PC# 741

Account Name: Affinity Medical Center

Director: Steven Savage
Chef: James Crookston
Retail Manager:
CNM: Nancy Kazakis / Linda VanTwisk
PSM: Robert Smith
VP: Brian Kice
Performance Score:
Purchasing, Receiving, St
Food Production/Preparat
Patient Services
Retail & Catering
Clinical & Regulatory
Premisis, Equipment & Sa
rchasing, Receiving, Storage 89.58%
od Production/Preparation 0.00%
tient Services 94.64%
tail & Catering 0.00%
nical & Regulatory 0.00%
emisis, Equipment & Sanitation 0.00%
Purchasing, Receiving, Storage
In
Line Item Description Compliance
Purchases made only through approved vendors
Ensure GPO purchasing compliance >90% Yes
No evidence of vendor auto-delivery (PARs, no one present during delivery, Yes
etc)
No unapproved vendor invoices identified Yes
Products purchased in compliance with recipe specifications to ensure accurate Yes
nutritional data
Products are received, inspected and documented for safety and quality
Deliveries received in person by receiving clerk/designee Yes

Receiving logs complete with adequate number of food items tested No

Frozen food received solid or temp<0F Yes

Refrigerated food received at temp <40F Yes
Packaging and product quality inspected Yes
Action steps documented for any noncompliance No
Products are labeled with received date Yes
Dry goods are stored appropriately

Storage ambient temp should be between 50-70F. Ensure each storeroom has a No
thermometer, preferably one that also measures humidity

Dry goods stored at least 6 inches from the floor and away from the wall to allow
air flow Yes
Items are not stored within 18 inches from the ceiling Yes
Containers are durable, leak proof and sealed or covered Yes
Products rotated in accordance with FIFO Yes
Corrugated cardboard minimized in storage areas Yes
Dented cans are stored separately from other inventory and labeled Dented Yes
Cans ONLY-Return to Vendor for credit
Produce stored/prepped appropriately
No evidence of spoiling or quality issues Yes
Fruits and vegetables properly washed with Victory wash prior to Yes
service/production
Prepped/washed fruits & vegetables labeled and stored separately from raw Yes
product
CNS fruit & vegetable washing instructions sign (MQAS-21) posted in designated Yes
produce washing area
Refrigeration units maintained between 34-41F with current and complete
temperature log
Each refrigerator unit contains an independent thermometer located near the Yes
door
Temperature logs complete Yes
Action steps documented for any noncompliance Yes
Only current months temp log posted, others filed for 1 year Yes
Refrigerated foods stored appropriately-- minimum or 3 foods individually
assessed for compliance per refrigeration unit
Refrigerated TCS foods stored <41F Yes

All opened and prepared food labeled completely with CNS approved label: Item No
Description, Date/Time Prepared, Date/Time Expires, and employee initials

NO out dated products observed Yes

Food Containers are durable, leak proof and sealed or covered Yes
Items stored at least 6 inches from the floor and away from walls to allow air flow Yes
Products rotated in accordance with FIFO Yes
Food is stored to prevent cross-contamination in accordance with CNS food
storage hierarchy policy-- Top-to-bottom: RTE, Seafood, Beef/pork, Ground Yes
meat/fish, Poultry
Freezer units maintained between -10-0F with current and complete
temperature log

Each freezer unit contains an independent thermometer located near the door Yes
Temperature logs complete Yes
Action steps documented for any noncompliance Yes
Only current months temp log posted, others filed for 1 year Yes
Frozen foods stored appropriately-- minimum or 3 foods individually assessed
for compliance per refrigeration unit
Frozen foods labeled appropriately and NO out dated products Yes

All opened and prepared food labeled completely with CNS approved label: Item No
Description, Date/Time Prepared, Date/Time Expires, and employee initials

Frozen foods stored appropriately Yes

Food Containers are durable, leak proof and sealed or covered Yes
Items stored at least 6 inches from the floor and away from walls to allow air flow Yes
Products rotated in accordance with FIFO Yes
Food is stored to prevent cross-contamination in accordance with CNS food
storage hierarchy policy-- Top-to-bottom: RTE, Seafood, Beef/pork, Ground Yes
meat/fish, Poultry

Evidence of active managerial oversight of purchasing, receiving, storage process

Required documentation on file and available per policy Yes
Required signage, staff training, department meetings, etc to ensure compliance Yes

Appropriate and timely actions taken and documented to correct deficiencies Yes

AP process in place to ensure accurate billing/invoices, returns/credits are Yes

applied, invoices are submitted for payment in timely manner, etc.
43
89.58%
 Comments

Receiving logs need to be completed and an

adequate number of food items need to be
tested.

Action steps need to be documented for any

noncompliance.

