FOOD AND NUTRITION SERVICES TEST TRAY EVALUATION. MEAL: M N Ex DAY OF CYCLE 4 DIET: Regular 1

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1 FOOD ND NUTRITION SERVICES TEST TRY EVLUTION DTE: 5 / 2 / 2 DY: S M T Wx T F S MEL: M N Ex DY OF CYCLE 4 DIET: Regular NURSING UNIT: 5 INSTRUCTIONS: COMPLETED BY: Becky Schneider. Do not remove cover/lid(s) until ready to take temperature. 2. Take the temperature of each cold item on the tray first, followed by each hot menu item. 3. Insert thermometer into the center of each serving and hold until indicator comes to rest. 4. Record temperature of each item as it is taken. 5. ttach menu to evaluation 6. Score quality control factors (satisfactory=, unsatisfactory=0) and compute "total possible" and "total" points scored for each factor. 7. dd the points scored for temperature, taste/aroma, portion, appearance and delivery & overall appearance. dd the number of possible points for temperature, taste/aroma, portion, appearance and delivery & overall appearance. Divide total points scored by the total possible points scored to compute the overall evaluation score. 8. Develop action plan for overall evaluation score of <90%. = STISFCTORY (Very Good, Good) QULITY CONTROL FCTORS 0 = UNSTISFCTORY (Fair, Poor) Standard Temperature/(Optimal) Menu Item Trayline Temp. Point of Serv. Temp. Temp. Ta ste / Portion ppearance Delivery & Overall ppearance Score TRY DELIVERY INFORMTION TL >40 /(65 ο ) PPETIZE R/ SLD: SOUP: MILK: ENTREE: r om a N/ N/ N/ N/ DELIVERY WITHIN _52_ MIN. (meets P&P) CCURTE TTRCTIV E CLEN/DRY 0. TIME CRT LEFT KITCHEN _4:25 pm 2. TIME CRT RRIVED ON UNIT _4:26 pm. TIME LST TRY WS PSSED 5:7 pm 2.SCHEDULED RRIVL TIME 4:00 4:30 pm TL >40 /(55 Ο ) TL >40 /(55 Ο ) HOT ENTREE: Fried Chicken STRCH: 64ºF 40ºF 6ºF 32ºF WELL RRNGED GRNISHE TOTL TRY DELIVERY TIME (3 minus above) OVERLL EVLUTION

2 Rice w/ gravy D VERY GOOD (95-00%) (90-94%) (85-89%) TL >40 /(55 ο ) Satisfactory Unsatisfactory TL >40 /(65 ο ) VEGETBL E: Braised greens BRED: Dinner roll DESSERT: Peach cobbler BEVERG E: Iced tea HOT BEVERG E: 6ºF 37ºF 70ºF 97ºF 0 32ºF 32ºF See Instructions #7 for explanation of scoring process. N/ TOTL POINTS SCORED = TOTL POSSIBLE POINTS = 6 TOTLS (<85%) OVERLL EVLUTION SCORE 93% %

3 TRY QULITY SSESSMENT CTION PLN DTE OPPORTUNI TY FOR IMPROVEM ENT CTION PLN PERSON RESPONSIBL E TRGET DTE FOLLOW-UP/EFFECTIVENESS OF CTION

4 No plan needed since score is over 90%. FOOD ND NUTRITION SERVICES TEST TRY EVLUTION DTE: 5 / 3 / 2 DY: S M T W Tx F S MEL: N E Mx DY OF CYCLE 5 DIET: Regular NURSING UNIT: 4 INSTRUCTIONS:. Do not remove cover/lid(s) COMPLETED BY: Becky Schneider 6. Score quality control factors (satisfactory=, unsatisfactory=0) and compute "total possible" and "total" points scored for each factor. 7. dd the points scored for temperature, taste/aroma, portion, appearance and delivery & overall appearance. dd the number of possible points for temperature, taste/aroma, portion, appearance and delivery & overall

5 until ready to take temperature. 2. Take the temperature of each cold item on the tray first, followed by each hot menu item. 3. Insert thermomete r into the center of each serving and hold until indicator comes to rest. 4. Record temperature of each item as it is taken. 5. ttach menu to evaluation appearance. Divide total points scored by the total possible points scored to compute the overall evaluation score. 8. Develop action plan for overall evaluation score of <90%. = STISFCTORY (Very Good, Good) QULITY CONTROL FCTORS 0 = UNSTISFCTORY (Fair, Poor) Standard Temperature/ (Optimal) TL >40 /(65 ο ) Menu Item PPETIZER/ SLD: SOUP: Trayline Temp. Point of Serv. Temp. Temp. Taste/ roma Portion ppearance Delivery & Overall ppearance DELIVERY WITHIN _32 MIN. (meets P&P) CCURTE Score TRY DELIVERY INFORMTION. TIME CRT LEFT KITCHEN 7:40 am 2. TIME CRT RRIVED ON UNIT 7:4 am MILK: ENTREE: TTRCTIVE CLEN/DRY 3.TIME LST TRY WS PSSED 8:2 am 4. SCHEDULED RRIVL TIME 7:30 8:00 am

