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JCAHO Survey –
Houston, Tx – Summer 2003
Large Multi-Facility Acute Care Health System
Part 2
Facility Tour Questions – Various Locations
Kitchen Facility Tours – Most tours were brief,
to the point and between 10 and 30 minutes in total duration. Tours were
conducted by either the Administrator or the Nurse on the JCAHO Team and
sometimes both attended.
Nurse Surveyor stated that she was looking for
infection control issues because patients are so compromised. She peeked
her head in the storeroom, the cooler and the freezer. Did not physically
enter any of those three areas at one facility.
Nurse Surveyor asked about temperature logs.
When shown to her, she turned to the Administrator and said, "now that's
how logs should be - graphed - so you can see at a glance when there is a
problem.”
In the cook's area, the Nurse Surveyor asked one
cook what she was putting on the asparagus? The Cook answered, “vegetable
base to give flavor without added fat”. This is a Destination 10
Healthcare Culinary Tip that the D10 Success Coaches teach in culinary
class!
The Nurse Surveyor asked the other cook what she
would do if there were a fire on the stove or in the fryer. The Cook
answered appropriately, that the halon system would automatically go off,
or she could pull the ring, or she could use the G fire extinguisher,
which is used for grease fires. (Great Job with Employee Education!).
The Nurse Surveyor asked to see the dish room.
She questioned the dirty laundry bags of aprons and tablecloths stored in
the dish room. The Food Service Director explained that the soiled linen
wouldn’t get picked up for a day or two by the linen company. The Nurse
Surveyor asked why they didn't put it outside with the other linen?
The FSD explained that that load was from a different linen company, and
if it were put it outside, the wrong company would pick it up, and
incorrect charges would be incurred. The Nurse Surveyor asked if
the Infection Control Department had a problem with the linen being stored
in the dish room? The FSD said no because it was contained in bags, it was
off the floor and it was on the dirty side of the dish room. The Nurse
Surveyor was content with that answer.
The Nurse Surveyor asked to go in the office to
look at past dish machine temperature logs. All logs were up to date. She
looked until she found one temperature that was out of compliance, and she
asked how that was handled. The FSD responded by reviewing the
department’s procedure of requesting a maintenance service request and
then using bleach for sanitizing back up.
Surveyors did focus on dish machine temperatures at
most facilities and wanted to be sure that all machines had the correct
hot temperatures at all 3 meals and that they were monitored throughout
the day.
One of the Administrative Surveyors asked the
following questions or made the following comments to the Food Service
Director at one facility:
Are you a contract food service company employee? He
also asked the FSD if she was part of a buying group.
The Surveyor commented that there were lots of “chefs”
on staff at this facility. The FSD explained that most were “Cooks” and
that this was the professional dress code standard complete with Chef’s
hat. This too is a Destination 10 suggested standard from our
Healthcare Culinary Academy, which seemed to bode well with the Surveyors.
How many days of food do you keep on the shelves at one
time? (The question related to what you would do in a disaster in the
event that you couldn’t get a food delivery for a couple of days).
What would you do in the event of a fire drill?
The Surveyor seemed pleased that the FSD told him that they would actually
evacuate even if it were a drill.
Do you ever take cultures of your flatware or dishes?
The FSD stated that she just made sure that the dish machine worked
properly. The Surveyor apparently practiced this way in his younger years.
The FSD asked him if any of the cultures ever were positive – none were.
Enteral Formula Questions:
One of the facilities in this system also had a
children’s hospital. The Administrative Surveyor asked to see the
formula room and asked questions about the various products. The Surveyor
asked if there was any special ventilation system in the room? The FSD
explained that the formulas were not sterile, and that a decision had been
made in conjunction with the Infection Control Department to not use a
laminar flow hood.
Another FSD was asked by an Administrative Surveyor
how her department handled baby formulas and whether they had an enteral
kitchen. This department did not have an enteral kitchen, but did dispense
formulas in enclosed containers. The FSD explained that her department did
not hand mix any formulas. Baby formulas were dispensed by another
department in the hospital.
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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