Thermometer needs to be placed in storeroom to

ensure appropriate temperature range.
 All opened and prepared food labels need to be
completed with CNS approved label including item
description, date/date prepared, date/time expires,
and employee initials.

All opened and prepared food labels need to be

completed with CNS approved label including item
description, date/date prepared, date/time expires,
and employee initials.
Food Production/Preparation
In
Line Item Description Compliance
Production areas are clean and sanitized
Workstations, cutting boards and utensils are clean, sanitized, and in good
condition
Each workstation has a green cleaning bucket- free from debris, suds present,
cleaning cloth present
Each workstation has a red sanitizing bucket- free from debris, strip test WNL,
sanitizing cloth presentMinimum 3 sanitizing solutions tested

Staff can verbalize how/when to use each bucket and when/how often to change
No loose towels (wet or dry) observed
Production staff in compliance with personal hygiene and uniform
Appropriate hair covering in place, including facial hair longer than inch
Aprons clean and not used to cleanse/dry hands or to handle hot food
No tongue rings, gauges, false eyelashes, false finger nails, or inappropriate
jewelry (single band ring ok)
Disposable, non-latex gloves in use
Hands washed before and after donning gloves and/or handling food items

Cutting glove with disposable glove covering it wore at ALL TIMES when cutting
items
Appropriate utensils, small wares, cutting boards used
Cutting boards used in accordance with CNS policy: Green-Produce, Red-Raw
Animal Meat, White-Cooked and RTE
Adequate small wares and measuring utensils available and used
Thermometers available and used by all cooks/production staff
Each employee or workstation has a working thermometer available for use

Thermometers calibrated weekly and documented on a log. Logs maintained for

3 months
Bi-metal dial type thermometers are not in use
Staff demonstrate proper use of thermometer, including sanitizing and
calibration
Foods are thawed in accordance with policy
Walk-in Cooler is preferred for thawing over water thawing method
No food cooling within reach-in cooler
Thawing food labeled appropriately with accurate expiration/used by dates:
Meats no longer than 5 days, Deli Meats no longer than 4 days

Water thawing method to be used minimally and according to policy: Potable

water temp at 70F, 2 hour maximum submerge time, clean pot/pan used

Foods NOT thawed in bare sink

Produce properly washed with approved anti-microbial wash prior to
service/production
Proper dilution used
Anti-microbial wash log current and complete, previous logs maintained for 6
months
Staff demonstrate and/or verbalize proper use of anti-microbial wash
Final cooking temperatures/Minimum internal temperatures are in accordance
with policy- minimum 2 items temped per production area
Rare roast beef, corned beef, pork roasts (including ham)-145F for 4 minutes
OR 140F for 12 minutes OR 130F for 112 minutes
Fruits and vegetables, hot holding foods- 140F for 15 seconds
Poultry, stuffing/stuffed foods, gravies, sauces, soups, reheated foods-165F for
15 seconds
Raw animal foods cooked in microwave oven and TCS foods reheated in
microwave- 165F for 15 seconds AND remained covered for 2 minutes after
165F reached
Hamburger patties- 158F for 1 second
Pork, ground meat of any kind (except poultry), injected meat- 155F for 15
seconds

Beef and fish (except ground and roasts), liquid pasteurized shell eggs/egg
product prepared for immediate retail consumption- 145 F for 15 seconds

PAR cooked items are prepared/handled appropriately

Initial cook time does not exceed 60 minutes
Food is cooled in accordance with policy and documented on cooling log
Food is stored in accordance with policy
Food is reheated to 165F prior to serving
Hot foods AND TCS foods prepared using room temp ingredients are cooled in
accordance with policy- identify at least ONE leftover in cooler to vaidate
compliance
Cooling/cooled items labeled correctly
Item documented on complete and current cooling log, previous logs on file for
one year
Food item cooled from 140F to 70F within 2 hours or discarded
Food item cooled from 70 F to 41F within 6 hours from beginning of cooling
process or discarded
Staff can verbalize appropriate cooling techniques/methods: use shallow pans,
ice-water bath, ice paddle, chiller/cooler
Hot holding foods are minimized for quality using batch cooking and temp held at
140F or higher to prevent pathogen growth- minimum of 3 items temped per
workstation/service area
No evidence of mass/cook-ahead production

Hot held food temps are documented on service records and actions documented
for noncomplianceReview tray line AND retail service records

Staff can verbalize when reheating is required and proper reheating techniques

Cold holding food temps are held between 34-41F to prevent pathogen growth-
Minimum of 3 items temped per workstation/service area

Cold held food temps are documented on service records and actions
documented for noncomplianceReview tray line AND retail service records

