CFIA Assessment of Establishment 38, XL Foods Inc.
Annex A: Corrective Action Request and Action Plan Summary Table

HACCP system is not designed to control all hazards including E. coli O157:H7.

• Operator does not meet regulatory requirements related to developing and maintaining an effective HACCP System, specifically:
• Individual responsible for maintenance procedures not identified and ineffective to ensure implementation and monitoring of the HACCP system.
• No description of reassessment procedures.
• Incomplete log book regarding follow-up activities for positive sample investigations.
• Plant schematic form 4 for processing does not meet requirements.
• Critical Control Point (CCP) for offal chilling and steam pasteurizer did not meet requirements.
• Validations not undertaken for alternative to Sanova in steam pasteurizer; CHAD wash validation incomplete.
• Disposition guidance document does not include sufficient detail relating to investigations in response to positive samples.
• Guidance decision document does not take into account high positive occurrences on an hourly or per shift basis.
• Guidance document instruction for when positives exceed 20 per cent in a single production not consistent with company decision document.
• Bracketing procedure not clearly identified or followed.
• Lack of investigation procedures/guidance for root cause analysis on high event days.
• No trend analysis procedures to explain rational for action limits and how action limits are linked to sampling plan.
• N-60 sampling procedures not followed: employees were not sampling all areas of combo surface representatively and consistently. Sampling technique inconsistent.

• Letter of commitment revised to include all required statements.
• HACCP maintenance and reassessment procedures revised.
• Log book reviewed for completeness based on interviews.
• Plant schematic Form 4 was revised to meet requirements regarding flow/removal of waster.
• Plant schematic Form 4 for slaughter and processing revised to identify hazards associated with flows.
• CCP for offal chilling revised to ensure 7 degrees Celsius or less within 12 hours of production.
• CCP for steam pasteurizer: inspection staff notified to record monitoring results.
• Deviation procedures and protocol to revalidate statistical process control of CHAD cabinet redesigned in light of change to process.
• Monitoring procedure for dwell time for CHAD revised.
• Results for E. coli O157:H7/ Non-0157 Shiga Toxin-Producing E. coli (STEC) are reviewed upon receipt and decision guidelines are followed per the current written standard operating procedures (SOP) and to record actions taken appropriately prior to performing pre-shipment review.
• Confirmed that the establishment consistently engages in bracketing activities, diverting tested negative pre-grind raw material to cook only with lots that are found positive.
• Senior management is committed to assess the potential for additional controls in association with trend analysis.
• Establishment 38 commits to intensify bracketing activities on days with multiple positives by further assessing the need to take action on negatives produced adjacent in time to positive lots that occur within short or defined time frames.

Multiple unsanitary conditions.

• Grease build-up and blood clots on evisceration table.
• Cleaning of refrigeration unit frequency not recorded.
• Cleaning of overhead structures in "old cow boning line" not undertaken.
• Lunch room benches not thoroughly cleaned.
• Large amounts of fat and meat build up throughout.
• Boot foamer chemical bottle not labelled for identification.
• Specified Risk Material (SRM) container used for conveyance of cleaning chemicals.

All unsanitary conditions were addressed, including:

• Cleaning of all affected areas undertaken.
• Cleaning chemicals were placed in a container, which was in turn placed inside SRM container; removed.
• Boot foamer label addressed.

Structural and Maintenance issues.

• Improperly sealed doors.
• Poor condition of floors causing water pooling.
• Walls do not meet program requirements.
• Eye/Hand wash tap broken.
• One drain had no P-trap insert.
• Three drain lines from overhead structure in combo storage not effectively plumbed into floor drains causing water pooling.

• All doors repaired.
• Floors repaired to prevent pooling.
• Walls refurbished.
• Hand/eye-wash station re-plumbed to prevent pooling.
• P-Trap in drain installed.
• Drain lines in combo storage fixed.
• Quality Assurance (QA) manager will re-train QA inspectors on assessing building maintenance.

Water dripping from overhead structures and beading condensation.

• Condensation in the offal hallway dripping onto boxed product.
• Condensation present in combo storage area and slaughter floor
• Antimicrobial dripping onto rusty pipe and onto product.
• Improper air flow at the processing floor, maintenance hallway door and CH4 stairwell door.

All ventilation issues were addressed including:

• Condensation in offal hallway dried and boxed product on which condensation was observed dripping was either repacked or discarded.
• Plastic barrier placed over affected pipes; pipes repaired or replaced.
• Store room receiving dock and processing door sealed properly.
• Enhanced/revised air flow monitoring SOP implemented for monitoring air flow throughout the plant.
• QA manager has re-trained QA inspectors on assessing and controlling condensation.

Equipment maintenance issues.

• Pitted welds throughout slaughter floor and processing floors were observed.
• Evisceration table sanitizer water temperature gauge was not functioning.

• Water temperature gauge was replaced.
• Quality assurance function to detect pitted welds including training of QA inspectors has been instituted.

Multiple Food Hygiene issues.

• Company employees not wearing beard nets.
• Company employee pulled trim from pipe and then returned to sorting trim without washing/changing gloves.
• Clean up employee pushed inedible colour coded bucket in a manner that allowed contact with back side of production team members white smocks.
• Grease and fat build up on grading stamp handles
• Mesh gloves left on pipe during break.
• Garbage cans in proximity of white smocks hanging area.
• Sanitizer in offal packaging below 180 degrees Fahrenheit.
• Bung bags in contact with sink.

All Food Hygiene issues were addressed including:

• Supervisor instructed employees to employ beard nets.
• Employee handling trim without washing/changing gloves immediately halted from handling product.
• Smocks were changed.
• Grading stamp handles were cleaned.
• Gloves were removed from pipe and cleaned.
• Smocks in proximity to garbage were replaced and cleaned.
• Sanitizer temperature was addressed.
• Bung bags were discarded
• QA manager has retrained all QA and production supervisors on sanitation requirements.