Food Safety and Sanitation Audits in Long-Term Care

Poor food safety practices are among the most common tags or deficiencies that surveyors cite in long-term care.

The most frustrating part is that they’re easily preventable.

The best way to prevent these tags is to understand how to keep food safe so you can educate your employees and then conduct regular audits to ensure they are practicing good food safety.

This article explains the basics of food safety that dietitians and dietary managers working in long-term care must know and the importance of regular food safety and sanitation audits.

Food safety in long-term care

Regardless of age or medical conditions, residents of long-term care centers like nursing homes and assisted living facilities are considered a highly susceptible population.

Highly susceptible populations are more likely than the general public to develop foodborne illnesses and experience health complications from them.

This makes following good food safety practices especially important.

The Centers for Medicare and Medicaid (CMS) — the regulator of long-term care centers — recognizes the Food and Drug Administration’s (FDA) Food Code as the natural standard for food safety regulations (1).

These are the federal guidelines but you must also follow any specific state guidelines for food safety in your long-term care center.

It’s your responsibility as the dietitian or dietary manager to be familiar with these regulations so that you can educate your employees and ensure that they are following them.

Food safety throughout the flow of food

The flow of food is the path that food takes from purchasing and receiving through storage, preparation, cooking, holding, cooling, reheating, and service.

There are multiple opportunities for food to become contaminated with pathogens — disease-causing organisms like bacteria and viruses — and make residents sick.

As such, you must know how to keep food safe throughout its flow.

Purchasing and receiving

You must purchase all food from approved, reputable food suppliers.

This helps reduce the risk of unsafe food entering your kitchen.

Reputable suppliers:

• have been inspected
• meet all local, state, and federal laws
• follow good manufacturing practices (GMPs)
• follow good agricultural practices (GAPs)

However, purchasing from reputable suppliers does not mean that you can trust the food you receive is safe.

You must inspect the food delivery as soon as it arrives to ensure boxes are in good condition, cans aren’t dented, and there are no leaks or signs of pest contamination.

Additionally, check the temperature of time-temperature control for safety (TCS) foods.

Examples of TCS foods include:

• milk and milk products
• meats, poultry, and seafood
• cut melons, tomatoes, and leafy greens
• garlic-in-oil mixtures

Receive all TCS foods at 41ºF (5ºC) or below, except live shellfish, milk, and eggs, which you can receive at an internal temperature of 50ºF (10ºC) or below.

If you receive hot TCS foods, you must receive them at the top of the temperature danger zone — 135ºF (57ºC) or higher.

Storing

Store cold food in fridges and freezers and dry foods in dry storage.

Refrigerators must maintain a temperature of 41ºF (5ºC) or below and freezers should be cold enough to keep food frozen — around 0ºF (-18ºC) or below.

Label TCS foods stored in the fridge with a use-by date and use the first in, first out (FIFO) method of food storage to ensure products closest to their use-by date are the first to be used.

Foods that you prepare and hold for 24 hours or more must be labeled with the item name, the date prepared, and the date it should be served or tossed.

You can safely store leftovers for up to seven days, with the day of preparation or opening counting as the first day.

Store food in the refrigerator in order of their minimum internal cooking temperature, with those that require the highest on the bottom.

Maintain the temperature of the dry storage between 50ºF and 70ºF (10ºC and 21ºC). Label any product in dry storage that you remove from its original container with the common name.

Store food at least 6 inches off the floor in cold and dry storage. In dry storage, store food at least 18 inches from the ceiling to prevent the obstruction of water from the sprinkler in the case of a fire.

Preparation and cooking

Unsafe food preparation techniques can result in cross-contamination, which occurs when pathogens are accidentally transferred from one food to the next.

Cross-contamination usually occurs when a food handler works with raw animal products and then switches to handling ready-to-eat (RTE) foods like cooked hot dogs, washed fruits and vegetables, salads, or sandwiches.

At no time should food workers handly RTE food with their bare hands — there must always be a barrier.

This barrier may include single-use gloves, tongs, deli tissue, or other serving equipment.

Use a calibrated food thermometer to verify that food has reached a safe minimum internal temperature.

