When was the last time your facility looked at tracers in the dietetic and food service areas?
"There have been a number of updates published in recent months on the topic, so it's a good time to take a look at best practices on the topic," says Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor.
In terms of Joint Commission standards, the following chapters have the most bearing on dietetic services:
- Emergency Management
- Environment of Care
- Human Resources
- Infection Control
- Patient Care, Treatment, and Services
- Record of Care, Treatment, and Services
Specific EPs to review include: PC.02.02.03, HR.01.04.01, and HR. 01.05.03.
Now let's take a look at CMS' Conditions of Participation (CoP). The CoPs require that a hospital have organized dietary services directed and staffed by adequate personnel. (Note: If your facility has a contract with an outside food management company, keep Joint Commission leadership standards in mind as well.)
What policies are required? Your facility should have and follow a minimum of the following policies and procedures, according to the CMS CoPs:
- Availability of a diet manual and therapeutic diet menus to meet patients' nutritional needs
- Frequency of meals served
- A system for diet ordering and patient trays delivery
- Accommodation of non-routine occurrences—e.g., parenteral nutrition (tube feeding), total parenteral nutrition, peripheral parenteral nutrition, change in diet orders, early/late trays, nutritional supplements, etc.
- Integration of the food and dietetic service into the hospital-wide Quality Assessment and Performance Improvement and Infection Control programs
- Guidelines for acceptable hygiene practices of food service personnel
- Guidelines for kitchen sanitation
All of these policies apply whether the food services are provided by the hospital alone or through a contracted vendor.