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Solving the Survey Puzzle for F371. Sara Gosnell, RD, CD. Objectives. Describe the relationship between the regulation and the interpretive guidance Describe how to use the investigative protocol Describe and apply components of the investigative protocol

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Solving the survey puzzle for f371 l.jpg

Solving the Survey Puzzlefor F371

Sara Gosnell, RD, CD


Objectives l.jpg
Objectives

  • Describe the relationship between the regulation and the interpretive guidance

  • Describe how to use the investigative protocol

  • Describe and apply components of the investigative protocol

  • Identify areas of noncompliance with the sanitary conditions regulation

  • Appropriately categorize the scope and severity of noncompliance


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F371 Revisions

  • F370 merged into F371

  • Regulatory language was kept the same

  • Revisions now provide:

    • 13 new definitions

    • Education

    • Explanations

    • Examples for surveyors to reference


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Defined by Federal Regulation

  • The facility must

    • 483.35(i) (1) Procure food from sources approved or considered satisfactory by Federal, Stated, or local authorities

    • 483.35(i) (2) Store, prepare, distribute and serve food under sanitary conditions


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Intent

  • Facility obtains food for resident consumption from sources approved or considered satisfactory by federal, state, or local authorities

  • Follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness; beginning with the vendor through the facility’s food handling processes.


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Cross contamination

Danger zone

Dry storage

Food contamination

Food preparation

Food service/distribution

Foodborne illness

Highly susceptible population

Pathogen

PHF

Ready-to-eat food

Storage

Toxins

Definitions


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Cross Contamination

  • The transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils that are not cleaned after touching raw food, and then touch ready-to-eat foods. This may also occur if raw food touches or drips onto cooked or ready-to-eat food.


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Danger Zone

  • Used for PHF

  • Temps between 41°-135° F* that allow rapid growth of pathogenic microorganisms that can cause foodborne illness

  • >4 hours during preparation

  • >6 hours for items cooked and cooled

    *the temps are based on the food code which are the most stringent


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Dry Storage

  • Storing and maintaining dry foods (e.g., canned goods, flour, sugar) and supplies (disposable dishware, napkins, and kitchen cleaning supplies)

    • Examples: ensuring paper goods are open from the right end and plastic bags of silverware are sealed and not left open


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Storage

  • The retention of food (before and after prep) and associated dry goods

    • Example: NOT keeping scoops in flour or sugar bins even if the handle is up


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Food Contamination

  • The unintended presence of potentially harmful substances, including but not limited to microorganisms, chemicals or physical objects in food.

    • Example: fake fingernail in food


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Food Preparation

  • The series for operational processes involved in getting foods ready for serving, such as: washing, thawing, mixing ingredients, cutting, slicing, diluting, concentrates, cooking, pureeing, cooling and reheating.

    • Example: not washing fruit; rinsing a knife, not washing it and using it again


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Foodborne Illness

  • Illness caused by the ingestion of contaminated food or beverages

    ►Foodborne outbreak

    • 2 or more unrelated people that ate a similar meal


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Food Service/Distribution

  • The processes of getting food to the resident

    • Holding foods hot on the steam table or under refrigeration for cold temp control

    • Dispensing food portions for individual residents

    • Family style and dining room service

    • Delivering trays to residents’ rooms or units


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Highly Susceptible Population

  • Persons who are more likely than the general population to experience foodborne illness because of their susceptibility to becoming ill if they ingest microorganisms or toxins (e.g., immunocompromised, chronic disease and advanced age)


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Pathogen

  • An organism capable of causing a disease (e.g., pathogenic bacteria or viruses)

    • Norovirus


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Potentially Hazardous Food (PHF or TCS)

  • Food that requires time-temp control for safety to limit the growth of pathogens or toxin formation

    ٭TCS- time/temp control for safety


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Ready-to-Eat Food

  • Food that is edible with little or no prep to achieve food safety

    • Includes foods requiring minimal preparation for palatability or culinary purposes, such as mixing with other ingredients (e.g., tuna, chicken or egg salad)

