Cortland Memorial Hospital
Welcome to CMH Food & Nutrition Services!
As you begin your employment with CMH Food & Nutrition, I would like to welcome
you to our department and invite you to read and become familiar with the contents of
this packet. I hope that you will find it full of helpful and valuable information about the
department’s policies, work practice & procedures, developed to guide and assist you in
performing to the best of your ability and to meet the expectations of our department.
Please take a moment and read the information and if you have any questions or need
further assistance about any subject, please consult with your immediate supervisor or
coordinator during your initial department orientation.
Once again, we welcome you and wish you success as together we strive for meeting our
department goals and providing “Service Excellence” to all of our customers.
Wanda Rawson, Food Management Coordinator
Anna Baranosky, Nutrition Coordinator
David Emperor, Supervisor
Julie Bush, Supervisor
Phil Gilbert, Supervisor
Becky Fox, Relief Supervisor
Eric Metcalf, Relief Supervisor
Karen Rose, Secretary
Together we can accomplish great things!
The Food Service department is responsible for the quality and timely provision of meal
service and other related services to our patients, residents, employees and all CMH
customers following individual nutritional needs and regulatory guidelines.
“The team takes off when everyone is willing to do their part”
The department provides well-balanced meal service and appropriate in-between meal
snacks to all patients, residents, adult medical day care registrants, childcare center
registrants, cafeteria & catering customers, visitors, volunteers, other guests and
customers. Our customers range in ages infant (six months) to elderly. We will prepare
more than 315,000 meals this year. These meals and services are provided within the
standards of state department of health, JCAHO regulations, physician ordered diet
prescriptions and the recommended guidelines for health and wellness.
In addition to the total meals served we also provide services to all CMH & RCF
patient/resident units, Coffee Shop, Non-nursing departments and Nutrition services. We
provide floor stock and snacks so that foods are available in-between meals for requests.
We fill food supply orders for the Coffee Shop and other CMH departments. Lastly we
offer support to the Registered Dietitians by provision of safe, sanitary food service,
avoiding health hazards while providing all diets according to the RD's optimal
nutritional care plan.
“To give real service, you must add something which cannot be bought or measured with
money, and that is sincerity and integrity.”
Hours of Service
The food service department's hours of operation are 6 a.m. - 8 p.m. daily, 365 days per
year. All patients and ADHC registrants receive their meals via traditional hospital meal
service using the pellet tray system. Bulk foods are provided to the child day care center.
RCF residents are offered a home style-dining atmosphere via satellite steam table system
at lunch and supper meals. The food service staff is responsible for direct customer meal
The Food Service department performs several distinct functions while supporting and
maintaining the CMH established mission statement and the CMH vision and values.
These services are offered with commitment to meeting our department goals and
standards of excellence within our food service, cafeteria and catering components.
“Accomplishments are built on the unwavering effort of each team member.”
Who Regulates Us?
In addition to our own Performance Improvement (PI) process of checking and
improving our services, we are also checked by regulatory agencies. These agencies are
the New York State Department of Health (DOH) and Joint Commission on the
Accreditation of Health Systems Management (JCAHO). These agencies check us in a
variety of ways. They review patient/resident charts for records of care, diet plans and by
touring our department. During the tour they will check our department for cleanliness,
job knowledge and review of temperature recording.
“When everyone strives for quality, the team can hit the right notes.”
Our appearance represents CMH. Therefore, our grooming and dress will reflect the
respect for our customers. While on duty, we will first consider our customers’
expectation in how we present ourselves. Our manner and expression will convey our
concern for and willingness to serve our customers. We will take pride in our facility and
do our part to maintain an uncluttered and litter-free work place.
“PRIDE is a personal commitment. It is an attitude which separates excellence from
Good personal hygiene is required and it is very important to the safety of our customers.
Before coming to work daily shower and wear a clean uniform. The following are
additional department dress & personal appearance standards:
1. Work clothes or uniform must be clean, neat and not revealing. Not torn, worn,
stained, or faded clothing will be allowed.
2. Blue jean pants or acid wash denim will NOT be allowed. Shorts are only allowed
On “dress down Fridays.” Sweat pants, wind pants, skin-tight pants are not allowed.
