1. MASTERING CA TITLE 22 AND NEW SURVEY PROCEDURES IN DIETARY SERVICES
By Linda Handy, MS, RD
Based upon manual of same title, available at

2. OBJECTIVES PARTICIPANTS WILL BE ABLE TO:
Learn HOW surveyors in CA are being trained to inspect healthcare with new 2016 survey procedures (under Title 22 for hospital, but very applicable to LTC)
Review high risk Title 22 regulations for LTC (often cited)
Define applicable CA Food Code requirements
Describe the new revised federal regulations for LTC, including QAPI (Quality Assessment and Performance Improvement)
Develop QAPI using the CMS Process Tools
Identify Title 22 deficiencies, especially with Immediate Jeopardies and deaths related to dietary services

3. HOW SURVEYORS IN CA INSPECT HEALTHCARE WITH NEW 2016 SURVEY PROCEDURES
Hospital Regulations with Survey Procedures: Access at and Certification> For Health Care Providers> General Acute Care Hospital Relicensing Survey
%20Regulations%20with%20Survey%20Procedures%20-%20for%20merge.pdf
HOW CAN THE SURVEYORS “TRAINING” AND PROCEDURES HELP YOU SELF EVALUATE?

4. KNOWING TITLE 22 REGULATIONS FOR LTC/SKILLED NURSING FACILITY
TO ACCESS TITLE 22 (for LTC): (or goggle California Regulations): On the Left top listing are the Codes->CCR California Code of Regulations->Titles->Title 22 Social Security-> Division 5 Licensing and Certification: Health Care->Chapter 3 Skilled Nursing Facility (SNF)
Article 3 Required Services, Dietary: Examples: Dietary Services
(a) & (b) Defines required services of Registered Dietitian & if RD not full time: a full time, qualified Dietary Supervisor
Changes to Title 22, usually found in Health and Safety Code:
Revised (72351) in 2009, adding educational requirements for DSS: H & S

5. HIGH RISK TITLE 22 REGS FOR LTC: OFTEN CITED
72349 (1) At least one week's supply of staple foods…shall meet the requirements of the weekly menu including the therapeutic diets ordered. (Manager should say, “We always order so there is 7 days of staples to match the weekly menu at all times on the shelves.”
Requirements of DSS (Dietary Supervisor): in above slide
Wt loss or gain of 5 lb within 30 days to be reported to Dr (acted on)
Menus: 3 week duration
Diet Manual: Readily available, reviewed yearly, revised q 5 yrs
Itemized records of food purchases shall be kept for one year
No rebates
I and O for Indwelling catheter, Foley, for min. 4 weeks (monitored)

6. ACCESSING AND DEFINE APPLICABLE CA FOOD CODE REQUIREMENTS
Survey procedures: and Certification>For Health Care Providers> General Acute Care Hospital Relicensing Survey Pg. 64:
NOTE (Guidance to Surveyors): please use the California Retail Food Code as reference if needed (not Federal Food Code).
CA Food Code can be found as part of Health and Safety Code or (JANUARY 2017 REVISION) :
***THIS ALLOWS YOU TO ‘SEARCH’ FOR A SECTION OR CODE

7. SELECTED SECTIONS OF CA FOOD CODE
Manual Dishwashing (3 compartment sink): (Go with strictest) Washing water temp: Not less then 100 F/T 22:72347(c)110 F Contact with a solution of 200 ppm quaternary ammonium for at least one minute (Low temp Dishmachine): min. Chlorine Final Rinse: 50 ppm (High Temp Dishmachine):achieving a utensil surface temperature of 160*F as measured by an irreversible registering temperature indicator (b) Refuse containers inside a food facilityneed not be covered during periods of operation Employee Health, PIC training to prevent Food Borne Illness; Food Safety Training for PIC every 5 yrs

8. ACCESSING NEW REVISED FEDERAL REGULATIONS FOR LTC, INCLUDING QAPI (QUALITY ASSESSMENT & PERFORMANCE IMPROVEMENT)
Google: S and C letter from CMS regarding DRAFT of revised LTC regulations.
(see website below). Implementation of phase I on All the new revisions, changes are in RED.
The State Operations Manual, Appendix PP for LTC: The Interpretive Guidance for revisions will be developed in 2017
Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter pdf

9. LTC FED REVISIONS: DIETARY SERVICES
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers
(4) Reflect the religious, cultural and ethnic needs of the residents, as well as input received from residents and resident groups;
(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and
(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
(4) Food that accommodates resident allergies, intolerances, and preferences;
(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law. Note: CA regs require a “board”(licensing) to establish competency and sanctions for allied health (RDs-even with protocols-cannot have practicing privileges as allied health (But may be able to modify, add to diet order)

10. LTC FED REVISIONS: DIETARY SERVICES (cont)
(i) Food safety requirements. The facility must—
(1) Procure food from sources approved or considered satisfactory by Federal, State, or local authorities;
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.
(2) Store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, and

11. LTC FEDERAL REVISIONS: NURSING, CARE PLANNING, TRAINING
(a) Baseline care plans. (1) The facility must develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.
(i) Be developed within 48 hours of a resident's admission.
(2) A comprehensive care plan must be—
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to—
(D) A member of food and nutrition services staff.

