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Regulatory Questions


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Regulatory Questions
I am looking for staffing needs for meal times in a Nursing home.
Having adequate staff during mealtime is key to the quality of care of residents in any facility. There are no established guidelines that identify the ratio of number of residents to number of staff. However, by contacting your state department of health, you can obtain the regulations which provide accurate information regarding role the staff should play during mealtime, and the dynamics a surveyor looks for. In general, a nursing staff member should be present in the dining room at all times, while a meal is being served and eaten. You may have one staff member feeding more than one resident at a time. The goal is that the residents are being assisted, fed effectively and with dignity. The staff should be conversing and encouraging the residents during this time, and personal conversations with other staff members should be limited.
 
What resources (current research, standards of practice, algorithims, etc...) are available in care of patients with chronic wounds.
For more information on this, go to the National Pressure Ulcer Advisory Panel website at: www.npuap.org, www.ahca.org or www.amda.org.
 
Is there a regulation or Standard of Practice on how often a diet manual needs to be revised or a new one purchased for nursing homes?
The standard is every three years. Research provides us with new information constantly and diet manuals must be revised accordingly.
 
Recently in SC, state surveyors have been focusing on care plans, specifically whether or not they have been updated between review dates. Do you have any quidelines for how quickly care plans should be updated, ie., changes in diets, wt. changes, etc. Also, do you recommend listing the specific diet/tf/supplement orders on cp approaches, or "diet as ordered" etc.?
In our company, we set the standard that whenever a nutrition assessment, re-assessment or progress note is done, the care plan is updated at the same time. This way, we are sure we don't miss anything important on the care plan updates. As far as updating between review dates, our standard is that we update minimum of once a month on any residents with significant weight changes, pressure ulcers or enteral feedings and any other high-risk residents. For changes or updates related to the RD's recommendations, the dietary manager or a nurse could do the care plan update if you are not in the facility on a daily basis. (As long as they are just following up on your recommendations, and not doing a nutritional assessment and making recommendations themselves). Everyone does care plans differently, so it is difficult to say whether you should list the specific diet, enteral feeding order or supplement order. All of this information is noted elsewhere in the chart. Your care plans need to be consistent with how the rest of the interdisciplinary team does theirs--are they that specific with their care plans, or do they refer to other sections of the chart for details? The care plan should reflect that you really do know what is going on with the individual resident, and you are keeping up with changes (however, those specific changes could be noted elsewhere in the chart).
 
I recently went through a DOH survey and the facility received an IJ for hot coffee-temperature was 160-165 DOH stated we are to send coffee out of kitchen between 130-135. Have you had any experience with this? I feel it was an unreasonable deficiency with no actual harm.
I have heard of facilities being cited for this in the past, however, it was usually based on actual harm. An IJ does not make sense if there was no harm. It is actual harm that is not immediate jeopardy and is widespread, and requires denial of payment for new admissions and other additional penalties. J is immediate jeopardy to resident health and safety and is Isolated, and requires temporary management of the facility. If the facility is willing, you may want to take this to internal review board. As far as the DOH stating that coffee should go out of the kitchen at 130-135 degrees F, as far as I know there is no regulation or any guidance written to that affect. (So it may just be based on one surveyor's personal opinion.) All of that said, as part of a plan of correction, you may want to develop some policies / procedures and training programs for serving hot foods and beverages. Emphasis should be placed on careful serving of trays and beverages to avoid spilling. And monitoring of residents, especially residents who need extra assistance, have difficulty with motor dexterity, and/or have dementia.
 
