Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 010001	(X3) Date Survey Completed 09/29/2017
Name of Provider or Supplier Southeast Health Medical Center	Street Address, City, State 1108 Ross Clark Circle, Dothan, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

A0620

DIRECTOR OF DIETARY SERVICES
CFR(s): 482.28(a)(1)

The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training.

This STANDARD is not met as evidenced by:
Based on a tour of the Dietary Department, interviews, review of facility's policies, National Restaurant Association Educational Foundation poster and Safety Data Sheet, it was determined the Dietary Department failed to: 1. Label opened foods appropriately. 2. Maintain temperature logs for all refrigerators and freezers. 3. Ensure proper attire for employees. 4. Ensure cleaning of the dish washing machine was performed properly. 5. Check the temperature for the sanitizing solution sink. 6. Use a test kit to check the concentration of the sanitizing solution. 7. Store sanitizing solution properly. This had the potential to affect all people served by the facility. Findings include: ****** Policy Number L-23: Storage of Food and Supplies Revised: 1/17 Food and supplies should be stored in a manner to accommodate known practices for storing food in a safe and sanitary manner. ...6. Leftovers should be covered, labeled as to content, dated and refrigerated within one hour after use. They should be used within 3 days. ...15. Storage area temperatures should be monitored and recorded daily. ****** Policy Number C-1: Professional Appearance Revised: 1/17 ...Hair: Hair confinement should be used in areas where appropriate for job duties. Hair must be confined by a hairnet, cap, or other means. ****** Policy Number K-32: Policy Title: Dish Machine Policy: To ensure cleaning of dish machine is performed properly. Procedures: A. De-Liming: Overview ... 2. Put in Lime-a-way... 4. Run Lime-a-way out... ****** National Restaurant Association Educational Foundation poster located in the three compartment sink work area: Title: How To Clean And Sanitize In A Three-Compartment Sink ... There are 5 steps for cleaning and sanitizing in a three-compartment sink... 4. Immerse items in sanitizer in the third sink, Check the time and temperature requirements for the sanitizer you are using and use a test kit to check concentration... ****** Safety Data Sheet (ECOLAB) Title: Oasis 146 Multi-Quat Sanitizer ... Section 7. Handling and storage... Storage: Keep out of reach of children. Keep container tightly closed... ****** 37268 1. During a tour of the Dietary Departments conducted on 9/26/17 at 9:16 AM with EI # 8, the following observations were made: A rusty can opener located in the Main kitchen food preparation area. The dishwashing machine had lime and calcium build-up throughout the inside. The staff failed to de-lime the machine properly per policy and procedure. The staff in the Main kitchen did not check the temperature and chemical concentration during manual dishwashing of pots and pans per posted procedure instructions. Further observation revealed the chemical concentration test strips available for use were expired on 4/15/14. EI # 8 stated, "All of the test strips are expired; We will contact our vendor and have them to over night us some more test strips" There were no test strips available to verify the chemical concentration for the sanitizing sink per posted procedure instructions. There were open containers of sanitizing solution buckets throughout the Main kitchen, Oak Garden kitchen, and the Physician's Lounge kitchen. The staff failed to follow the manufacturer's instructions for storing sanitizing solution. The staff in the Oak Garden kitchen did not check the temperature and chemical concentration during manual dishwashing of pots and pans per posted procedure instructions. The surveyor asked EI # 30, Dietary Assistant, "Who verifies that chemicals are being dispensed into the sanitizing sink appropriately?" EI # 30 replied, "Maintenance ensures that the chemicals are being delivered through the dispenser." The surveyor asked EI # 30, "Do you ever check the chemical concentration in your sanitizing sink?" EI # 30 stated, "No." 2. During a tour on 9/26/17 at 9:45 AM of the Oak Garden dining facility, the surveyors observed the following: a. The temperature log for the large refrigerator was missing data for 9/26/17, and the dining facility was open and serving food. There was no temperature log for the under the counter small refrigerator. b. The cleaning log for the kitchen was missing data for 9/25/17. c. Upon entering the kitchen, the surveyor observed the cook was not wearing a hair net. d. The following items were observed in the large refrigerator: (1) One opened container of Kraft Mayonnaise labeled "Use by 9/20/17." (1) One opened container of orange juice with no expiration date. (1) One opened container of apple juice with no expiration date. (1) One opened container of Reser's Quality Deli Salad with no expiration date. e. All prepared food items in the display case were missing expiration dates. During an interview on 9/26/17 at 10:15 AM, with Employee Identifier (EI) # 8, Dietary Manager, the above findings were confirmed. 3. During a tour of the Dietary Department on 9/26/17 at 10:20 AM, the surveyors observed the following: a. In cooler # 8: A large pan of "pasta casserole" as identified by EI # 8, with no label as to content and expiration date. A tray of sliced ham with no label or expiration date. A rack of rolls, opened, with no expiration date. (2 )large containers of fruit mixture with no label or expiration date. (1) container of clear yellow liquid with no label or expiration date. b. In the storage room, the following items were found opened, with no expiration date: 1 bottle Marsala Cooking Wine 1 bottle Worcestershire 1 bottle of Molasses with a manufacturer's expiration date of 2016 1 bottle of Regina Cooking Wine 1 bottle of Fine Sherry 1 bottle of Hot Sauce 2 bottles of La Choy soy sauce 1 bottle of Red Wine vinegar 1 bag Mini Marshmallows 1 bottle of Hershey's Syrup 1 bag of soft tortillas, laying open 1 half used bag of Rotini pasta 1 bag elbow macaroni 1 bag wide noodles 1 bag bowtie pasta At 10:30 AM the surveyors observed plating of food items for patient consumption. (1) One of (2) two servers failed to wear an apron. During an interview on 9/26/17 at 11:55, with EI # 8, the above findings were confirmed. 4. During a tour of the Physician's Lounge on 9/26/17 at 2:53 PM, the following items were observed: One large freezer, One large refrigerator, and 3 small refrigerators with no temperature control logs. One can opener with rusted blades. 10 prepared sandwiches with no dates of expiration. One large refrigerator which contained the following: 4 large salad dressings, opened, with no expiration date. 1 container of egg whites, with no label or expiration date. 1 container of fruit, 8 containers of vegetables, no label or expiration date. One large Freezer which contained the following: 2 cake halves, with no label or expiration date. 1 opened bag of meat patties, not sealed. 1 opened bag of frozen biscuits. An interview was conducted on 9/26/17 at 3:20 PM with EI # 8 who confirmed the above findings.