Food Safety and Inspection Service reports on Boar’s Head investigation

The USDA’s Food Safety and Inspection Service (FSIS) has published its report on inspection practices used by the agency in relation to the deadly 2024 Listeria outbreak traced to Boar’s Head deli meats.

“The FSIS review of records and data from the Boar’s Head Jarrett, VA, production plant indicated a pattern of conditions that presented an elevated risk for Listeria monocytogenes contamination,” the FSIS reported.

The Boar’s Head plant in Jarrett, VA, was sampled by FSIS at the highest frequency rate (monthly), yet this sampling did not identify the establishment’s Listeria problem.

The Centers for Disease Control and Prevention began investigating the outbreak on July 19, 2024. Ultimately the outbreak sickened 61 people across 19 states, killing 10. Sick people’s samples were collected from May 29, 2024, to Sept. 13, 2024.

In relation to the outbreak Boar’s Head, which is a family owned business with $1 billion in annual sales, closed its production plant in Jarratt, VA, on Sept. 13 and permanently stopped liverwurst production nationwide. Boar’s Head recalled more than 7 million pounds of deli meats because of the outbreak.

The USDA began an investigation into the food safety mitigation and inspection processes used by Boar’s Head and the inspection processes used by government inspectors. The U.S. Department of Justice is conducting its own investigation into the situation.  

The FSIS report on its handling of the situation includes a timeline of its investigation at the Boar’s Head production plant in Jarratt, VA.

“FSIS arrived at the establishment on July 22, 2024, to prepare for an FSA (food safety assessment) and conduct IVT (intensified verification testing) sampling. On July 24 – 25, 2024, FSIS enforcement, investigation and analysis officers conducted IVT sampling and collected a total of 81 samples — 20 product samples, 40 food contact surfaces samples, 20 non-food contact surfaces samples, and 1 brine sample,” according to the report.

The FSIS investigation into the outbreak also included document reviews from 2022 through 2024 and included FSIS-generated inspection records, memoranda, and microbial testing results, as well as establishment programs, procedures, microbial testing results, corrective actions, and findings from Boar’s Head’s internal investigation at the production plant.

When the inspection reports were initially released, it was clear that the Jarrett, VA, production plant had been violating food safety regulations since at least 2022.

The plant opened in April of 1984. The FSIS contracted with the Virginia Department of Agriculture and Consumer Services for inspection services at the plant. Government inspectors manned the plant during all production hours.

Next steps

The FSIS is applying information learned in its investigation into the Boar’s Head outbreak to its overall operations.

“FSIS has already begun to implement several of the short-term actions identified in its report. The short-term actions are intended to strengthen the agency’s inspection and oversight by enhancing its ability to proactively identify and respond to the types of systemic problems that could lead to outbreaks,” according to the FSIS report.

At the same time, FSIS will continue to work toward its long-term vision to modernize the agency’s regulatory approach to Listeria monocytogenes.

“Any expanded approach to Listeria control will require commensurate funding. As requested in the FY 2025 President’s Budget, additional resources are necessary for the agency to continue to meet its mission to keep meat, poultry, and egg products safe and wholesome, and these findings are in addition to the significant resource needs that were previously identified in that request,” according to the FSIS report.

Findings related to the production plant

FSIS reviewed inspection documents and establishment sampling data from January 2022 to September 2024 and conducted in-person observations as part of its review. Based on records and observations, FSIS identified several factors that may have contributed to the outbreak.

A notable contributing factor was the facility’s inadequate sanitation practices. 

“Observations by government inspection personnel documented in noncompliance records demonstrated multiple instances of noncompliance with Sanitation Standard Operating Procedures and Sanitation Performance Standards. While sanitary conditions were required to be restored for each documented noncompliance, repeated instances of insanitary conditions can present opportunities for growth or sustained presence of Listeria monocytogenes,” the FSIS reported. 

Documented instances of noncompliance included:

• Product Residue: Inspectors identified the presence of meat and fat residue from the previous day’s production on equipment, including packaging equipment and in the ready-to-eat processing area during pre-operational sanitation checks. Residue can provide a substrate for Listeria monocytogenes to survive and grow in the food processing environment and form biofilms, which can become more resistant to cleaning regimens. Biofilms are thin layers of bacteria that can form on equipment and other surfaces — similar to plaque on teeth. Once biofilms form, they must be removed by scrubbing or other mechanical action.

• Condensation: Inspectors identified multiple instances of condensation in the RTE environment including dripping condensate on exposed product and a fan blowing condensate directly on products.

• Structural and facility problems: Inspectors observed facility and structural-related issues, including cracks, holes and broken flooring, that could hold moisture and contribute to wet conditions. Additional conditions documented included rust, beaded condensation and peeling caulk.

