The American Health Care Association - AHCA/NCAL · August 12, 2009 CD Network 11 The American...

August 12, 2009August 12, 2009 CD NetworkCD Network 11

The American Health Care The American Health Care

AssociationAssociation

Melissa Temkin, Director of Membership Melissa Temkin, Director of Membership and Regulatory Relationsand Regulatory Relations

[email protected]@ahca.org, 202, 202--898898--28222822


AHCA/NCAL Annual MeetingAHCA/NCAL Annual Meeting

�� October 4October 4--7, 20097, 2009�� McCormick Place, Chicago, ILMcCormick Place, Chicago, IL�� 13 tracks, including Care Practice, 13 tracks, including Care Practice,

Quality, Survey, etc.Quality, Survey, etc.�� Sessions can be listed in ADASessions can be listed in ADA’’ss

activity log for CEUsactivity log for CEUs�� For more information, go to For more information, go to

www.ahcancal.orgwww.ahcancal.org


TheThe Quality Indicator SurveyQuality Indicator Survey

(QIS) and Nutrition(QIS) and Nutritionis sponsored by the CD Network and Provide Nutritionis sponsored by the CD Network and Provide Nutrition


The Consultant Dietitian NetworkThe Consultant Dietitian Network(CD Network)(CD Network)

�� Who We AreWho We Are•• Registered, licensed dietitians who Registered, licensed dietitians who

provide nutrition consulting and food provide nutrition consulting and food service management services across service management services across the United States.the United States.

•• We provide services to all aspects of the We provide services to all aspects of the healthcare industry with a special healthcare industry with a special emphasis on Longemphasis on Long--Term Care.Term Care.

August 12, 2009 CD Network 5

The Quality Indicator

Survey

(QIS) and Nutrition

Presented by: Pam Brummit, MA, RD, LD

Brenda Richardson, MA, RD, LD, CD

CD Network 6August 12, 2009

QIS DEVELOPMENT�University of Colorado, University of

Wisconsin, Maverick Systems, and Alpine Technology� Development from 1998-2005

� Field tests by research, CMS staff, CO, IA, MD, NJ and WI

� Demonstration and evaluation by CA, CT, KS, LA, OH 2006


PURPOSE AND OBJECTIVES of the QIS

� To guide surveyors through the federal survey process

� Improve consistency and accuracy of Quality of Care/Quality of Life problem identification using a more structured process

� Comprehensive review of regulatory care areas using current resources


QIS PURPOSE AND OBJECTIVES - cont

� Enhanced documentation by organizing survey findings through automation

� Focus survey resources on facilities with largest number of quality concerns

� For providers, makes IDR process more difficult


PRELIMINARY RESULTS

� Review of initial testing has shown increased consistency and improved documentation of survey findings

� Result, QIS will be implemented on a larger scale.


The Good NewsThe survey process has changed, but the F-Tags

and Interpretive Guidelines are the same.


QIS SURVEYTwo-stage computer-

assisted survey process,

which includes 9 Tasks


STAGE I PROCESS� Preliminary investigation of residents

�Randomly selected by QIS Data Collection Tool (DCT)

�Based on a range of care areas covered by the federal regulations

�Resident assessments are based on observations, interviews, review of the clinical records and an analysis of MDS data.


STAGE I PROCESS -continued�Constructs 160 resident outcome and

process indicators called Quality of Care Indicators (QCIs)

� The QCIs are then compared to national norms

� QCIs that score above the statistical threshold are computer-selected for a detailed in-depth investigation in stage II.

� Includes Tasks 1-6


STAGE II PROCESS

� In-depth investigation of residents with care areas identified by the computer in Stage I that exceeded thresholds (national norms)

� Triggered care areas and residents are systemically investigated using Critical Element Pathways to determine regulatory compliance

� Includes Tasks 6-9


STAGE I


TASK 1: OFF-SITE SURVEY PREPARATION

�MDS data is loaded into primary PC to create resident pool from which further Stage I random samples are selected.�MDS data are also used to calculate the

QCIs for Stage II.�Review of past deficiencies, Ombudsman

information and complaints in order to facilitate investigation during the survey.