Staff can verbalize when re-cooling is required and proper cooling techniques,
including documentation on cooling log
Only approved CNS recipes used
Standardized recipe file available and current
Written approval available for any Non-CNS standardized recipe
Recipes available for production staff and followed as written for quality and
consistency
Staff can verbalize knowledge regarding how and why to follow recipes
Food production sheets are used daily
Each item produced is listed on the current production sheet

Production sheets include required contents in accordance with policy: Portions,

Amounts prepared, Amounts leftover, Recipe number, and final cooking temp

Production sheets are retained on file for 1 year

Staff can verbalize and demonstrate proper use and documentation of
production sheet
Food prepared meets CNS safety and quality standards- minimum 3 food items
inspected per workstation/service area
Only pasteurized eggs or egg products used
Food presentation is appealing and of high quality

Prepared food labeled completely with CNS approved label: Item Description,
Date/Time Prepared, Date/Time Expires, and employee initials
Prepared food is tasted for quality prior to service
Staff can verbalize and demonstrate proper tasting techniques to prevent food
contamination and manager reporting process
Evidence of kitchen/culinary/floor leadership
Production meetings are conducted daily
Chef is engaged in production functions, catering events, staff training/support,
etc
Kitchen flow/design/organization is adequate to meet production needs,
enhance productivity, reduce waste
0
0.00%
Comments
Patient Services
In
Line Item Description Compliance
Trayline area clean, sanitized and stocked
Trayline equipment free from debris, dirt, food, etc to prevent contamination:
steam well, refrigeration units, tables/carts, plate warmer, condiment Yes
stands/containers, tray storage, shelves, etc.
Cutting boards, utensils, china, silverware, etc are clean, sanitized, and stored to Yes
prevent cross contamination

Each trayline workstation has a green cleaning bucket- free from debris, suds No
present, cleaning cloth present

Each workstation has a red sanitizing bucket- free from debris, strip test WNL, Yes
sanitizing cloth presentMinimum 1 sanitizing solutions tested

Staff can verbalize how/when to use each bucket and when/how often to change Yes

No loose towels (wet or dry) observed No

Trayline staff in compliance with personal hygiene and uniform

Appropriate hair covering in place, including facial hair longer than inch Yes
Aprons clean and not used to cleanse/dry hands or to handle hot food Yes
No tongue rings, gauges, false eyelashes, false finger nails, or inappropriate
jewelry (single band ring ok) Yes
Disposable, non-latex gloves in use Yes
Hands washed before and after donning gloves and/or handling food items Yes

Cutting glove with disposable glove covering it wore at ALL TIMES when cutting Yes
items
Menu spreadsheets current and being followed
Available for tray line staff reference Yes
Observe proper small wares in use for portion control Yes
Appropriate condiments offered Yes
Nutritional analysis consistent with menu spreads, approved by CNM/RD, and
followed by tray line.
Copy of nutritional analysis signed and dated by CNM/RD Yes
Nutritional analysis matches menu and recipe items served Yes
All alternatives approved by RD and listed on spreadsheets Yes
Patient allergies are identified and process in place to prevent patient
consumption/injury
Multi-disciplined food allergy policy in place Yes
Clinical and CNS personnel knowledgeable regarding policy and Yes
roles/responsibilities
Food allergies are clearly identified within the patients record Yes
Food allergies are clearly communicated to CNS personnel: use of stickers, Yes
specified tray tickets, notation on production sheets, etc.

Food allergy log is current, available for CNS staff reference and maintained for No
30 days

Tray presentation diagram posted and followed with attention to presentation

and sight appeal.
China and beverage cups match Yes
Pureed/mechanically altered foods are attractively presented (molds used) Yes

Side dishes and/or casserole dishes are used for runny vegetables and entrees Yes
Silverware is clean and correctly positioned on trays Yes
Appropriate actions observed to ensure consistent food temperatures
No more than 3 hot beverage or soup/cereal poured at once Yes
No more than 3 plates removed from warmer at once Yes
Heat on demand bases are at least 225F Yes
Steam table pans are in good condition and fit, not allowing steam to escape Yes
No fan or A/C vent blowing directly on trayline Yes
Tray line temp sheets completed accurately and any deficiencies noted with
action steps.
Minimum of 3 items temped on trayline Yes
Hot held food temps are documented on service records and actions documented Yes
for noncomplianceReview tray line
Cold held food temps are documented on service records and actions Yes
documented for noncomplianceReview tray line

