Follow-up review. Food-Pool-Tourist Program, Department of Human Resources

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Russell W. Hinton State Auditor

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Performance Audit Operations Division

August 2004 Report 04-18 Report 02-6

This is a Follow-Up Review of the Performance Audit of the Food-Pool-Tourist Program released by the Department of Audits in March 2002. This Review was conducted to determine the extent to which the Department of Human Resources (DHR) has addressed the recommendations presented in the 2002 Performance Audit. A copy of the original report can be obtained through the contact information on the back of this Review.
Background
The purpose of the Food-Pool-Tourist Program is to protect the public health and safety by regulating food service establishments, swimming pools, and tourist accommodations. Acting on behalf of DHR, county boards of health are responsible for permitting and inspecting restaurants and other food service establishments, public swimming pools, and tourist accommodations such as hotels and motels. The Food-Pool-Tourist Unit within the Environmental Health Section of DHR's Division of Public Health is responsible for developing Program regulations, providing technical assistance and training, and monitoring the overall Program.

Status of Audit Recommendations Program Administration
Recommendation No. 1 (As reported in 2002): The state should continue its efforts to regulate food service establishments, swimming pools, and tourist accommodations. Because unsanitary conditions in restaurants, swimming pools, and tourist accommodations can have a serious impact on public health, there is a legitimate need for the regulation provided by the Food-Pool-Tourist Program.
Current Status
DHR has continued its efforts to regulate food service establishments, swimming pools, and tourist accommodations. It is in the process of revising the regulations governing food service establishments; has issued interpretive guidelines regarding the swimming pool regulations; and is considering revising the regulations governing tourist accommodations.