      • Examples include deli items and raw fruits and vegetables


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Toxins

  • Poisonous substances that are produced by living cells or organisms (e.g., pathogenic bacteria) that cause foodborne illness when ingested


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Overview

  • The risk for foodborne illness (FBI)

  • Importance of effective food safety systems

  • Identify hazards and critical control points (CCPs)

  • Operational steps to eliminate hazards


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Types of Food Contamination

  • Biological

  • Chemical

  • Physical



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Biological Contamination

  • Most common types of disease producing organisms

    • Bacteria

    • Viruses

    • Toxins

    • Spores

    • Parasites


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Factors Influencing Bacterial Growth

  • Food

  • Acidity

  • Time

  • Temp

  • Oxygen

  • Moisture


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Chemical Contamination

Monitor to ensure spray cleaners are not within proximity to food prep area to prevent food from being sprayed

Ensure bottles are properly labeled

  • Soap should not be stored in an unlabeled styrofoam container

  • Powder cleaners could be mistaken for a cooking product


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Physical Contamination

  • Foreign objects in food

    • Hair

    • Fingernails

    • Metal shavings

    • Jewelry

  • Do NOT use:

    • a glass as an ice scooper

    • A steel scouring pad to clean


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Other Factors Involved in Foodborne Illness

  • Poor personal hygiene

  • Inadequate cooking and improper holding

  • Contaminated equipment

  • Unsafe food sources


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Prevention of Foodborne Illness

  • Food handling and preparation

  • Employee health

  • Hand washing, gloves, antimicrobial gel


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Employee Illness

An employee will be restricted from working with food if they are experiencing symptoms of:

  • Fever

  • Cough/sore throat

  • Diarrhea

  • Open wound, not bandaged/covered


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Safe Food Storage

  • FIFO!!

  • Dry food storage should be maintained in a clean and dry area

  • Safe refrigerator practices

    • Monitoring temps

    • Proper handling/cooling of hot foods

    • Separation of raw, cooked and ready-to-eat foods


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Safe Food Preparation

  • Cross contamination

  • Thawing

  • Final cook temps

  • Modified consistency

  • Cooling

  • Reheating food

  • NO pooled eggs unless pasteurized


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Thawing Foods Properly

  • Under cold water, < 70°F, agitating enough to get off ice

  • In the cooler

  • Microwaving; food needs cooked immediately following

  • Cook from frozen state



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Proper Cooling Techniques

  • Techniques

    • Shallow pans for smaller quantities

    • Ice bath

    • Frequent stirring

    • Cooling paddles

  • 135° F ► 70° F► within 2 hours

    70 ° F► 41° F ► within 4 hours

    ٭Total time not to exceed 6 hours


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Proper Reheating Procedures

  • Required internal temp = 165°F for 15 seconds minimum

    • Only for foods properly cooled

    • Can only reheat a food item once!

      ٭Facility-made pureed food cannot be reheated


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Equipment and Utensil Cleaning and Sanitization

  • Machine wash and sanitize

  • Manual wash and sanitize

  • Cleaning fixed equipment

    √ Test strips should be at each station and used!!


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Food Service and Distribution

  • Tray line, alternative meal preparation and service are

  • Food distribution

  • Snacks

  • Special events

  • Transported foods

  • Ice

  • Refrigeration


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Wiping Cloths

  • Service area wiping cloths are cleaned and dried, or

  • Place in a chemical sanitizing solution of appropriate concentration

    √ test strips need used periodically as sanitizer strength decreases over time


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Surveying Facilities That Receive Food Prepared by Off-site Kitchens

When a nursing home receives food services from an off-site location, the surveyor must assess whether the facility is compliant with 42 CFR 483.35 (i)

٭Your facility should have on hand a copy of the most recent sanitation inspection from the off-site location


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Culture Change Provisions Kitchens

  • Family members, or other resident guests, who bring in food for the resident’s consumption are not regulated under this federal tag.