Minimum Internal Temperature	Food
165ºF (74ºC) < 1 second (instantaneous)	• Poultry, including chicken, turkey, and duck • Stuffing made with fish, meat, or poultry • Stuffed meat, seafood, poultry, or pasta • Dishes that contain previously cooked TCS ingredients • Previously cooked TCS foods reheated for hot-holding • Wild game animals
155ºF (68ºC) for 17 seconds	• Ground meat, including beef, pork, and other meats • Injected meats, including brined ham and other flavor-injected roasts • Mechanically tenderized meat • Ground seafood, including chopped or minced • Shell eggs that will be hot-held for service • Ratites, including ostrich and emu
145ºF (63ºC) for 15 seconds	• Seafood, including whole fish and shellfish • Meats, including whole cuts of pork, beef, veal, and lamb • Commercially-raised game like rabbits • Shell eggs served immediately
145ºF (63ºC) for 4 minutes Alternate cooking times: • 130ºF (54ºC) – 112 minutes • 131ºF (55ºC) – 89 minutes • 133ºF (56ºC) – 56 minutes • 135ºF (57ºC) – 36 minutes • 136ºF (58ºC) – 28 minutes • 138ºF (59ºC) – 18 minutes • 140ºF (60ºC) – 12 minutes • 142ºF (61ºC) – 8 minutes • 144ºF (62ºC) – 5 minutes • 145ºF (63ºC) – 4 minute	• Roasts, including pork, beef, veal, and lamb

All eggs must be cooked through so that the yolk is firm unless you use pasteurized eggs.

Holding and cooling

Hold hot foods at 135ºF (57ºC) or higher and cold foods at 41ºF (5ºC) or lower.

Monitor the temperature at least every four hours to ensure the food is at a safe temperature.

You cannot rely on the temperature gauge of cold- or hot-holding equipment like a steam table since the gauge displays the temperature of the device, not the internal temperature of the food.

Use the two-stage cooling method to safely cool foods.

In the first stage, you must cool foods from 135ºF (57ºC) — the minimum temperature at which foods must be hot held — to 70ºF (21ºC) within two hours.

Then, cool from 70ºF (21ºC) to 41ºF (5ºC) within four hours to complete the second stage.

The entire process should take six hours or less. If you cannot cool foods to 41ºF (5ºC) within six hours, you must recondition the food by reheating it to 165ºF (74ºC) and then try again.

You can set up an ice water bath, stir the food using an ice paddle, or use a blast chiller to cool food more rapidly.

Additionally, you can speed up the cooling process by separating dense or liquid items like casseroles, mashed potatoes, and rice into shallow pans and cutting thick items like roasts into smaller pieces to allow heat to dissipate more rapidly.

You can also add cold water or ice to soups, stews, and other liquid water to cool them more quickly. Just make these items with less and then add water or ice after it’s finished cooking to cool.

Reheating and serving

Reheat TCS foods to at least 165ºF (74ºC) for 15 seconds.

In the case of shelf-stable, commercially prepared RTE foods like soup concentrate, you only need to reheat them to the minimum hot-holding temperature of 135ºF (57ºC).

Reheat food safely using any type of cooking equipment that can bring food to 165ºF (74ºC) within two hours.

You cannot use a steam table to reheat food since it won’t bring food to the proper temperature within two hours.

The biggest safety concern with serving is poor hand hygiene and bare-hand contact with RTE foods.

Food workers must wash their hands any time they become contaminated and before and after wearing single-use gloves.

Food workers often have a sense of protection when wearing single-use gloves in that they don’t need to change them so relying less on them and more on dispensing equipment could be a better option.

Conducting food safety and sanitation audits

You don’t want to wait for a surveyor to issue a tag for poor food safety practices and then correct the concerns.

Instead, you need to take a proactive approach so that you can identify and correct food safety concerns.

This will save your center from often costly survey tags but more importantly, keep your residents safe.

Conduct food safety and sanitation audits at least monthly but more often if you identify multiple and reoccurring food safety concerns.

Conduct these audits at different times of operation and at different stages of food flow, such as during receiving, preparation, and serving.

Food workers are likely to catch on and act more cautiously if they know that you’re conducting an audit so recruiting other staff members — including those who are not involved in foodservice — to conduct them can provide a more clear picture of food safety concerns.

If you don’t have an audit form, you can download this one as a PDF document for free:

Along with your audits, don’t forget to educate your staff on any required training by your state.

For example, South Dakota required regular dietary inservice training on specific food safety topics.

The bottom line

It’s your responsibility as the dietitian or dietary manager that your staff are following the best practices when it comes to food safety.

Know how to keep food safe through each stage of its flow — from receiving to serving — so you can educate your staff.

Conduct regular food safety and sanitation audits to identify and correct unsafe food handling practices to prevent costly tags and keep your residents safe.