TASK 2:ON-SITE ENTRANCE CONFERENCE

�Team Coordinator announces survey and introduces team�Obtains an alphabetical resident census and

list of residents admitted within last 30 days that reside in the facility�List of residents who receive dialysis, on

ventilator, on hospice services�Staffing schedules for Licensed and

Registered Nursing staff�Begin process of finalizing Stage I sample


TASK 2 – Concurrent Activities

� INITIAL KITCHEN/FOOD SERVICE OBSERVATION WHILE OTHER MEMBERS ARE GATHERING INFORMATION

�Dining observation (starts with first meal that can be observed in full)

�Must identify emergency water source/supply

�Must provide schedule of meal times and location of all dining rooms


TASK 3: INITIAL TOUR� Obtain BRIEF overall impression of the

facility and the resident population� Meet as many staff/residents/families as

possible� Record egregious resident care situations

to be investigated further in Stage II� Document concerns with environment

(dining room, cleanliness, smells, etc.)� Ask staff to identify family members that

visit regularly


TASK 3: INITIAL TOUR – cont.� Observations:� staff/resident interactions (privacy and dignity)� staff availability� activities in progress� characteristics of resident populations, i.e.

residents with dementia, rehabilitation, and sub-acute clinically complex residents, residents with special care needs (feeding tubes, ventilators, intravenous fluids/medications, tracheostomy tubes, oxygen therapy)

� If meal service begins during tour, will begin dining service observation.


TASK 4: SAMPLE SELECTION�Quality Indicator Survey Data Collection Tool (QIS

DCT) provides a systematic automated resident sampling process.�QIS DCT generates 3 Stage I samples from the

resident pool� 1) MDS sample � 2)Admission sample� 3)Census sample (subset of resident pool)

� Surveyors may generate a non-random, surveyor-initiated sample (subset of resident pool).�Once samples are generated, data is downloaded

to surveyor’s individual PCs


TASK 4: MDS SAMPLE

�Drawn from resident pool generated off-site.� Includes all residents who have had an

MDS assessment any time during the past six months� Excludes residents with only a discharge or

re-entry MDS and residents with only an admission MDS


TASK 4: ADMISSION SAMPLE REVIEW� The sample is randomly generated

offsite by QIS DCT from the resident pool.

� Up to 30 residents with an admission MDS submitted within six months (180 days) prior to the extraction date and admitted to the facility more than 30 days prior to the extraction date.


TASK 4: ADMISSION SAMPLE REVIEW� Focus is on quality of care within first

six months for short stay and long stay residents at critical points (i.e. hospitalization, weight loss, rehabilitation)

� Focal points: Nutrition, Rehab, Skin Care

� Completed by records review only� Includes closed record reviews


TASK 4: ADMISSION SAMPLE REVIEW - continued

Weight loss

� Weights obtained from an appropriate source for time period being reviewed

� Must use the same charting or documentation source for all of the weights, if possible.

� Excludes residents with explicit terminal diagnosis and residents with LOS < 15 days


TASK 4: ADMISSION SAMPLE REVIEW - continued

� Weight information may be collected from the following sources:� Medication and/or Treatment Administration

Records� Dietary notes� Nursing notes� Weight and height records� The charting or documentation source that

includes the weights recorded when the resident was actually weighed (e.g., Certified Nurse Aide flow sheets, weight books, etc.)

� MDS is only used as the source of last resort)


TASK 4: CENSUS SAMPLE REVIEW

� The Census Sample is selected randomly by the QIS DCT from the Resident Pool.

� Offsite, 40 residents randomly drawn as the Stage I Census Sample.

� Reconciled onsite to ensure that the sample only includes residents who are currently residing in the facility.