You are awesome and highly respected in this field! I always like seeing what's new when things come out. I have a question about the article in Today's Dietitian: (August 2004) Enhancing the Dining Experience. You mentioned the passing of the feeding assistant's rule. What was the rule that was passed, and does it pertain nationwide, or just to some states. I am very interested, as I have been trying to get more people involved in the mealservices, and this may be the way I can do this. Any related articles/websites etc. on the passing of the rule would be gratefully appreciated.
Thank you for your kind note. The Paid Feeding Assistant Rule is a federal rule that went into effect last fall. Each state must determine if it will follow the federal rule as written, or if it will adjust (add, not take away) it for the state. I did a simple web search and found the federal rule at: http://a257.g.akamaitech.net/7/257/2422/05dec20031700/edocket.access.gpo.gov/cfr_2003/octqtr/42cfr483.160.htm. You would need to check your state department of health to determine whether your state is doing something different from the federal rule.
 
I am revising the menus for an adult care facility, the director did not give me any guidelines to go by. Does anyone here know where I can find the JACHO guidelines for therapuetiuc diets for a nursing home?
The CMS guidelines can be found here: www.cms.hhs.gov/manuals/107_som/som107ap_pp_guidelines_ltcf.pdf. Federal Regulations: CMS (F360 Dietary Services begins on pg 233) . JCAHO guidelines should follow fairly closely--the JCAHO site is www.jcaho.org.
 
I have been asked to go into a long term care facility to help them prepare for the state survey. There are two dietitians who are not registered and have no clinical manager. What are the basic things I should be looking for with documentation. Are there any other things I should be focusing on?
It will be important to know the state regulations for Nursing Homes at the facility you are going to. Each state has specific regulations for compliance. The Long Term Care Survey Guidance Manual will give you the F Tags for federal guidelines as well as the Investigative protocols for the survey process. If you are doing the clinical component only, you will need a list of the nutrition at risk residents at the facility. Significant weight changes, all pressure ulcers, and tube feedings should be a major part of your review. The facility Quality Indicators, roster matrix, menu and spreadsheets will be valuable tools for you to have prior to your arrival. Documentation review should include: 1. Individualized assessment based on identified nutrition and hydration risk factors. 2. Correct and accurate nutritional needs assessment for calories, protein and fluids. Needs should have been re-calculated upon each nutritionally significant occurrence (for example, if a pressure ulcer developed, the needs should be re-calculated to promote healing). 3. Appropriate nutritional interventions in place to promote healing, weight goals, intake goals etc. 4. If on tube feeding that needs were assessed and the formula meets those needs. 5. Compare intake to what is actually needed by the resident (needs 1800 calories, eats 50% of meals, supplement adds 300 calories but resident refuses it) and what the intervention will change to to meet needs. 6. If forms are in place are they clear, concise and identify the nutritional concerns. 7. Are the MDS accurate? 8. Are the RAPS written appropriately? 9. Does the POC give a clear picture of the current nutritional status and is it changed often to reflect current status? 10. Have the dietitians followed best practice guidelines for the clinical documentation?
 
I would like some information regarding the MDS forms. What is the difference of 7d, 30d, 60d, 90d (I am not sure w/the days)? How do you distinguish from all of these and how does one know what belongs to which resident? How are residents screened nutritionally? Does everyone need to be seen within 48 hours?
Your MDS coordinator will help you keep all of this straight. There are also many manuals you can refer to such as the MDS User's Manual and the MDS 2.0 Assessment Guide from Med-Pass/Heaton Resources (we do carry this manual here at Becky Dorner and Associates it is item #C8). The MDS is an assessment in a period of time for residents on Medicare. The MDS generates the reimbursement to the facility for care. The difference is that you are assessing the resident for a specific time frame thus the 5/14/30/60/90 days of admission. The MDS coordinator will tell you what is due and when for each resident. Screening is facility specific and most have policies and procedures in place for time lines of assessment. States may also have different specific time frames. All residents in LTC will need to be assessed by the nutrition professional usually by the 5th day of admission. The resident should be visited for food preferences and desires within the first 48 hours of admission.
 
