October 18, 2013

Association of Nutrition and Foodservice Professionals

Sandra Frahm RD, LD

Health Facilities Surveyor

sandra.frahm@dia.iowa.gov

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