Maricopa County, located in the Arizona desert, is the fourth-most populous county in the U.S., with a population of 4.49 million residents (2019 Census) residing primarily in the Phoenix metropolitan area. The dry, mild winters have long attracted seniors and retirees to the region. According to the 2019 Census, 15.5% of the population in Maricopa County is over 65 years old. Maricopa County Environmental Services Department (MCESD) currently oversees about 600 permits at long-term care facilities dedicated to quality of life for seniors. In late March, due to the spread of COVID-19, the MCESD Environmental Health Specialists (EHSs) were refused entry into assisted living and nursing home facilities to conduct routine food safety inspections. These facilities were not allowing other vendors and, in some cases, even family members to protect their residents. Because of the highly susceptible populations (HSPs) in long-term care facilities, more than half of the food permits require four inspection visits per year.

In late March, due to the spread of COVID-19, MCESD made the decision to have the EHSs stop conducting in-person routine food safety inspections at these establishments. This was to protect both the residents and personnel at the long-term care facilities, as well as the EHSs. The governor later issued an executive order preventing anyone other than essential medical personnel from entering these establishments to try to stop the spread of the virus.

To ensure food safety, even during these trying times, the Department developed guidance documents for both operators and EHSs for conducting virtual inspections. The document for operators described the new inspection procedure and what equipment and information would be needed for the inspection. The EHS document described new and modified procedures to take for each inspection. Two platforms were piloted for conducting inspections (FaceTime and GoToMeeting) in May and feedback was implemented immediately.

In the month of June, 360 virtual inspections were conducted. Feedback from both operators and inspectors was overwhelmingly positive. Although both preferred in-person inspections, everyone felt that this was the best alternative. The person-in-charge (PIC) at the establishment leads the inspection (with help from the inspector as needed) and demonstrates active managerial control. And, at the same time, food safety inspections are conducted, and important food safety information and training is immediately provided.

The success of this new practice is due to both the inspector’s and operator’s willingness to try new practices, outside of their comfort zone, for the safety of the residents, patients, and personnel at these establishments. The inspectors spent a lot of time training operators on the different platforms and walking them through an inspection. Patience was required from both sides when there was difficulty with the apps and Internet connectivity. It was truly a joint effort and would not have been successful without both groups’ willingness to work together on something new. Residents and patients were served safe food, with no negative impact to them.

MCESD has always conducted in-person, unannounced health inspections at all establishments. A specialized team of inspectors conducts inspections at the institutional care facilities, specifically hospitals, nursing homes, assisted living homes, jails, homeless shelters, daycares and other special facilities. However, due to COVID-19, and restrictions from entering most of these facilities, MCESD had to be innovative in order to successfully complete the state-delegated food safety inspections for which it is responsible. Laptops/tablets and iPhones have been used for many years for completing inspection reports in the field and for email correspondence. However, this mobile technology had not been used for conducting virtual inspections. (And we are unaware of any other agency conducting extensive virtual inspections.)

The pilot program began with the use of FaceTime for iPhones and GoToMeeting for Android devices as the Department had these platforms available. EHSs learned and practiced with the apps before conducting inspections. After receiving feedback from operators about incompatibility and failure with apps and mobile devices, MCESD decided on the use of VuSpex, a virtual inspection app that connects the end user and EHS via a link without downloading an app, which was recommended by the MCESD IT department. This platform has become the preferred app for its ease of use for both operators and staff.

New guidance documents were quickly developed for both inspectors and operators to ensure consistency of virtual inspections. The “Virtual Inspection Instructions” document for the food industry introduces the virtual inspection; describes the reasons for the inspection (from social distancing, to ensuring that food safety audits could be conducted safely); lists the technology needed; and lists supplies needed onsite (such as a food thermometer and a flashlight). The Virtual Inspection Guidance document for the inspectors provides the purpose and objective of the new virtual inspections; provides the process for conducting the inspection and specific violations to be aware of (or discussed if not observed); and procedures that the PIC must demonstrate to the inspector.

Virtual inspections have been pre-scheduled to ensure that the establishment is technologically prepared, and that staff is available to lead the inspection. Only one person is required to assist in the inspection, but we have found that having a second person available for holding the phone or tablet while the other employee is taking temperatures to be very helpful.

An unexpected bonus of the virtual inspections has been the PIC being put in an active, hands-on role and learning from this. For example, the PIC must calibrate the food thermometer, verify the temperature of foods in hot-holding and/or cold-holding tables, open containers in the walk-in refrigerator and verify cold-holding temperatures, etc. Feedback from PICs has included how helpful this approach has been in training them to follow through with the verification step of Active Managerial Control (AMC). (For several years, MCESD has promoted AMC, that management be proactive with policies that address foodborne illness risk factors and verify that the risks are under control.) Managers have stated that they have learned so much from leading an inspection and that the knowledge has helped them to better train their own employees. Many PICs are now conducting “mini-inspections” as part of their daily shift.

The first virtual inspections were on May 20, 2020 at an assisted living and nursing home campus that had three food permits. As of Dec 22, a total of 1,472 virtual routine inspections have been conducted by the staff of the institutional care program, including inspections at non-HSP food facilities and for plan review. Virtual inspections accounted for two-thirds of the HSP inspections that were completed in 2020. Of these, 79% of virtual inspections took place at long-term care facilities and 17% at hospitals.

The effectiveness of the virtual inspections in terms of violations and inspection time have yet to be fully analyzed quantitatively and compared to previous years. However, MCESD inspectors are confident that violations, if occurring, are being observed during inspections. If an establishment lacks the knowledge to prevent violations from occurring, the EHS documents the violation and trains the PIC on how to prevent those violations from recurring. They are providing them with training resources to assist them with gaining long-term control over those risk factors.

