Presentation on theme: "Food and Nutrition Services and the Survey Process"— Presentation transcript:
1Food and Nutrition Services and the Survey Process October 18, 2013Association of Nutrition and Foodservice ProfessionalsSandra Frahm RD, LDHealth Facilities Surveyor
2Objectives 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.
3Survey ProcessResident-Centered – based on investigation of the care and services provided to meet the individual needs and preferences of the sample residentsOutcome-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
4Surveyor’s Perspective Outcome-oriented approachActual and potential outcomeLook for implementation of systems to meet regulationsInvestigation based on observations, interviews, and review of documents
5Deficiencies Statement of deficiencies – Form CMS-2567 which includes: Problems foundEvidence to support the deficiencyServes as the basis for the plan of correction
6Top 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
7Top 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
8Additional 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 residentF361 – 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)
9Additional 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 temperature365 – 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)
10Additional 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
11Additional 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
12Additional Dietary/Nutrition TAGS F325 – Maintain nutrition status unless unavoidable (16)F327 – Sufficient fluid to maintain hydration (6)
13Survey and Certification Letters Guidance, clarifications and instructions to State Survey Agencies and CMS Regional OfficesMay simply provide clarification of an existing federal tagMay accompany a new or revised tag with an explanation and instructionsCommunications from CMS
14S & C NHDementia 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
15S & C NHNew Dining Standards of Practice Resources Available Released March 1, 2013
16New Dining Practice Standards August 2011 – Pioneer Network Food and Dining Clinical Standards Task ForceGOAL STATEMENT: Establish nationally agreed upon new standards of practice supporting individualized care and self‐directed living versus traditional diagnosis‐focused treatment.ningPracticeStandards/
17New Dining Practice Standards Nine StandardsIndividualized Nutrition Approaches/Diet LiberalizationIndividualized Diabetic/Calorie Controlled DietIndividualized Cardiac DietIndividualized Altered Consistency DietIndividualized Tube FeedingReal Food FirstHonoring Food ChoicesShifting Traditional Professional Control to Individualized Support of Self‐Directed CareNew Negative Outcome
18Person Centered Care Offer resident choices Encourage individual resident decisionsHomelike atmosphereLess institutionalReplace large units w/smaller onesEliminate/reduce overhead pagingClose relationships between resident and staff – promotes same care givers (consistent staffing)
19Diet determined with the person and in consideration of his/her informed choices, goals, and preferences rather than exclusively by diagnosisConsider beginning with a regular diet and monitoring the individual response to it, unless a medical condition warrants a restricted diet.
20Ensure 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)
21Explain the nutrition problem you identified to the resident Develop an agreed upon, measurable nutrition goalDevelop interventions with resident inputIf resident refuses any interventions, explain risk/benefit and honor choiceDocumentation is an important part of this process!
22S&C: NHPreview of Nursing Home Quality Assurance & Performance Improvement (QAPI) Guide – QAPI at a GlanceReleased December 14, 2012Rollout of Quality Assurance and Performance Improvement (QAPI) Materials for Nursing HomesReleased June 7, 2013
23What 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.
24Five Elements of QAPI Design and Scope Governance and Leadership Feedback, Data Systems and MonitoringPerformance Improvement ProjectsSystematic Analysis and Systemic Action
25QAPI QA and PI are never a quantity: Number of meals served Number of hours staff workedCafeteria incomeNumber of diet instructions
26Quality AssuranceQA 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.
27Performance 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 problemsThe goal is to improve systems involved in the delivery of care and resident quality of life
28Quality AssuranceIncludes routine actions to assure a certain standard is continually achievedExamples:Refrigerator and freezer logsMeal service food temperature logsPractitioner’s order matches diet card/list
29Performance Improvement Involves identification of a system breakdown and/or identification of a problem (may be a single incident)Can be identifiedObjectively or subjectivelyFormally or informallyImpact residents
30Performance Improvement Examples:Nutritional screening not complete and/or not timelyNutritional assessments - not complete, accurate, timely, communicated, implementedSnacks not distributedExcessive plate wasteImproper food handling
31What is a system? Collection of interrelated parts/subsystems Unified by design or flow of workDesigned to meet one or more objectives
32Systems Food handling Menu planning Holding Cooling Purchasing DistributionReceivingServingStoringPreparationReheating
33Systems Nutritional Care Nutritional screening Nutritional assessment Communication - implementation of recommendations and evaluation of implemented recommendations
36Systems Management Leadership and organizational change Decision MakingCommunicationBudgetManagement of human resourcesManagement of financial resourcesQuality AssuranceMarketing
37QUAPISteps include:Identification of problem or opportunity for improvementGathering dataConsidering options to correct problemImplementing solution(s)Gathering data after implementationEvaluating (current and, then, long-term correction)
38ResourcesEnrollment-and- Certification/SurveyCertificationGenInfo/Dow nloads/Survey-and-Cert-Letter pdfEnrollment-and- Certification/QAPI/NHQAPI.html1st 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 HomeAffordable 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.
39Resources State Operations Manual - Appendix P and PP – Long term care - Appendix W – Critical Access HospitalWebsite:Guidance/Guidance/Manuals/downloads//so m107_Appendixtoc.pdfWebsite goes to the appendices table of contents – from there pick the desired appendix
40Resources Survey and Certification Letters web site: Enrollment-and- Certification/SurveyCertificationGenInfo/Polic y-and-Memos-to-States-and-Regions.html
41Iowa Administrative Code ResourcesIowa Administrative CodeChapter 51 – hospitalsChapter 58 – nursing facilitieshttps://www.legis.iowa.gov/IowaLaw/AdminCode/chapterDocs.aspx?pubDate= &agency=481Department of Inspections and Appealshttps://dia-hfd.iowa.gov/DIA_HFD/Home.doWebsite goes to the table of contents
42US Food and Drug Administration Food Code Chapter 51 – refers to the 2005 versionProtection/FoodCode/ucm htmChapter 58 – refers to the 1999 versionProtection/FoodCode/ucm htm2009 versionProtection/FoodCode/default.htmImportant 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.