staff would not be aware of the correct and current procedures for sanitizing and handling equipment. The facility's own policy and procedure document specified that food and nutrition services staff should be in-serviced at least monthly, a requirement that was not met.
Plan Of Correction
F801: Qualified Dietary Staff CORRECTIVE ACTION On 03/11/25, Dietary Supervisor conducted a 1:1 staff in-service to dishwasher 1 regarding the facility policy and procedure of sanitizing, dishwashing practice, and handling equipment. On 03/11/25, Dietary Supervisor performed skills check regarding sanitizing, dishwashing practice, and handling equipment. OTHER RESIDENTS AFFECTED IDENTIFICATION On 03/11/25, Dietary supervisor conducted in-service to dietary staff regarding the facility policy and procedure of sanitizing, dishwashing practice, and handling equipment. On 03/11/25, Dietary supervisor performed skills check to dietary staff regarding sanitizing, dishwashing practice, and handling equipment. Dietary staff will conduct daily dishwasher chlorine check and temperature using the form titled "Daily Dishwasher Chlorine and Temperature Log." MEASURES AND SYSTEMIC CHANGES Dietary supervisor/designee will conduct in-service upon hire and monthly every 1st of the month for 3 months, and annually thereafter, regarding dietary staff duties and responsibilities. Dietary supervisor/designee will conduct competency skills training upon hire and monthly every 1st of the month for 3 months, and annually thereafter, regarding dietary staff duties and responsibilities. Dietary supervisor will review the daily dishwasher chlorine check and temperature log; any significant findings will be discussed with the administrator. MONITORING PERFORMANCE The Administrator/Designee will review the daily dishwashing chlorine and temperature log weekly, and any significant findings or trends will be reported to the QAA committee during the monthly meeting for review and recommendations for any deficient practice for 3 months.