3. The following are examples of shirts/tops that are allowed; nursing uniform tops,
Shirts with collars (no advertising or decals), button-up shirts (no advertising or
decals), pullover polo shirts (no advertising or decals), turtlenecks with sleeves, CMH
logo shirts, and sweaters. We realize at times it is cold, but sweaters should not be
worn on the tray line or anytime dishing/serving food. The reason is that most
sweaters are fuzzy and collect lint/fuzz easily and it could fall into the food.
The following are examples of shirts/tops that ARE NOT allowed; t-shirts, any
style any kind (other than CMH logo), sweatshirts, tank tops, midriff shirts (any shirt
that exposes stomach or back when arms are raised), fleece type sweaters/sweat
shirts, and sleeveless tops/shirts.
4. For safety purposes skid-resistant shoes are recommended, backless or toeless shoes
are not allowed. All shoes must be clean and in good shape.
5. Bare legs are unacceptable except on “dress down Fridays” when shorts are allowed,
however, socks must be worn.
6. No excessively long or dangling earrings will be allowed (posts are acceptable).
7. Rings will be limited to one per hand and must be removed when serving food or
must have a glove on.
8. No unusual hair color will be allowed and hair is worn so that it is completely
covered with hair restraint. Facial hair must be closely trimmed.
9. Nails must be kept short, clean and well groomed. Nail polish is not allowed.
Artificial nails are not allowed.
10. All employees must visibly wear a nametag or identification badge, as provided, at all
times while at work. Nametags must not be damaged or covered up. Only CMH or
professional pins may be worn.
11. Smoking is limited to designated areas and designated break times. Gum chewing or
candy is not allowed.
12. Poor grooming practices, which may be offensive to others, such as body odors,
strong perfume and a generally unprofessional appearance are not acceptable.
13. Any skin lacerations, rashes, boils or infected wounds will be completely covered
when working with food, tray line or handling clean dishes.
“We must value ourselves, each individual, and each other, for safety is a vital
component of all effort, and the factor that permits us to savor success.”
A good attendance record is essential for the smooth operations of the department and
your successful employment. Employees are expected to arrive at work on time and be
prepared to begin their assigned duties, as assigned. Employees with excessive
absenteeism and/or tardiness will be subject to corrective action through the Hospital’s
progressive disciplinary system.
Tardiness is defined as:
An arrival after the scheduled start of the shift, or
Leaving a shift early (not initiated by supervisors)
Absenteeism is defined as:
Unscheduled time off for reasons such as personal business, illness or accident, or
any other unscheduled occurrence affecting an employee’s work schedule.
It is extremely important that a supervisor be notified if you expect to be absent from or
late for work. IN the event that you are unable to report to work, YOU must personally
notify the supervisor on duty prior to the scheduled start time (one hour).
Prior to 6 a.m. – call extension 3596 and leave a message. You must call back
and personally talk to a supervisor after 6 a.m. to confirm that they got your
After 6 a.m. – call extension 3597. A clerk will answer the phone, request to
speak to the supervisor on duty.
You will also be required to call employee health sick hot line 756-3199 for any
injuries or illnesses.
“A successful team beats with one loyal heart.”
Requesting Time Off – Scheduling
You will be required to work a variety of tasks and hours. Your schedule and
assignments will rotate. Once the schedule is posted, you will be required to work the
hours that you are assigned. Schedules are posted approximately two weeks in advance
and there is usually a full month of schedules posted in advance. If you need time off
you need to request that well in advance. Once the schedule is posted and something
important arises, you are asked to work with your co-workers to trade shifts.
When you request time off, make sure to work around your normal weekend to work.
Weekends are very difficult to find coverage for and you will be required to work your
normal weekend or again, work with a co-worker for coverage.
In addition to working weekends, it will be necessary to work some holidays. To make it
the fairest possible, employees rotate holidays. Holidays rotate from year to year. For
example, if you work Christmas this year, next year you would have it off. In addition
to receiving holiday pay if you work the holiday you will receive special pay for the
hours worked on the holiday. In order to get your holiday paid day off, you must work
the scheduled days before and after the actual holiday and the day that you are scheduled
your paid holiday.
