JCAHO Inspection – Atlanta, Georgia
Multi-Site Acute Healthcare System 
November 2002

Surveyors:
Dr. Robert Matthews
Gwen McGee R.N.
Phillip Todd – Administrator

Length of Survey: 6 weeks for 5 hospitals and 1 assisted living facility
Hospitals varied in bed size from 25 – 539
Services included: long-term care, intervention services and hospice 

The “System Review”- the corporate survey focused on a global approach to healthcare. The surveyors looked for “system-ness” and like practices throughout the facilities in items such as policies and procedures and competency checklists to name a few and were satisfied with this area.

Hospice – Two type 1 citations were given in this area for the following reasons:
Pain Control and grieving – due to the fact that there were no measurable outcomes available in the data reviewed.
Proper chemical usage – a housekeeper was observed using a cleaning solution that the surveyor knew needed a 10 second delay before actually starting to work with the chemical after application to a surface. The housekeeper failed to wait the 10 seconds and the surveyor called them on it.

Hospice also received a “supplemental” due to lack of advanced directives found in charts.
This system treated “Pain” as one of the 5 vital signs and the received Kudos from the surveyors for that. The patient was to assign a number rating to pain from 1 –10, which the surveyors liked because it was easy and measurable.

Home Health Care – the R.N rode in the car with the Home Healthcare employees and observed that they didn’t bring in CPR masks and commented on this and asked them to include masks in the future.

Nutrition Screening –the surveyors were very “Pro” R.D. and wanted their time to be spent wisely. In one of the facilities with long-term care beds they received a “Supplemental” because they felt the R.D. was working too hard. The facility was using the same screening triggers in long-term care as they were in the acute side. The surveyor strongly felt that the triggers needed to be different to indicate both a less urgent and more urgent need for follow-up. In other words, their levels of risk should vary from less acute to greater acuity-and in this respect the surveyor felt that the R.D. was working to hard and making it impossible for herself for timely follow-up.

Phillip Todd – Administrator – performed the food service walk-through in the kitchens’. He checked hoods for grease and exhaust fans in coolers for grime and dirt. He checked dish machine temperatures and asked who checked them and what mechanism was used to test the temperature?

One facility was given a “supplemental” because there was a buckle in the ceiling of the cooler. It was felt that this was an infection control issue.
He asked an R.D. how she determined her special diets.
These facilities were cook/chill and questions regarding the food turn-around time were asked. How long is food “prepped” versus assembly and then time in the cooler? He wanted to know how long this process took & what the exposure and shelf life was.

All 5 of these facilities cafeterias’ were reimaged by a D10 Success Coach prior to the JCAHO tour and this really impressed the inspectors. They commented on how much care had been given to make the cafeteria environment “homey” and not so sterile. These surveyors ate in the cafeterias’ daily versus requesting catered meals! A big D10 Service success story!

Various Facilities: The inspectors were impressed with staff knowledge throughout these facilities, especially in the familiarity that the staff had of their residents in the assisted living area. The Food Service staff that initiated greetings were basically not asked many questions. 
Hospital staff in general asked big, global questions of the surveyors and then let them expound on the answers.

The surveyors talked to staff a lot about safety issues in a sort of lecture format.

One facility did receive a “supplemental” in the nutrition screening process. This was specifically due to the fact that nursing wasn’t referring the “high risk” patients that fell out of the screen to the R.D. 

P & P for weekend clinical nutrition coverage was asked about, as was the allowable time that a patient was NPO.

Emergency Rooms – a Type 1 was given to one facility that had 20 patients waiting in a hallway in ER. The surveyors felt that this was an urgent, privacy issue; the facility changed its process during the length of the tour.

Bioterrorism – the surveyors stated that the hospital system should be fully integrated into the community resources for optimal communication and effectiveness.

JCAHO 2004 – the surveyors stated that the unit meetings would be phased out in 2004 and noted again that the whole focus would be more of a day in the life of patient journey in the future. A theme that we are repeatedly hearing from our customers.

Great work from this Food Service System Team that survived a rigorous 6week survey!

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