Volume 2025 | No. 2
SURVEYOR
CRITICAL ACCESS HOSPITAL
CHAPTER 06: PROVISION OF SERVICES | 06.03 NUTRITIONAL SERVICES 06.03.08 Policy requirements: Food preparation and storage 06.03.09 Lighting, ventilation, and temperature control Frequency of the citation: 06.03.08: 67%, 06.03.09: 44% Overview of the requirement: Policies and procedures define storage and preparation requirements for food products across all patient care areas. Policies and procedures are implemented consistently to maintain quality and safety. Comment on deficiencies: Compliance is assessed through direct observation, interview, and review of policies and procedures. The standard is designed to address a consistent approach to managing food safety. Most deficiencies were cited for deviation from written policies and procedures, or failure to take action when temperature readings fell out of range. Examples of ACHC Surveyor findings: ■ A labeling system exists but dry goods and produce were unlabeled, and two containers of chicken were past the expiration date marked on the container. ■ Corrugated cardboard boxes and unboxed food items were commingled in the main dry storeroom. ■ Debris and supply items were observed on the floor under shelving units in dry storeroom A and the front freezer. ■ Storage bins and storeroom shelving had dried, spilled liquid residue. ■ Refrigerator and freezer temperature checks (46 of 92 over a three month period) were out of range with no corrective action documented. ■ The dish machine did not meet the manufacturer’s wash cycle temperature requirement of 160° or higher on 20 of 30 days in October. It did not meet the rinse cycle threshold of 180° on one day in the same period. ■ Freezers showed moderate ice and condensation build up near fans and lights. The ceiling and light fixture in cooler 3 were visibly dirty.
Compliance tips for:
The intent of the standard is to define requirements for food storage and preparation including aspects of the environments in which food is stored and handled. Specific parameters are provided for the cleanliness of the environment and the temperatures for hot and cold food items. ■ Document an expiration date for all stored food items. ■ Audit supplies and discard expired products. ■ Include kitchen areas in environmental rounding activities for maintenance issues. ■ Audit temperature logs for all food-related equipment. ■ Train staff on required temperature ranges (hot and cold) for equipment and food. ■ Develop a protocol for actions to take if temperatures fall outside of the acceptable range.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
CHAPTER 06: PROVISION OF SERVICES | 06.10 PATIENT RIGHTS 06.10.01 Notice of patient rights Frequency of the citation: 44% Overview of the requirement: Patients and their representatives are provided information adequate for them to understand and exercise their rights. This includes the patient’s right to identify or designate a representative. Comment on deficiencies: Compliance is assessed through observation, interview, and document review. Deficiencies focused on inconsistency with regard to presentation of patient rights.
Examples of ACHC Surveyor findings: ■ Patient rights brochures are available but not proactively provided.
■ One of five records reviewed lacked documentation that Patient Rights were provided. Four of five records included evidence that the document was provided at admission, but multiple documents were not legible. ■ Patient Rights are posted at the hospital’s entry, but the documents are very small, making it difficult for a patient to reasonably read the information. ■ The hospital’s “EMTALA Signage” policy was not being followed.
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