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Recommendation No. 2 (As reported in 2002): The Department of Human Resources should take a more proactive role in ensuring that the Food-Pool-Tourist Program is administered in an efficient and effective manner throughout the state. At the time of the 2002 Audit, the food-pool-tourist programs administered by the 159 counties operated with little or no administrative oversight by DHR, resulting in a lack of uniformity, consistency, and accountability.
Current Status
To improve the level of administrative oversight, the Program has hired an additional staff person to provide guidance and direction to counties' food-pool-tourist programs. As discussed in the Current Status section of subsequent Recommendations, action has also been taken to collect additional statistical data on the counties' performance and to standardize the restaurant inspection procedures.
Recommendation No. 3 (As reported in 2002): The Department should revise its grant-in-aid agreement with county boards of health to provide increased accountability over how the funds are spent. As noted in the 2002 Audit, DHR did not know the dollar amount of grant-in-aid funds that were expended by county boards of health to administer their food-pool-tourist programs and did not require them to comply with its regulations as a condition of receiving the funds.
Current Status
No action has been taken to require county boards of health to document the amount of grant-in-aid funds they expend to administer their food-pool-tourist programs. The master agreements between DHR and the county boards of health have been revised, however, to include performance levels and standards regarding the local environmental health programs. Although DHR personnel have indicated that these standards, in combination with monthly reporting requirements, enable them to monitor program performance at the county level, there are no specific consequences for counties that fail to meet the specified performance levels.
Recommendation No. 4 (As reported in 2002): Action needs to be
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taken by DHR and by county health departments to compile statistical data for managing the Food-Pool-Tourist Program at the state and county level, respectively. As reported in the 2002 Audit, insufficient management information was being compiled by DHR and by some of the counties to effectively monitor the Program's operation. Data was not compiled, for example, to enable DHR to determine if restaurants and other facilities were being inspected as required, to monitor variances in counties' inspection scores, or to evaluate the number of personnel the counties had assigned to the Program.
Current Status
DHR continues to seek funding to implement a statewide information management system for statistical data to be reported directly from the counties to the Program. In the absence of such a system, the Program collects programmatic data from the 19 public health districts on a monthly basis. The statistical data, however, does not provide information for evaluating the operation of the food-pooltourist programs at the county level.
Recommendation No. 5 (As reported in 2002): The Department should work with the Office of Planning and Budget (OPB) to develop additional goals and performance objectives for the Food-Pool-Tourist Program. For fiscal year 2002, the Program's only Results-Based Budgeting (RBB) goal was to reduce the rate of food-related illness; the only performance objective was to reduce the number of foodborne outbreaks from 21 in fiscal year 2001 to 18 in fiscal year 2002. The Program did not have goals or performance objectives for the regulation of swimming pools and tourist accommodations.
Current Status
For fiscal year 2004, the Program's only RBB goal was to reduce the rate of food-related illness. The Governor's Budget Report for fiscal year 2005 does not include any desired results or performance measures regarding the Food-Pool-Tourist Program. Similarly, Program personnel have not developed their own performance objectives for monitoring Program effectiveness on an ongoing basis. Program personnel indicated, however, that their ability to establish
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goals and performance measures will improve with the development of a statewide database. By compiling information regarding the types of complaints and the number of injuries and drownings, Program personnel feel they can measure the effectiveness of their regulation of tourist accommodations and swimming pools.
Recommendation No. 6 (As reported in 2002): The Department should continue its efforts to enable county health departments to attract and retain qualified personnel. Fourteen of the 19 county health departments visited during the 2002 Audit cited problems with employee turnover and/or difficulties in filling vacant positions. Current Status
Action has been taken to develop a career ladder for the environmental health specialists and to increase their compensation levels.
Restaurants
Recommendation No. 1 (As reported in 2002): The Department should continue its efforts to revise the current restaurant inspection form. The restaurant inspection form used in 2002 did not always serve as an accurate guide for consumers to use in determining whether they wanted to eat at a particular restaurant. A restaurant could be cited for significant deficiencies and still receive an above-average inspection score (as perceived by the general public). The average inspection score for a sample of 7,431 restaurants was 94.5.
Current Status
A revised inspection form has been developed by DHR that uses letter grades (A, B, C, and U) instead of numerical scores. The grade that is received by a restaurant will be based on the number of critical and non-critical violations that are noted. The critical categories include those risk factors identified as critical by the Centers for Disease Control and Prevention (CDC). Every county will be required to use the new form once it has been formally approved by the DHR Board.
Recommendation No. 2 (As reported in 2002): Action should be taken by DHR to ensure that county health departments are
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reasonably consistent in their evaluations of restaurants' compliance with food safety standards. On-site reviews of county health departments during the 2002 Audit revealed an overall lack of consistency and uniformity, including the use of different inspection forms and scoring procedures. As a result of this lack of consistency, the inspection scores received by restaurants in different counties did not provide a uniform basis for the public to use in determining if they should eat at a particular restaurant.
Current Status
The proposed rule changes for food service establishments will require county health department staff to complete a standardization process modeled after the standardization program developed by the Food and Drug Administration (FDA). The Program's additional staff person will be responsible for ensuring that the standardization process is implemented by all of the counties.
Recommendation No. 3 (As reported in 2002): The Department should take steps to ensure that county health departments comply with DHR regulations and inspect restaurants at least twice a year. In 2002, our review found that 95% (7,138) of 7,521 restaurants had been inspected within the preceding eight months (indicating they were being inspected approximately every six months, or twice a year). Six of the county health departments that were visited, however, had inspected fewer than 95% of their restaurants during the preceding eight months, ranging from 81% to 93%.
Current Status
Program personnel have developed a proposed rule change that provides for a risk-based approach to conducting restaurant inspections. Instead of having to inspect every restaurant twice a year, counties will base the frequency of inspections on the type of food preparation activities conducted by the restaurant. Restaurants that only serve food that has been prepared off-site, for example, will only have to be inspected once a year. DHR personnel have indicated that this change will enable counties to focus their resources on those facilities that pose a greater potential risk of foodborne illness.
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Recommendation No. 4 (As reported in 2002): The Program should be commended for taking steps to revise the regulations governing restaurants and other food service establishments. At the time of the 2002 Audit, the Program was in the process of revising the rules and regulations that govern the frequency of restaurant inspections, the training of restaurant personnel, and the training and standardization of inspection personnel.
Current Status
The revised rules and regulations for food service establishments are in the final approval stage within DHR.