    ● many state regs address this

    • Dietary is responsible for foods cooked by recreation department, and should be trained accordingly

    • A cake from the bakery is ok, but bake sales to the residents should notbe done

    • Families/guests can bring food in for the individual but it should not be set out for others


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Pathogenic Microorganisms and Strategies for Their Control Kitchens

  • Commonly identified ingestible items associated with illness-producing organisms

  • Primary agents of concern (hazards) are organisms associated with the food source

  • PHF/TCS primary control strategies to minimize potential for foodborne illness outbreak


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Investigative Protocol Sanitary Conditions Kitchens

Use this protocol to investigate compliance

at F371 (483.35 (i) (1) and (2))


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Objectives Kitchens

  • To determine if the facility procured food from approved sources

  • To determine if the facility stores, prepares, distributes and serves food in a sanitary manner to prevent FBI

  • To determine if the facility has systems (e.g., policies, procedures, training, and monitoring) in place to prevent the spread of FBI and compromising of food safety

  • To determine if the facility utilizes safe food handling from the time the food is received from the vendor and throughout the food handling processes in the facility


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Investigative Protocol Procedure During Survey Kitchens

  • Observations

  • Interviews

  • Record reviews

  • Review of facility practices


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Observation Kitchens

  • Surveyors will observe

    • food procurement

    • Service of food during meals

    • Service after meal

    • Storage of food


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Observation of Food Procurement Procedures Kitchens

  • Observe when, where and how food is procured

    • Invoices (to verify sources)

    • Vendor records

    • Source verification

    • Temps upon arrival

    • Visually observe items

      • Are boxes wet?


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Observation of Food Preparation Procedures Kitchens

  • Food handling practices

  • Food labeling and dates

  • Hand washing

  • Handling of potential cross contamination foods

  • Acceptable cooking and cooling temps


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Observation of Trayline Service Kitchens

  • Observe staff measuring the temp of all hot and cold menu items at all points of service

    • Cold food should be ≤ 41° F

    • Hot foods should be ≥ 135° F

      ٭ensure staff are taking temps from the middle of the food item


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Observation of Dish Room Procedures Kitchens

  • Observe whether staff are properly operating dish machine and evaluate sanitization processes

  • Check for proper equipment and supplies to evaluate dish machine operation

  • Observe the 3 step process of manual pot and pan washing

    • What sanitizer do you use with what test strip?


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Observation of Service After Meals Kitchens

  • Observe store dishes, utensils, pots/pans, and equipment for evidence of soiling

    • Can the lowerator be splashed by dirty water?

  • Evaluate whether proper hand washing is occurring between handling soiled and clean dishes to prevent cross contamination of the clean dishes


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Observation of Food Storage Kitchens

  • Look for evidence of pests, rodents and droppings and other sources of contamination

  • Observe whether foods are labeled and dated

  • Observe whether foods are stored off of the floor

  • Check for canned goods that have a compromised seal

  • Observe whether staff access bulk foods without touching the food


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Interview Protocol Kitchens

  • Surveyor will interview multiple staff regarding the policies and procedures for procurement, preparation and service of food to the residents

    • Staff need to be able to answer these questions, as well as, possibly perform the task if asked correctly


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Record Reviewal Protocol Kitchens

  • Resident records

  • Dietary/kitchen policies and procedures

  • Maintenance records, such as work orders and manufacturer's specifications, related to equipment used to store, prepare and serve food

  • Facility infection control records


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Determination of Compliance for F 371 Kitchens

Did the facility:

  • Procure food from approved sources?

  • Properly store, prepare, distribute and serve foods for residents’ consumption?

    ٭٭٭Important to review food temps in resident council, or food committee, monthly to ensure temps are palatable at point of service to the residents. After point of service, it becomes a palatability issue, rather than a temp issue.