Review of the other Boar’s Head facilities

On Sept. 5, 2024, FSIS broadened the scope of its review of the Listeria monocytogenes illness outbreak to include a review of all FSIS-regulated establishments owned and operated under the Boar’s Head Provisions Company corporate umbrella. Inspectors conducted food safety assessments at other Boar’s Head establishments located in Arkansas, Indiana, Michigan, and Virginia. As part of the assessments, FSIS also conducted intensified verification sampling for Listeria monocytogenes at these Boar’s Head facilities, and ensured any identified deficiencies were corrected and monitored in both the short- and long-term, according to the FSIS report.

Short-term opportunities for strengthened FSIS oversight

In addition to assessing the Jarrett, VA, production plant responsible for the tainted deli meats and the other Boar’s Head facilities, the FSIS review also included a review of its processes and procedures related to Listeria monocytogenes controls and agency inspection and oversight in ready-to-eat establishments. 

The FSIS reported that this work yielded several key areas for improvement including those related to sampling, inspector training, oversight of plants staffed by state inspectors, and the future of the agency’s Listeria regulatory policy.

As outlined in the agency’s Dec. 17, 2024, announcement, many of these new policies and practices are already being put in place.

Equipping FSIS inspectors with updated training

FSIS is equipping its personnel with the training and tools to recognize and respond to systemic food safety issues, through:

• Updated instructions and training for food safety inspectors to better equip the workforce to recognize and highlight systemic problems in a standardized way.

• Prioritized in-depth food safety reviews at ready-to-eat meat and poultry facilities. In fiscal year 2025, reviews will provide information about the plants individually and collectively. FSIS will publicly share findings and trends from these assessments that result in any future policy or process changes to target this microorganism.

• Updated protocols for food safety assement follow-up. FSIS field supervisors will conduct in-person, follow-up visits when systemic issues are identified during an FSA.

• Revised establishment-review alert criteria. One significant criterion used to guide a district office’s decisions is a monthly list of facilities with higher rates of noncompliance related to public health that is generated using an algorithm. Using additional data from the new weekly verification of Lm-related risk factors, FSIS intends to update its algorithm and criteria to better identify high-risk facilities.

Tightening oversight of regulated establishments

The Boar’s Head Jarrett, VA, production plant was inspected by Virginia state inspectors as part of a cooperative agreement with the federal government. The TA Act of 1962 provides the USDA’s Food Safety and Inspection Service with the authority to enter into agreements with a State Department of Agriculture, or any other state agency responsible for its meat or poultry inspection program, to perform inspection duties in federal establishments on behalf of FSIS.

These state inspectors receive the same training and meet the same duty requirements as federal inspectors. There are currently nine states — Alabama, Georgia, Illinois, Mississippi, North Carolina, Oklahoma, Texas, Utah, and Virginia — with cooperative agreements with the federal government. Through updated cooperative agreements with each participating state, FSIS is setting specific requirements, including clear expectations for oversight and enforcing federal food safety laws, comprehensive federal training for state inspectors, and enhanced regular coordination with FSIS.

After reviewing existing practices, FSIS has identified and implemented the following action to strengthen oversight of establishments, including those inspected by states under cooperative agreements:

• Inspectors, both in TA facilities and federally-inspected facilities, are now verifying specific Listeria monocytogenes-related risk factors at all ready-to-eat facilities weekly. These risk factors include changes in physical plant modifications, such as new construction; indicators of sanitation problems, such as condensation, roof leaks, damaged equipment, or cracked floors; and Listeria species positive test results from company testing. FSIS district offices, agency field supervisors and inspectors will review, analyze and consider the weekly data from each facility to determine if there are systemic issues that warrant further action, such as an FSA, intensified sampling, or enforcement steps.

Regulation of ready-to-eat plants

The FSIS currently regulates approximately 2,600 establishments producing ready-to-eat (RTE) products. On a routine basis, FSIS inspection personnel collect, and the labs analyze, finished RTE product samples throughout the year. FSIS collects a minimum of two product samples per year and a maximum of one per month at these establishments under its routine RTE sampling program for Listeria onocytogenes. The frequency of sampling is determined based on a variety of factors including establishment size, sampling history, product type and alternative used.

Looking across RTE establishments in FY 2023, for its routine RTE sampling program, FSIS collected approximately 15,000 samples at these establishments, and 0.187 percent of the samples were positive for Listeria monocytogenes. 

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Source: https://www.foodsafetynews.com/2025/01/food-safety-and-inspection-service-reports-on-boars-head-investigation/