October 18, 2013
Association of Nutrition and Foodservice Professionals
Sandra Frahm RD, LD
Health Facilities Surveyor
sandra.frahm@dia.iowa.gov
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.


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

Outcome-oriented approach
◦ Actual and potential outcome


Look for implementation of systems to meet
regulations
Investigation based on observations,
interviews, and review of documents

Statement of deficiencies – Form CMS-2567
which includes:

Problems found

Evidence to support the deficiency

Serves as the basis for the plan of correction





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)





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



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)



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)


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


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


F325 – Maintain nutrition status unless
unavoidable (16)
F327 – Sufficient fluid to maintain hydration
(6)



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
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
New Dining Standards of Practice Resources
Available
Released March 1, 2013



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/Di
ningPracticeStandards/
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







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)


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.
 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)
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!

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
 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.
Design and Scope
 Governance and Leadership
 Feedback, Data Systems and
Monitoring
 Performance Improvement Projects
 Systematic Analysis and Systemic
Action

 QA
and PI are never a quantity:
◦ Number of meals served
◦ Number of hours staff worked
◦ Cafeteria income
◦ Number of diet instructions
 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.


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
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
 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
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
Collection of interrelated
parts/subsystems
 Unified by design or flow of work
 Designed to meet one or more
objectives












Food handling
Menu planning
Holding
Cooling
Purchasing
Distribution
Receiving
Serving
Storing
Preparation
Reheating

Nutritional Care
◦ Nutritional screening
◦ Nutritional assessment
◦ Communication - implementation of
recommendations and evaluation of
implemented recommendations

Physical Environment
◦ Safety
◦ Sanitation
◦ Maintenance

Staff
◦ Hiring
◦ Training
◦ Evaluating

Management
◦ Leadership and organizational change
◦ Decision Making
◦ Communication
◦ Budget
◦ Management of human resources
◦ Management of financial resources
◦ Quality Assurance
◦ Marketing
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)


http://www.cms.gov/Medicare/ProviderEnrollment-andCertification/SurveyCertificationGenInfo/Dow
nloads/Survey-and-Cert-Letter-13-05.pdf
http://cms.gov/Medicare/ProviderEnrollment-andCertification/QAPI/NHQAPI.html

State Operations Manual
- Appendix P and PP – Long term care
- Appendix W – Critical Access Hospital
Website:
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads//so
m107_Appendixtoc.pdf

Survey and Certification Letters web site:
http://www.cms.gov/Medicare/ProviderEnrollment-andCertification/SurveyCertificationGenInfo/Polic
y-and-Memos-to-States-and-Regions.html
Iowa Administrative Code
Chapter 51 – hospitals
 Chapter 58 – nursing facilities
https://www.legis.iowa.gov/IowaLaw/Admin
Code/chapterDocs.aspx?pubDate=01-112012 &agency=481
 Department of Inspections and Appeals
https://dia-hfd.iowa.gov/DIA_HFD/Home.do


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