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Item No.:
*
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Site:
Children Area-Illness Exclusion Sign
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Violation:
In the signs posted at the outer and inner entry door to Club Hal child center the statement is written that 'As this is a USPH requirement regular charges will apply for all services rendered by the medical facility'. This statement incorrectly implies that the requirement that children with signs or symptoms of infectious illness should be evaluated by medical professionals before being allowed in the facility in some way demands a fee from CDC or the U.S. Public Health Service. The decision to demand a fee for medical evaluation is solely and completely a corporate decision by Holland America Line and in no way is required by the CDC or the Vessel Sanitation Program. Reference to the U.S. government with regard to such fees should be removed from this and all such signs in the child activity center or anywhere else on the ship.
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Recommendation:
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Item No.:
*
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Site:
*General Comments-
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Violation:
The management and operations observed in all the hotel, food and beverage, facilities, housekeeping, and potable water departments were very strong today.
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Recommendation:
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Item No.:
02
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Site:
Medical-Acute Gastroenteritis (AGE) Surveillance Log
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Violation:
The electronic AGE surveillance log did not include all the data elements and was not in the exact order and placement as the form provided in section 13.2.2 of the VSP Operations Manual 2011. Additionally, the electronic database could not generate or export the form required from section 13.2.2.
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Recommendation:
Ensure the AGE surveillance log entry for each passenger or crew member contain the following information in separate columns: (1) Date of the first medical visit or report to staff of illness; (2) time of the first medical visit or report to staff of illness; (3) case identification number; (4) person?s name; (5) person?s age; (6) person?s sex; (7) designation as passenger or crew member; (8) crew member position or job on the vessel, if applicable; (9) cabin number; (10) meal seating information; (11) date of illness onset; (12) time of illness onset; (13) illness symptoms, including the presence or absence of the following selected signs and symptoms, with a separate column for each of the following: (a) number of episodes of diarrhea in a 24-hour period; (b) number of episodes of vomiting in a 24-hour period; (c) bloody stools; (d) recorded temperature; (e) abdominal cramps; (f) headaches; (g) muscle aches; (14) entry (yes/no) for whether this was a reportable case; (15) entry (yes/no) for antidiarrheal medications sold or dispensed by designated medical staff; (16) presence of underlying medical conditions that may affect interpretation of AGE. Ensure the AGE surveillance log contains the above information in the exact order and is entered in the template in Annex 13.2.2. Ensure that the log data is exported in the exact order as in the example template in Annex 13.2.2 with analyzable formats such as Excel or Access. Ensure that any additional data fields are entered only outside of the form margins when exported to VSP.
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Item No.:
02
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Site:
Medical-Reportable Case
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Violation:
The electronic database programming did not use the current definition of an acute gastroenteritis (AGE) case. The database specifically did not permit entry of reportable as a case any individual with less than 3 diarrheal episodes (loose stools) unless the vomiting symptom was marked. A test case was entered with 2 diarrheal episodes, fever, abdominal cramps, headache, muscle ache, and bloody stool and the system determined this was not a reportable AGE case. Additionally, for persons with more than 3 diarrheal episodes the system automatically determined them to be an AGE case, even if there were pre-existing medical conditions which would explain that this numbe of episodes was normal for the individual.
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Recommendation:
Ensure a reportable case of AGE is a case reported to the master of the vessel, the medical staff, or other designated staff by a passenger or a crew member and meets the case definition based on the following symptoms: (1) Diarrhea (three or more episodes of loose stools in a 24 hour period or what is above normal for the individual. See section 4.1.2.1.3, illness symptoms); or (2) vomiting and one additional symptom including one or more episodes of loose stools in a 24-hour period, or abdominal cramps, or headache, or muscle aches, or fever (temperature of greater than or equal to 38C [100.4F]).
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Item No.:
02
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Site:
Medical-Case Recording
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Violation:
The electronic AGE surveillance log was programmed to leave a blank in the yes/no column for a symptom where the number of episodes was marked zero It also did not enter a yes value when the symptom field for diarrhea was marked 2 or 1 episodes.
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Recommendation:
All the fields in the form which can be completed should be filled in for each case or non-case who is issued anti-diarrheal medications. This includes even the underlying symptoms field, where if none exist the word none should be written in the field.
