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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of
University of Wisconsin Hospital and Clinics and University of Wisconsin Medical Foundation.
Policy Title: Food Safety Practices
Policy Number: 3.02
Effective Date: November 20, 2017
Chapter: Culinary Services
To outline the procedures required to prevent the contamination of food items by micro-organisms that
are harmful to human beings and particularly dangerous for highly susceptible populations (HSP).
Microorganisms: is an organism so small it is not visible to the naked eye.
Highly Susceptible Populations(HSP): are individuals who are pregnant women, young children, older
adults and those with compromised immune systems and/or who are receiving services at custodial care,
health care, assisted living, child/adult day care center, kidney dialysis center, hospital, nursing home, or
nutritional or senior center.
A person in charge: is someone who is able to demonstrate regulatory authority knowledge of foodborne
disease prevention, application of the Hazard Analysis Critical Control Point (HACCP) principles, and
the requirements of the Wisconsin Health Code.
Food Employee Health: is a section of the Wisconsin Food Code that reviews an employee’s obligation
to report their own foodborne illness.
Food Employee Reporting Agreement: is a form that is completed by all new employees at the time of
hire to indicate that they have read and understand their obligation in reporting food employee health.
ServSafe: is a food safety education program that is certified by the National Restaurant Association.
Ready to eat food (RTE): is food that will not undergo further processing prior to consumption.
TCS foods: are foods that require time and temperature controls to prevent the growth of microorganisms
and the production of toxins.
Over-production: amounts of food items remaining after the meal service for which they were prepared.
A. A Person in charge as defined above is present at the food establishment during all hours of
B. A food safety and food borne illness education program is in place for all employees who work
1. New employees
a. A health examination through Employee Health Services is completed prior to the
employee’s start date to identify if they may be suffering from a disease that can be
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transmitted through food and is done in compliance with Title 1 of the Americans with
Disabilities Act of 1990.
b. The Wisconsin Food Code section 2-2 titled Food Employee Health is reviewed during
new employee orientation.
c. Employee signature is obtained using the Food Employee Reporting Agreement and a
copy is retained in the employee’s education and training file.
2. All employees
a. Employees with the following job titles are ServSafe certified no later than 90 days after
their start date: food production cook, cuisine chef, and chef’s assistant III.
b. Food safety education is completed and documented at a minimum of annually with all
employees and includes but is not limited to:
i. Risks of contacting ready to eat foods with bare hands, proper use of disposable
ii. Proper handwashing techniques, including when to wash hands and where
iii. Proper fingernail maintenance;
iv. Good hygienic practices; and
v. How to check and record product temperatures.
C. Additional procedures are followed to reduce the risk of contamination by microorganisms that
are harmful to HSP.
1. Hand Hygiene
a. Employees are continually monitored to ensure they are effectively completing the
appropriate hand hygiene procedures as outlined in Hospital Administrative Policy 13.08-
b. Employees may not contact exposed RTE food with their bare hands, except when
washing fruits and vegetables. Disposable gloves may be worn by employees when
handling non RTE although frequent hand washing is acceptable.
c. A FDA approved hand antiseptic is available for employee use but is not a substitute for
soap and water handwashing.
2. Personal Hygiene
a. All employees must report to work in clean uniforms and with a food thermometer.
i. A hair restraint for heads, mustaches and beards must be worn. If hair is longer than
shoulder length, hair must be restrained in a braid or bun in addition to wearing a hat.
b. Each employee will keep their work area clean and follow the appropriate food safety
3. Food Purchasing
a. All food is purchased from sources that comply with laws pertaining to food and food
labeling per 2001 Wisconsin Food Code and State statute 97 titled “Food Regulation”
and are approved UW Health vendors.
4. Time and Temperature for Safety
a. Minimum Cooking Internal Product Temperatures
165°F (74°C) for 15 seconds
Poultry; stuffed foods (fish, meats, pasta,
poultry); stuffing containing fish, meat,
poultry; and raw animal foods with a non-
continuous cooking process.
