Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 010006 (X3) Date Survey Completed 04/11/2019
Name of Provider or Supplier North Alabama Medical Center Street Address, City, State 1701 Veterans Drive, Florence, 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, review of the policy and procedure and interviews with the staff it was determined the Dietary Department failed to follow their policy and procedure and ensure: a). All open food products were sealed and labeled properly. b). All pots and pans were dry prior to stacking on shelf. c). Proper handling of all food items while completing plating. Findings include: Policy Food Preparation, Storage and Service Policy Number: H110.801.059 Review Date: 10/20/18 Purpose: To ensure that all food is stored and served in a manner that is compliant with all applicable regulations. Procedure: All food prepared and served will be handled with clean and sanitary gloves and utensils...Gloves will be changed and hands washed per hand washing policy between tasks. ...Original packaging that has been opened will be labeled with the date it was opened and a use by date that will not exceed the package date. on 4/9/19 at 9:30 AM a tour of the dietary department was conducted. During the tour Employee Identifier (EI) # 11, Dietary Manager and EI # 12, Assistant Administrator, was present. The dry storage area was observed during the tour. While observing the dry storage area the surveyor discovered the following: 1- 4 pound (lb) bag of sugar open with no open date and not sealed properly. 2- 10 lb boxes of graham cracker crumbs in a bag inside each box. Both boxes and the bags were opened and no open date was on the box and the bags were not properly sealed within the box. During the tour the kitchen area the surveyor noticed pots and pans sitting on a shelf. With further inspection of the pots and pans, the pans were wet when stacked. When lifting and separating the pots and pans water ran out from around each one. The surveyor spoke with EI # 11 who stated "the pots and pans are to be completely dry prior to stacking them on the shelf." On 4/9/19 at 11:00 AM the surveyor observed the plating of the food. During the plating of the food the surveyor noticed a bag of dinner rolls and a package of hamburger buns sitting on the counter. Observations conducted revealed after plating the hot food and using utensils and resting hands on the counter EI # 10, Dietary Server, reached into the bag containing dinner rolls with a gloved hand and removed a dinner roll and placed on a plate. Further observations revealed EI # 10 began a new plate and reached in to the bag containing hamburger buns and removed one bun with a gloved hand and placed on a plate. EI # 10 failed to use tongs or remove gloves and sanitize his/her hands and don clean gloves prior to removing the rolls from the bag. The surveyor asked EI # 11 if using a gloved hand was proper protocol for removing the rolls. EI # 11 stated "no it is not tongs should by used." EI # 11 then obtained a pair of tongs and placed on the food line for EI # 10 to use for the rolls. An interview was conducted on 4/9/19 at 11:35 AM with EI # 11 who confirmed the above mentioned findings.