Until widespread vaccinations are available, Maricopa County HSP facilities will have the option of receiving virtual inspections through 2021.

The purpose of the virtual inspection is to keep employees and those in the inspected facilities safe during a pandemic situation, where foodservice operations must continue while minimizing contact with and exposure to others.

As an educationally focused agency, MCESD has a long history of working with and listening to their constituents. In order to maintain productive relationships between the EHS and the operator, staff oversee their assigned work areas for a three- to four-year period. MCESD partners with several industry groups, such as the Arizona Restaurant Association, the Chinese Restaurant Association, the Arizona Food Marketing Alliance, and other industry groups to build strong relationships. The pandemic has created a climate of shared understanding to find ways to keep things working under restrictions that made virtual inspections easier to introduce.

When the decision was made to pilot the virtual inspections, phone calls were made to several operators to see if they would be willing to participate in piloting the virtual inspection and provide feedback after the inspection. This was initially piloted with five permits. After receiving and implementing feedback, the guidance documents were finalized, and a training PowerPoint was developed and provided to more than 50 managers.

This training included:  how to use the apps on the phone and laptop/tablets; the supplies needed during the inspection; why the virtual platform for inspection was used; procedures the PIC would be asked to demonstrate; the risk factor violations that the inspector would be addressing during the inspection; and in conclusion, items that would be discussed during the exit interview, such as employee health and the AMC toolbox resources available on the MCESD website.

Maricopa County operators are invested in protecting their residents and patients, and they are willing to do everything that they can to ensure the safety of the food and their residents.

A primary objective of MCESD is to provide excellent customer service while completing all required food safety inspections effectively and efficiently. Introducing virtual inspections allowed MCESD and the HSP permit holders to successfully complete those required inspections.

As we began virtual inspections, feedback from the operators and the inspectors was discussed and shared. After their initial inspections, the inspectors quickly grasped the new technology and were comfortable teaching it to their operators. They also became more confident with leading operators through the inspection (over the phone) and were able to lead and conduct risk-based inspections. Despite not being onsite and being able to see everything that was happening around them, they were able to identify both violations and good retail practices.

Most of the HSP operators were working with reduced staff due to COVID-19 and had new procedures that they needed to follow. In the past, most establishments had dining rooms where residents could pick out their meals from a buffet or order off a menu. With COVID-19, most residents had to remain in their rooms all day, every day, to prevent infection and possible contamination. Facility staff had to plate up food in a kitchen on disposable trays that were delivered to rooms on multiple floors, while trying to keep the food in temperature without the proper equipment. Disposable utensils and wares were hard to find. Equipment to maintain food hot and cold was difficult to obtain.

Extensive cleaning procedures were put in place which, at times, required the kitchen staff to take on additional cleaning duties. Challenges arose when equipment broke, and vendors weren’t allowed into the building to service the equipment. Chemicals, such as bleach and other sanitizers, were almost impossible to find due to supply chain shortages. This was all occurring when COVID-19 illnesses, hospitalizations, and deaths were increasing daily. Executive orders from the governor were changing rapidly, as were recommendations for the food industry. These rapid changes would be difficult to manage in the best of times, let alone when employees were sick and kitchens were running on skeleton crews, many of them new.

MCESD received phone calls daily about how to manage and implement the changes and executive orders. As we received calls, those concerns were brought up to management who updated the website with resources and provided industry with newsletters with additional information to assist operators. Knowing that operators were short staffed, our virtual inspections became even more focused on foodborne illness risk factors to allow operators the time they needed to get safe food out to residents. The inspectors were patient with operators and stopped inspections if the operators became overwhelmed during meal service and finished the inspection after meals were served. If time allowed, more in-depth training was provided to operators to assist them.

Time savings from not driving to inspections allowed for additional inspections to be conducted daily. At the beginning of the pandemic, when HSP inspections were on hold, other permit types were inspected. Once virtual inspection procedures were finalized, the required inspections at HSP facilities were efficiently completed, and the state-delegated inspection frequency requirements were subsequently met.

To mitigate the challenges of conducting virtual inspections from the EHSs’ homes, particularly in the absence of a dedicated home office or the distraction of family or pets, additional equipment, such as computer monitors and headsets, were needed to conduct professional inspections. Resources including Coronavirus Aid, Relief, and Economic Security (CARES) funding purchased monitors, headsets, and Bluetooth mice to assist with inspections and reports while teleworking. For nine months, the stay-at-home executive order also made it difficult for co-workers and supervisors to share and coordinate work. The solution was to hold more frequent, small-group virtual meetings to discuss challenges that operators and inspectors had to ensure inspection consistency.

As more inspections were conducted, it became apparent that additional apps were needed to assist operators when compatibility problems arose between apps and mobile devices. Since October, the VuSpex app, designed to conduct virtual inspections with any mobile device without the need to download an app, is becoming the preferred inspection platform.

Overall, feedback from the virtual inspections has been positive from both operators and field inspectors. Virtual inspections are becoming standard. In addition to routine inspections at HSPs, EHSs have conducted re-inspections at HSPs that have visitor restrictions; inspected inside mobile food units where social distancing is not possible; inspected facility construction projects; and responded to weekend and evening complaints of violations of public health measures that were enacted by executive order. A virtual inspection was completed in a large processing plant that had a COVID-19 outbreak and restrict access to only employees. Importantly, virtual inspection procedures are currently being developed for jail permits and other permits with large congregate settings where social distancing is not possible and/or active outbreaks are occurring.

In conclusion, MCESD was flexible, agile, and patient in learning, adopting, and teaching new methods and procedures to solve a series of problems for itself and its stakeholders, with the shared goals of protecting public health, during trying times.