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 670031 (X3) Date Survey Completed 01/12/2012
Name of Provider or Supplier St Luke's Patients Medical Center Street Address, City, State 4600 East Sam Houston Parkway South, Pasadena, TX
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 observation, interview and, record review the facility (a) Failed to have a dietary director who is a full time employee of the hospital; (b) Failed to enforce its food and supply storage policy# B006 and; (c) Failed to ensure Dietary equipment were routinely cleaned. Findings: During observation on 1/11/12 at 8:15 am in the Dietary Suite at the facility Staff # 14N presented herself as the Director of Dietary Services and had been working in that capacity since July 2011. According to the staff she was a full time employee of a contract agency (MMS) and that all the dietary staff were employee of that contract agency. Staff # 14N further stated she reports directly to the Regional Director Operations at MMS however, if she had problems at the facility she would also discuss them with the facility ' s Chief Executive Officer (CEO). Review of the facility 's current dietary policy manual revealed the entire operation and day to day management of the dietary department was conducted by employee of the contract agency MMS. There was no facility employee designated to oversee the operations of the dietary department. During an interview on 1/11/12 at 2:00 pm with Staff #28 B, Chief Nursing Officer (CNO) She stated there was no hospital employee with direct oversight of the Dietary Department. Review of Personnel file for Staff # 14 N revealed she was hired as Dietary Director since July 2011. The Job description summary stated the following information: " Direct the operation of Food & Nutrition Services. Performs a variety of duties including the planning, and supervision of special functions, maintaining cash control, payroll records, hiring and training of personnel. Ensure customer satisfaction and good public relations are achieved through the safe and efficient uses of resources. " Observation on 1/11/12 at 8: 25 am in the dry storage room in the dietary suite revealed multiple food items that were opened and were not stored in a manner to prevent contamination. There were opened bags of pasta wrapped in saran wrap with the edges open; there were several opened packages of pasta, cornbread mix, and walnuts that had no wrappings and was not placed in covered containers. Further observation on 1/11/12 at 8: 40 am in the dietary suite revealed a food rack with multiple shelves stocked with prepared pastry to be baked had visible build up of dust webs on the bars of the shelves. There was heavy build up of dust webs on the dish washing machine, dust particles in corners of the floor. A dish cart in the clean dish room with clean glass ware, had visible dust and particles on the shelves of the cart. The cart was heavily stained with a whitish substance giving the appearance of a very dirty cart. These findings were also observed by Staff # N14 (Dietary Director) who was present at the time of the observation. During an interview on 1/11/12 at 9:45 am with Staff # N14 regarding the observation she stated the matter would be addressed with the dietary staff. Review of the facility's food supply storage procedure # B006 dated 3/11 gave the following information: 'Policies: All food , non-food items and supplies used in food preparation shall be stored in such a manner as to maintain the safety and wholesomeness of the food for human consumption. Store foods in their original packages. Foods that must be opened must be stored in NSF(National Sanitation Foundation) approved containers that have tight fitting lids."