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Criteria for Compliance with F371 Kitchens

  • Procures, stores, handles, prepares, distributes and serves food to minimize the risk of FBI

  • Maintains PHF/TCS foods at safe temps, cools food rapidly, and prevents contamination during storage

  • Cook food to the appropriate temp and hold PHF/TCS foods cold or hot

  • Utilizes proper hand washing and personal hygiene practices to prevent food contamination

  • Maintains equipment and food contact surfaces to prevent food contamination


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Noncompliance with F371 Kitchens

May include, but is not limited to, one of more of the following, failure to:

  • Procure, store, handle, prepare distribute and serve food in accordance with the standards summarized in the guidance

  • Maintain PHF/TCS foods at safe temps, at or below 41°F (for cold foods) or at or below 135°F (for hot foods.

    • Exception: during prep, cooking or cooling

  • Ensure that PHF/TCS food plated for transport was not out of temp control for more that 4 hours

  • Store raw foods properly to reduce the risk of contamination of cooked or ready-to-eat foods

  • Ensure that foods are cooked to the appropriate temp and cooled properly to prevent FBI


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Severity Determination Kitchens

  • Harm/negative outcome(s) or potential for negative outcomes due to a failure of care and service

  • Degree of harm (actual or potential) related to noncompliance, and

  • Immediacy of correction required


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Determining Actual or Potential Harm Kitchens

Actual or potential harm/negative outcomes for F371 include:

  • Foodborne illness

  • Ingestion or potential ingestion of food that was not procured from approved sources, prepared, distributed or served under sanitary conditions


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Determining Degree of Harm Kitchens

How the facility practices caused, resulted in , allowed, or contributed to harm (actual/potential)

  • If harm has occurred, determine if the harm is at the level of serious injury, impairment, death, compromise, or discomfort, and

  • If harm has not yet occurred, determine how likely the potential is for serious injury, impairment, death, compromise or discomfort to occur to the resident.


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Severity Level 4 Deficiency Categorization Kitchens

Immediate Jeopardy

To Resident’s Health or Safety


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Level 4 Immediate Jeopardy Kitchens

  • Has allowed/caused/resulted in, or is likely to cause serious injury, harm, impairment, or death to a resident; and

  • Requires immediate correction, as the facility either created the situation or allowed the situation to continue by failing to implement preventative or corrective measures.


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Level 4 Deficiency Kitchens

  • Example #1

    • A roast thawing on a plate in the refrigerator had bloody juices overflowing and dripping onto uncovered salad greens on the shelf below

    • The contaminated salad greens were not discarded and were used to make salad for the noon meal


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Level 4 Deficiency Kitchens

  • Example #2

    • The facility had a recent outbreak of norovirus as a result of a food worker experiencing episodes of vomiting and diarrhea, and the facility allowed the staff to continue preparing food.

    • Observations and interviews indicate that there are other food service staff experiencing gastrointestinal illnesses who are still permitted to prepare food.


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Severity Level 3 Deficiency Categorization Kitchens

Actual Harm that is not immediate jeopardy

The negative outcome may include but may not be limited to clinical compromise, decline, or the resident’s inability to maintain and/or reach his/her highest practicable level of well-being.


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Level 3 Deficiency Kitchens

  • Example #1

    • An outbreak of nausea and vomiting occurs in the facility related to the inadequate sanitizing of dishes and utensils

  • Example #2

    • A milk episode of food poisoning occurred because the facility had a special even tin which tuna, chicken, and potato salads served in bulk were not kept adequately chilled and were left out for eating after 5 hours


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Severity Level 2 Deficiency Categorization Kitchens

No actual harm with potential for more than minimal harm that is not immediate jeopardy


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Level 2 Deficiency Categorization Kitchens

  • Noncompliance tat results in a resident outcome of o more than minimal discomfort, and/or

  • Has the potential to compromise the resident’s ability to maintain or reach his or he highest practicable of well-being


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Level 2 Deficiency Kitchens

Example #1:

  • food service workers sliced roast pork on the meat slicer

  • The meat slicer was not washed, rinsed and sanitized after usage

  • During the dietary service system assessment, two days later, the surveyor observed the meat slicer soiled with dried meat underneath the blade

