CMS SOM App. A, Tag A-0620

(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.

Interpretive Guidelines §482.28(a)(1)

The service director must be a full-time employee who has been granted the authority and

delegated responsibility by the hospital’s governing body and medical staff for the operation of

the dietary services. This authority and delegated responsibility includes, the daily management

of the service, implementing training programs for dietary staff, and assuring that established

policies and procedures are maintained that address at least the following:

• Safety practices for food handling;

• Emergency food supplies;

• Orientation, work assignments, supervision of work and personnel performance;

• Menu planning, purchasing of foods and supplies, and retention of essential records (e.g.,

cost, menus, personnel, training records, QAPI reports, etc);

• Service QAPI program.

Additionally, the service director must demonstrate, through education, experience and/or

specialized training, the qualifications necessary to manage the service, appropriate to the scope

and complexity of the food service operations.

Survey Procedures §482.28(a)(1)

• Verify that the director of the food and dietetic services is a full-time employee.

• Review the service director’s job description to verify that it is position-specific and that

responsibility and authority for the direction of the food and dietary service has been

clearly delineated.

• Review the service director’s personnel file to verify that he/she has the necessary

education, experience, and training to manage the service, appropriate to the scope and

complexity of food service operations.