Tips and Tools to Prepare for Surveys

Nutrition Care Manual (NCM) users must meet facility policies and procedures and local, state, and national requirements. To assist in facility customization and to prepare for the survey process, follow the tips and tools below to meet your facility's individualized needs. Instructions on how to create a Diet Order Matrix and other Facility Pages may also be helpful for facility individualization.

Tools available to NCM subscribers for survey preparation:

In 2010 the following statement was issued by the Academy’s Quality Management regarding NCM and therapeutic diets:

Based on the hospital’s patient mix and core businesses such as orthopedic, cardiovascular, nephrology, oncology, endocrinology, obstetrics, gynecology, pediatrics, and so on and in conjunction with the Academy’s Nutrition Care Manual, the hospital RD staff should determine the hospital’s “formulary” of diets (regular and therapeutic), which then equates to the hospital's nutrition (diet) orders. It is the hospital RD staff’s responsibility to design nutritionally adequate menus, both regular and therapeutic, including modified consistency options. Upon completion of this process, the Academy’s Nutrition Care Manual (or other diet manual used by the facility), formulary of diets, menus (traditional or room service style), and patient/client education materials must be approved by the hospital’s medical staff and also may be reviewed through the appropriate hospital committee (nutrition, pharmacy and therapeutic, or quality).

The Academy’s NCM staff recommends each facility create a mini manual backup using the above tools. A surveyor may be interested in viewing the facility-specific mini manual as part of the survey question period or tracer methodology. This includes storing in a binder the facility’s signed and dated approval form, backup CD, and printed materials of the most commonly used client education pieces and therapeutic diets, which include a rationale, meal plans, food lists, and education. Also included should be a facility crosswalk (diet order matrix) of the facility’s physician diet orders matched to existing NCM diets/handouts. Facilities can create their individualized crosswalk directly in the NCM Facility Pages area, which can then be printed and included within the facility-specific mini manual.

NCM and Therapeutic Diet Tips and Tools:

  • Use the sample approval form for facility customization; print and sign.
  • Print the update summary listing annual changes and present to the appropriate facility committee.
  • Use the manual’s table of contents for appropriate facility committee approval.
  • Use the printable handouts to show rationale, food lists, and sample menu.
    • The food lists can be used by the facility when planning patient room service or cycle menus to determine appropriate food choices. The food lists are resources to answer patient and provider questions about recommended and not recommended foods.
  • Print the nutrient analysis from the onscreen sample 1-day menu.
    • The facility will also need to complete nutrition analyses for its standard room service or cycle menus for the regular diet as well as for commonly used modified diets and have these analyses available for review by the committee and by surveyors.
    • Any nutrient deficits that occur on modified menus should be identified in the nutrient analysis and addressed on an individual basis in the nutrition care plan, to ensure that the patient’s nutrient needs are met. 
  • Create a backup CD for facility emergency power outage.
  • Customize the facility pages to the facility’s individualized therapeutic diets, procedures, or other facility-specific documents.
  • Create a facility custom link on clinical work stations to allow every facility computer access to the NCM without a username and password.