Besides excellent medical care and appropriate medications, a critical access hospital must ensure patients receive proper nutrition. Food and supplements must be maintained and stored in a way that ensures patient safety. The Food Services Department should collaborate with Clinical Services as well as Infection Prevention to develop policies and procedures regulating storage of food and nutritional supplements throughout the facility.

Accreditation Commission for Health Care (ACHC) Critical Access Hospital Accreditation Standards address safe food handling, preparation, and storage.

Stay Informed

Standard 06.03.08 – Policy requirements: Food preparation and storage

The ACHC standard requires that policies be in place at the Critical Access Hospital to address food storage centers and patient care areas. The policies, at a minimum, should acknowledge the following:

• Rotation of stock and supplies.
• Monitoring and removal of outdated supplies.
• Following of cleaning procedures and frequency of cleaning for all food preparation work areas and equipment.
• Measuring and recording of refrigerator and freezer temperatures.
• Storage, refrigeration, preparation, and heating of nutritional supplements, infant formulas, breast milk, and patient food brought from home.
• Labeling of food items with patient name, room number, and expiration date.
• Separation of refrigerators for patient food, employee food, breast milk, and medications.
• Guidelines for ordering infant formulas.
• Guidelines that govern acceptable ingredients that may be added to formulas.
• Storage, preparation, and temperature control of breast milk and infant formula products.
• Patient safety with heated breast milk and infant formula.

Maintain Compliance

When a Surveyor Visits

While conducting a survey, an ACHC Surveyor will ask to review the food safety policies and will look for evidence demonstrating the policies have been developed in collaboration with food services, clinical services, and infection prevention. The Surveyor will also assess:

• All food safety policies and evidence that they have been reviewed and approved by the Infection Control Committee.
• The manner in which food items are stored and labeled.
• Food refrigerators for the presence of medications being stored erroneously (medications are not to be stored in refrigerators designated for food).
• Refrigerator temperatures and evidence that they are maintained within safe guidelines and are monitored appropriately.
• Breast milk refrigerators to ensure they are labeled appropriately and contain only breast milk or formula.
• Refrigerator and freezer temperature logs to ensure they are maintained.
• Processes for food preparation and storage to ensure they are standardized and system-wide (for example, processes are consistent in the kitchen, nursing units, and occupational therapy).

Tips for Compliance

Establishing and following policies and procedures will help the critical access hospital safely store and provide food and nutritional supplements.

• Implement a method to ensure the Infection Control Committee reviews the food safety policies at a minimum every two years or when changes are made.
• Provide staff education on safe food handling, safety, and storage.
• Provide staff education on temperature management, documentation requirements, and steps to take if the temperature falls outside of the acceptable range.
• Include food storage and management observation in your Environmental Surveillance Rounds – checking for rotation of food products and use by and expiration dates.

Here to Help

ACHC is more than an accreditor. We are your partner. For more information, or to obtain a copy of the ACHC Critical Access Hospital Accreditation Standards Manual, contact your Account Advisor, email [email protected], or call (855) 937-2242.