� When discharged residents are replaced during the reconciliation process, newly admitted residents are added to the sample as replacements


TASK 4: CENSUS SAMPLE REVIEW

�Focus on care of long term residents currently residing in the facility and encompasses activities of daily living, nutrition, medications, elimination/incontinence, resident room, oral health, quality of life, skin care �Data collection through observations,

interviews and record reviews


TASK 4: CENSUS SAMPLE REVIEW - continued

� This information will be comprehensively analyzed in Stage II.

� Observations concerning compromised quality of care of sampled and non-sampled residents are recorded on surveyor worksheets for further review in Stage II.



Resident Observations�Collect and record resident-specific

information which takes into account situation and time of day�Multiple observations may be madeResident Interviews� Interview those residents assessed as

interviewable by the QIS DCT�Questions asked as they are written



Interview Questions

� What is the food like here?

� Are you able to participate in making decisions regarding food choices/ preferences?

� Is this acceptable to you?

Resident

Observations

� None related



Interview Questions

� Does the food taste good and look appetizing?

� Is food served at the proper temperature?

� Do you receive the fluids you want between meals?

Resident

Observations

� Physical signs of dehydration (dry,cracked lips and/or dry mouth, exhibits signs of thirst)



Interview Questions

� Do you have mouth/facial pain with no relief?

� Do you have any chewing or eating problems (could be due to: no teeth, missing teeth, oral lesions, broken or loose teeth)?

� Do you have tooth problems, gum problems, mouth sores, or denture problems?

Resident Observations

� Mouth contains debris, or teeth/dentures not brushed, or mouth odor, or dentures not in place

� Teeth broken/loose, or inflamed/bleeding gums, or problems with dentures



Family Interviews� Surveyors ask questions as written� Select families from various units�Conducted with three family members or

resident representatives that know the resident well and visit often enough to provide information about the facility’s services�Concerns identified during the interviews may

need to be investigated immediately, with the family present



Family Interview Questions� Does the facility honor the resident’s

preferences on what he/she eats or drinks?� Does the facility honor the resident’s desires

and preferences?� Does the resident receive the assistance with

meals that she/he needs?� Does the resident have any chewing or eating

problems, or mouth pain?� Does the resident have any tooth problems,

gum problems, mouth sores or denture problems?



Staff Interviews�Conducted with licensed staff (RN/LPN)�Nurse must have frequent and direct contact

with the resident�Document what is stated, even if information

contradicts information gathered from another source (observation or record review)



Staff Interview Questions� Question: Is this resident receiving a

nutritional supplement, defined as a prescribed high protein, high calorie, nutritional supplement between or with meals?

� If yes, there must be documentation in the medical record and staff must show documentation to surveyor.



Staff Interviews� Documentation may include a checkbox or checklist

that the supplement was given, provide a percentage of supplement consumed or list the amount consumed.

� The following sources may provide supporting documentation:� Medication Administration Record� Treatment Record� Snack/Supplement List� Meal documentation with supplements listed

separately� Other source as indicated by facility staff



Clinical Record Review�Encompasses pressure ulcers,

psychotropic medications, and weight loss�Surveyors are instructed to attempt to

conduct record reviews on the unit to continue observations of activities and staff-resident interactions.�Weights documented the same as the

Admission Sample


TASK 4: SURVEYOR-INITIATED SAMPLE�Chosen by a surveyor at his/her

discretion, to be further evaluated during Stage II�Based on resident-specific information

obtained from complaints, observations, interviews� Example: Dependent diner with a Stage I

pressure ulcer who is not being fed and family has verbalized complaints


TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS -

continued

� Nutrition� Sources – MDS, medical records, staff interviews,

observations, chart

� Prevalence of weight loss (MDS)

� Prevalence of significant weight loss that exceeds the interpretive guidelines (MDS/Medical records)� Excludes residents with terminal illness and on planned

weight loss program


TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS -

continued

� Nutrition (continued)

� Weight loss since admission: unplanned weight loss of 5% or more any time within 60 days of admit (MDS/Chart)

� No supplements and resident underweight (Observation/chart)

� Staff interview: Is the resident receiving a nutritional supplement defined as a high calorie/high protein product with or between meals?


TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS

�Hydration� Sources - Resident and staff interviews

and observations, MDS� Do you have access to fluids?� Do you receive fluids between meals?� Does the resident show signs of

dehydration, such as cracked lips, etc.?� Prevalence of dehydration - output

exceeds input (from MDS)


TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS

- continued

� Tube Feeding

�Sources – MDS/Chart�Prevalence of tube feeding (MDS)�Significant weight loss on tube feeding

(MDS/Chart)


TASK 4 : RELEVENT FINDINGS

� Document:�Observed problems� Areas of concern� Date, time, and source� Person interviewed and title

� IDRs WILL BE DIFFICULT


The CD Network and Provide Nutrition would

like to introduce

Brenda Richardson, MA, RD, LD, CD


TASK 5: FACILITY-LEVEL SURVEY AREAS

Survey tasks to be completed:1. Demand billing2. Dining observation3. Infection control4. Kitchen/Food Service Observation5. Med Pass


TASK 5: FACILITY-LEVEL SURVEY AREAS - continued

6. QAA Review7. Resident Council president interview8. Abuse prohibition review*9. Admission, transfer, discharge review*10. Environmental Observations*11. Nursing services, sufficient staffing*12. Personal funds*

* completed only if triggered by complaints or Stage

I interviews, observations or record reviews.


TASK 5: DINING OBSERVATION�Begins with the first full meal that occurs

after the team enters the facility�General observations� Adequate staff to assist residents� Positive dining experience� Not limited to observation of specific residents

� If concerns identified, may watch a different meal to see if problem exists during that meal� If more than one dining room, observe all

dining rooms plus residents dining in-room


TASK 5: DINING OBSERVATION - continued

� If there are problems identified, the surveyor can initiate the full dining observation at any point�Majority of time spent observing residents

who require the most assistance.�Names of residents observed not receiving

needed services, positioning, or adequate assistance will be recorded on the dining room worksheet to further investigate in Stage II.



�Dining observations will also occur during Stage II for sampled residents with nutrition-related concerns, such as weight loss, decline in eating ability, or dehydration, using the nutrition critical pathway�Family and residents with dining

concerns should be documented for private follow-up. In-depth interviews will be conducted.



� If surveyor identifies concerns (e.g. resident complaints or high prevalence of unintended weight loss), surveyor may request sample tray (same process as current procedure)�Test tray will be sent to unit the furthest

distance away�Food temperatures and palatability will

be checked when the last resident is served.



� If concerns are identified, such as F371 or F364 - unpalatable food or at improper temperatures or unsanitary conditions -the surveyor will initiate the appropriate tag and document concerns in the computer to address further in Stage II



�The entire team will be making observations.�Any surveyor can initiate a dining

observation.�Observations will be documented in the

computer in the Stage II section and combined with all other observations.�The team will then make decisions

about compliance.



Dining Observation Questions:

� Are meals prepared and served and staff assisting with dining at scheduled times?

� Is there no more than 14 hours between dinner and breakfast?

If either question is answered no, residents and staff will be interviewed to find out how often meals are beyond the

posting time.



�Do residents receive timely and appropriate assistance with meals?

Staff will be interviewed to determine how the dining areas are monitored to ensure residents needs are accommodated.



� Does staff follow proper tableware handling techniques?� Does staff utilize proper hygenic practices?� Are staff who handle food free of signs of infection?

Surveyors will observe how staff handles food, utensils and non-food items and observe for signs of open sores and

other signs of illness.



� Does staff act, or interact, with residents during meals in a manner to promote dignity?� Are non-disposable cutlery and plates used

and napkins available?� Are residents’ desires considered when using

clothing protectors?� Are assistive devices provided as needed to

promote independence?

Surveyors will observe how plates are cleared, how staff talks with residents and other staff and if sufficient time is allowed for residents

to complete meals.



