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Hints and Tips -
JCAHO Inspection
352 bed community hospital in Michigan -
SEPTEMBER 2001 JCAHO INSPECTION
Donald Larimore, Administrative Surveyor
Yvonne Van Hoven, RN, Nurse Surveyor
Philip Landry, MD, Physician Administrator
Hospital Preliminary Score: 92
KITCHEN TOUR WITH ADMINISTRATOR
Started at the loading dock where food deliveries come right into the
Dry Storeroom. He asked about flammable storage (Sterno), which is kept in
a metal shed adjacent to the loading dock.
He looked into the dishroom, stated it looks tight in there, and asked
if we had enough space. I told him that I have a great staff who do a good
job with the space we have. I had already informed him at the beginning of
the tour that we were in the 1926 physical plant and have begun reviewing
the capital required to relocate the food production, tray assembly, and
dishroom operations. He also inquired regarding maintenance of temperature
records. I showed him the temperature recording sheets and the sheets to
which we attach temperature tapes that we run through twice daily, a
double-check on the dishmachine. As we walked by our walk-ins, I asked him
which ones he wanted to see. He only looked at our dairy walk-in.
Upon entry to the production area, all on the tour were given a blue
surgery bonnet to wear. He explored the production center walk-in, where
we keep our cook/chill products, looking for dates. He did come upon a
tall stand-up rack on which frozen lasagna had been panned up and was
tempering prior to cooking. This rack did not have a date on it. Although
he expressed some concern, he did not cite this in the final report. He
observed tray assembly for a short while, then asked what our patients
think of the food. I took him over to the menu processing area where I
post a blown up excel bar graph of our Press Gainey scores compared to the
norm. Luckily, we are showing a positive trend over time. The whole visit
was rather short as we were at the tail end of the building tour.
QUESTIONS DIRECTED TO DIETITIANS BY NURSE AND PHYSICIAN
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Clarification of our NPO policy.
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About our food/drug interaction policy.
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Do we follow the Medicare guidelines for weight loss?
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Do we see new Mom’s who want to lose weight?
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How many RD’s on staff? CDM’s?
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Are we busy?
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How much input do we have with the education for lactating mothers?
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How would we rate our department on how well we work as a team on the
unit?
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What has changed on this unit since our last visit?
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How do we communicate with other disciplines including physicians?
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Do we see every patient with decubs?
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What are CDM’s responsible for?
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How do we monitor the temperatures on the patient trays?
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How do you evaluate age specific competencies?
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Have we had any food borne illness incidents?
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How are we notified to see patients?
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What is our weekend coverage?
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How do we communicate with physicians?
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Where do we chart?
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What triggers a referral to the dietitian?
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How do you handle herbal medications?
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What do you do when you suspect abuse?
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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