Staff can verbalize when reheating is required and proper reheating techniques Yes
Staff can verbalize when cold foods must be discarded Yes
Substitutions listed and approved on trayline temp sheet by RD. Yes
Trays are built and delivered safely according to established schedule and
Ensure approved 2 patient identifiers listed on tray ticket Yes
Review trayline temp sheet for start and stop times Yes
Ensure14-hour rule achieved Yes
Late tray process in place and monitored for safety and quality
Late trays are less than 5% per meal period Yes
Late trays/plates are NOT prepared in advance and held in warmer for later use Yes
Hot food held on trayline no longer than 1 hour after trayline ends Yes
Trayline refrigeration units stocked appropriately
No food cooling within trayline cooler Yes
Patient food labeled appropriately with accurate expiration/used by dates: Yes
Meats no longer than 5 days, Deli Meats no longer than 4 days
Items rotated using FIFO method Yes
Liquids (juice/milk/etc) stored on sheet pan or solid shelf to avoid cross-
contamination Yes

Patient satisfaction goals and achievement consistent with hospital expectations

Patient satisfaction goals and results posted in department-at least 3 months Yes

Ambassadors are knowledgeable regarding their results and performance by unit Yes

Any hospital required patient satisfaction improvement activities are completed Yes
per hospital expectations

Observations indicate a pre-service meeting conducted prior to each meal period

to review menu items, substitutions, production issues, patient concerns, etc.

Review patient service temp sheet for evidence of meeting and topics discussed Yes
Review prior meeting sign in sheets Yes
Ambassador Shadow Report completed weekly per Ambassador and current Yes
action plan in place for score <90%.
Secret Shopper report completed monthly per Ambassador and current action
plan in place for score <90%. Yes

Tray Accuracy Report completed weekly per meal period and current action plan Yes
in place for score <90%.
53
Percentage Score 94.64%
 Comments

Each workstation needs a green bucket free from

debris, suds present, and cleaning cloth present.

No loose towels should be observed. Towels

should be kept in sanitary buckets or in storage
room.
 Food allergy log needs to be current and available
for CNS staff reference and maintained for 30 days.
Retail & Catering Services
In
Line Item Description Compliance
Service areas clean, sanitized and stocked

Service equipment free from debris, dirt, food, etc to prevent contamination:
steam well, refrigeration units, salad/self-serve bars, tables/carts, beverage
stations, condiment stands/containers, tray storage, shelves, etc

All surfaces are debris free, including floors, counters and sneeze guards
observe from customer perspective
Cutting boards, utensils, china, silverware, etc are clean, sanitized, and stored to
prevent cross contamination
Each service workstation (including cashier) has a green cleaning bucket- free
from debris, suds present, cleaning cloth present
Each service workstation (including cashier) has a red sanitizing bucket- free
from debris, strip test WNL, sanitizing cloth presentMinimum 1 sanitizing
solutions tested

Staff can verbalize how/when to use each bucket and when/how often to change
No loose towels (wet or dry) observed
Retail staff in compliance with personal hygiene, safety and uniform
Appropriate hair covering in place, including facial hair longer than inch
Aprons clean and not used to cleanse/dry hands or to handle hot food
No tongue rings, gauges, false eyelashes, false finger nails, or inappropriate
jewelry (single band ring ok)
Disposable, non-latex gloves in use
Cutting glove with disposable glove covering it wore at ALL TIMES when cutting
items

Hands washed before and after donning gloves and/or handling food items

Hot foods are held at 140F or higher to prevent pathogen growth- minimum of 3
items temped per workstation/service area

Hot held food temps are documented on service records and actions documented
for noncomplianceReview previous week retail service records

Staff can verbalize when reheating is required and proper reheating techniques

Cold foods are held at temps between 34-41F to prevent pathogen growth-
minimum of 3 items temped per workstation/service area
Cold held food temps are documented on service records and actions
documented for noncomplianceReview previous week retail service records

Staff can verbalize when re-cooling is required and proper cooling techniques,
including documentation on cooling log
Staff can verbalize when cold foods must be discarded
Refrigerated retail foods stocked and labeled appropriately and NO out dated
products- minimum 3 food items inspected per refrigeration unit

All opened and prepared food labeled completely with CNS approved label: Item
Description, Date/Time Prepared, Date/Time Expires, and employee initials

*** Placeholder for nutritional label when available

Products rotated in accordance with FIFO
Products fronted with labels facing forward
Commercially packaged food labels include: Item Description/Expiration
Date/Ingredients
Consumer allergy and advisories posted in accordance with CNS policy
Allergy sign posted
Consumer alert sign posted in the cook to order station which advises against
consumption of raw or undercooked animal food
Recommended signage at cafe exit to cover all food before leaving cafe