165°F (74°C) in all parts of the food
Microwave Cooking: for raw animal
foods: covered, rotated or stirred
throughout or midway through the cooking
process, and held for 2 minutes covered
after cooking to ensure even temperature
distribution throughout the food.
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155°F (68°C) for 15 seconds
145°F (63°C) for 3 minutes
150°F (66°C) for 1 minute
158°F (70°C) instantaneous
Comminuted (ground, chopped,
restructured, combined, etc.) foods such as
fish, meat; mechanically tenderized and
injected meat; raw shell eggs not prepared
for immediate service (pooled or hot held).
145°F (63°C) for 15 seconds
Raw shell eggs prepared for immediate
service; and other fish and meat not
otherwise specified in the table.
Whole Meat Roasts of Beef, Corned Beef, Lamb, Pork and Cured Pork (such as
Note: The period of time at each temperature may include post-cooking heat rise.
Temp F (C) Time
Temp F (C) Time
Temp F (C) Time
130 (54.4) 112 140 (60.0) 12 min 151 (66.1) 54
131 (55.0) 89 142 (61.1) 8 min 153 (67.2) 34
133 (56.1) 56 144 (62.2) 5 min 155 (68.3) 22
135 (57.2) 36 145 (62.8) 4 min 157 (69.4) 14
136 (57.8) 28 147 (63.9) 134 sec 158 (70.0) 0
138 (58.9) 18 149 (65.0) 85 sec
5. Raw or Undercooked Proteins
a. Intact whole-muscle, non-injected beef (e.g. steak, prime rib, etc.) if not served to HSP,
is labeled “whole-muscle intact beef” and the beef reaches a surface temperature of
145°F on all sides and accompanies a cooked color change on all external surfaces then
no consumer advisory (for beef) is required. If all conditions are not met, then a
consumer advisory must be posted.
b. Raw or partially cooked eggs, fish, raw marinated fish, shellfish, other raw meat (other
than whole muscle intact beef) may not be prepared, served or offered for sale upon
consumer request or selection in a ready to eat form. This includes food provided to the
i. Eggs used for patient meals must also be pasteurized
6. Cooking Plant Foods for Hot Holding
a. 135°F (57.2°C) for fruits and vegetables are cooked for hot holding.
7. Hot Holding
a. Hot food >/=135°F (57.2°C), except beef roast cooked or reheated as stated for time and
temperature parameters above may be held at 130°F (54°C).
8. Cold Holding
a. Cold foods =41°F (5°C).
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9. Reheating for Hot Holding
a. Cooked and cooled TCS foods shall be reheated to at least 165°F (74°C) for 15 seconds.
Foods reheated in the microwave are rotated or stirred, covered, held for 2 minutes and
achieve an internal temperature of 165°F (74°C).
b. RTE commercially processed food, hermetically sealed or RTE foods from an intact
package from an approved food processing plant shall be reheated to at least 135°F
c. Cooked and cooled TCS foods and RTE foods reheated for hot holding shall be done
rapidly and completed in 2 hours or less.
d. Remaining unsliced portion of beef roast cooked as stated above may be reheated with
the same initial cooking parameters.
10. Reheating for Immediate Service
a. Cooked and cooled TCS foods and RTE food may be served at any temperature.
a. Use rapid chill method
i. Cool hot foods from 135°F to 70°F within 2 hours and within a total of 6 hours
from 135°F to 41°F or less.
ii. Cool ambient temperature ingredients to 41°F (5°C) or less within 4 hours, e.g.
tuna salad, fruit salad.
12. Cold receiving
a. Shipping temperatures >/=41°F (5°C) for milk, eggs, shellfish and cheese curds
manufactured at a Wisconsin-licensed dairy shall be cooled to 41°F within 4 hours.
b. Frozen food
i. Maintain the product frozen “solid” state. Note: This temperature varies with
ii. Freezing fish for parasite destruction, except certain species of tuna:
• -4°F (-20°C) or below for 168 hours or 7 days.
• -31°F (-35°C) or below for 15 hours in a blast freezer.