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Item No.:
02
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Site:
Medical-AGE Surveillance Questionnaire
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Violation:
The questionnaire's used for AGE cases did not include many of the data elements provided and required from the VSP AGE questionnaire provided in annex 13.2 of the 2011 VSP Operations Manual. The question on knowing other persons with same symptoms and if yes please list their names was not included. Did you stay overnight in the boarding city before joining the vessel, and if so what city and what lodging was not included. Mode of travel to the boarding city was not included. Are you part of a tour group was not included. In the meal and activity portion snacks was not listed and activities were only listed as on the ship, not AM or PM, and they weren't listed for the entire 72 hour period working back from symptom onset. There was also no time entered on the meal form. This form must include all data elements provided in the version from the VSP Operations Manual or the violation will be a repeat in the next inspection.
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Recommendation:
Distribute questionnaires detailing activities and meal locations for the 72 hours before illness onset to all passengers and crew members who are AGE CASES. Ensure that the self-administered questionnaires contain all of the data elements that appear in the questionnaire found in Annex 13.2.2. Ensure that completed questionnaires are maintained with the AGE surveillance log.
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Item No.:
08
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Site:
Food Service General-
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Violation:
The nonpotable chilled water lines connected to the back of the ice machines and ice cream machines in food areas throughout the ship were not uniquely identified. (2011 VSP Operations Manual)
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Recommendation:
Uniquely identify all refrigerant brine lines in all galleys, pantries, and cold rooms to prevent cross-connections.
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Item No.:
08
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Site:
Potable Water-Cross-Connection Control Program
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Violation:
The backflow prevention devices installed on the 2 Natura water purification systems onboard appeared not to be vented devices.
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Recommendation:
Use air gaps where feasible and where water under pressure is not required. Install backflow prevention devices when air gaps are impractical or when water under pressure is required. Ensure to install only vented devices.
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Item No.:
10
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Site:
Recreational Water Facilities-Whirlpool Spas
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Violation:
There was no monitoring of flow rates in the whirlpool spas as there are no flow meters installed.
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Recommendation:
Monitor and adjust the RWF?s flow rates, free and combined halogen levels, pH, total alkalinity, and clarity as recommended by the manufacturer and to maintain optimum public health protection and water chemistry.
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Item No.:
10
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Site:
Recreational Water Facilities-Whirlpool Spas
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Violation:
There were no automated pH and bromine analyzers or chart recorders installed to a sample line from the existing return lines or as a separate line at each whirlpool spa tub and before the compensation tank to monitor and record pH and halogen levels in each whirlpool spa.
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Recommendation:
Install chart recorders or electronic data loggers with security features that record pH and halogen measurements for each individual RWF. Ensure the sample line for the analyzer probe (monitoring) is either directly from the RWF or on the return line from each RWF and before the compensation tank. Install appropriate sample taps for analyzer calibration. In the event of equipment failure, measure free residual halogen and pH by a manual test kit at the RWF or return line at least hourly for whirlpool spas, spa pools, children?s pools, and wading pools and every 4 hours for all other RWFs. Record manual readings on a chart or log, retain for at least 12 months, and ensure that they are available for review during inspections. Complete repairs on malfunctioning halogen analyzer-chart recorders within 30 days of equipment failure. Provide an audible alarm in a continuously occupied watch station to indicate low and high free halogen and pH readings in each RWF.
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Item No.:
10
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Site:
Recreational Water Facilities-All RWF's
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Violation:
The various pools, whirlpool spas, and hydro pool safety and health warning signs were missing some or all of the new elements required in sections 6.7.1.1.1 and 6.7.1.1.3 in the 2011 VSP Operations Manual. Staff stated the new signs were ordered.
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Recommendation:
Provide safety signs for all RWFs, except for baby-only water facilities. Ensure the signs, at a minimum, include the following words: (1) do not use these facilities if you are experiencing diarrhea, vomiting, or fever; (2) no children in diapers or who are not toilet trained; (3) shower before entering the facility; and (4) bather load #. For children?s RWF signs, include the exact wording ?TAKE CHILDREN ON FREQUENT BATHROOM BREAKS? or ?TAKE CHILDREN ON FREQUENT TOILET BREAKS.? In addition to the safety sign requirements in section 6.7.1.1.1, install a sign at each whirlpool spa and spa pool entrance listing precautions and risks associated with the use of these facilities. Include, at a minimum, cautions against use by the following: (1) individuals who are immunocompromised; (2) individuals on medication or who have underlying medical conditions such as cardiovascular disease, diabetes, or high or low blood pressure; and (3) pregnant women, elderly persons, and children. Additionally, caution against exceeding 15 minutes of exposure.