We are paid every two weeks. Pay day falls on the first Friday of the pay period
(schedule). ON payday Friday, you can pick your paycheck up anytime between 9 a.m. –
3 p.m. from Karen Rose, our department secretary. You will be asked to sign for your
check. At that time you will also be asked to sign department birthday cards and accept
any handouts made available.
If you are unable to pick your check up before 3 p.m. and do not want your check mailed,
you MUST call or make prior arrangements with Karen. All checks must be put in the
afternoon mail if not picked up in person.
If someone other than yourself picks up your paycheck, they must have a note from you
giving them permission to sign for and receive your paycheck.
Everyone who enters our hospital is our customer. This includes patients, residents,
families and visitors, volunteers, students, vendors, surveyors, doctors and especially –
Our patient and resident’s satisfaction of our services is measured through Press-Ganey
surveys. Press-Ganey is a national firm who performs satisfaction surveys for 1000’s of
nursing homes and hospitals nation wide.
A survey is mailed to our patient’s home once they are discharged. The patient is asked
to complete the survey and give us information so that we can better serve them. Press-
Ganey will then put together reports that we can use to compare ourselves to other
hospitals based on our customer’s perception of their service.
Our goal is to be in the top 5% of hospitals and nursing homes nationwide. This is a heft
goal and with everyone’s help we will reach it and maintain it!
“Learn to see things as they really are, not as we imagine they are.”
Play – Work made fun gets done, especially when we choose to do serious tasks in a
lighthearted, spontaneous way. Play is not just an activity; it’s a state of mind that brings
new energy to the tasks at hand and sparks creative solutions.
Make Their Day – When you “make someone’s day” (or even moment) through a
small kindness or unforgettable engagement, you can turn even routine encounters into
Be There – The glue in our humanity is in being fully present for one another. Being
there also is a great way to practice wholeheartedness and fight burnout, for it is those
halfhearted tasks you perform while juggling other things that wear you out.
Choose Your Attitude – When you look for the worst you will find it
everywhere. When you learn you have the power to choose, you can look for the best
and find opportunities you never imagined possible. If you find yourself with an attitude
that is not what you want to be in the world, you can choose a new one.
Standards and Behaviors Expectation
At Cortland Memorial we believe that we are here to serve our customers. Our customers
include patients, residents and their family, visitors, co-workers including other
departments, volunteers, physicians and students. Our customer’s most basic expectation
is to be treated with courtesy. We are committed to providing the highest quality of
service and meeting our customer’s needs with utmost care and courtesy
You impact Service Excellence!
Department Chain of Command
Our department leadership consists of Food Management Coordinator (Wanda Rawson)
and a Nutrition Coordinator (Anna Baranosky) & department supervisors. The
supervisors each have areas of responsibility.
Cafeteria & Catering Services – Julie Bush
Hot Food Production – Phil Gilbert
Cold & RCF Food Production – Eric Metcalf
Sanitation – Becky Fox
Purchasing – David Emperor
One way that we can determine how well we are performing is to collect information and
maintain a self-checking system. This will also let us know how well we will meet the
requirements of the annual Department of Health survey and the JCAHO standards.
In our department we monitor:
Quality – look and taste of meals
The ways we perform a self-check in these areas are:
Dish machine temperatures
Nutritionist patient medical chart reviews
Meetings and in-services
Every month we review the information and compile a summary using:
Temperature Sheets (refrigerator, steam table, tray line, cafeteria, dish machine)
Test tray forms and comments
Patient and resident surveys
Quality Improvement is all about looking for problems and then developing plans to
correct them. Four times a year we summarize the problems and corrections made and
send a report to the Hospital Q. I. Department. IN the Q.I. department they review the
reports and develop an organizational performance improvement report that is sent to the
Board of Trustees. Q.I. is an organized program to help us meet our goals!
C.M.H. Benefits and Human Resource Policies
Upon hire you should have received an employee handbook from Human Resources.
This handbook will explain to you all the hospital policies and benefits. This is an
important handbook – keep it in a safe place for future reference.
