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

2. Objectives Learn about common survey deficiencies.
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)
Based on data from the past fiscal year: 7/1/12 to 6/30/13

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
Communications from CMS

14. S & C 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 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.
ningPracticeStandards/

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: 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
Impact residents

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
Enrollment-and- Certification/SurveyCertificationGenInfo/Dow nloads/Survey-and-Cert-Letter pdf
Enrollment-and- Certification/QAPI/NHQAPI.html
1st website – link to CMS S & C letter and booklet “QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home
Affordable Care Act (ACA) directs the Secretary to provide technical assistance and promulgate regulations for each nursing home to implement a QAPI system, and permits the Secretary to sequence these actions so the technical assistance is available prior to the regulations. This document is part of the initial roll-out of technical assistance materials.
CMS has created a core set of tools and resources to help nursing homes establish the foundation for QAPI as required in Section 6102(c) of the Affordable Care Act.

39. Resources State Operations Manual - Appendix P and PP – Long term care
- Appendix W – Critical Access Hospital
Website:
Guidance/Guidance/Manuals/downloads//so m107_Appendixtoc.pdf
Website goes to the appendices table of contents – from there pick the desired appendix

40. Resources Survey and Certification Letters web site:
Enrollment-and- Certification/SurveyCertificationGenInfo/Polic y-and-Memos-to-States-and-Regions.html

41. Iowa Administrative Code
Resources
Iowa Administrative Code
Chapter 51 – hospitals
Chapter 58 – nursing facilities
Code/chapterDocs.aspx?pubDate= &agency=481
Department of Inspections and Appeals
Website goes to the table of contents

42. US Food and Drug Administration Food Code
Chapter 51 – refers to the 2005 version
Protection/FoodCode/ucm htm
Chapter 58 – refers to the 1999 version
Protection/FoodCode/ucm htm
2009 version
Protection/FoodCode/default.htm
Important to also be familiar with the 2009 version and would be held the stricter standard.
The Bureau of Food and Consumer Safety of DIA has conducted hearings about adoption and been in conversations with relevant agencies. Adoption will not occur until these discussions have been finalized. My understanding is that it would apply to licensed food establishments in the state effective January Communication will occur with entities under their jurisdiction related to changes and how to meet the new requirements – one involves the requirement for CFPP with a timetable to meet the new requirement.