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Item No.:
14
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Site:
Preparation Room-
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Violation:
The butcher was cutting beef at the time of the inspection. He had a pronunciated mustache and was wearing no facial hair restraint.
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Recommendation:
Ensure food employees wear hair restraints and clothing that covers body hair. Ensure these items are designed and worn effectively to prevent hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
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Item No.:
16
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Site:
Pantry-Lido
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Violation:
The milk in the milk refrigerator of the espresso machine was on time control according to the staff. Even though the door of the refrigerator was identified as a time control unit, the milk was not identified with a discard time. The time control plan for this area instructed to place a green dot on the milk container inside the refrigerator indicating that it had a set up time of 1700 and a discard time of 2100. The time control plan was not followed.
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Recommendation:
If time only?rather than time in conjunction with temperature?is used as the public health control for a working supply of potentially hazardous food before cooking, or for ready-to-eat potentially hazardous food that is displayed or held for service for immediate consumption, ensure the food (1) Has an initial temperature of 5C (41F) or less or 57C (135F) or greater before placement on time control. (2) Is not be placed on temperature control again. (3) Is marked or otherwise identified to indicate the time 4 hours past the point in time when the food is removed from temperature control (if the time between service set-up and closing is greater than 4 hours. and (4) Is discarded within 4 hours of placement on time control.
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Item No.:
16
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Site:
Food Service General-Consumer Advisories
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Violation:
The menus for the Pinnacle Grill, Le Cirque, main dining room and Tamarind had consumer advisories, but did not identify with asterisks the animal derived foods that could be served undercooked or raw. (2011 VSP Operations Manual)
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Recommendation:
If an animal food such as beef, eggs, fish, lamb, milk, pork, poultry, or shellfish that is raw, undercooked, or not otherwise processed to eliminate pathogens is offered in a ready-to-eat form or as a raw ingredient in another ready-to-eat food, ensure the consumer is informed by way of disclosure using menu advisories, placards, or other easily visible written means of the significantly increased risk to certain especially vulnerable consumers eating such foods in raw or undercooked form. Locate the advisory at the outlets where these types of food are served. Ensure that disclosure is on a menu using an asterisk at the animal-derived foods requiring disclosure and a footnote with a statement indicating that consuming raw or undercooked meats, seafood, shellfish, eggs, milk, or poultry may increase your risk for foodborne illness, especially if you have certain medical conditions.
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Item No.:
18
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Site:
Galley-Hot Galley
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Violation:
There was a pan of raw ground beef stored next to a pan of ready to eat fish cake mixture in undercounter refrigerator # 3.15 A. The pans were repositioned in different refrigerators.
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Recommendation:
Protect food from cross-contamination or other sources of contamination by the following methods: (1) Physically separating raw animal foods during storage, preparation, holding, and display from raw ready-to-eat food so that products do not physically touch and so that one product does not drip into another. (2) Separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry?except when combined as ingredients?during storage, preparation, holding, and display by using separate equipment for each type, or by arranging each type of food in equipment so that cross-contamination of one type with another is prevented, or by preparing each type of food at different times or in separate areas. (3) Cleaning and sanitizing equipment and utensils. (4) Storing the food in packages, covered containers, or wrappings. (5) Cleaning visible soil on hermetically sealed containers of food before opening. (6) Protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened. (7) Separating damaged, spoiled, or recalled food being held on the vessel. (8) Separating unwashed fruits and vegetables from ready-to-eat food.
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Item No.:
19
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Site:
Other-Cushion Store L.9.2.03
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Violation:
Two bottles of liquor were stored directly on the deck of this locker. There were napkins soiled with food debris also stored in this locker. This area was also not finished in accordance with sections 7.7.4 and 7.7.5 of the VSP Operations Manual for food storage areas.
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Recommendation:
Protect food from contamination by storing the food: (1) Covered or otherwise protected; (2) In a clean, dry location; (3) Where it is not exposed to splash, dust, or other contamination; and (4) At least 15 centimeters (6 inches) above the deck. Do not store foods in locker rooms and in areas not finished in accordance with 7.7.4 and 7.7.5 for food storage areas.
