Nutrition Fundamentals and Medical Nutrition Therapy

Participate in Regulatory Surveys

Corresponds with LEARNING PLAN 17Copyright 2016 Association of Nutrition and Foodservice Professionals

17

Objectives

Identify regulatory standards

Develop an appropriate plan of correction

Demonstrate professional interaction with surveyors

Use regulatory agencies as professional resources

Explain how regulations influence the quality management process

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Regulatory/Accrediting Agencies

Centers for Medicare & Medicaid Services (CMS)» Branch of Department of Health and Human Services (HHS)» Administers the Medicare program» Federal survey guidelines» Oversees HIPAA» Review regulations in CMS State Operations Manual

(SOM)

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Regulatory/Accrediting Agencies

State licensing requirements

Facility is held to the strictest state or federal regulatory requirement

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

CMS Regulations Specific to Nutrition Quality of Care

» 483.25 (c) Pressure sores» 483.25 (i) Nutrition» 483.25 (j) Hydration

Dietary Services» 483.35 (a) Staffing» 483.35 (d) Food» 483.35 (e) Therapeutic diets

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Brain Break

Why is it important to review CMS regulations?

» The operations manual contains helpful information other than regulations. Since CMS provides guidance for surveyors, reviewing the regulations can help dining services be better prepared for the survey.

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

CMS Regulations Specific to Nutrition F-tag = specific guidance for long-term care

» F501 Medical Director and the requirements for effective nutrition policies and oversight

» F520 Quality Assessment and Assurance and the requirements for developing and monitoring effective client nutrition maintenance systems

A-tag = specific guidance for hospitals

C-tag = small rural hospital or critical care hospital

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Voluntary Accreditation

The Joint Commission (TJC)» Originally only accredited hospitals» Now also works with long-term care» Subject to CMS requirements

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Survey Process for Long-Term Care

Both TJC and CMS use surveys as part of their accreditation effort

CMS Quality Indicator Survey (QIS)» Survey process focuses on quality indicators

- MDS, observations, interviews, clinical record reviews» May include a detailed tour of dietary areas» CDM should accompany a surveyor and cooperate fully

Be “survey ready” at all times

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Survey Process Conclusion

Survey team will note any deficiencies and reference F-Tag numbers

Deficiency is a finding that the facility is not in compliance with guidelines» Categorized by the level of risk/harm that may occur

Deficiencies must be followed up promptly and effectively

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Assuring Quality

Policy may be called a number of names

Recognition that quality is an essential element of organizational strategy, not a single initiative» Focus on what client wants and needs, not staff tasks» Use an interdepartmental team approach» Use and evaluate data» Be proactive and continuous» Include a performance improvement segment

‘Outcome’ is most important» Quality Indicators (QIs) = measures of outcomes

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Brain Break

What does it mean to be “survey ready” at all times and how is it achieved?

» It means that regardless of when the survey is conducted, dining services staff can readily answer surveyor questions, necessary documentation is available, and the kitchen is clean and sanitary.

» Regular reviews of what information is expected; maintaining all required documentation; using checklists for kitchen cleanliness and sanitation; use a quality assurance process

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Process for Implementing QA

FOCUS» F = Find a process to improve» O = Organize to improve a process» C = Clarify what is known» U = Understand variation» S = Select a process improvement

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Process for Implementing QA

PDCA» P = Plan» D = Do» C = Check» A = Act

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

QAPI

Quality Assessment and Performance Improvement

Both hospital and long-term care regulations require» Develop, implement and maintain a quality assessment

program- Involves all departments- Focuses on indicators related to improved health outcomes

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17

Brain Break

Why is it important for the CDM to understand the regulations for all departments and the facility’s QA process?

» Often the CDM is the most accessible person during a survey

» CMS regulations are not divided up by department and handed out

» CDM plays a pivotal role in the lives of the clients

Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17