• -31°F (-35°C) or below until solid and stored at -4°F (-20°C) or below for a
minimum of 24 hours.
a. Moderating the temperature under refrigeration at =41°F (5°C), or at any temperature
if the food remains frozen.
a. In the refrigerator =41°F (5°C).
b. As part of an uninterrupted cooking process.
c. Any procedures for thawing a ready-to-eat (RTE) food for immediate services.
d. Completely submerged under running water at a water temperature of 70°F or below,
with sufficient water velocity to agitate and float off loose particles in an overflow, and
for a period of time that does not allow thawed portions of RTE food to rise above
e. For a period of time that does not allow thawed portions of a raw animal food requiring
cooking to be above 41°F for more than 4 hours including the time the food is exposed
to the running water and the time needed for preparation for cooking or the time it takes
under refrigeration to lower the food temperature to 41°F.
f. Receiving on the Dock
i. Foods that are refrigerated, Ready-to-Eat (RTE) Potentially Hazardous Food
(PHF) or Time/Temperature Controlled for Safety (TCS) and are received using
the specifications outlined in the Wisconsin Food Code to meet the standards for
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1. Foods that are refrigerated, potentially hazardous shall be received at a
temperature of 5°C (41°F) or below except when:
ii. A specified law governing distribution, such as laws governing milk and
molluscan shellfish, indicates a food may be received at a different specified
iii. Raw shell eggs, which may be received in refrigerated equipment that maintains
an ambient temperature of 7°C (45°F) or less.
iv. Upon receipt all potentially hazardous food will be inspect to ensure it is free
from evidence of previous temperature abuse.
v. Food that is labeled frozen and shipped frozen by a food processing plant will be
vi. Food or food packages that are not in good condition to protect the integrity of
the food will be declined and/or moved to a segregated area until they can be
vii. Food vendor will be contacted for credit to be issued.
1. All food will be moved to the appropriate storage area within the
appropriate time frame to ensure integrity and safety of the foods.
g. Food Labeling
a. All potentially hazardous, ready-to-eat food that has been held for longer than 24
hours must be properly labeled. The label must include the name of the food and
a use-by date.
i.. The following items need to be labeled with a use-by of three days from
when the packaging was opened:
1. Fresh produce
2. Raw meat
3. Liquid eggs
5. The following items need to be labeled with a use-by of five days from
when the packaging was opened:
b. All Cooked/Preserved foods including:
1. Soups and Casseroles
2. Sliced deli meats and Cheese
3. Salad dressings /Mayo
4. Ice cream
5. Baked foods and Canned foods
c. The following Bulk Items need to be labeled with opened-on date:
5. Dry beans
1. Over-produced foods shall be properly paned, covered, dated, and
2. Maximum holding time for entrees, starches and vegetables shall be 3
days from date of production.
3. Scheduling and appropriate use of over-produced hot foods shall be
determined by the executive chef manager or Culinary Services
4. Over-production will be evaluated to identify trends and implement
corrective actions to ensure budgeted cost per meal.
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A. Ahn Dao, HT and Thanh Yen, P. Study of Salmonella, Campylobacter, and Escherichia coli
contamination in raw food available in factories, schools and hospital canteens in Hanoi,
Vietnam. Annuals of New York Academy of Science. 2006;1081:262-265.
B. Reis Coasta WL, dos Santos Ferreira J., Silva Carvalho, JS, Souza Cerqueira, E;, Cardoso
Oliveira, L, and Comastri de Castro Almeida, R. Methicillin-Resistant Staphylococcus aureus in
raw meat and prepare foods in public hospitals in Salvador, Bahia, Brazil. Journal of Food
C. U.S. Department of Health and Human Services. FDA Food Code. U.S. Food and Drug
D. Wisconsin Department of Trade, Agriculture & Consumer Protection. Wisconsin Department of
Health Services. Wisconsin Food Code.
Sr. Management Sponsor: VP, Facilities & Support Services
Author: Director, Culinary and Clinical Nutrition Services
Reviewers: Director, Professional Services at The American Center
Approval Committee: UW Health Administrative Policy and Procedure Committee
UW Health Chief Administrative Officer