� Are residents positioned to maximize eating abilities?

� Is lighting and ventilation adequate?� Do noise levels promote socialization?� Are dining rooms free of offensive odors?� Are dining rooms adequately furnished to meet

residents’ physical and social needs?� Do dining rooms have sufficient space to

accommodate all activities?



� Are meal substitutes offered when foods are refused?

� Does the facility serve meals in an attractive manner?

� Are the residents provided with sufficient fluids and assisted as needed?

Staff may be interviewed to determine their awareness of the need for adequate fluid intake.


TASK 5: KITCHEN/FOOD SERVICE OBSERVATION

� Brief visit during initial tour� Observe general sanitation practices, cleanliness of the

kitchen, and any practices that might indicate potential for food-borne illness

� Repeated unannounced focused visits to the kitchen.� Can occur at any time during either stage of the survey.� Make observations, conduct staff interviews. � If CDM/RD not in attendance, can ask staff questions

regarding procedures that they do not observe.


TASK 5: KITCHEN/FOOD SERVICE OBSERVATION -continued

Kitchen Observation Questions

� Is food stored and prepared under sanitary conditions?

� Is food stored at the proper temperature?� Does the facility prohibit staff with open

wounds, signs and symptoms of infection or indications of illness from handling food?

� Was food prepared and served in a sanitary manner that preserves nutritional value?

� Were dishes and utensils cleaned and stored under sanitary conditions?



� Is food preparation equipment clean and in safe operating condition?

� Was garbage disposed of properly?� Are food storage, preparation and

service areas free of signs of insects and rodents?



� Is food placed on the steam table two or more hours prior to service?

� Are hot foods (above 1400F) cooled to 700F within 2 hours; and from 700F to 410F within 4 hours?


PRESIDENT OF RESIDENT COUNCIL IS INTERVIEWED

� May be questioned about food satisfaction, cold food complaints, poor quality, sanitation, service, honoring preferences, etc.


TASK 6: TRANSITION FROM STAGE I TO STAGE II

�Team of surveyors meet�Surveyors verify items completed in

Stage I�Data is merged and Relevant Findings

Report is printed�Printing of Quality of Care results,

identifying residents and care areas for inclusion in Stage II


This CD Network and Provide Nutrition Presentation

returns to Pam


STAGE II


TASK 7: CARE AREAS AND CRITICAL ELEMENTS

�Stage II Survey of residents� In-depth review of residents whose Quality of

Care indicators exceeds thresholds in Stage I process and residents selected by surveyors.� Each care area has a set of Critical Elements

of care which are mapped to the F-tags� Minimum of three residents for each triggered

care area are reviewed.� Nutrition, Hydration and Tube Feeding has one

set of critical elements, but are considered as three care areas. Therefore, a minimum of three residents will be selected for each triggered care area.


NUTRITION, HYDRATION, TUBE FEEDING STATUS CARE AREA

� In-depth, detailed review of residents that have triggered care areas� Observations� Medical record reviews� Resident/Representative Interviews


TASK 7: CRITICAL ELEMENT PATHWAYS

� Critical Element (CE) Pathways�Guide the surveyors through the process of

determining if the Critical Elements of care are in place

�Assist in completing a consistent, organized, systematic review of triggered areas

�Computer-assisted to identify all care areas�Help surveyors determine compliance


TASK 7: CRITICAL ELEMENT PATHWAYS - continued

Critical Element Pathways:1. Activities2. ADLs and/or ROM3. Behavioral/Emotional Status4. Bowel & Bladder/Catheters5. Communication/Sensory Problems6. Dental Status/Services7. Dialysis8. General9. Hospice/Palliative Care


TASK 7: CRITICAL ELEMENT PATHWAYS - continued

10. Hospitalization or Death11. Nutrition, Hydration, Tube Feeding Status12. Pain Management13. Psychoactive Medications14. Physical Restraints15. Pressure Ulcers16. Rehab/Community Discharging17. Ventilators