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Item No.:
19
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Site:
Buffet-Port Salad Line
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Violation:
There was no serving utensil for a lettuce container. This buffet line was open for service at the time of the inspection.
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Recommendation:
Provide food-dispensing utensils for each container displayed at a consumer self-service unit such as a buffet or salad bar.
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Item No.:
19
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Site:
Buffet-Crew Mess
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Violation:
There was no serving utensil for a hotel pan of vegetables. This buffet line was open for service at the time of the inspection.
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Recommendation:
Provide food-dispensing utensils for each container displayed at a consumer self-service unit such as a buffet or salad bar.
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Item No.:
21
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Site:
Pantry-Lido
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Violation:
The interior of the door lid to the ice bin of the ice machine had a cracked stainless steel profile strip that created a sharp edge and a difficult to clean seam.
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Recommendation:
Ensure nonfood-contact surfaces are free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.
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Item No.:
21
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Site:
Dining Room-Pinnacle Grill Restaurant
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Violation:
A portable induction unit, a rolling cart, and a portable waiter station had rough surfaces and raw wood, making them difficult to clean.
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Recommendation:
Ensure nonfood-contact surfaces are free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.
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Item No.:
30
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Site:
Buffet-Dishwash
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Violation:
The handwash station located next to the scraping area where a crew member was prewashing plates was getting wet and soiled with water from this prewash. The paper towels were also wet.
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Recommendation:
Keep handwashing facilities clean and in good repair.
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Item No.:
34
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Site:
Galley-Deck 2
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Violation:
The deck drain behind the left ice machine had a few inches of pooled water and was not draining.
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Recommendation:
Ensure the plumbing system in the food area is maintained in good repair.
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Item No.:
34
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Site:
Buffet-Ice Cream Parlor
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Violation:
The dipper well was continiuosly leaking.
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Recommendation:
Ensure the plumbing system in the food area is maintained in good repair.
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Item No.:
36
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Site:
Food Service General-Lighting
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Violation:
The light intensity behind and around many pieces of deck-mounted equipment was less than 110 lux, such as behind and around the ice machine of starboard Lido pantry, behind and around the combination oven of the crew galley, and behind and around the ice machine of the pantry of the Ocean Bar. In addition, the light intensity over the handwash station of the Ocean Bar could not be raised to 110 lux. (2011 VSP Operations Manual)
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Recommendation:
Ensure the light intensity is at least 110 lux (10 foot candles) behind and around mounted equipment, including counter-mounted equipment. Ensure the light intensity is at least 110 lux (10 foot candles) at handwashing stations in bars.
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Item No.:
41
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Site:
Housekeeping-Outbreak Prevention and Response Plan (OPRP)
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Violation:
The written OPRP refers to use of a Virox disinfectant in a 1:16 concentration for disinfection onboard, but another product is actually used on this ship. Additionally, from the review of OPRP there were not specific methods described everywhere for the respiratory and dermal protection of passengers exposed to the disinfection chemicals used, with the exception of the fogging in shops and one case where virox was specified to be wiped on surfaces and not sprayed (super-san cleaning and disinfection).
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Recommendation:
Ensure each vessel has a written OPRP that details standard procedures and policies to specifically address AGE onboard. Include the following in the written OPRP: (1) Duties and responsibilities of each department and their staff for all the passenger and crew public areas; (2) Steps in outbreak management and control and the trigger for required action at each step. Ensure the triggers address a graduated approach to outbreak management in response to increasing case counts; (3) Disinfectant products or systems used, including the surfaces or items the disinfectants will be applied to, concentrations, and required contact times. Ensure the disinfectant products or systems are effective against human norovirus or an acceptable surrogate (e.g., caliciviruses); (4) Procedures for informing passengers and crew members of the outbreak. Ensure this section also includes procedures for notification of passengers embarking the vessel following an outbreak voyage or segment of a voyage; (5) Procedures for returning the vessel to normal operating conditions after an outbreak; (6) Procedures to protect the passengers and crew from exposure to disinfectants, if not already included in the vessel?s safety management system. Ensure this protection includes: (a) Material safety data sheets (MSDSs); (b) Personal protective equipment for crew; (c) Health and safety procedures to minimize respiratory and dermal exposures to both passengers and crew.
Ensure the OPRP is clear about the products used on this ship and their concentrations.
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