Ftag of the Week – F813 Personal Food Policy

Our next “Ftag of the Week” on the CMSCG Blog is one that facilities may not have had to deal with frequently due to COVID-19 visitation restrictions, F813 Personal Food Policy. The lack of visitors may have contributed a reduced need to think about storing, reheating and discarding personal food items, but now that visitation is back, all those food containers may be too. F813 requires that facilities have a policy in place for use and storage of foods that are brought into residents by their families and other visitors to ensure safe and sanitary storage, handling and consumption of these items. Even pre-COVID-19, ensuring the system for personal food items was working was problematic, so now is a good time for a reminder on what facilities need to have in place for compliance.

Facility Responsibilities

Facilities are required to have a personal food policy in place. The policy needs to cover:

  • Staff responsibility and procedures for assisting residents with accessing food and consuming it if the resident is not able to do so independently. Who is in charge of reheating outside foods? Does that staff know the appropriate temperature food must be reheated to? Is information readily available for reference when food needs reheating?
  • How food brought from outside the facility will be stored in a manner that keeps them separate or allows them to be easily distinguished from facility-procured foods. If the decision is to utilize multiple refrigerators, the policy needs to reflect how items being stored throughout the facility will be discarded and who is responsible for doing so. Procedures should clearly define who is responsible for checking these food storage areas and making sure expired food items are discarded.
  • How visitors will be educated on safe food handling processes, including preparation, hand hygiene and holding temperatures for foods being brought for residents or even what the facility protocol is for visitors who are reheating or preparing foods with residents. Who is the person responsible for ensuring this education is complete?  There will always be a family member who brings in a home prepared food item that the “resident loves” and informs the staff that it can keep for a week in the refrigerator.  Family education is so important!

On Survey

Surveyors can check with residents and families/visitors to identify if they were provided with the facility’s personal food policy and if safe food handling practices were explained to them.

Surveyors can also interview the facility’s staff to see if they are aware of the facility’s policy, and if they are involved in assisting with personal food items, if they understand safe food handling practices. For instance, if CNAs are responsible for storing and reheating items rather than members of the dietary staff, are they aware of the facility’s procedures for doing so? It is important to ensure all involved staff are competent in safe food handling to minimize the potential for a negative outcome.


Citation Example S/S: F

Surveyor observed staff carrying a container of liquid, stuck it in the microwave and did not take the temperature of the food before taking it to a resident. The nurse told the surveyor that she thought it was hot enough, but it wasn’t she would reheat it. The surveyor observed her reheating the soup without taking the temperature before bringing it back to the resident. The surveyor further observed that there were no thermometers for staff/family use in 6 of 7 unit pantries.

The Food Service Director was interviewed and he confirmed that no education had been provided to staff on how to reheat food in the microwave to the appropriate temperature. He also said that he had provided thermometers to staff at the nursing stations, but they had not been calibrated and could not be located by staff when asked.


Unfortunately, the above scenario can happen in your facility on any given day. Education and a monitoring system should help you avoid an easily cited deficiency.  While you are at it when making rounds, peek into the refrigerators used for resident food storage and see how many items are unlabeled, undated or expired or staff use these refrigerators for storage of their own lunches. All are deficiencies in the making.


Reach out today and let's get started!

Urgent Compliance Concern? Call CMSCG

(631) 692-4422
cmscg podcast. five-star quality

Contact CMS Compliance Group

© 2011-2024 CMS Compliance Group, Inc. All Rights Reserved.