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October 18, 2013
Association of Nutrition and Foodservice Professionals
Sandra Frahm RD, LD
Health Facilities Surveyor
Food and Nutrition Services and the Survey
Process
Participants will:
Learn about common survey deficiencies.
Key quality improvement activities to consider, analyze, implement, or improve to meet applicable regulations.
Learn about available resources for federal and state regulations applicable to healthcare facilities.
Objectives
Resident-Centered – based on investigation of the care and services provided to meet the individual needs and preferences of the sample residents
Outcome-Oriented – look at actual and potential for negative outcomes and failure by the facility to help residents achieve their highest practicable level of well-being
Survey Process
Outcome-oriented approach◦ Actual and potential outcome
Look for implementation of systems to meet regulations
Investigation based on observations, interviews, and review of documents
Surveyor’s Perspective
Statement of deficiencies – Form CMS-2567 which includes:
Problems found
Evidence to support the deficiency
Serves as the basis for the plan of correction
Deficiencies
F323 – Free of accident, hazards, supervision (298)
F441 – Infection control (162) F312 – ADL care provided for dependent
residents (160) F281 – Services provided meet professional
standards (160) F371 – Food procure, store, prepare, serve
(134)
Top 10 deficiencies in SNF/NF
F309 – Provide care/services for highest well being (125)
F465 – Safe, functional, sanitary, comfortable environment (77)
F363 – Menus meet resident needs, menus prepared in advance and followed (73)
F156 – Notice of Rights, Rules, Services (61) F329 – Drug regimen free from unnecessary
drugs
Top 10 deficiencies in SNF/NF
F360 - Dietary Services – the facility must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident
F361 – Staffing: the facility must employ a qualified dietitian either full-time, part-time, or on a consultant basis (2)
F362 – Standard Sufficient Staff – adequate support personnel to carry out department functions (2)
Additional Dietary/Nutrition TAGS
364 – Food : Each resident receives and the facility provides: food prepared by methods that conserve nutritive value, flavor, and appearances; Food that is palatable, attractive, and at proper temperature
365 – Food prepared in a form designed to meet individual needs (3)
366 - Substitutes offered of similar nutritive value to residents who refuse food served (1)
Additional Dietary/Nutrition TAGS
367 – Therapeutic Diets: therapeutic diets must be prescribed by the attending physician (5)
Intent - Assure the resident receives and consumes foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician
Additional Dietary/Nutrition TAGS
368 – Frequency of meals: the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community, no more than 14 hours between a substantial evening meal and breakfast the following day unless a nourishing snack is provided at bedtime, must offer snacks at bedtime daily (19)
369 - Assistive Devices - The facility must provide special eating equipment and utensils for residents who need them
Additional Dietary/Nutrition TAGS
F325 – Maintain nutrition status unless unavoidable (16)
F327 – Sufficient fluid to maintain hydration (6)
Additional Dietary/Nutrition TAGS
Guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices
May simply provide clarification of an existing federal tag
May accompany a new or revised tag with an explanation and instructions
Survey and Certification Letters
Dementia Care in Nursing Homes
Released May 24, 2013
Provides clarification to Appendix P State Operations Manual (SOM) and Appendix PP in the SOM for F309 – Quality of Care and F329 – Unnecessary Drugs
S & C 13-35 NH
New Dining Standards of Practice Resources Available Released March 1, 2013
S & C 13-13-NH
August 2011 – Pioneer Network Food and Dining Clinical Standards Task Force
GOAL STATEMENT: Establish nationally agreed upon new standards of practice supporting individualized care and self‐directed living versus traditional diagnosis‐focused treatment.
http://www.pioneernetwork.net/Providers/DiningPracticeStandards/
New Dining Practice Standards
Nine Standards Individualized Nutrition Approaches/Diet
Liberalization Individualized Diabetic/Calorie Controlled Diet Individualized Cardiac Diet Individualized Altered Consistency Diet Individualized Tube Feeding Real Food First Honoring Food Choices Shifting Traditional Professional Control to
Individualized Support of Self‐Directed Care New Negative Outcome
New Dining Practice Standards
Offer resident choices Encourage individual resident decisions Homelike atmosphere Less institutional Replace large units w/smaller ones Eliminate/reduce overhead paging Close relationships between resident and
staff – promotes same care givers (consistent staffing)
Person Centered Care
Diet determined with the person and in consideration of his/her informed choices, goals, and preferences rather than exclusively by diagnosis
Consider beginning with a regular diet and monitoring the individual response to it, unless a medical condition warrants a restricted diet.