12. LTC FEDERAL REVISIONS: QAPI
Training requirements. (Competency)
A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles:
(a) Communication.
(b) Resident's rights and facility responsibilities.
(c) Abuse, neglect, and exploitation.
(d) Quality assurance and performance improvement. A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth
(e) Infection control.
(f) Compliance and ethics

13. DEVELOP QAPI USING THE CMS PROCESS TOOLS
In the S and C letter, for changes, scroll down to F tag 520:
(a) Quality assurance and performance improvement (QAPI) program. Each LTC
facility, including a facility that is part of a multiunit chain, must develop, implement, and
maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.
The facility must:
(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program
that meets the requirements of this section. This may include but is not limited to
systems and reports demonstrating systematic identification, reporting, investigation,
analysis, and prevention of adverse events; and documentation demonstrating the
development, implementation, and evaluation of corrective actions or performance
improvement activities

14. CMS PROCESS TOOLS FOR QAPI
Certification/QAPI/Downloads/ProcessToolFramework.pdf
PROCESS TOOLS FOR QAPI BASED UPON 5 ELEMENTS
Example:
ELEMENT 1: DESIGN AND SCOPE
GOAL: Learn the basics of QAPI • Review QAPI five elements • Understand how QAPI coordinates with QAA TOOLS: QAPI Five Elements, QAPI at a Glance, QAPI News Brief - Volume 1
GOAL: Assess QAPI in your organization TOOL: QAPI Self-Assessment Tool
GOAL: Create a structure and plan to support QAPI TOOLS: Guide to Developing Purpose, Guiding Principles and Scope for QAPI, Guide for Developing a QAPI Plan

15. CMS PROCESS TOOLS FOR QAPI
ELEMENT 4 – PERFORMANCE IMPROVEMENT PROJECTS
GOAL: Implement performance improvement projects • Focus on topics that are meaningful and address the needs of residents and staff • Plan, implement, measure, monitor, and document changes, using a structured PI approach TOOLS: Worksheet to Create a PIP Charter , PIP Launch Checklist: Helpful hints, Plan-Do-Study-Act (PDSA) GOAL: Enhance QAPI communications TOOLS: QAPI at a Glance, Communications Plan Worksheet, Storyboard Guide for PIPs, Improvement Success Story Template

16. CMS PROCESS TOOLS FOR QAPI
ELEMENT 5 – SYSTEMATIC ANALYSIS AND SYSTEMIC ACTION
GOAL: Understand and focus on organizational processes and systems • Model and promote systems thinking • Practice RCA – get to the root of problems • Take action at the systems level TOOLS: Guidance for Failure Mode and Effects, Analysis (FMEA), Guidance for Root Cause Analysis (RCA), Flowcharting, Five Whys, Fishbone Diagram

17. CMS FORMAT FOR QAPI: 3 QUESTIONS
Each facility may have a format for QAPI, determined by its corporation. Here are the CMS website and Toolkit, with the PDSA Model: Three questions for improvement
What are we trying to accomplish (aim)? State your aim (review your PIP charter –and include your bold aim that will improve patient/resident health outcomes & quality of care)
How will we know that change is an improvement (measures)? Describe the measureable outcome(s) you want to see
c. What change can we make that will result in an improvement? Define the processes currently in place; use process mapping or flow charting; Identify opportunities for improvement that exist

18. EXAMPLES OF QAPI-PERFORMANCE IMPROVEMENT PROJECTS BASED UPON CMS FORMAT
Ensuring Correct Diet & Interventions are served
Ensuring Adequate Hydration & Accurate I & Os
Pressure Ulcer (Injury): Prevention, Nutrition Care
Meeting CA NICU standards of care, Formulas, Human Milk, & Infection Control

19. ALL FACILTY LETTERS RELATED TO DIETARY SERVICES
POSTED at hand)licensing and certification>Publications>AFL (back to 2005)
Example (Last one issued): Diet Manuals, Orders, Menus, and Disaster Menu Planning Must Meet Patient’s Nutritional Needs 14-32
This is a VERY important letter (2014) It is an AFL regarding guidance on requirements of Diet Manual (clearly defined approved diets provided by facility), Modified Menu requirements (to implement delivery of the ordered diet), Nutrient Analysis (CA and fed regs) , Emergency Menu and Stock requirements, including puree, therapeutic (renal, diabetic).

20. IDENTIFY TITLE 22 DEFICIENCIES, ESPECIALLY IMMEDIATE JEOPARDIES & DEATHS RELATED TO DIETARY SERVICES
and Certification>
For Consumers (Listed by county)
Hospital Administrative Penalties (Civil Money Penalties)
Nursing Home AA Citations
“AA” citations are the most serious violation and are issued when a resident death has occurred and it has been determined that the facility’s violation was a direct proximate cause of death. “AA” citations carry fines of $25,000 to $100,000.
“A” citations are issued when violations present imminent danger to patients or the substantial probability of death or serious harm, and carry fines from $2,000 to $20,000. “B” citations carry fines from $100 to $1000 and are issued for violations which have a direct or immediate relationship to health, safety, or security, but do not qualify as “A” or “AA” citations. All nursing facilities in California are required to be in compliance with applicable state laws and regulations governing health care facilities. 

21. MAY YOU MASTER CA TITLE 22 (AND FEDERAL REGS) AND THE NEW SURVEYOR PROCEDURES. MAY YOUR SURVEYS TO WELL!