6 TL >40 /(55 Ο ) HOT ENTREE: Bacon Eggs 6ºF 45ºF 4ºF 28ºF 0 WELL RRNGED TOTL TRY DELIVERY TIME (3 minus above) 32 min. TL >40 /(55 Ο ) STRCH: Potatoes 7ºF 2ºF GRNISHED OVERLL EVLUTION VERY GOOD (95-00%) (90-94%) (85-89%) TL >40 /(55 ο ) VEGETBLE: (<85%) Satisfactory Unsatisfact ory BRED: Biscuit DESSERT: TL >40 /(65 ο ) BEVERGE: Orange Juice HOT BEVERGE: Regular Coffee 40ºF 57ºF 58ºF 40ºF TOTLS See Instructions #7 for explanation of scoring process. OVERLL EVLUTION SCORE 96% % TOTL POINTS SCORED = TOTL POSSIBLE POINTS = TRY QULITY SSESSMENT CTION PLN

7 DTE OPPORTUNITY FOR IMPROVEMENT CTION PLN PERSON RESPONSIB LE TRGET DTE FOLLOW-UP/EFFECTIVENESS OF CTION No action plan needed since score was greater than 90% FOOD ND NUTRITION SERVICES TEST TRY EVLUTION DTE: 5 / 3 / 2 DY: S M T W Tx F S MEL: M Nx E DY OF CYCLE 5 DIET: Cardiac

8 NURSING UNIT: 5F INSTRUCTIONS: COMPLETED BY: Becky Schneider. Do not remove cover/lid(s) until ready to take temperature. 2. Take the temperature of each cold item on the tray first, followed by each hot menu item. 3. Insert thermometer into the center of each serving and hold until indicator comes to rest. 4. Record temperature of each item as it is taken. 5. ttach menu to evaluation 6. Score quality control factors (satisfactory=, unsatisfactory=0) and compute "total possible" and "total" points scored for each factor. 7. dd the points scored for temperature, taste/aroma, portion, appearance and delivery & overall appearance. dd the number of possible points for temperature, taste/aroma, portion, appearance and delivery & overall appearance. Divide total points scored by the total possible points scored to compute the overall evaluation score. 8. Develop action plan for overall evaluation score of <90%. = STISFCTORY (Very Good, Good) QULITY CONTROL FCTORS 0 = UNSTISFCTORY (Fair, Poor) Standard Temperature/(Optimal) Menu Item Trayline Temp. Point of Serv. Temp. Temp. Ta ste / Portion ppearance Delivery & Overall ppearance Score TRY DELIVERY INFORMTION TL >40 /(65 ο ) TL >40 /(55 Ο ) TL >40 /(55 Ο ) PPETIZE R/ SLD: SOUP: MILK: ENTREE: HOT ENTREE: Turkey w/ gravy STRCH: Mashed potatoes r om a N/ N/ N/ N/ 70ºF 04ºF 0 74ºF 4ºF 0 DELIVERY WITHIN _55_ MIN. (meets P&P) CCURTE TTRCTIV E CLEN/DRY WELL RRNGED GRNISHE D 0. TIME CRT LEFT KITCHEN :56 2. TIME CRT RRI VED ON UNIT :59 3. TIME LST TRY WS PSS ED_ 2:5 4. SCHEDU LED RRI VL TIME :30-2:00 _ TOTL TRY DELIVERY TIME (3 minus above) 55 OVERLL EVLUTION VERY GOOD (95-00%)

9 (90-94%) (85-89%) TL >40 /(55 ο ) Satisfactory Unsatisfactory VEGETBL E: Green Beans BRED: Roll DESSERT: Carrot Cake 89ºF 0ºF 0 45ºF 66ºF (<85%) TL >40 /(65 ο ) BEVERG E: Tea HOT BEVERG E: 32ºF 32ºF See Instructions #7 for explanation of scoring process. N/ TOTL POINTS SCORED = TOTL POSSIBLE POINTS = 6 TOTLS OVERLL EVLUTION SCORE 87% % TRY QULITY SSESSMENT CTION PLN DTE OPPORTUNITY FOR IMPROVEMENT CTION PLN PERSON RESPONSIB LE TRGET DTE FOLLOW-UP/EFFECTIVENESS OF CTION

10 5/3/2 The main opportunity for improvement is to decrease the total tray delivery time. This C had 29 trays to deliver and many customers needed help or requested something extra so it was difficult for her to deliver quickly. lso, there were a lot of rooms with contamination protocols, so she had to gown up before entering the room, which took more time. Finally, she had two carts to maneuver and keep track of. She left one in a certain area so she could return to it after emptying her first cart, but this still added time on to her total. The C should try to deliver the trays more quickly while still being courteous to customers. She did start asking nurses to help the customers with their trays when she was getting behind. She also mentioned that she has only been a C for 4 months; so, her speed will probably improve with practice. C- Violet Individual performing test tray- Becky Schneider 06/03/2 Perform another test tray procedure with this C at a later date to assess whether tray delivery time has improved. If it has not, maybe this C can have a smaller unit until she has more experience.

PEAK 2.0 SAMPLE ACTION PLAN FOOD ACTION PLAN

PEAK 2.0 SAMPLE ACTION PLAN FOOD ACTION PLAN Facility Name: Example 5 Nursing Home Domain: #1 Resident Choice Core: #1 Food ACTION PLAN Provider Number: Action Plan Contact: Phone number and/or e-mail: WHAT HAS BEEN WORKED ON IN THIS CORE AREA SINCE