Food & Nutrition Polices
Our department policies and procedures are on file in Karen’s office. If anyone should
want to review policies they are more than welcome. Policies are also available in the
In addition to working weekends you are required to work holidays. To be fair we rotate
holidays. There is a holiday rotation list that is located above the employee computer
work station. This list rotates from year to year so that you never work the same holiday
two years in a row unless you volunteer to do so.
If you work on the actual holiday you will receive overtime for all the hours you work on
the holiday, and you will also be given another day off – paid. All part time and full time
employees are given holiday pay.
In order to receive your holiday pay, you must work the day before and the day after the
actual holiday and the paid holiday. If you call in sick before the holiday or the holiday
paid day off, you will lose your holiday pay and be required to use vacation or personal
time to cover the time.
Anyone who works 4 hours or more is entitled to a 15 minute break. If you work an 8
hour shift, you receive a 15 and a 30 minute break. Break times are assigned by the
supervisor. If you should leave the hospital for your break, you must notify the
supervisor and punch out.
Weekend Call-In Guidelines
If you should call in sick on your weekend day to work, you will be required to work the
next week end. This is a policy that was initiated by the food service staff to resolve
staffing issues on the weekend. If you are unable to work the next weekend, you will still
need to make the weekend day up at a future date. If you are put out of work due to an
extended illness you are not required to make up the weekend days.
It is important to our customers that we park in the employee designated parking lots.
This allows enough convenient parking spaces for our customers. The parking map is
located on the employee “schedule” bulletin board. Employees can park in the lots of
West Main Street and in the day care lot on Homer Avenue.
Work Related Injury
It is very important that you report all work related injuries IMMEDIATELY to a
supervisor. The goal is to make our environment as safe as possible, but we realize that
there are hazards in our work areas. If we do not know what they are we can not fix
Attached you will find a copy of the CMH Employee Accident/Incident Report. These
forms are located in the Supervisors office. You will be asked to complete the form and
give as much information about your injury as possible.
If you injury requires medical attention, you will be asked to report the incident to the
Employee Health nurse at ext. 3616. You will then need to keep her informed of all
doctor’s appointments and medical attention that you receive.
If you are taken out of work, you will be required to provide us with a written doctor’s
note that includes how long you will be out, your next doctor’s appointment and any
restrictions that may apply.
If you are put on restrictions, you may be able to return to work. Depending on your
restriction you may work your normal job or you may be assigned to other duties.
Use of Phones
If you need to make a personal phone call you can use the pay phone in the lobby. If it is
difficult for you to leave the department at that time you may ask the supervisor if you
can use the phone. DO NOT use the clerk’s phone; this phone must be kept open for
These are the behaviors and standards that will enable us to perform proper phone service
with our customers to enhance PATIENT AND CUSTOMER SATISFACTION.
Smile at the telephone, the person on the other end can hear it in your voice.
Answer all calls by identifying our department and yourself. Always ask the
caller “How may I help you”. Speak clearly. For example: Food/Nutrition,
this is Wanda, How may I help you.
When transferring a call, first provide the caller with the correct number in
case the call is lost. All calls to extension 3597 or 3299 should be answered
within 3 rings.
Get the caller’s permission before putting him or her on hold. When you
return to that line, thank the caller for holding.
Callers on hold will be acknowledged periodically and given the status of
their call and asked if they want to continue to hold.
If you cannot assist the person tell them that you will find someone who can
help them with their questions.
It is very important that you report any equipment problems to the supervisor on duty.
Problems you may find are: equipment won’t work, disposals won’t work, cords frayed,
electric plugs broke, etc. The supervisor will place a work order to engineering
requesting for a repair. If necessary a piece of equipment may be taken out of service or
“locked out tagged out”.
We try to keep all staff up to date with department activities and information. We do
this by sending emails, posting meeting minutes and in-services. We also have a daily
communication board. We will note all important information of the day on the board,
which is located next to the employee computer station. We recommend that you check
this board every day at the start of your shift.
Safety & Infection Control Manuals
Every department has a RED SAFETY MANUAL and a YELLOW INFECTION
CONTROL MANUAL. These manuals include various “safety rules” to help you. Our
manuals are located at the employee computer workstation.
You are encouraged to look at these manuals and be familiar with the information inside.
