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Recent
JCAHO Survey –
Houston, Texas
One of the 80 bed hospitals in our D/10
networking group in Houston went through a JCAHO inspection in June of
2001. This facility was being reviewed as a “deemed status”, which meant
that they were being reviewed as if they were only open four months. The
reason for this status difference was that the hospital was moving off of
a sister hospital’s provider number and receiving their own provider
number.
Surveyor Profile
Surveyor - Angie Smeal R.N., from Florida, is a “train-the-trainer”
for JCAHO and she is part of the faculty that assists in writing new JCAHO
standards. This faculty assists in steering the direction that JCAHO takes
in the future. Angie made it clear various times during this survey that
JCAHO was “setting a new tone” and a “higher level of scrutiny” during
this survey. So get ready folks! Throughout the survey, the feeling that
JCAHO was making an effort to reprove themselves to HICFA prevailed.
Statements were made to the effect that in the future we could expect to
see scores in the low to mid 80’s contrary to the low to mid 90’s that
have been prevalent in recent years.
Basic information:
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Time spent in non-clinical portion
of food service – 30 minutes
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All surveyors’ (Administrator, R.N.
etc.) arrived 60 to 90 minutes early each morning and worked through
5:30 p.m. each day
-
No odd or specific food requests
were made
What did she say and do?
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The surveyor did not ask the general
food service workers any questions; she directed questions to the
director, supervisors and expected the clinical dietitian to be present.
-
The surveyor did not ask to see any menus, nor menu analysis.
-
There were a total of 4 actual write-ups/recommendations for the main
kitchen. Time was spent on all of the following issues which included
discussion, questioning, and physical inspection as listed:
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The surveyor made recommendations to
clean a small, rather obscure, dirty air vent in the storeroom. To
make or illustrate her point, the surveyor turned out the lights and
used a flashlight to show the lint and dirt.
-
An opened package of dry pasta was
found to be out-dated (5/27/00) and consequently “written-up”. The
Director tried to explain that this was the pasta that was used in
the café for decorative purposes but the surveyor didn’t want to
hear it.
-
The surveyor observed that a label
gun was used to date food items with a “use by” date, and was also
used to date incoming juices with the policy of discarding them 14
days after the date. The surveyor did not like the dual use for the
label gun, and recommended using two label guns, one for each
different use.
-
Potatoes were found in cardboard
delivery boxes. The surveyor recommended that they be stored in
plastic containers with lids, or stored in the original cardboard
box only if they arrived shrink wrapped on a pallet. The surveyor
stated that unprotected cardboard boxes harbored mites.
-
The surveyor scrutinized
food-serving temperatures very heavily. All of the surveyor’s
recommendations were based upon previous temperature charts kept on
the tray line. She did not take any current temps. The surveyor did
“write-up” past food temperature records found to be within the
danger zone because they did not document the action taken to
correct the problem.
Continued:
For example: if it was documented that a food product was found to
be at 120o, then documentation should have accompanied it that
stated that the product was pulled and rethermed to 155o etc..
-
The surveyor looked at pots and pans
and touched them to be sure that they were absolutely dry. She
stressed this issue to staff and checked the stacks of pots and pans
to make her point.
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The surveyor checked the ice machine
scoop to see if it was housed in a container with a lid. She also
wanted to see a policy and procedure documenting the cleaning
process of both items.
-
The surveyor really liked
refrigerator temperature charts that graphed or plotted out
temperatures to visibly show when they fell out of line, with an
area for initials/comments on corrective measures taken.
Ancillary areas:
The food service director reported limited clinical nutrition questioning
and it was mainly done while the surveyors were in the various hospital
units. This surveyor did ask about the 72-hour screening policy and
procedure that this facility followed. She allowed it for weekend
coverage, as long as the Registered Dietitian was “on-call” and able to
come in address any patients found to be at high-risk. This particular
hospital allows Registered Nurses and food service supervisors to give
diet education on evenings/weekends, also.
The surveyor asked for a policy and procedure on blind mothers. She asked:
“How would a blind mother know that the baby was hers? And how would
nursing assist in this situation?”
The surveyor discussed “agency” personnel used anywhere throughout the
hospital. She put a heavy emphasis on orienting outside agency personnel
to the facility because she felt that these people more than anyone, need
familiarity with the hospital policies and procedures.
The surveyor discussed the need for detailed, age-specific competencies.
The surveyor emphasized the need for inter-disciplinary charting in the
medical record.
Good luck with your next survey. Call us to report the details so we can
keep everyone informed.
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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