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State and JCAHO Inspection Results at a
Long-term Care Facility
June 2002 – Long Island. N.Y.
As a coincidence, this long-term care facility experienced both an early state survey for 3 days in early June and then as planned, their JCAHO survey later in the month.
State Survey Overview
Length of survey: 3 days
Survey Team of 10 consisted of: 2 state Dietitians
Social Workers
Registered Nurses
The RD surveyors observed the assembly of at least 2,000 trays over the three days and pulled temperatures on many of
them, without incident.
The RD surveyors toured the kitchen and storeroom without event. Notes were made about some needed repairs and a plan of action was implemented and work requisitions were issued.
The R.D. surveyors asked FS employees questions about fire safety. They also asked an employee that was obviously on their break, what was done if a resident had a food request while an employee was on break? The employee appropriately responded, saying that the request would take precedence and be addressed immediately.
The R.D. surveyors glanced at the weekly menu rotation but asked nothing in terms of menu analysis. The surveyors did look at staff RD files and wanted proof of licensure (certificate).
The only issue that came close to a problem was when the state RD surveyors found 2 unserved trays on a tray cart in a hallway. These trays belonged to residents who were “feeders” (meaning they needed assistance at mealtimes) Unfortunately there was no available nursing staff at the time of feeding, causing the trays to sit out and temperatures climbed into the danger zone. After a philosophical discussion about which department held the most responsibility for this problem, it was recommended that an additional nursing tech be added to this unit for optimal feeding assistance.
The survey team attended a Resident’s Council meeting and was pleased with the consensus of happy resident responses.
JCAHO Survey Overview
Facility size: 280 beds
Length of Survey: 3 days
Overall score: 91%
Survey Team: 1 RN Surveyor
The Food Service Manager did comment that this JCAHO Surveyor took a highly educational attitude and one of support during this survey versus a “policing” of policy.
The surveyor went through past temperature logs for the dish machine and reviewed the policy & procedure for this process. She asked how problems in this area were tracked.
The surveyor wanted to be shown performance issues and how they were tracked and solved. She wanted to see staff education on various issue oriented topics substantiated. The surveyor wanted to see if what management said jived with staff responses and did this through staff observation and interviews.
JCAHO Standard 4.2.2 Medication Refrigeration – was addressed per this FS Manager. The surveyor wanted to see daily temperature checks on the refrigerators by nursing-there was a lack of daily documentation.
During closed record review:
JCAHO Standard P.F..3 on Education - There was no documentation that education was provided during a resident’s stay. The surveyor wanted to see an interdisciplinary education form RNs, R.Ph., R.D. and P.T. and felt that the form should reflect everyone’s documented involvement.
The surveyor did like a storyboard that was used to describe a High Fiber/Hydration Program which reduced the needs for laxative meds such as MOM and Cascara and showed the involvement of the R.N., R.Ph., R.D. and M.D..
Bioterrorism – The surveyor wanted to see a specific policy & procedure on this topic, especially in light of its location. This facility was prepared for this and had a policy & procedure in place that was generated from the Security Department.
Hot areas included in this P & P included the reporting of anyone /any circumstance that was “not usual”, heightened staff “awareness” in general, use of name tags, badges, locked doors, limited facility entrance/exit access, and heightened Security Department awareness.
Staff discussed that they now question things like an unmarked vendor van, a change from the usual driver, arrival of unmarked packages, new staff faces, discontinuation of allowing staff family/friend access at meal times, etc. Everyone agreed that there was much more caution and security mindfulness, in general. The surveyor was pleased with this response.
There were no Type 1’s given, however there were
3 Supplemental Recommendations made as follow:
Involving JCAHO Standard P.E. 2.1.8 – Cultural, religious/Kosher or ethnic food preferences. Some resident charts lacked documentation, including some blanks left on chart. The surveyor said that if there were no preferences, then staff needed to write “none” and not leave blanks, otherwise it does not look as if the questions were asked.
Involving JCAHO Standard P.E.2.1.13 – Initial education did not include assessment of the family’s educational needs,
preferences, abilities and readiness to learn.
The surveyor wanted to see everything educational in “layman’s terms” and
understandable, no medical abbreviations such as T.I.D allowed – spell it out
as “three times per day” etc.
Involving JCAHO Standard PE.3 - Residents didn’t receive a weekly body
surface assessment, or if they did they needed to have a specific form reflecting that this was done. The surveyor did offer the solution, a form with a
Federal tag code 274,275,276, which will now be included in this facility’s chart.
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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