Food and Nutrition Services and the Survey Process

1. Food and Nutrition Services and the Survey Process October 18, 2013 Association of Nutrition and Foodservice Professionals Sandra Frahm RD, LD Health Facilities Surveyor sandra.frahm@dia.iowa.gov

2. Objectives 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.

3. Survey Process • 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

4. Surveyor’s Perspective • Outcome-oriented approach • Actual and potential outcome • Look for implementation of systems to meet regulations • Investigation based on observations, interviews, and review of documents

5. Deficiencies • Statement of deficiencies – Form CMS-2567 which includes: • Problems found • Evidence to support the deficiency • Serves as the basis for the plan of correction

6. Top 10 deficiencies in SNF/NF • 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)

7. 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

8. Additional Dietary/Nutrition TAGS • 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)

9. 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)

10. 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

11. 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

12. Additional Dietary/Nutrition TAGS • F325 – Maintain nutrition status unless unavoidable (16) • F327 – Sufficient fluid to maintain hydration (6)

13. Survey and Certification Letters • 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

14. S & C 13-35 NH 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

15. S & C 13-13-NH New Dining Standards of Practice Resources Available Released March 1, 2013

16. New Dining Practice Standards • 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/

17. 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

18. Person Centered Care • 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)

19. 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.

20. 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)

21. 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!

22. S&C: 13-05-NH 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

23. What is QAPI? • 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.

24. Five Elements of QAPI • Design and Scope • Governance and Leadership • Feedback, Data Systems and Monitoring • Performance Improvement Projects • Systematic Analysis and Systemic Action

25. QAPI • QA and PI are never a quantity: • Number of meals served • Number of hours staff worked • Cafeteria income • Number of diet instructions

26. Quality Assurance • 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.

27. Performance Improvement • 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

28. Quality Assurance 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

29. Performance Improvement • 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

30. 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

31. What is a system? • Collection of interrelated parts/subsystems • Unified by design or flow of work • Designed to meet one or more objectives

32. Systems • Food handling • Menu planning • Holding • Cooling • Purchasing • Distribution • Receiving • Serving • Storing • Preparation • Reheating

33. Systems • Nutritional Care • Nutritional screening • Nutritional assessment • Communication - implementation of recommendations and evaluation of implemented recommendations

34. Systems • Physical Environment • Safety • Sanitation • Maintenance

35. Systems • Staff • Hiring • Training • Evaluating

36. Systems • Management • Leadership and organizational change • Decision Making • Communication • Budget • Management of human resources • Management of financial resources • Quality Assurance • Marketing

37. QUAPI 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)

38. Resources • 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

39. 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

40. 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

41. Resources Iowa Administrative Code • Chapter 51 – hospitals • Chapter 58 – nursing facilities https://www.legis.iowa.gov/IowaLaw/Admin Code/chapterDocs.aspx?pubDate=01-11-2012 &agency=481 • Department of Inspections and Appeals https://dia-hfd.iowa.gov/DIA_HFD/Home.do

42. US Food and Drug Administration Food Code • Chapter 51 – refers to the 2005 version http://www.fda.gov/Food/GuidanceRegulation/RetailFood Protection/FoodCode/ucm2016793.htm • Chapter 58 – refers to the 1999 version http://www.fda.gov/Food/GuidanceRegulation/RetailFood Protection/FoodCode/ucm2018345.htm • 2009 version http://www.fda.gov/Food/GuidanceRegulation/RetailFood Protection/FoodCode/default.htm