NUTRITION, HYDRATION, TUBE FEEDING STATUS CARE AREA� Critical Elements (CE) incorporate each step

of the resident care process reflected in the regulations� CE 01: Assessment – F272

� CE 02: Care Planning – F279

� CE 03: Implementation of care plan that meets professional standards – F281

� CE 04: Care Plan Revision – F280

� CE 05: Provision of care and service to meet the needs of resident (outcomes) – F321, F322, F325, F327, F328


TASK 7: NUTRITION/HYDRATION/ TUBE

FEEDING – OBSERVATIONS

� Is the care plan consistently implemented over time and across various shifts?�Observe signs of altered nutrition/hydration:�Decreased or absent urine output; c/o dry eyes�Poor oral health�Dry chapped lips, mouth, sunken eyes�GI complications �Substantial muscle wasting �Edema




� Observe if assistive devices are available.� Observation of staff providing appropriate

assistance for residents dependent upon staff for care.

� Does the resident receive therapy or restorative care to improve swallowing or feeding skills?

� Does assistance promote dignity and maintain resident’s rights?




� Are proper feeding techniques used for positioning, cueing, totally feeding?

� Observe staff response to resident’s intake.� Is fresh water available in the room and

accessible to the resident.� How is fluid restriction monitored?


TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING – OBSERVATIONS

� Were fluids provided at and between meals?�Was the resident encouraged to drink?� If the resident has dysphagia, what

measures were taken to ensure adequate fluid intakes?

� Are supplements given to minimize interference with meal intakes?


TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING - OBSERVATIONS

� Does the resident consume supplements and to what extent? (from medical records)

� Is food served according to the diet and menu plan?

� Is family involved in the plan of care re: nutrition? (Family interview)

� Are the resident’s preferences honored regarding choices, portion sizes, nourishments, fluid restrictions?



� Observe if the tube feeding is being administered as ordered for flow rate, type of formula, free water, flushing, etc.

� Insertion site is free of complications and care of the site is given.

� Safe techniques are used in changing tube feeding bags.



� Placement of tube is checked and monitored; residuals are checked.

� Liquids are used to flush the tubing before and after medication per orders.

� Staff verify the amount of fluid and feeding administered independent of the rate on the feeding pump.

� Formula is labeled with date and time of hanging and flow rate.


TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING – Interviews

� If foods/fluids are refused, are other interventions or substitutions offered.�Did staff provide counseling on

alternatives and potential consequences of refusing food and fluid?� Interview staff on various shifts when

concerns about hydration, nutrition, or G-tubes have been identified.


TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING – Interviews

�Are staff aware of nutrition/hydration problems?�Are staff aware of facility specific

protocols regarding food/fluid intake?�Are staff aware of nutrition/hydration

care plans?


TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING – ASSESSMENT� Did the initial assessment include a baseline

BMI, height, weight, and weight history?�Were calorie, protein, and fluid needs

assessed?� Did the facility identify labs suggestive of

dehydration?�Were preventive plans of care in place to

promote a specific amount of fluid to prevent hydration?�Were methods in place to record food intakes

and report deviations?


TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING – ASSESSMENT

�New or existing conditions/diagnoses that may affect overall intake, nutrient utilization, and weight stability �Clinical indications for feeding tube�Factors contributing to the resident

refusal to eat/drink�Review of medications


TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING – CARE PLAN�Care plan is developed that is

consistent with resident’s specific conditions, risks, needs, behaviors, and preferences and current standards of practice.�Did the facility implement practices to

prevent decline in nutritional parameters, hydration, and/or complications of tube feeding that meet professional standards of care?


