All three hospitals said the violations had been quickly corrected.
Food generally isn't considered when patients choose a hospital. Yet a review of inspection reports from around the region found scores of violations, as well as wide variations in what was cited from county to county. Some evidence suggests that the scrutiny is more rigorous in the city.
Inspections are a far-from-perfect measure of risk: Inspectors found nothing amiss before or after an outbreak sickened 54 people and killed three patients at a Louisiana state hospital in May. And experts say most hospital kitchens go overboard with food safety, cooking so thoroughly to kill microbes that flavors may be lost.
They know that a slipup could be devastating.
"Anybody who has a compromised immune system is going to be more susceptible to food-borne illness. And hospitals are full of people with compromised immune systems," said Sheri Morris, food program manager at the Pennsylvania Department of Agriculture, which regulates restaurants and stores but not hospitals.
There are an estimated 76 million cases of food-borne illness in the United States each year and 5,000 deaths, according to the U.S. Centers for Disease Control and Prevention. A CDC database shows a tiny portion of them originating in hospitals and even fewer affecting patients.
Virtua, like other health systems here, said it had experienced no outbreaks at any of its hospitals. The latest inspection of the Virtua Memorial Hospital kitchen, on June 28, cited one violation that is a major risk factor for food-borne illness: a blocked hand-washing sink, for the second time in a row.
Five other violations, in a secondary category, ranged from the live and dead cockroaches to a cooked chicken that was cooling in a walk-in refrigerator in a covered pan more than 4 inches deep.
"Nowhere in the report does it reflect that there was any danger of food-borne illness," said Steve Boyle, senior general manager of Virtua food services and an employee of Sodexo, the multinational that operates food services for the health system.
For example, Boyle said, the chicken was not in a shallow pan that "allows it to cool quicker," but it was "already in the fridge."
"It was a teaching moment for us, as inspectors often do," he said.
That finding may not seem significant. But investigations of May's fatal outbreak at Central Louisiana State Hospital in Pineville identified the source as a cooked chicken that kitchen employees had cut up and then refrigerated in 6-inch-deep pans overnight.
"It clearly violates code," said Lisa Faust, a spokeswoman for the Louisiana Department of Health and Hospitals. "It has to be in shallow bins that will allow it to cool faster. It allowed the Clostridium [bacteria] to grow."
Since inspections are a snapshot of a constantly changing kitchen, they have limited ability to predict either safety or danger. "Just because you went in there and the place had no violations doesn't mean that 15 minutes later the place didn't go to pot," said Dennis J. Bauer, food-safety coordinator for the Bucks County Health Department.
Still, they are the best tool available.
Inspectors in Bucks, Chester, Montgomery, Burlington, Camden, and Gloucester Counties - all working for the county health departments - cite a handful of violations in most hospital kitchens.
In Philadelphia, however, city inspectors find far more.
Of more than two dozen hospitals in the city, only one - Aria Health-Torresdale Campus - got through its latest surprise visit with a fully clean bill of health. Just three more - Chestnut Hill Hospital, Children's Hospital of Philadelphia, and Pennsylvania Hospital - had zero violations in the more serious of two categories.
Of the 14 citations at HUP, four were in the more serious category. Among them: Raw chicken was stored above ready-to-eat foods in a prep area, a potential for drip contamination; a dishwasher did not bring utensils to the 160 degrees required for sanitizing; and cut deli meats were being held at 54 degrees rather than below the 41-degree temperature required to prevent growth of microbes.
All three were corrected during the inspection - the dishwasher was removed from service, and the foods were moved - but a hand sink without cold water required later repairs.
HUP and its sister hospital, Presbyterian Medical Center, tied for the most violations in their latest inspections.
The reports are "not an overall indicator of quality," said Marc Kaplan, a Penn health system spokesman. "Any items needing improvement were either corrected at the time of the inspection or shortly thereafter."
Violations cited by the city follow no apparent pattern of big teaching hospitals vs. small community hospitals, or institutions that operated their own kitchens vs. those that used vendors.
