NACCHO Program Standards Mentorship Self-Assessment

Objectives: Define Program Standards Self-Assessment Review FDA Resource Disk (Retail Food Program Standards) Conducting the “At 1st Glance” Assessment Versus Conducting the “Auditable” Self-Assessment Standard 2 Self-Assessment Overview

Program Standards Self-Assessment (SA) Internal review by program manager or designee Determines if the existing retail food safety program meets each of the 9 VNRFRPS SA is a Requirement of Standard 9 Initial SA conducted within 12 months of enrollment Conducted every 60 months thereafter Must use latest version of VNRFRPS SA updates on individual standards

Food Establishment Guides Retail Food Program Standards FDA Resource Disk Employee Health Food Code Food Defense Food Establishment Guides Retail Food Program Standards 2011 Version Risk Factor Study Standardization

Retail Food Program Standards Standard 1: Regulatory Foundation Standard 2: Trained Regulatory Staff Standard 3: Inspection Program Based on HACCP Principles Standard 4: Uniform Inspection Program Standard 5: Foodborne Illness & Food Defense Preparedness & Response Standard 6: Compliance & Enforcement Standard 7: Industry & Community Relations Standard 8: Program Support & Resources Standard 9: Program Assessment Administrative Procedures for VNRFRPS

The “At 1st Glance” Assessment Basic level of application of each standard’s requirements to the food program Not time consuming Not intended to be verified No completion of SA documentation/worksheets Identify those standards that there is the potential to meet Look for common elements across standards (e.g. IN, OUT, NO, NA inspection form) Can identify gaps, quick fixes, and short or long-term improvements Today’s Focus: Standard 2 (Option 1)

Standard 2 – Option 1 “At 1st Glance” Resource Disk – Standard 2 Requirement Summary: Basic considerations: LHD’s current retail food protection employee training and continuing education program Availability of training, continuing education, professional credentials, and standardization records for all employees assigned to the retail food protection program who conduct field inspections Note: Make sure to review the Clearinghouse Q&A interpretations related to Standard 2

Standard 2 - Option 1 “At 1st Glance” Description of Requirement: Retail food program staff have the KSAs needed to effectively perform their required duties. Consider how this is/can be determined for following “categories” of staff: Staff conducting food inspections prior to LHD’s enrollment in Program Standards Staff new to food safety program after enrollment with some prior experience in food regulatory activities New employee hired after enrollment with no prior experience Retail food program staff completion of a prescribed 5-step training and standardization process

Standard 2 – Option 1 “At 1st Glance” Questions to consider: Can you describe or outline your current training curriculum for staff in the different categories? How do you determine if staff have KSAs needed to perform their duties well and conduct quality inspections? Do you have in place a method to determine the training needs of staff? Can you describe your LHD’s standardization process? Are records easily accessible to verify training, continuing education, standardization activities, maintenance of credentials, etc.? Note: Keep other standards in mind as you develop the training curriculum!

The “Auditable” Self-Assessment Extensive application of each standard’s requirements to the food program Much more time consuming and detailed Meant to provide sufficient verifiable documentation for subsequent verification audit to be successful Uses the standard-specific worksheets available on the resource disk Start with performing the SA for those standards that “At 1st Glance” you meet Devise improvement plans for unmet standards Can conduct a SA update at any time you feel a standard has been met

The “Auditable” Standard 2 – Option 1 Self-Assessment You will need for reference: Resource Disk – Standard 2, Self-Assess Guide Resource Disk – Clearinghouse Work Group Q & A Listing of employees currently working in the retail food program, including date of hire/assignment to program Records of completion of a training curriculum Records of the assessment of each employees KSAs needed to conduct quality inspections (Standard 4) Records of standardization and re-standardization Records of contact hours for continuing education relative to retail food work

