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February 2002
Follow-up JCAHO Survey by Center for Medicare/Medicaid Services (CMS) to our Eastern Kansas Facility JCAHO Survey last reported on in November Hints & Tips
Reviewer: The state surveyor was an R.D. and the only R.D. at CMS currently. Both she and the Food Service Director were coincidentally professional acquaintances. The surveyor was part of a 6 member team.
Length of time: 2.5 days
Results: No recommendations in any area given
Narrative Report:
The R.D. surveyor spent about 8 total hours with this FSD over the course of the 2.5 day period. She reviewed policies, reports and observed tray line quite a bit while also performing several departmental rounds. She reviewed the department’s last quarterly CQI report and asked several questions about the graphs and statistics. She reviewed the JCAHO data regarding the poor completion rate by nursing of the admission assessment form and had no comments, unlike the original JCAHO surveyor who had several issues with this area.
The R.D. surveyor requested the nutritional analysis spreadsheets for all the patient menus and noted that fiber was not analyzed. She recommended that 30 gms. Of fiber per day would be an important goal and that methods to increase patient dietary fiber be explored.
Typically, most CMS surveyors are not usually registered dietitians, so therefore was quite a nutritional focus and several interesting conversations took place on a professional level regarding philosophies, latest research etc.. All in all a long three days, but a very successful survey for not only the Nutrition Services Department but for the entire hospital.
Important aspects of rounds, observations and opportunities for improvement:
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Iced tea glasses stacked 2 deep in rack; there can only be one glass in each section/slot
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Found dirt in dishroom under cabinets and in edges and corners
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Grease container in dock area missing a top and almost full – needed emptying ( called National By Products for pick-up this week)
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Greasy film on pans – need to check and make sure that the temperature of the pot & pan water matches the need of the soap that we are using and need to change the water more often. (called chemical vendor to check
on soap requirements)
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Asked for preventative maintenance list and cleaning schedules for equipment
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Silverware packed too tightly in cylinders going through the dishmachine (checked in manual and found that only 12 – 15 pieces should be put into a cylinder at one time as they go through the machine)
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Drain in front of steam kettles needed to be cleaned. Also, concrete is chipping and it needs to be resealed with fresh concrete.
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Back of convection oven greasy ( Plant Services Department was called and cleaned the back of equipment- possibly placing a plexiglass wall between table and oven or building a cover for the motor area so that it can cleaned easier)
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Light fixtures above steam kettles have loose or missing screws, causing a place for grease build-up (Plant Services took care of this immediately)
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Remove paper towel dispenser over pot & pan sink ( placed on zone maintenance clipboard)
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Found various items in the cafeteria cooks drawer including measuring spoons, masking tape and china markers all mixed together
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Food for tray line needs to be cooked at 30 minute intervals to retain the nutrients of vegetables and meats
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Pellet lowerator temperature was only 112º at lunch, 123º at supper, this is too low and needs to be increased
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Make sure that there is a 18” clearing from the ceiling from boxes (noted in the stainless storeroom that there were boxes 12” from the ceiling, but a moot issue since there are no sprinkler heads in there due to the nature of the product stored there (stainless steel) – the room was a central part of a cook/chill system from the 80’s).
Don Miller & Associates thanks this network member for their time and appreciates all that they candidly shared in order to assist us all in more successful JCAHO inspections. Kudos to you!!.
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
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