Emergency Preparedness Plans
Chemical Safety Plans
Material Safety Data Sheets (MSDS)
Bomb Threat Plan
Weather Emergency Plans
Loss of Facilities Plans – Evacuation Plans
WE also have a red safety communication board. Our red safety board is located near the
dish room, above the ice machine by the cafeteria door. You are encouraged to check
this bulletin board for safety information.
Electricity can be very dangerous. Dangers include: shock, fire, explosion and burns.
Luckily we have had none of these in our department. However, we must all use
common sense rules to prevent an electrical injury.
Follow the manufacturer’s instructions for use and maintenance of all electrical
tools and appliances.
Check tools, appliances, and extension cords regularly for mechanical damage,
wear and tear on the cords and plugs.
Disconnect any tool or appliance that: sparks, stalls, blows a fuse, and gives a
shock or broken/frayed cord.
Remember -- Water + Electricity = DANGER
Personal Safety (Body and Back Safety)
What do you suppose is the largest single cause of back pain and injury? If you guessed
car accidents, or sports, or falling, or even stress, you’d be offering some good
possibilities. However, the fact is that improperly lifting moderate to heavy objects is the
most common cause of back pain.
Whether you’re standing, sitting, or lying down, you posture affects the amount of strain
you put on your back. Poor posture increases strain on the back muscles and may bend
the spin into positions that will cause trouble.
General Safety Rules
The foodservice business is busy. It seems we are moving quickly all the time. With all
the movement taking place, you need to be careful not to slip, trip or fall.
How to prevent slips and falls
Practice safe walking skills. Be alert to slippery surfaces and the speed at which
you walk. If you must walk on or over wet surfaces, take short steps to maintain
your center of balance and point your feet slightly outward. Move slowly and pay
attention to the surface you are walking on.
Clean up spills right away. Even minor spills can cause a slip. Whenever you see
a spill, clean it up yourself or ask the person who is responsible to clean it up.
Put up wet floor signs!
Always pick up the items you drop or that someone else has dropped. Food items
can be especially slippery.
Wear the right shoes. Wearing shoes with non-skid soles will decrease your
chance of slipping.
Make sure you can see where you are going. If you are carrying a load, be certain
you can see over the top of it.
Keep your work area clean. Don’t clutter pathways, aisles, or stairs. Store all
foods and materials in their designated areas.
Report to your supervisor any hazards you notice.
Cuts and Knife Handling
Here are some helpful hints when you are handling sharp knives:
Keep knives sharp. If they appear dull, notify a supervisor.
Use a cutting board that gives you plenty of space for cutting.
Use your knife correctly
Cut with the edge pointing away from you
Do not try to catch a falling knife
Use knives for their intended purpose only
Store knives in knife holder (both dirty and clean)
Do not put knives in a sink
Infection Control & Sanitation
Working in a health care facility, we are exposed to many infections. The most important
thing you can do to protect yourself and others is to WASH YOUR HANDS! The term
“sanitation” goes beyond just cleaning equipment and your work area. Sanitation refers
to all the practices and step-by-step procedures necessary to keep ourselves and our
department clean, and ultimately the food we serve free from bacteria.
Good sanitation includes:
Personal hygiene and cleanliness – shower and clean clothes every day
Cleaning and sanitizing work areas and equipment before and after every use
Using and storing clean chemicals and supplies
HACCP & Food Safety
HACCP stands for Hazard Analysis and Critical Control Points. The program was
pioneered in the 1960s with the U.S. space program. The goal of HACCP is to create
food that is virtually 100% risk free. The goal is to ensure against contamination that
would cause illness or injury to anyone who eats it.
The steps are designed to identify potential hazards and eliminate them from the process.
The steps begin at the time the food is received and goes through frozen storage, thawing,
and cutting/preparation, cooking, holding and finally serving to the customer.
There are seven principles to the HACCP approach to food safety:
Conduct a hazard analysis ( look at the steps )
Identify critical control points (CCP)
Set critical limits for each CCP
Establish procedures to monitor each CCP
Establish corrective actions
Establish a record keeping system
Verify that HACCP is working
Time and Temperature Control
Controlling the temperature of food is critical practice in keeping food safe. That’s
because all food has some bacteria that can grow rapidly within a certain temperature
range. In fact, temperature control is the number one defense against contamination
(besides hand washing).
