Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Summary of Survey

  • Number of deficiencies found during this inspection

Clinical Section of Kitchen Tracer

  • Select a patient with a special diet. Have the dietary staff member describe how they are communicated to about the special diet

  • Observe, if possible, a diet tray being delivered to a patient, did the dietary person delivering the food tray to the patient use 2-patient identifiers?

  • Review process for a dietician referral as part of a patient tracer

  • “Trace” that patient to the kitchen

  • Determine how the diet order is communicated to the kitchen and how that order is applied to items selected for a patient meal tray

  • Are menus posted or otherwise available to staff making the tray

  • Verify that the medical staff (and dietician) approve the current diet manual (diet manuals good for 5 years but still need annual review)

  • Review the job descriptions to make sure responsibilities are clearly defined

Infection Control

  • Are all staff members wearing hair nets

  • Are all beards covered

  • Is there an eyewash station, if yes, have all weekly checks been documented

  • Is handwashing being done

Kitchen Environment

  • Kitchen is organized and free of clutter

  • Dishes and utensils stored to prevent contamination

  • No sign of “pests”

  • Proper use and cleaning of cutting boards (one for meat, one for veggies) and other prep surfaces to avoid contamination

Food Temperatures

  • (Make sure to check all logs )

  • Monitor the food temperature checks of the hot and cold items used to prepare patient meals

  • There should be logs of temperatures for each meal service; usually at the start, midpoint, and end if meal service is extended. Ask how these temperatures are monitored and when a mid-meal check is required (The log should have 3 times for EACH meal time served - breakfast, lunch, dinner). Are all logs filled in correctly?

  • Final cooking temps should be as follows:

  • Poultry – 165

  • Ground meat, ground fish, eggs- 155

  • Fish and other meat – 145

  • Precooked, cooled, then reheated - 165

  • Holding temps should be at least 135 or higher for hot foods and 41 or below for cold foods

Refrigerator Temperatures and

  • Are refrigerator temperatures 41 degrees or below?

  • Is there action taken for any temperature out of range?

  • Is there a log for each freezer / refrigerator?

  • Is all food labeled with expiration date; food should also be covered

  • Look for labeling of opened containers with expiration date

  • Are there any expired food items?

  • Look for precooked food in the cooling process (may also be in the freezer)

  • Ask for policy/process on how the cooling process of food is done. (Should be cooled to 70 within 2 hours and to 41 within 4 (total cooling time not over 6 hours)

  • No uncooked food (chicken or other meat) stored over cooked food or produce to prevent contamination (should be on bottom shelves)

  • No thawing of frozen food at room temperature

  • Make sure food is stored in refrigerator/freezer to allow for ventilation

  • Look for sprinklers inside with adequate clearance

  • Look for monitoring of freezer temps

  • Ask for frequency and temperature limits per policy (temperature to assure food stays frozen)

  • Make sure monitored per policy

  • If temps out of range, what was done – is there evidence

  • Look for expiration dating as above

  • Are there sprinklers inside with adequate clearance

  • Look for ice build-up – there shouldn’t be any

  • Dry Storage

  • Look for any expired items

  • Look for unobstructed sprinkler flow

  • May ask about EM preparation and food storage items (how would they prepare for 90 days of supplies during emergency)

  • Ask about dishwasher temps or chemical preparation

  • Ask for policy on monitoring of dishwasher temps

  • Ask for log of dishwasher temperature/chemical monitoring

  • Wash temps 150

  • Rinse temps 180

  • If chemical process then wash temp 120 and 50ppm (reference IFUs)

  • If temps out of range, what was done, and what was evidence

  • Review the process of the 3-sink cleaning. How much chemical per gallon of water? Review log that pH strip is done.

  • §482.42 - (A-0747) - §482.42 Condition of Participation: Infection Control This Condition is NOT MET as evidenced by: In the kitchen, is the pH test strips used at the 3-part sink current

Life Safety

  • Do sprinkler heads have adequate 18" clearance?

  • Deep fat fryer. Is there at least 16" space between the fryer and surface flames from adjacent cooking equipment?

  • K fire extinguisher placard identifying need to activate the fixed suppression (ansul) system before using the extinguisher?

  • is the grease hood clean with no grease buildup?

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