CNS personnel knowledgeable regarding policy and roles/responsibilities- when

to notify manager of customer concerns/questions/etc

Entrance/welcome area meets HHS CNS standards

Proper signage on display, including nutritional data, daily/weekly specials,
themed/seasonal items, etc
Standard HHS welcome banner on display
Weekly menu displayed and available to-go
Trays are well-stocked, clean and dry
Guests greeted timely with eye contact, a smile and verbal greeting
Standard/approved retail signage visible, current and in accordance with CNS
standards
Signage includes: item description, price, combo specials, etc.
Hot food/service stations are clean, attractive and stocked throughout meal
period
Attractive signage with daily options and pricing
Appropriate utensils used to ensure accurate portions AND same color and/or
style at each station with handles extending out of food
2 inch pans used and replenished/replaced when empty
Food stirred frequently to ensure proper temperature, attractiveness, and
consistency
Food presented so that it is portionable and attractive-Casseroles served
individually

Food is displayed attractively- vegetable/starches with variety of color/textures

Specials/combos clearly identified with appropriate signage
Chef Table service area is clean, attractive and stocked throughout meal period
Attractive signage with daily special and pricing
Station must provide action: carving station, saute , etc
Healthy options available: olive oil vs butter, wheat vs white pastas, lean
meats/sides
Menu offerings account for through put challenges
Extensions available a la carte and/or in combo options: salads, fruit, soup, fries,
etc

Self-serve/salad bars are clean, attractive and stocked throughout meal period

Each food item has dedicated utensil with handles extending out of food and
changed every hour
Salad bars consists of 90% fresh product
Ice is replenished when soiled with liquid/food and when melting
Pans fit securely in hot wells with NO escaped steam
Soups are available to compliment salad bars
Hot cereals are available to compliment breakfast bars
Grill service areas are clean, attractive and stocked throughout meal period
Attractive signage with daily special and pricing
Healthy options available: grilled chicken, boca burger, turkey burger, etc
Proteins NOT held in au jus
Evidence of batch cooking during peak times to expedite through put
Appropriate vegie-stackers and condiments available
Grab n go options available to expedite through put, as appropriate: fries,
chicken strips, patty-only options, etc
Breakfast and dinner options available during dining hours
Extensions available a la carte and/or in combo options: salads, fruit, soup, fries,
etc

Deli service areas are clean, attractive and stocked throughout meal period
Attractive signage with daily special and pricing
Healthy options available: vegetable options, healthy grains, lettuce wraps, etc

Evidence of batch preparation during peak times to expedite through put:

popular sandwiches, paninis, wraps, etc
Appropriate vegie-stackers and condiments available
Extensions available a la carte and/or in combo options: salads, fruit, soup, fries,
etc

Pizza service areas are clean, attractive and stocked throughout meal period

Attractive signage with daily specials and pricing: flatbreads, calzones, baked
pastas, etc

Healthy options available: vegetable options, low-fat cheeses, wheat crust, etc

Evidence of batch preparation during peak times to expedite through put:

popular pizzas, calzones, etc
Extensions available a la carte and/or in combo options: bread sticks, garlic
knots, salads, fruit, soup, fries, etc
Dining area is clean, attractive and pleasing to retail guests
All surfaces are debris free, including floors, walls, tables, chairs and
decorations/plants/displays/etcobserve from customer perspective

Tables and chairs are in good repair and are made of solid, sanitize-able material

Flooring in good repair (carpet free from stains, rips, holes- tile is clean with
shiny finish
Convenience stations are clean and attractive: condiment station, plastic-
ware/napkin dispensers, displays, etc
Tables are cleaned and sanitized in a timely manner after each customer
Cashier area is clutter free and contains only approved items
Manager business card available
No loose change or other counting item on/around register: toothpicks,
condiments, etc
Register is pre-loaded with menu items and pricing- NO manual entry
Recommend scanning technology in place
Scales verified by 3rd party annually and documentation on file
Cashier audits are completed with average score of >90%- Review current and
previous month audit findings to ensure 1/month/cashier
Beverage strategy in place with appropriate plan o grams
Infused water available and attractively displayed
Coolers compliant with plan o grams
Adequate variety of fountain, can, bottled beverages
Size and pricing appropriate
Grab n go strategy in place with appropriate plan o grams
Variety of entre e salads, sandwiches, side items, desserts, etc
Breakfast items offered during peak times
Coolers compliant with plan o grams
Appropriate PARs maintained to fill space AND reduce waste/out of dates

Local/regional/diverse menus are developed based upon sales analysis and/or

customer feedback, using standardized, scalable CNS recipes

Ethnic cuisines should be authentic and prepared in accordance with recipes

Vegetarian options are available at every meal
Healthy options are available at every meal
At least 2 monotony breakers offered every month
Customer satisfaction tool in place to garner hospital staff and visitor feedback

Catering/special function menus are developed based upon contract

requirements, client requests, and cost considerations using standardized,
scalable CNS recipes
A catering menu is in place with accurate pricing/costs- P&L accounts must
account for labor and non-food costs in catering pricing

Special function meals are provided as requested and priced accurately- P&L
accounts must account for labor and non-food costs in special function pricing