Recommendation No. 5 (As reported in 2002): Restaurants that are cited for serious deficiencies should be re-inspected in a timely manner to verify they no longer pose a serious public health risk. As noted in the 2002 Audit, DHR regulations governing food service establishments did not require county health departments to re-inspect restaurants that had been cited for serious deficiencies to ensure that the deficiencies had been corrected as required. Absent specific regulatory guidance from DHR, counties had developed their own reinspection policies. These policies, however, differed substantially from one another and did not always ensure that restaurants cited for serious deficiencies were re-inspected in a timely manner.
Current Status
The proposed regulations specify that critical items must be corrected immediately upon receipt of the inspection report or as otherwise directed by the health authority; non-critical items must be corrected within 72 hours of the restaurant's receipt of the inspection report or as otherwise directed. The proposed regulations also specify that failure to correct the violations to the satisfaction of the health authority in a timely manner may result in the restaurant being closed or having its permit suspended or revoked. DHR personnel have indicated that the District Environmental Health Directors have informed the counties in their districts that follow-up inspections should be performed as required to bring restaurants into compliance.
Recommendation No. 6 (As reported in 2002): Consideration should be given to increasing the penalty for restaurants that fail
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to post their most recent inspection report as required. At time of the 2002 Audit, there was no substantial penalty for restaurants that failed to post their inspection report. Only 2/3 point was deducted (from a maximum score of 100) for failing to post the previous inspection report.
Current Status
As noted in the 2002 Audit Report, DHR personnel did not think that any additional penalty would be appropriate since failing to post the inspection report did not constitute a potential disease hazard. The proposed regulations, however, include additional requirements for posting the inspection reports and require that a cling sticker or placard of the current inspection grade be placed on the restaurant door and in the drive-in window (if the restaurant has one).
Recommendation No. 7 (As reported in 2002): The Department should consider requiring county health departments to inspect new restaurants within the first 60 days of their opening for business. Although health department personnel in the 19 sampled counties indicated that they conducted on-site inspections prior to a restaurant opening for business, 6 of the counties did not have a policy of inspecting restaurants shortly after they opened (i.e., within 60 days).
Current Status
As noted in the 2002 Audit Report, DHR personnel felt that the preopening inspection process provided sufficient opportunities for assessing the capabilities of the restaurant manager and staff as well as the need for early inspections. The proposed regulations, however, specify that the first routine inspection will be conducted within sixty (60) days following the opening of the establishment.
Recommendation No. 8 (As reported in 2002): Action should be taken to ensure that county health departments have all of the equipment necessary to conduct thorough restaurant inspections. At the time of the 2002 Audit, DHR did not have a list of the necessary equipment every county health department should use in conducting restaurant inspections. On-site reviews at 19 county
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health departments found a lack of uniformity in the type of equipment used by the inspectors.
Current Status
The Food-Pool-Tourist Program will use approximately $117,000 in federal bio-terrorism funds to purchase the necessary inspection equipment for use by county personnel.
Swimming Pools
Recommendation No. 1 (As reported in 2002): The Department should monitor the application of its swimming pool regulations to ensure that they do not result in pool operators being overly penalized for minor violations. As noted in the 2002 Audit, the Program's regulations specify that a pool must receive an unsatisfactory rating if it is cited on a follow-up inspection for any repeat violation, including non-substantial health hazards, such as failing to have a clock visible to spa users. The regulations did not specify when follow-up inspections should be conducted or whether the inspections should include all checklist items or only those items cited on the previous inspection.
Current Status
There have not been any changes to the regulations since the release of the Audit. DHR did, however, release an interpretive document to provide guidance in the scope and application of the current rules.
Tourist Accommodations
Recommendation No. 1 (As reported in 2002): The Department should reconsider the need for county health departments to conduct routine inspections of tourist accommodations. At the time of the 2002 Audit, DHR regulations required that all tourist accommodations be inspected at least twice a year. As was noted by health department officials in 10 of the 19 sampled counties, the need for routine inspections was questionable.
Current Status
Although there have not been any changes to the regulations since the
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release of the 2002 Audit, DHR personnel indicated that rule revisions are being considered. These changes include: reducing the required inspection frequency; making the inspections of tourist accommodations more risk-based; changing the inspection scoring procedure to be more reflective of the actual condition of the accommodations; and clarifying the applicability of the rules to "extended stay" facilities.
Recommendation No. 2 (As reported in 2002): The Department needs to establish written procedures for conducting inspections of hotels, motels, and other types of tourist accommodations. On-site reviews conducted during the 2002 Audit disclosed substantial differences among the counties in the percentage of rooms inspected and the items that were reviewed during the inspections.
Current Status
DHR personnel indicated that action has not been taken to develop written procedures for inspecting tourist accommodations due to the differences in the facilities' size and occupancy rates. They did, however, indicate that they planned to develop inspection guidelines for counties to use.
Legislative Issues
Recommendation No. 1 (As reported in 2002): Consideration should be given to amending current state law to provide for the regulation of swimming pools at apartment complexes, subdivisions, and country clubs. State law in effect in 2002 specified that DHR regulations only applied to public swimmimg pools that charged a daily access fee and to swimming pools that were operated by municipalities, hotels/motels, and schools. Swimming pools at apartment complexes, subdivisions, and country clubs were exempt from DHR regulation.
Current Status
DHR personnel have indicated that they plan to advocate for an amendment to the law to include the regulation of swimming pools at apartment complexes, subdivisions, and country clubs.
Recommendation No. 2 (As reported in 2002): Although
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legislation was enacted in 1997 to provide for a civil penalty for restaurant workers who fail to wear an appropriate hair restraint, this legislation is not being enforced. This data was presented for informational purposes only. Restaurant workers that failed to properly restrain their hair were not being fined in accordance with the 1997 legislation.
Current Status
DHR's proposed revisions to the food service regulations contain expanded language to better define hair restraint, and include requirements regarding beards and mustaches longer than one half inch. DHR personnel have indicated that counties cannot fine food service employees for not wearing the appropriate hair restraint unless a local ordinance has been passed allowing them to issue such a fine.
Recommendation No. 3 (As reported in 2002): Consideration should be given to ensuring that all of the food service establishments, swimming pools, and tourist accommodations throughout the state are subject to uniform regulations. State law in effect in 2002 allowed counties with a population of 550,000 or more to establish a board of health and wellness with its own rules and regulations in order to monitor health and sanitation within the county. DHR did not have a mechanism in place to ensure these counties would adopt regulations that were in line with those established by DHR (ensuring that all food service establishments, swimming pools, and tourist accommodations were subject to the same minimum standards regardless of their location in the state).
Current Status
Although DHR personnel have indicated their concurrence with this recommendation, they believe that a legislative amendment would be required to ensure that any regulations adopted by the counties were in line with DHR's regulations. DHR personnel also indicated their belief that it would be difficult to obtain such an amendment.
For additional information, please contact John Abbey, Deputy Director, Performance Audit Operations Division, at 404-657-5220.
Copies of Performance Audit can be obtained by calling the number above or on our website: http://www.audits.state.ga.us/internet/pao/rpt_main.html
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