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Ready for the new focus area that’s now a part of Joint Commission surveys? It’s the Dietary Tracer. TJC now includes a Dietary Tracer on all triennial surveys of hospitals (including psychiatric hospitals) that use Joint Commission accreditation for deemed status.

TJC Tracer on Dietary Services: What’s the Focus?

The focus of the Dietary Tracer is twofold. First, it covers the clinical aspect of patients’ receiving appropriate diets based on their nutritional needs. Second, it covers safe storage and preparation of patient food.

In addition, the Dietary Tracer covers the credentials and competency of Dietary Services staff. The tracer covers standards from the Provision of Care, Environment of Care, infection Control, and Life Safety chapters.

TJC Tracer on Dietary Services: What’s included?

Clinical Component

A clinical surveyor conducts one component of the Dietary Tracer. The Life Safety Surveyor conducts another component. Typically, the clinical surveyor selects a patient on a special diet and conducts a focused tracer. The surveyor evaluates the following functions:

  • Written policies and procedures for Dietary Services
  • Meeting patients’ nutritional needs based on assessments
  • Physical environment where the organization stores and prepares food
  • Human Resources: Staffing and competencies for Dietary & Food Service staff

Life Safety Component

The Life Safety surveyor evaluates the kitchen’s compliance with Environment of Care and National Fire Protection Association (NFPA) Life Safety requirements. This includes a review of:

  • Sprinkler heads
  • Deep fat fryers
  • Fire suppression systems
  • Eyewash stations
  • Hood systems
  • Fire evacuation and relocation plans

Trends in Survey Findings

We’re seeing the following trends in survey findings from the Dietary Tracer:

  • Nutritional assessments not conducted timely
  • Special diet orders not followed
  • Nutritional assessment recommendations not reflected in treatment plans
  • Unsanitary food storage in refrigerators
  • No documentation of ServSafe certification for Food Service staff
  • Dietary Manual outdated and/or not approved by Medical Staff
  • Eyewash stations: No eyewash stations in kitchen when using corrosive chemicals (e.g. bleach, Lime-Away)
  • Grease buildup on range hood

Food Storage on Patient Units

Heads up! Even if your organization doesn’t have a kitchen, surveyors routinely inspect food storage areas in patient care settings. Consequently, you need to keep those areas on your radar as well. Common survey findings include:

  • Expired food items
  • No process for labeling food with discard dates
  • Lack of monitoring of refrigerator temperatures

How to Prepare for the Dietary Tracer

We highly recommend you convene a workgroup with representatives from your Facilities, Infection Control, and Clinical departments to review these hot spots related to Dietary Services. Most importantly, make sure you have processes in place for meeting patients’ nutritional needs based on nutritional assessments. And, remember, you need clear procedures for safe food preparation and storage.

Barrins & Associates Resources

We include a Dietary Tracer when we conduct our Mock Surveys and Continuous Readiness Consultations. In addition, we share the Kitchen Tracer Checklist that surveyors use so you can be fully prepared for this session.

On a related note, be sure you’re up to speed on the requirements for nutrition screening in Behavioral Health programs surveyed under the BH standards. See our post Joint Commission Nutrition Screening Requirements for Behavioral Healthcare Programs.

Joint Commission Resources

For TJC guidance on food storage, see their FAQ Refrigerator Temperature – Patient Care Food Storage.  Also, check out their advice on Minimizing Waterborne Pathogens in Ice Machines.

Lastly, remember that if you’re serving special diets to patients, you need to use two identifiers. See the FAQ Two Patient Identifiers – Understanding the Requirements.

As always, staying up to speed on survey trends and TJC guidance should be an integral part of your continuous readiness program!