KEEP HOT FOODS HOT! KEEP COLD FOODS COLD!
Bacteria are known to multiply quickly at temperatures between 40°to 140°F; this range
is called the “temperature danger zone”. No food should be allowed in the danger zone
for more than two hours. Keep in mind; this is a total time limit, including each state of
handling and serving. These times add up quickly!
Eight Frequent Causes of Food borne Illness
1. Failure to cool food properly
2. Failure to cook food properly, to a high enough temperature, allows bacteria to
3. An infected employee with poor hygiene contaminates the food
4. Food prepared a day or more in advance is handled carelessly.
5. Raw food is mixed with food that has already been cooked
6. Food is left in the temperature danger zone too long
7. Leftover food is not reheated to the proper temperature
8. Cross-=contamination occurs. For example a cutting board is used with raw food,
then without cleaning or sanitizing, it is used with cooked food.
Chemical Safety & Right to Know
The “Right to Know Law” is a NYS law that entitles employees and customers to know
what chemicals are being used that they might be in contact with, what dangers may
result in using them or special instructions on proper usage, handling and disposal of
We are required to have an MSDS (Material Safety Data Sheet) for every chemical used
in our department. The MSDS are located in the RED SAFETY MANUAL that is kept
on the employee computer workstation table.
An MSDS will have the following information:
Trade name of Chemical
Group if falls in (classification)
Hazardous usage of mixture
Safety steps to take when using
Long term effects of exposure
PPE (Personal Protective Equipment) that MUST be worn/used – goggles, gloves,
masks, aprons, etc.
Why is personal Hygiene Important? Everything including healthy people carries
harmful bacteria and viruses. Personal hygiene – HAND WASHING – is one important
area of food safety that people can control.
Proper Hand Washing Techniques:
Use a hand washing sink only, not a prep sink
Always wash your hands after using the rest room
Wash your hands if you touch anything that could cause contamination, such as
your hair or raw food
Wash your hands after you take a break, mop the floor, or take out the garbage
It takes about twenty seconds to properly wash your hands
Wash all areas of your arms and hands that are exposed to food – up to your
Always wash your hands in hot water
Dry your hands using single-service hand towels or hot air dryers
Disposable gloves should be worn over thoroughly washed hands only. Wear
them if you have a cut or abrasion. Change them if they become torn, dirty or
contaminated – or if you are changing food products or going from food to
Use of Gloves
Wearing gloves is the Law! Wearing gloves helps prevent cross contamination from
bacteria on our skin. But wearing gloves is not a complete protector against it.
Gloves act as a “second skin” for hands, but gloves can easily become contaminated and
spread contamination onto food contact surfaces or directly onto the food itself, and
ultimately, to your co-workers and customers.
We should always avoid any bare hand contact with foods. Always wear gloves or use
proper serving utensils.
Fire Safety & Emergency Codes
The CMH Emergency Codes are:
Code Red – Fire
Code Blue – Cardiac/Respiratory Emergency
Code Yellow- Need for internal assistance for a patient disturbance or
Code Pink – Infant abduction – armed or unarmed abductor
Code Orange – Armed Intruder
Code Green – Any type of situation that will impact the normal facility
operations due to mass casualty, weather conditions, communications,
equipment or electrical failure, disruption of medical gas system, bomb
threat or need for evacuation
Code White – all clear
Fire Safety Procedures (RACE):
Rescue – patients/residents in the endangered fire area should be rescued immediately.
Close the door and alert co-workers by announcing CODE RED and the room number.
Alarm – pull the nearest fire alarm pull station. Dial “2222” to state that a CODE RED
exists and to confirm the location.
Confine the fire: close all doors and windows to prevent smoke from entering the area.
Evacuate – move people horizontally beyond compartment smoke doors and vertically
down but never up.
It is important that you locate all the fire alarm pull stations and fire extinguishers in our
department. Remember their locations!
What do you do when a Code Red is called?
1. If you are on the floors – stop what you are doing and report back to the department
and sign in. If you were passing trays, make sure to close the cart door and park the
cart out of the way.