Ensure the physician and pharmacist are aware of resident food & dining preferences and intake so medication can be addressed & coordinated (e.g. med timing & impact on appetite)
Explain the nutrition problem you identified to the resident
Develop an agreed upon, measurable nutrition goal
Develop interventions with resident input
If resident refuses any interventions, explain risk/benefit and honor choice
Documentation is an important part of this process!
Preview of Nursing Home Quality Assurance & Performance Improvement (QAPI) Guide – QAPI at a Glance
Released December 14, 2012
Rollout of Quality Assurance and Performance Improvement (QAPI) Materials for Nursing Homes
Released June 7, 2013
S&C: 13-05-NH
QAPI is the combination of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). They both involve gathering and using information, but differ in specific ways.
What is QAPI?
Design and Scope Governance and Leadership Feedback, Data Systems and Monitoring
Performance Improvement Projects Systematic Analysis and Systemic Action
Five Elements of QAPI
QA and PI are never a quantity:◦Number of meals served◦Number of hours staff worked◦Cafeteria income◦Number of diet instructions
QAPI
QA is a process of meeting quality standards and assuring that care is at an acceptable level. Nursing homes typically set QA thresholds to comply with regulations or may create standards that go beyond regulations.
Quality Assurance
PI (also called Quality Improvement - QI) is a pro-active, continuous study of systems with the intent to prevent or decrease the likelihood of problems
The goal is to improve systems involved in the delivery of care and resident quality of life
Performance Improvement
Includes routine actions to assure a certain standard is continually achieved
Examples: Refrigerator and freezer logs Meal service food temperature logs Practitioner’s order matches diet card/list
Quality Assurance
Involves identification of a system breakdown and/or identification of a problem (may be a single incident)
Can be identified ◦Objectively or subjectively◦Formally or informally
Performance Improvement
Examples: Nutritional screening not complete and/or not timely
Nutritional assessments - not complete, accurate, timely, communicated, implemented
Snacks not distributed Excessive plate waste Improper food handling
Performance Improvement
Collection of interrelated parts/subsystems
Unified by design or flow of work Designed to meet one or more objectives
What is a system?
Systems Food handling Menu planning Holding Cooling Purchasing Distribution Receiving Serving Storing Preparation Reheating
Nutritional Care◦Nutritional screening◦Nutritional assessment◦Communication - implementation of recommendations and evaluation of implemented recommendations
Systems
Physical Environment◦Safety◦Sanitation◦Maintenance
Systems
Staff◦Hiring◦Training◦Evaluating
Systems
Management◦Leadership and organizational change◦Decision Making◦Communication◦Budget◦Management of human resources◦Management of financial resources◦Quality Assurance◦Marketing
Systems
Steps include: Identification of problem or opportunity for
improvement Gathering data Considering options to correct problem Implementing solution(s) Gathering data after implementation Evaluating (current and, then, long-term
correction)
QUAPI
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf
http://cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html
Resources
State Operations Manual- Appendix P and PP – Long term care- Appendix W – Critical Access Hospital
Website:http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//som107_Appendixtoc.pdf
Resources
Survey and Certification Letters web site:
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html
Resources
Iowa Administrative Code
Chapter 51 – hospitals Chapter 58 – nursing facilitieshttps://www.legis.iowa.gov/IowaLaw/AdminCode/chapterDocs.aspx?pubDate=01-11-2012 &agency=481 Department of Inspections and Appealshttps://dia-hfd.iowa.gov/DIA_HFD/Home.do
Resources
Chapter 51 – refers to the 2005 versionhttp://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/ucm2016793.htm
Chapter 58 – refers to the 1999 versionhttp://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/ucm2018345.htm
2009 versionhttp://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/default.htm
US Food and Drug Administration Food Code