The “Auditable” Standard 2 – Option 1 Self-Assessment Five elements for training and standardization: Completion of FDA ORA-U online food curriculum courses (“Pre”-Requisite) – done prior to release (a) Completion of minimum 25 joint field training inspections with verification that employee has demonstrated KSAs and has ability to conduct independent inspections, AND (b) Completion of the LHD’s field training plan/curriculum (a) Completion of minimum 25 independent inspections, AND (b) Completion of FDA ORA-U online food curriculum courses (“Post”-Release) Completion of process similar to FDA Standardization procedures within 18 months of hire/assignment to food program Completion of 20 contact hours of continuing food safety education every 36 months, part of maintenance of standardization

The “Auditable” Standard 2 – Option 1 Self-Assessment You will need to evaluate each Standard 2 criteria based on Self-Assess Guide: Criteria 1(a): Verification of Employee Training Records Standard 2: Self-Assessment Worksheet ; or LHD’s employee training records; or Other type of summary record Criteria 1(b): Confirmation of Pre-Requisite Training Curriculum LHD’s listing of food program employees at time of SA with date of hire/assignment, and Records of course completion

Complete Standard 2 Self-Assessment Form Employee Training Records   Criteria Jurisdiction’s Self Assessment Auditor’s Verification YES NO Self-Assessor’s General Comments If NO, Auditor is to specify why criterion is not met 1. Employee Training Records a. The jurisdiction maintains a written training record for each employee that includes the date of hire or assignment to the agency’s retail food protection program.       b. The jurisdiction’s written training record provides documentation that each employee has completed the Standard #2 pre-requisite (“Pre”) training curriculum PRIOR to conducting independent retail food or foodservice inspections.

The “Auditable” Standard 2 – Option 1 Self-Assessment Criteria 2(a): Staff Completion of 25 Joint Field Training Inspections Standard 2: Self-Assessment Worksheet ; or LHD’s listing of food program employees at time of SA with date of hire/assignment; and Records of 25 joint field training inspections or affidavits of completion of required inspections Criteria 2(b): Staff Completion of a Field Training Process Written documentation of field training plan similar to CFP Field Training Manual

Complete Standard 2 Self-Assessment Form Initial Field Training   Criteria Jurisdiction’s Self Assessment Auditor’s Verification YES NO Self-Assessor’s General Comments If NO, Auditor is to specify why criterion is not met 2. Initial Field Training a. The jurisdiction maintains a written training record that provides confirmation that each employee completed a minimum of 25 joint field training inspections of retail food and/or foodservice establishments (if less than 25 joint field training inspections are performed, written documentation on file that FSIO has successfully demonstrated all required inspection competencies) PRIOR to conducting independent retail food or foodservice inspections       b. The jurisdiction maintains a written training record that provides confirmation that each employee successfully completed a field training process similar to that contain in the CFP Field Training Manual provided in Appendix B-2, Standard 2, PRIOR to conducting independent inspections of retail food and/or foodservice establishments.

The “Auditable” Standard 2 – Option 1 Self-Assessment Criteria 3(a): Staff Completion of 25 Independent Inspections Standard 2: Self-Assessment Worksheet ; or LHD’s listing of food program employees at time of SA with date of hire/assignment; and Records of 25 independent inspections or affidavits of completion of required inspections Criteria 3(b): Staff Completion of Post Curriculum Training Records of course completion

If NO, Auditor is to specify why criterion is not met Complete Standard 2 Self-Assessment Form Independent Inspections/Completion of ALL Curriculum Requirements   Criteria Jurisdiction’s Self Assessment Auditor’s Verification YES NO Self-Assessor’s General Comments If NO, Auditor is to specify why criterion is not met 3. Independent Inspections / Completion of ALL Curriculum Requirements a. The jurisdiction maintains a written training record that provides confirmation that each employee completed a minimum of 25 independent retail food and/or foodservice inspections PRIOR to field standardization.       b. The jurisdiction written training record provides documentation that each employee has completed ALL aspects of the Standard #2 training curriculum (“Pre”) and (“Post”) courses PRIOR to field standardization.