Eastern Regional Medical Center runs its own organic kitchen using mostly local ingredients; during the summer, all herbs and many vegetables are grown on site. Yet the cancer hospital was cited for eight violations during its last inspection, on April 26. A spokeswoman said all the violations had been fixed right away.
Most were minor. Three were considered more serious: ham and deli meats held at 50 degrees in the sandwich-prep area, 9 degrees above the minimum; lack of a sign by a hand-washing sink reminding employees to wash their hands; and no Philadelphia Food Safety Certificate, indicating that someone on staff has had 16 hours of food-safety training and passed a national test.
Those three are among the most frequently cited violations, said Palak Raval-Nelson, director of environmental services for the city health department.
Scientists have found in recent decades that - although not as off-putting as dead roaches - temperature control, cross-contamination, and hygiene play a far greater role in food-borne illness. And while equipment can be fixed, a kitchen's culture is more important.
"Education and training is 95 percent of prevention of food-borne illness," said Richard Linton, a food-safety professor at Purdue University.
Inspection programs that emphasize training and other factors known to play a role in food-borne illness are known as "risk-based." Most counties in the region have phased in risk-based systems in recent years; Philadelphia began doing so last year.
Although comparisons are difficult, city inspectors clearly find more violations than their suburban counterparts at restaurants and all other retail food establishments.
And city hospitals are nearly 50 percent more likely to be out of compliance than food establishments as a whole - a disparity that doesn't appear at all in the suburbs. The reasons are unknown.
There's no evidence that hospital kitchens in Philadelphia are riskier than elsewhere.
"I wonder whether Philadelphia is doing inspections better," said André Weltman, an infectious-disease specialist who tracks food-borne and other diseases at the Pennsylvania Department of Health.
The two sanitarians who inspect city hospitals automatically declare them out of compliance if even one major violation cannot be corrected during the visit, Raval-Nelson said. Her counterparts in other counties said their inspectors had more leeway. Reports in some other counties also often note "not observed" when procedures on the checklist were not done during the visit. That rarely appears on city reports.
Philadelphia inspects hospitals and other institutional kitchens quarterly. That is two to four times as often as every surrounding county in Pennsylvania and New Jersey - and eight times as often as the Pennsylvania Department of Health.
The state inspects every hospital kitchen in Pennsylvania as part of its full license review every other year. In Delaware and other counties without their own health department, this is the only inspection of the kitchen by the government.
The state's hospital code is at least 20 years old, although parts reference updates from other agencies, and it does not focus on food-borne illness issues.
So while other counties require at least one kitchen employee to be trained or certified to national food-safety standards, hospitals in Delaware County need only have a dietitian. And while other counties give more than a page of guidance on hand-washing - how often, how long, how vigorously, how hot the water - the state code gives one sentence.
The inspectors are different as well. Elsewhere, sanitarians have specific training in food science or environmental health. The state uses nurses.
"They don't necessarily have any specific training in food safety," said Stacy Mitchell, deputy secretary for quality assurance in the Pennsylvania Department of Health.
Delaware County also is the only place in the region where hospital kitchens' full inspection reports are not available to the public, even upon request. (Specific violations are posted online.)
Officials at Children's Hospital of Philadelphia said they welcomed the city's rigorous inspections.
"Patient safety is the No. 1 priority here," said Chad Hough, senior vice president of clinical support services. Children's relies on a mix of in-house staff and outside management and technology from Aramark, the Philadelphia food-services multinational, to prepare solid food in several kitchens for visitors, employees, and patients, plus 150 types of infant formula as well as fortified breast milk.
The first "risk-based" inspection of the hospital's main kitchen found eight violations, but two more visits, the latest on June 25, deemed it among the safest in the city.
"Going from two inspections to four inspections a year doesn't even cause me to blink. We could go to 365 inspections a year," said Hough. "We are ready any time they walk in the door."
Links to inspections of most hospitals: http://go.philly.com/inspect
Contact staff writer Don Sapatkin at 215-854-2617 or firstname.lastname@example.org.