Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 24: NUTRITIONAL SERVICES
Compliance tips for:
Food products must be maintained to ensure safety and quality. This includes processes to identify expiration/discard dates and remove supplies prior to expiration. Products are stored at least six inches off the floor in a sanitary environment. All food preparation areas and equipment are maintained in sanitary condition and refrigerator and freezer temperatures are logged within specified ranges. ■ Ensure that food items are labeled and include expiration dates. ■ Rotate stock and supplies to use oldest products first. ■ Assign responsibility for daily temperature logging of unit-based refrigerators and freezers. ٝ Identify acceptable range temperature range. ٝ Educate staff to immediately report equipment maintenance issues. ■ Unit-based food products are the responsibility of nutrition services, but all staff can be trained to observe for and discard expired items. ■ Educate staff to avoid commingling patient-assigned food, staff food, and medications. ■ Include kitchen areas in environmental rounding for assessment of cleanliness and properly working equipment.
Nerd Newbies (understand the requirement)
24.01.03 Policy requirements: Food preparation and storage in patient care areas 24.01.08 Physical Environment Frequency of the citation: 24.01.03 61%, 24.01.08 39% Overview of the requirement: These two standards are closely related. The first addresses the requirement for written policies developed collaboratively by the food service department and patient care teams and reviewed by the Infection Control Committee for food storage and preparation in patient care areas. The second focuses on similar requirements in the hospital kitchen(s) and extends to include specific expectations for a sanitary environment. Comment on deficiencies: This standard is frequently cited for noncompliance. Evaluation involves direct observation, policy review, and review of temperature logs. Many deficiencies were the result of poor temperature management. Freezer/refrigerator logs were missing or temperatures logged were out of range without corrective action documented.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Examples of ACHC Surveyor findings:
CHAPTER 25: PHARMACY SERVICES/MEDICATION USE
■ Products (produce, proteins, dairy) lacked “use by” dates. ■ The walk-in freezer log was missing daily temperature checks for four of 20 days in August. The walk-in freezer’s daily temperature checks were outside the acceptable range on 15 of 20 days with no documentation of corrective action. ■ The dry food storage area had a buildup of dust and debris. ■ The dietary policy on cleaning had not been reviewed within the time frame required by the organization’s policy. ■ Significant dust and grease build-up was observed on the cooking hood and cooler fans.
25.01.03 Security of medications Frequency of the citation: 61% Overview of the requirement: Medication is secured to prevent unauthorized assess.
Comment on deficiencies: The standard is evaluated through observation, interviews, and document review. Most deficiencies noted the presence and easy accessibility of frequently diverted drugs. Examples of ACHC Surveyor findings: ■ The hospital allows patients to bring their medications from home; however, it has no process to secure them. ■ CT contrast media are stored in an unsecured cabinet (no locking mechanism). Anesthesia carts in four ORs were found to contain unlocked inhalant anesthetic (Sevoflurane).
■ Twenty-two desserts in the freezer were expired by nine days. ■ Food bins were stored directly on the floor of the freezer. ■ There was standing water on the floor of the dish room. ■ The walk-in freezer had ice buildup on the coil.
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