BACKGROUND: Adults over 65 have increased incidence of enteric disease, subsequent hospitalization and death. Seniors living in long term care facilities (LTCF) consume most of their meals onsite; lapses in food safety puts residents at risk. As is the case in many other states, Colorado LTCF kitchens are exempt from retail food inspections. LTCF kitchens are regulated by the Health Facilities Emergency Medical Services Division (HF) as part of facility-wide inspections conducted every 1-3 years by non-EH personnel. Following a deadly LTCF Salmonella outbreak, HF and the Division of Environmental Health and Sustainability (EH) collaborated to assess inspections of LTCF kitchens.
METHODS: An EH specialist inspected 150 Colorado LTCF kitchens using a standardized inspection form. Results were compared to the most recent HF inspection of the same facilities. Violations are classified as critical (presence/introduction/ proliferation of bacteria, viruses, and other contaminants in food; directly related to foodborne disease) or non-critical (basic sanitation/ cleaning; unlikely to lead to foodborne disease). For each violation, results could be concordant (both or neither HF and EH identified violation) or discordant (only HF or only EH identified the violation). McNemar's test was performed to compare frequencies of discordant results (p=0.05); when values of discordant results <20, McNemar’s exact test was used.
RESULTS: EH found more violations than HF in these categories: cross-contamination (p<0.000), handwashing (p<0.000), hygienic practices (p<0.000), cooling (p=0.006), hot holding(p<0.000), cold holding (p<0.000), food thermometers (p<0.000), handwashing accessibility (p<0.000), soap and drying device availability (p=0.013), and plumbing installation/maintenance (p=0.006); all violations except plumbing were critical violations. HF found more violations than EH in these categories: food storage container (p=0.02), food protected from contamination (p<0.000), refrigerator thermometers (p=0.039), food-contact surfaces (p=0.002), non-food contact surfaces (p<0.000), single use utensils (p<0.000), floor/wall/ceiling maintenance (p=0.016), and personnel clothing /hair restraint (p<0.000); none of these were critical violations.
CONCLUSIONS: EH and HF inspections identified different types of violations. HF inspections identified non-critical violations that are observational, such as facility cleanliness, hair restraints, and utensil use. EH identified more critical violations associated with foodborne illness, such as cross-contamination, handwashing, and temperature violations. Though inspections occurred at different times, HF inspections likely missed critical violations that if not corrected can lead to foodborne illness. Based on these results, Colorado is recommending modifications to the current approach, that include more frequent, risk-based LTCF kitchen inspections be conducted by staff with specific training and expertise in food safety and environmental health.