TASK 7: GENERAL CRITICAL ELEMENT PATHWAYS

� General CE Pathways:� For core issues not already addressed� Accidents (Falls)� Fecal impaction� Other skin conditions (burns, skin tears)� Non-UTI infections� DM, COPD, CHF, Wound Care (excluding

pressure ulcers)� Includes probes


TASK 7: GENERAL CRITICAL ELEMENT PATHWAYS

� Based on identified concerns with related outcomes, further investigation may include other tags


TASK 8: ANALYSIS, DECISION-MAKING AND INTEGRATION OF

INFORMATION

�Analysis of information� Integration of facility-level information� Integration of Critical Elements�Analysis/assignment of scope and

severity, and team decision-making


TASK 9: EXIT CONFERENCE

�Surveyors will use a potential citation report to guide the exit

�Will provide list of residents if facility requests

�Report finalization�Revisit if needed


CD Network and Provide Nutrition now return you

to Brenda


CURRENT TRENDS & FUTURE PLANS

� Expect first several days to include a lot of surveyor observations

� Surveys are lasting 5 days � Trend - More cites, less severity, more

collateral tags� QIS in 12 states� Plans to be in 44 states within 4 years


Personal Experiences with QIS:

Per Liz*, an RD practicing in North Carolina:

�My experience with QIS is very positive. �Surveyors are much more focused, less

intrusive into your day. I have had 4 of these surveys in 4 different facilities.

�Each time they have come into the kitchen briefly on day one and not again until day 3 of 4 days, and then only briefly again.

* Liz Friedrich, MPH, RD, CSG, LDN, Nutrition and Health Promotion Consultant, Salisbury, NC


Personal Experiences with QIS: (cont)

� My experience has been that that if they don't have problems on the initial walk-through or meal observations and there are no complaints from the patients or families, they consider dietary to be functioning well and don't spend hours looking for moisture in a dish or waiting for a cook to get flustered and make an error on when plating a meal.

� It seems that unless they have reason to think there are issues in dietary, they are very hands off.

� My administrators and the facility staff say they like QIS...staff agree that the surveyors are better focused and stick to their "script" without deviations or getting off track.

* Liz Friedrich, MPH, RD, CSG, LDN, Nutrition and Health Promotion Consultant, Salisbury, NC


Personal Experiences with QIS:

Another experience shared by an RD:

� I have had one QIS thus far, but it has been positive overall.

�For the kitchen inspection, they came in on day 1 and day 4. A few small problems were noted and test tray was a problem.

�Care planning was a big focus.


TOOLS AND RESOURCES FOR

PROACTIVE READINESS

� Know current Regulations and Rules: SOM, State Rules, State Food Code, MDS Manual) (Federal, State and Local).

� Use:� CMS-22053 Form to prepare for the Dining Observation� CMS-20055 Form to prepare for the Kitchen Observation� CMS-20075 Form to Prepare for Nutrition/Hydration/Tube

Feeding Status� Identify concerns with structure, process, and/or

outcome requirements related to Process of Care.� Periodically review a copy of the QI Report to identify

residents that will be included in the sample selection.


TOOLS AND RESOURCES FOR

PROACTIVE READINESS

� Know previous survey information: CMS 2567 (Statement of Deficiencies), OSCAR Reports, Quality Measure Quality Indicator Reports, Plan of Correction (PoC)

� Request that the RD be notified of the arrival of surveyors as soon as possible.

� The RD should be introduced to the surveyors, particularly the one assigned to dietary and offer assistance as needed.


TOOLS AND RESOURCES FOR PROACTIVE

READINESS (CONT)

� Follow ADA* Standard of Practice (SOP/SOPP) and Evidence Based Best Practice Protocols.

� Incorporate the ADA* Nutrition Care Process (NCP) of assessment, diagnosis, intervention and monitoring/evaluation in medical record documentation.

� Remember that surveys are subject to change and revision. Be certain that you have the most current information:� CMS� State Health Care Association� Professional Organizations (AMDA, NPUAP,

ADA, Dietetics in HealthCare Communities DPG, Dietary Managers Association, others)

* American Dietetic Association


TOOLS AND RESOURCES FOR PROACTIVE

READINESS (CONT)

� http://www.uchsc.edu/hcpr/qis_forms.php

� http://www.aging.state.ks.us/Manuals/QIS/TabIndex.html


THANK YOU!!!