The “Auditable” Standard 2 – Option 1 Self-Assessment Criteria 4(a): Staff Completion of Initial Field Standardization Standard 2: Self-Assessment Worksheet ; or LHD’s listing of food program employees at time of SA with date of hire/assignment; and LHD’s Procedures for Standardization; and Records of Standardization within 18 months of hire/assignment Criteria 4(b): Staff Maintenance of Field Standardization Records of re-standardization every 36 months

Complete Standard 2 Self-Assessment Form Field Standardization   Criteria Jurisdiction’s Self Assessment Auditor’s Verification YES NO Self-Assessor’s General Comments If NO, Auditor is to specify why criterion is not met 4. Field Standardization a. The jurisdiction maintains a written training record that provides documentation that each employee successfully completed a Standardization process similar to the ‘FDA Procedures for Standardization’ within 18 months of hire or assignment to the retail food protection program.       b. The jurisdiction maintains a written training record that provides documentation that each standardized employee has maintained their standardization by performing a minimum of 4 joint inspections with a “training standard” every 3 years.

The “Auditable” Standard 2 – Option 1 Self-Assessment Criteria 5(a): Staff Obtains 20 Contact Hours of CEUs Every 3 Years Standard 2: Self-Assessment Worksheet ; or LHD’s listing of food program employees at time of SA with date of hire/assignment; and LHD’s Procedures for Standardization; and Records of contact hours (various methods recognized)

If NO, Auditor is to specify why criterion is not met Complete Standard 2 Self-Assessment Form Continuing Education & Training   Criteria Jurisdiction’s Self Assessment Auditor’s Verification YES NO Self-Assessor’s General Comments If NO, Auditor is to specify why criterion is not met 5. Continuing Education and Training a. The jurisdiction maintains a written training record that provides documentation that each employee conducting retail food and/or foodservice inspections has accumulated 20 hours of continuing education every 36 months after the initial training (18) months is completed.      

Sample Standard 2 Training Record   No Employee Name Date of Hire or Assignment to the Retail Food Program Completion of Training Pre-requisite (“Pre”) Curriculum* (Prior to conducting independent inspections) Completion of a Minimum 25 Joint Field Training Inspections* AND (successful completion of a field training process similar to the CFP Field Training Manual in Appendix B-2) Completion of a Minimum 25 Independent Inspections “Post” Curriculum Courses* (within 18 months of hire or assignment to the Retail Food Program) Completion of Field Standardization* (within 18 months of hire or assignment to the Retail Food Program) Number of Education Contact Hours (Minimum of 20 Contact Hours every 3 years) Meets the Standard 2 Criteria YES or NO 1       2 3 4 5 6 Ninety percent (90%) of the staff must meet each training element for the Jurisdiction to meet Standard 2 – Trained Regulatory Staff Based on the documentation from this worksheet, record your findings for each of the items on the Standard 2: Program Self-Assessment and Verification Audit Form

At the end of the Standard(s) Self-Assessment…. Completion of reporting forms: Self Assessment & Verification Audit Form Identifies who conducted the SA and reports whether or not the jurisdiction meets the standard Lists each of the criteria for the standard against which the self-assessor will individually mark YES or NO to meeting Allows the self-assessor to transfer specific details to the verification auditor FDA National Registry Report and Release Record & Agreement to Publish in National Registry (this is submitted after a SA or SA update) Updates the FDA’s online listing of the status of jurisdictions enrolled in the VNRFRPS

Self Assessment & Verification Audit Form

Documentation to Maintain for Verification Audit Completed Program Self-Assessment & Verification Audit Form Documentation used to support each of the Standard’s criteria Copy of LHD’s (or State’s) Standardization Procedures Staff Training Records

Fairfax County’s Employee Training Record Spreadsheet Review & Discussion

Questions