Iowa Dietetics in Healthcare Communities Food and Nutrition Services and the State Survey Process April 8, 2013

1. Iowa Dietetics in Healthcare CommunitiesFood and Nutrition Services and the State Survey ProcessApril 8, 2013 Sandra Frahm RD, LD Health Facilities Surveyor sandra.frahm@dia.iowa.gov

2. Terminology • Licensure – mandatory for Iowa facilities; the type of license determines which chapter of the Iowa Administrative Code applies. • Hospitals - Chapter 51 • Nursing Facilities - Chapter 58

3. Terminology • Accreditation – A hospital/Critical Access Hospital (CAH) accredited by Joint Commission, American Osteopathic Association (Health Facilities Accreditation Program) or Det Norske Veritas Healthcare (DNV) is considered “deemed” to meet applicable Federal regulations (CMS) and not subject to the routine survey schedule. Accreditation is optional. There is no accrediting organization approved for long term care.

4. Terminology • Certification – A recommendation by the State Agency (DIA) on the compliance of a provider with the conditions of participation, requirements and/or conditions of coverage and refers to Federal certification to receive Medicare/Medicaid funds.

5. Conditions of Participation and Conditions for Coverage • Developed by Centers for Medicare and Medicaid Services (CMS) • Health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs.

6. 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.

7. Focus is to determine whether the facility is actually providing services rather than whether the facility is capable of providing them and starts with observations. • The survey assesses compliance with residents’ rights and quality of life requirements, accuracy of residents’ comprehensive assessments and the adequacy of care plans based on those assessments, the quality of care and services provided and the effectiveness of the physical environment to accommodate residents needs and maintain safety.

8. Deficiencies • Statement of deficiencies – Form CMS-2567 • Includes the federal survey tags: Nursing facilities – F tags Critical Access Hospitals – C tags Acute Hospitals – A tags Serves as the basis for the plan of correction which must identify how it will correct the deficiencies identified.

9. Survey and Certification Letters(S& C 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

10. S&C: 12-46-NH • Released September 27, 2012 • Revisions to Interpretive Guidance at F tag 322 – Tube feedings • F tag 321 is deleted and the regulatory language and guidance moved to F tag 322.

11. S&C: 13-02-NH • Released November 2, 2012 • Clarification of Guidance related to Medication Errors and Pharmacy Services • Includes clarification and guidance regarding the administration of medications via a feeding tube, along with other medication related issues.

12. The majority of others released in 2012 do not directly address nutrition or dietary related activities, but some may apply indirectly with topics including quality, dementia care, MDS 3.0 revisions, advanced directives and infection control (related to laundry).

13. Top 10 deficiencies in SNF/NF1/1/12 thru 12/31/12 • F323 – Free of accident, hazards, supervision (315) • F441 – Infection control (186) • F281 – Services provided meet professional standards (183) • F312 – ADL care provided for dependent residents (161) • F371 – Food procure, store, prepare, serve (132)

14. Top 10 deficiencies in SNF/NF • F309 – Provide care/services for highest well being (129) • F363 – Menus meet resident needs, menus prepared in advance and followed (75) • F465 – Safe, functional, sanitary, comfortable environment (74) • F314 – Treatment/services to prevent/heal pressure sores (59) • 315 – No catheter, Prevent UTI (58)

15. Additional Dietary/Nutrition TAGS • F325 – Nutrition – Based on a resident’s comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible and receives a therapeutic diet when there is a nutrition problem. (19)

16. 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. (1) • F361 – Staffing: the facility must employ a qualified dietitian either full-time, part-time, or on a consultant basis. • F362 – Standard Sufficient Staff – adequate support personnel to carry out department functions. (4)

17. F364 – 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 the proper temperature (20) • F365 – Food prepared in a form designed to meet individual needs. (7) • F366 - Substitutes offered of similar nutritive value to residents who refuse food served. (1) • F367 – Therapeutic Diets: therapeutic diets must be prescribed by the attending physician. (4)

18. F368 – 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 (20) • F369 - Assistive Devices - The facility must provide special eating equipment and utensils for residents who need them. (1)

19. Top 10 deficiencies in Critical Access Hospitals • C278 – Patient care policies – A system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. (7) This is the area where kitchen sanitation/food safety issues are citied. • C276 – Patient care policies: rules for the storage, handling, dispensation, and administration of drugs and biologicals. (6) • 2400 – Compliance with 489.24; Special Responsibilities of Medicare Hospitals in Emergency Cases (6)

20. C308 – Protection of record information (5) • C222 – Maintenance – essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition (3) • C340 – Quality assurance – the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy are evaluated (3) • 2406 – Medical Screening Exam (Emergency Rooms) (3)

21. C229 – Emergency Procedures – Providing for an emergency fuel and water supply (2) • C241 – Governing body – related to the determination, implementation and monitoring the polices governing the CAH’s total operation. (10) • C259 – Responsibilities of MD or DO; In conjunction with the physician assistant and/or nurse practitioner members, periodically reviews the patient records, provides medical orders, and provides medical care services to patients. (2)

22. Resources • State Operations Manual - Appendix A – hospitals - 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

23. Appendix PP http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//som107ap_pp_guidelines_ltcf.pdf • Appendix W http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//som107ap_w_cah.pdf • Appendix A http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//som107ap_a_hospitals.pdf

24. 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 • Training Tools http://surveyortraining.cms.hhs.gov/index.aspx

25. 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

26. US Food and Drug Administration Food Code • Chapter 51 – refers to the 2005 version http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/ FoodCode/FoodCode2005/index.htm • Chapter 58 – refers to the 1999 version http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/ FoodCode/FoodCode1999/default.htm • 2009 version http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/ FoodCode/FoodCode2009/