Thank You to the Sponsors


CD NetworkCD Network ServicesServices

�� Cost Analysis and ControlCost Analysis and Control�� Quality Nutrition CareQuality Nutrition Care�� Regulatory Compliance/Crisis ManagementRegulatory Compliance/Crisis Management�� Menu and Purchasing SystemsMenu and Purchasing Systems�� Interim Staffing by Dietetics ProfessionalsInterim Staffing by Dietetics Professionals�� National Coverage with Regional ExpertiseNational Coverage with Regional Expertise�� Professional Presentations Professional Presentations –– Webinars,Webinars,

TeleconferencesTeleconferences or Onsiteor Onsite

104104

CD NetworkCD Network MembersMembersAbshire Dietary Consultants, Inc.Abshire Dietary Consultants, Inc.Mary Abshire, MS, RD, LDMary Abshire, MS, RD, LD

Becky Dorner & Associates, Inc.Becky Dorner & Associates, Inc.Becky Dorner, RD, LDBecky Dorner, RD, LD

Brummit & Associates, Inc.Brummit & Associates, Inc.Pam Brummit, MS, RD, LDPam Brummit, MS, RD, LD

Carolina Nutrition Consultants, Inc.Carolina Nutrition Consultants, Inc.Edna Cox, RD, CSG, LDEdna Cox, RD, CSG, LD

C L Gerwick & Associates, Inc.C L Gerwick & Associates, Inc.Cheryl Carson, RD, LDCheryl Carson, RD, LD

C S Johnson & AssociatesC S Johnson & AssociatesCandace Johnson, MS, RD, LDCandace Johnson, MS, RD, LD

Dietary Consultants, Inc.Dietary Consultants, Inc.Carolyn Breeding, MS, RD, LDCarolyn Breeding, MS, RD, LD

Dietitian Consulting Services, LLCDietitian Consulting Services, LLCTerri Raymond, MS, RD, LDTerri Raymond, MS, RD, LD

Dietary Directions, Inc.Dietary Directions, Inc.Mary VesterMary Vester--Toews, RDToews, RD

Nutrition Systems, Inc.Nutrition Systems, Inc.LynnLynn Carpenter Carpenter Moore, RDMoore, RD

Nutritious LifestylesNutritious LifestylesJanet McKee, MS, RD, LDJanet McKee, MS, RD, LD

Steffen & Associates, Inc.Steffen & Associates, Inc.Marolyn Steffen, RD, LDMarolyn Steffen, RD, LD


www.cdnetworkonline.comwww.cdnetworkonline.com


WhenWhen ProvideProvide Liquid ProteinLiquid Protein came on came on the market, the competition listened.the market, the competition listened.

�� They lowered their They lowered their priceprice•• By over 20%By over 20%

�� They adjusted their They adjusted their tastetaste

�� But there is still But there is still nothing better than nothing better than starting with quality!starting with quality!


ProvideProvide Protein PowderProtein Powder�� Whey Isolate baseWhey Isolate base�� Agglomerated powder for fastAgglomerated powder for fast--acting dispersion in liquidsacting dispersion in liquids�� Three flavors Three flavors –– Chocolate, Vanilla, and NaturalChocolate, Vanilla, and Natural�� 12 grams of protein in 4 oz. serving12 grams of protein in 4 oz. serving�� 32 servings per container32 servings per container

Contact us at: (801) 546-3399 or www.providenutrition.com


It’s what we do…


�� www.providenutrition.comwww.providenutrition.com

�� 801801--546546--33993399

�� [email protected]@providenutrition.com

�� [email protected]@providenutrition.com

The American Health Care Association - AHCA/NCAL · August 12, 2009 CD Network 11 The American...

Documents

Transcript of The American Health Care Association - AHCA/NCAL · August 12, 2009 CD Network 11 The American...