  • The facility failed to educate and train staff on how to clean and sanitize all kitchen equipment


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Level 2 Deficiency Kitchens

Example #2:

  • During the tour of the kitchen, two food service workers were observed on the loading dock

  • One was smoking and the other employee was emptying trash

  • Upon returning to the kitchen, they proceeded to prepare food without washing their hands


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Severity Level 1 Deficiency Categorization Kitchens

No actual harm with potential for minimal harm


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Level 1 Deficiency Categorization Kitchens

The failure of the facility to procure, prepare, store, distribute and handle food under sanitary conditions places this highly susceptible population at risk for more than minimal harm.

  • Therefore, Severity Level 1 does not apply for this regulatory requirement.


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Additional Investigation Kitchens

Potential tags from additional investigation

  • F322- Nasogastric Tubes

  • F325- Nutrition

  • F353- Sufficient Staffing

  • F361- Dietary Services- Staffing

  • F362- Standard Sufficient Staffing

  • 42 CFR 483.35 (h) Paid Feeding Assistant

  • F441- Infection Control

  • F444- Handwashing Techniques

  • F456- Maintain All Essential Equipment

  • F465- Other Environmental Conditions

  • F469- Effective Pest control Program

  • F540- Quality Assessment and Assurance


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F371 and the Food Code Application Kitchens

  • Know what the Federal Regs and your state have adopted in regards to a Food Code

  • Compare with F371, which uses the 2005 FDA Food Code


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Implications for the Foodservice Supervisor Kitchens

  • Must be more observant of staff practices and accountable for safe food handling

  • Be able to use the new surveyor “Investigative Protocol” to self-survey the kitchen

  • Enlist the Consultant, or in-house, RD

    • To help review the policies and procedures concerning current industry standards for safe food handling

    • Develop and implement thorough orientation and ongoing inservices in food handling


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Implications for the RD Kitchens

  • If you haven’t already, now is the time to

    • Begin developing inservices

    • Become certified in food safety

  • Determine if you will need more time in your facilities to ensure regulation compliance is maintained


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Implication for Administration Kitchens

As surveyors are trained on the revision of F371, the new Investigative Protocol for Sanitary Conditions, and the new Scope/Severity determinations NO Administrator will want a deficiency in “unsafe food handling”, especially NOT and Immediate Jeopardy


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Post Test Kitchens

1. Glove use is not important when handling ready-to-eat foods

True False

2. Which of the following is not part of the revisions for F371

  • Definitions

  • Education

  • Scope of practice

  • Explanations

  • Examples


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Post Test Continued Kitchens

3. During the Investigative Protocol, the surveyors are to have no contact with the staff, only with paper records.

True False

4. The Food Danger Zone is 40°F -140°F.

True False


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Post Test Continued Kitchens

5. A surveyor observed an employee load dirty dishes in the dish machine, then walk to the clean end to unload them without washing his hands. What level of severity would the facility be tagged with?

a.Level 1

b. Level 2

c. Level 3

d. Level 4


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Post Test Continued Kitchens

6. It is important to have an RD involved in developing and implementing policies and procedures

True False

7. What is the time frame allowed to correct a Level 4 Severity, or Immediate Jeopardy?

  • Immediately

  • 1 month

  • 3 months

  • 6 months


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Post Test Continued Kitchens

8. Which is not a potential for citation?

  • A cloth being kept in sanitizer solution

  • A roast in the cooler labeled and dated from the prior day

  • Temp of hot foods at point of service being 135°F

  • A staff member delivering a tray with no gloves

  • All of the above


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Post Test Continued Kitchens

9. If you receive food from an off-site facility, you do not need to be concerned with sanitation checks

True False

10. Which of the following is not part of the Investigative Protocol?

  • Observations

  • Interviews

  • Education

  • Record Reviews

  • Review of Facility Practices


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Answers Kitchens

1. False

2. C

3. False

4. False

5. B

6. True

7. A

8. E

9. False

10. C


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