A detailed account of all catering costs and revenue/department credit is

maintained
Supplemental billing is complete as appropriate
Physician/Administrative dining facilities are clean, attractive and stocked
throughout meal period

Food is served in an attractive manner in accordance with hospital guidelines

Food is maintained at proper temp throughout meal period
Approved specialty items are stocked throughout meal period
Attendees are monitored in accordance with hospital guidelines
Tables are cleaned and sanitized in a timely manner after each customer
Financial/Administrative
Facility is appropriately licensed/permitted to operate in accordance with local,
state and federal guidelines
Sales data is monitored, analyzed and used to develop retail strategy, menu
development, and pricing models
Retail food costs are within budgeted percentage
Catering and other free meals such as Drs dining is accurately costed, and billed
where appropriate, in accordance with contract terms
Client specified subsidy compliance AND mechanism to track, monitor and share
with client: free meals, discounts, etc
Evidence of cash handling policy compliance
One cashier per register, or drawer, at a time
Cashier has reviewed and signed cash handling policy
Cash handling policy posted
Cashier audits conducted monthly
Accurate account of overs/unders documented with appropriate actions taken
for noncompliance
Cash and deposit logs are complete, current and on file
Security measures in place to safeguard cash and associates: safe in locked room
with limited access, cash counted privately, cash transported in safe manner
within the facility
Appropriate process in place to transfer and deposit cash in a reasonable
frequency
Evidence of retail/catering/hospitality floor leadership

Pre-service meetings are conducted prior to each meal period to review menu
items, taste food, discuss specials, etc- review meeting sign in sheets

Operation is ready to open on time with staff in place and food ready for service

Management is present and rounding on customers during peak retail times

Manager is engaged in retail functions, catering events, staff training/support, etc

Retail flow/design/organization is adequate to meet service needs, enhance

productivity, reduce waste

0.00%
Comments
Premesis, Equipment & Sanitation
In
Line Item Description Compliance
Chemicals labeled, stored and inventoried per CNS standards
Chemical inventory current, available and complete
SDS readily available for each hazardous chemical/material in inventory
Chemicals securely stored and away from food and disposable/combustible
products

Combustible chemicals stored off premises or in an approved fire proof container

Staff can verbalize how to access and use SDS on all shifts
Containers properly identified and labeled with hazard warning, as appropriate
Proper PPE available and in use when handling hazardous chemicals
Working eye wash station available with continuous 15-minute flow of tepid
water
Documentation of chemical and hazard material training conducted upon hire
and annually
Storage areas are clean, organized and inventoried per CNS standards
Inventory current, available and complete
Inventory items rotated according FIFO
Step ladder in good condition and of adequate size for use
Ceilings, vents, walls, floors, doors and aisles clean and free of clutter
Wall/floor joints are coved and in good condition
Shelves and racks are clean, have adequate strength, are secured, and have solid
bottom shelves to prevent contamination when mopping floor
Heavy items are stored on shelves no higher than 36 inches to prevent lifting
injury

Bulk food containers are clean and staff can verbalized cleaning protocols
Bulk food container scoops are not stored in bins
Compressed gas cylinders stored in upright position, are individually chained and
those not in use have protective cap in place
There is adequate lighting to prevent injury
Refrigerated storage units are clean, organized and inventoried per CNS
standards
Inventory current, available and complete
Inventory items rotated according FIFO
Each refrigeration unit has an independent thermometer located near the door
and used to monitor internal temperature
Ceilings, vents, walls, floors, doors and aisles clean and free of clutter/water/or
other slip hazards
Refrigeration doors close tightly and have clean, undamaged gaskets
Shelves and racks are clean, have adequate strength, are secured, and have solid
bottom shelves to prevent contamination when mopping floor
Nothing stored within 6 inches from walls or below 6 inches from floor to ensure
adequate ventilation
There is adequate lighting to prevent injury
Freezer storage units are clean, organized and inventoried per CNS standards
Inventory current, available and complete
Inventory items rotated according FIFO
Each freezer unit has an independent thermometer located near the door and
used to monitor internal temperature
Ceilings, vents, walls, floors, doors and aisles clean and free of clutter/ice/or
other slip hazards
Freezer doors close tightly and have clean, undamaged gaskets
Shelves and racks are clean, have adequate strength, are secured, and have solid
bottom shelves to prevent contamination when mopping floor
Nothing stored within 6 inches from walls or below 6 inches from floor to ensure
adequate ventilation
There is adequate lighting to prevent injury
Dish and ware wash area clean and items washed according to CNS standards

Shelves, ceilings, vents, walls, and floors clean and free of clutter/water/or other
slip hazards

