November JCAHO Survey
Eastern Kansas Facility – 170 beds

Surveyors: John Comstock M.D.
                      Shirley Francisco R.N.
3-Day Survey: Overall Score: 93 with 0 Type I Citations

Food Quirks: M.D. claimed he didn’t like “overkill” of daily food buffet luncheon, but then did praise the food service team during the exit interview. No other special needs etc..

Physical Tour: The nurse surveyor spent 15 minutes in the food service department tour. She scanned the walk-in coolers and freezer. She noted that the sink sanitizer log was recorded on daily with the pH solution. She requested the latest state health department report of inspection. No written report was available due to no deficiencies or recommendations from the annual state survey. The inspector requested to see the dish machine temperature logs and checked to assure that the current day’s temperatures had been recorded. She also requested back-logs for the past several months to review. The surveyor also singled out one staff member to explain how to handle a grease fire and to identify the location of the extinguishers. She also wanted to know how long the employee worked there and whether or not he received orientation information. There had been a lot of staff education 6 weeks prior to the JCAHO inspection and this employee performed well.

Patient Care Interviews: The largest bulk of time was spent in Patient Care Interviews – this 30-year Food Service Director veteran noted that “these interviews were very intense.” It was also noted that the FS Director accompanied each dietitian at every patient care interview on their respective unit(s). She felt it was a good insurance policy and that her powers of persuasion would prove helpful.

At one of the patient care interviews, the physician surveyor asked about the FS Department’s no charge guest tray policy and procedure. He wanted to know how one qualified for a guest tray. (Ans. given was that if the guest assisted the patient in feeding or some other helpful function, the nurse could make a judgment call and order a guest tray. If the patient was an infant and the mom breast-fed that would also qualify for a guest tray.) 

The physician questioned who had input into the nursing admission assessment form regarding the nutrition assessment section. At this time he also asked what the hours the dietitians worked, how many there were and how many days per week that they worked. Coverage was stated as Monday through Saturday, 8 –10 hours each day and Sunday was an “on call” day. The surveyor was satisfied with this answer.

The nurse surveyor questioned why obesity was not a risk factor on the nutrition risk screen. (Ans. given was that this risk factor was better handled on an out-patient basis where there was time to deal with the problem on an on-going basis with counseling and measurable progress. A second reason given was because if obesity was used on the nursing admission assessment it would present something that nursing wasn’t able to make a judgment call on and that it was better left to the dietitian to address these issues. This answer accepted.)

The biggest challenge was clarifying the data regarding the accuracy and frequency in which nursing completed the nutrition risk screen on the inpatient admission assessment form (AAF). Data collected three months prior to the JCAHO survey indicated room for improvement with respect to nursing’s completion and referrals to the clinical dietitians’ form the nutrition risk screen. The nurse surveyor requested evidence of repeat data collection of which there was none due to the fact that there was no current change in the system process. Documentation stressing the fact that patients who had no nutrition risk screen completed, were in fact, assessed by dietitians’ was provided. High-risk patients were assessed because of several other “triggers” that were in place and that the dietitians worked around the missing data, so to speak.

The nurse surveyor did not like the idea that the nursing staff didn’t complete the AAF and was very ready to assign a Type I citation. This very persistent Food Service Director talked the surveyor out of giving the Type I by convincing her that it was more of an education process and that it would be resolved via education and training. The FSD stated that both she and the Administrator would be sure that this issue would be addressed. The surveyor asked the FSD “do I have your word on it?” 

This FSD was recently informed that by the luck of the lottery, a 5-day follow-up random CFMM (HCFA) visit would happen on January 7th. She has graciously agreed to keep us posted as to her experience and findings after this survey. 

Don Miller & Associates wishes her all the best of luck!

Don Miller, R.D., C.E.C.
Nancy Yezzi, R.D., L.D.
Bill Klein, C.I.C.
Success Coaches

Don Miller and Associates
346 Crestview Drive
Bonita, CA 91902
(619) 656-2100 PST
(619) 656-1321 fax
chefdon@cox.net
http://www.chefdon.com