2. Unless the fire is in the kitchen we most often stay in our department. If the fire is in
our area we evacuate from the door furthest away from the fire and go to the
An emergency could consist of multiple car accidents, industrial accidents, chemical
spills, bio-terrorism or natural disasters. In the event that an emergency situation occurs
we need to be prepared to take care of our customers.
During day shift (8 a.m. – 5 p.m.) hours of operation, at the announcement of “code
green”, the Food Service Coordinator (Wanda Rawson) and Nutrition Services
Coordinator (Anna Baranosky) or designee(s) will assess the department resources and
complete sections 1, 3 and 4 of the Department Status Report Form.
All staff will report to the department and sign-in with the Food Service Supervisor. The
sign-in list will be forwarded to the coordinators. Using the sign-in list the coordinator
will assess the department for current numbers of staff, amounts of supplies and on-hand
availability of supplies and foods. With the completed Status Report Form, the
Coordinators or designee(s) will sign-in at the Admitting Reception Desk and get a copy
of the Disaster Assessment Form (DAF) that will be used to further assess the department
needs for the duration of the emergency situation.
Employees on duty may be asked to stay longer than their normal shift if the emergency
is such that we need additional staff. We may also call people in if the situation was
Visitor and Patient/Resident Injuries
Often when we pass trays to our patients/residents they may complain about something.
We are responsible to report those complaints to someone who can handle them. If the
complaint is something you can immediately fix – do so. You should report complaints
to a nurse manager, charge nurse or your supervisor. We may also witness accidents in
the hallways or patient/resident rooms. Again it is our responsibility to report these
incidents to the appropriate person.
HIPPA & Privacy
Every employee is responsible to protect patients and residents personal health
information. We should only have access to information that we need to know to do our
job. Never discuss patient information in public places (such as the elevator, cafeteria,
etc.) Never look up your own or your family’s health or medical record information.
When you leave a computer make sure to sign off of it. Never share your password with
anyone else. If you are not sure if information should be disclosed, contact the CMH
Privacy Officer, Nancy Fuller at ext. 3687 or ask your supervisor.
All employees are given access to the computer. At hire you should have filled out some
paper work to get a computer password. The USER ID will always be NUT.AAA
(usually your 3 initials). The password will be 2 letters and 4 numbers that you had
Computer is used for communication and for actual work. All patient and resident
information found on the computer is confidential and should only be needed in order for
you to do your job, otherwise you will not have any access to patient/resident
Meditech email is available for all staff. This is a main way that CMH communicates
with its staff. The instructions for accessing meditech email are as follows:
1. Press Enter
2. The first screen you will see is the blue screen, look in the black area
3. The first line says “Cortland memorial….
4. The second line is the user ID – type NUT.AAA (your initials)
5. Hit Enter
6. Next enter your password (your 2 letters and 4 numbers)
7. Hit Enter
8. Find MOX Cortland Memorial Hospital NPR Magic Office, type the number for
that category, and hit enter
9. To view your mail, type in 1 and then hit enter
10. To send mail, type in 6 and then hit enter
11. To view the library, type in 12 and then hit enter
If you should need assistance, a supervisor or Karen Rose will assist you. If you have
forgotten your passwords you will need to contact information systems at ext. 3574.
TABLE OF CONTENTS
Department Purpose 2
Our Customers 2
Hours of Service 2
Regulatory Agencies 3
Dress Code & Personal Appearance 3
Requesting Time Off – Scheduling 6
Paycheck Distribution 6
Service Excellence 7
Standards & Behaviors 8
Department Chain of Command 8
Performance Improvement 9
Holiday Pay 10
Meal Breaks 10
Weekend Call-In Guidelines 10
Employee Parking 11
Work Related Injury 11
Use of Phones 11
Phone Etiquette 12
Equipment Malfunctions 12
Department Communications 12
Safety & Infection Control Manuals 13
Electrical Safety 13
Personal Safety (body and back safety) 14
General Safety Rules 14
Infection Control & Sanitation 15
HACCP & Food Safety 15
Chemical Safety & Right to Know 17
Hand Washing 17
Use of Gloves 18
Fire Safety & Emergency Codes 18
Emergency Preparedness 19
HIPPA & Privacy 20
Job Descriptions & Task Sheets 23