Floor mats, non-slip material, or strips properly placed and in good condition
Clean and dirty dishes/pots/pans/linens separated
There is adequate ventilation
Items allowed to air dry with no evidence of wet nesting or towel drying
There is no evidence of lime or other contamination build up
Protective cover over disposal opening
No water leaks from hoses, valves, dish machine, etc
Dish machine log is current and complete with final rinse temperature above
180F or approved chemical disinfection strips
Staff can verbalize when to clean, trouble shoot, and change water/chemicals for
dish machine
3-compartment sink clean, in working condition, test strips available, and
sanitation sink within limits
Staff can verbalize how to change 3-compartment sink
Chemicals are calibrated, properly used and sanitizing sink contents tested with
each use

Appropriate cleaning supplies used and stored in clean, designated mop area
Area is clean, odor free, organized, and away from food prep or storage
Adequate supply of clean mops and pails are available for routine cleaning and
spills- No water or mops sitting in buckets
Mops are clean and hung to dry between use
Brooms are stored properly
35 safety cones are used when mopping or to identify slip hazards
PPE is available
Adequate hand washing sinks available, clean and stocked per CNS standards
Hand washing sink is clean with NO evidence of food in or around sink
Hand washing sink has signage in place indicating sink is for hand washing ONLY
and includes instructions

Hand washing sink is properly stocked with hand soap, disposable towels and
hot water, at least 100F- preferably operated by a foot peddle

Proper procedure is used for hand washing- Observe at least 3 associates

Food prep areas clean, organized and free from potential contamination
Prep sinks clean and NOT used for hand washing
Back flow prevention is present on prep sinks
All prep surfaces made of solid, non-porous material and NSF approved
Prep surfaces cleaned and sanitized after each food item is prepped or at least
every 4 hours during pro-longed prepping of one item
Counter top equipment is at least 4 inches above counter top
All shelving clean, dry and organized
Food prep equipment is clean, commercially certified, used and maintained per
manufacturers guidelines
All equipment is commercially certified and maintained via preventive
maintenance schedule- no frayed cords, no peeling paint or surfaces, grounded,
etc
A lockout/tagout procedure in place according to hospital policy and staff can
verbalize their role in the procedure
Extension cords are not used
Floor positioned equipment is at least 6 inches from the floor and suitably
anchored to prevent creeping or tipping
All slicers and grinders equipped with safety shield and left unplugged, set at
zero when not in use or during cleaning- cut resistant gloves for both hands
available and used when cleaning blade
Guards for equipment in place, used and not damaged
Can opener, particularly blades, are clean and in good repair
Knives are stored in removable/cleanable knife racks
No sharp corners projecting from machines
Steamers, ovens, stoves clean, free from debris/food and chemical buildup and in
working condition

Proper PPE available and in use- oven mitts, cutting gloves, thermal aprons, etc
Ice machines are clean and maintained per CNS standards
Ice machine cleaned according to cleaning schedule and cleaning/sanitizing log
utilized
Interior clean, free from slime or mold
Scoop properly stored
No items stored in the ice
Non-skid mat in place to prevent slip hazard
All areas of CNS department meet TJC/CMS environment of care (EOC), local and
state standards
Staff can verbalize hospital emergency codes, how to activate and what actions to
take when called
Lighting adequate, fixtures shielded
Floor tiles free from cracks, missing grout, etc
Ceiling tiles are free from stains, cracks, and chips. Ceiling vents are free from
dust and debris
Interior trash containers are clean, lined, emptied as needed, and made of fire
retardant material- Depending upon local regulations, may also need to be
covered
Staff is able to verbalize action steps in case of fire (RACE), including use of fire
extinguisher (PASS) and activating central fire suppression system
The proper type of fire extinguishers accessible, inspected, dated and signed
according to state, local, and/or hospital policy
Instructions for manually operating the fire suppression system is posted
conspicuously in the kitchen
All exit signs are lit and egress maps are posted at all fire pull stations
Fire doors in proper operational condition, unobstructed with NO door stops

Staff is able to verbalize action steps to shut off gas/electric in case of emergency
Cover plates, switches, outlets, etc are in good condition
Switches and circuit breakers are unobstructed (at least 36), closed and clearly
marked to indicate equipment/areas controlled

Hoods are cleaned at least quarterly by a professional exhaust cleaning service

and documented- may be located in hospital maintenance department

Filters are free of grease and cleaned regularly according to the master cleaning
schedule- ideally weekly
Department safety and sanitation standards observed
Food safety signage posted appropriately

An emergency plan is available with contingencies for: freezer/refrigeration

failure, gas/electrical outage, disaster readiness, etc

Restrooms are available, clean, fully stocked and in good repair- Doors self
closing, trash cans covered, etc
Pest prevention program is effective with NO signs of pests present, pest control
devices properly installed and maintained, and no pest entry points or harborage
sites observed

Broken glass and china is disposed separately in a designated, labeled container

Exterior garbage storage and removal adequate, covered, kept clean, and odor
minimized
Grease disposal program in place and exterior storage and removal adequate,
covered, kept clean, and odor minimized
Master cleaning schedule reviewed, current and complete- Ensure each piece of
equipment and workstation/service area is scheduled appropriately with
documented compliance
Associate safety and sanitation standards observed
Every manager has current ServSafe Manager certification
Food handlers cards are on file and current for all associates if required by local
regulatory agencies
Associates aware of reportable illness, health information standards- no evidence
of infected associates handling food
All persons entering the kitchen/food prep & service areas have proper hair
restraints- facial hair longer than # must be covered
Eating, drinking and tobacco use restricted to designated areas
Personal items properly stored in designated areas (locker rooms)- NO cell
phones observed
Associates are wearing closed toe, slip-resistant shoes
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Line Item Description Compliance
Employee files secured and complete
Files are stored in a locked office to protect personal information
The associate file checklist has been completed and signed by manager
EMB/Kiosk/Orientation/Competency/Evaluations complete in accordance with
HHS standard
New hire orientation complete
New hire competency complete
Annual competency complete
Any hospital required training complete
Annual performance review complete
FSD meets minimum education/experience for position in accordance with
regulatory and HHS standards
FSD is a Registered Dietitian or Certified Dietary Manager
FSD is enrolled in an accredited CDM course with completion expected within 18
months
FSD education and experience approved by VP in accordance with CMS
guidelinesdocumented in FSD employment file

Clinical team members (including per diem/contract staff) meet minimum

licensure/education/experience for position in accordance with HHS standard

RD files contain primary source licensure verification UPON HIRE and annually

RD files contain proof of minimum CPEs per local, state and national licensure
RD files contain current proof of state requirements/licensure
Associates performing delegated tasks, such as nutrition screening, re-
assessment, patient teaching, etc, posses minimum qualifications

Nutrition Care Manual current, approved, and available to all hospital staff

Manual approved by RD and medical staffapproving email/letter or meeting

minutes
Staff aware of where and how to access NCMinterview food service AND
nursing staff
A local copy is available (CD or hard copy)
Clinical nutrition care is provided in accordance with professional and regulatory
standards
Clinical records reviewed to ensure initial assessment and re-assessments are
conducted according to policy

Clinical records reviewed to ensure appropriate nutrition

diagnosis/interventions/monitoring/education conducted according to policy

There is evidence of interdisciplinary collaboration in the clinical record (patient

education, discharge planning, etc)
Nutrition-related performance improvement activities are integrated into overall
organizations PI process
Indicators are multidisciplinary except for departmental QA activities such as test
tray results, ambassador performance, etc.
TJC and/or CMS required nutrition-related quality indicators are included when
appropriate (discharge diet instructions for heart failure)

Indicators include any deficiencies sited by most recent internal or external

regulatory agency (hospital PI team, CNS PI, TJC, CMS, Health department, etc)

The following are documented for each indicator: Data source, persons
responsible for collecting data, method of reporting data, sample size, and
frequency of data collection

There is evidence nutrition-related PI activities/findings are included in overall

hospital PI processmeeting minutes, copies of data presented, etc

Nutrition-related policy and procedure manual current, approved and available

to all hospital staff
Manual approved by qualified hospital representative (administrator/P&P
Committee/Medical Director/etcapproving cover page/email/letter or
meeting minutes
Staff aware of where and how to access nutrition-related policiesinterview
food service AND nursing staff
A local copy is available (CD or hard copy)
Minimum nutrition-related policies in place and in accordance with regulatory
guidelines-- If using hospital-owned policies, ensure there are NO conflicting HHS
policies on file

Policy requiring RN nutrition screen completed within 24 hours of admission

Policy defining assessment/reassessment timelines with prioritization for

medical nutrition therapy in accordance with regulatory standards
Policy defining nutrition education process, including timeframes,
roles/responsibilities by discipline, documentation, etc
Policy specifying dietitian and delegated (CDM) coverage, including weekends,
part-time and per diem
Policy addressing nutrient drug interaction process, including Coumadin
Other nutrition-related policies in place and in accordance with regulatory
guidelines-- If using hospital-owned policies, ensure there are NO conflicting HHS
policies on file
Policy defining RD order writing privileges IF permitted by state and approved by
HHS VP
Policy outlining tray delivery process, including times, roles/responsibilities by
discipline by unit, late tray process, etc
Policy regarding parenteral nutrition
Policy addressing HACCP principles for enteral products
Others as appropriate: herbal remedies/alternative nutrition, accommodating
personal dietary requests, etc

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