My question involves menus. Currently where I consult, the RD reviews and signs off on new menus. What is the responsibility of the RD when substitutions are made. How should these be documented by dietary staff? And overall, what steps should be addressed with menus to always maintain compliance with state surveys?
You'll want to refer to F363 Menus and nutritional adequacy for details on the federal nursing home regulations for menus (menus must meet the USRDA, be prepared in advance and be followed). Then review your state regulations for nursing homes (or assisted living, rest homes if that is your setting). Some states have very specific guidelines for menus. Be sure menus meet all the guidelines listed in these regulations. As far as substitutions go, the dietetics professional should provide guidance on what foods are appropriate for substitutions in each major food category. Staff should be inserviced and the list made available unless a supervisor is available to approve all menu subs. If special diets are included in substitutions, the dietetics professional should approve the special diet spread sheets in advance. All menu subs should be documented and reviewed for patterns. If subs are made frequently, the dietetics professional should assess for potential problems (purchasing or delivery issues, food use issues, resident dislikes, etc.).
 
What are the JCAHO standards for Nutrition Screening for a hospitalized patient?
For information about the Joint Commission you can visit www.jcaho.org. Prior to the survey the facility must determine what screening parameters they will be using in order to comply with the standard. Many use the Nutrition Screening Initiative, others have their own screening questions. Most assign levels of care as part of the screening process which are determined in-house. General nutrition screens ask simple questions about diet, weight, and nutrition related diagnosis that are "scored" and once the patient has a score of say 6 or more a referral is made to the RD or a consult. It is up to each facility to develop plans and procedures to meet the JCAHO standard.
 
Is there a reference that spells out appropriate spacing of meals in LTC?
The Long Term Care Survey (red book) includes the F tag for frequency of meals. It is F368. It states that (1) the resident receives at least 3 meals daily at regular times comparable to normal mealtimes in the community; (2) there must be no more than 14 hours between dinner and breakfast; (3) the facility must offer snacks at bedtime; (4) and if a nourishing snack is offered at bedtime, up to 16 hours may elapse between dinner and breakfast if the resident group agrees to this.
 
When working on section k3a in the MDS and I have checked that a resident has had a weight loss knowing that weight loss was due only to fluid loss. Then I get to section k5h where it asks if they were on a planned weight change program and I know they were not on a planned weight change program relating to nutrition but the fluid loss was desired, do I then check that section or leave it because the loss was not related to nutrition. Myself, the dietitian and the administrator all believe it should not be checked, but the MDS coordinator of our corporation and also the one in the building believe it should be checked.
I would not mark it in this situation as the RAI User's Manual states that in order to mark this a "planned program whose documented purpose and goal(s) are to facilitate weight gain or loss". If you restricted sodium and perhaps fluids and documented this accordingly, while the client was diuresed, then you would mark it.
 
When will the CMS revisions come out about weight? I heard it would be extensive.
F 325 is to be released sometime in 2007. The public comments were extensive and the work group will meet to revise the document. The original document did have extensive changes in it, but it is anyone’s guess what the final document will be—or when it will be released.
 
Are there regulations that the 14/30/60 days need a progressnote?
You may want to check with your state's regulations and your MDS Coordinator. I don't know of any regulation that states a progress note is required for the 14/30/60 day PPS MDS. You would need one if there were any significant changes with your resident (wt loss/gain, poor intake, new TF etc.). If your facility has a policy that states you will do one you must follow your facility's policy. I have seen it done both ways. Usually the dietitian writes a very short note "14 day completed, no significant change noted." Your state will have a main MDS person that you should contact if you have further questions. CMS has a great website www.cms.gov that you can use to access manuals and regulations for regulatory guidance.
 
Could you tell me what the requirements are currently for spacing of the evening meal and the next day's breakfast in long term care? My understanding was that it can not exceed 14 hours unless there is a bed time snack offered, in which case it could be 15 hours. Is this correct?
This falls under F368 Frequency of meals: Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community. There must be no more than 14 hours between a substantial evening meal and breakfast the following day except as provided in 4 below. The facility must offer snacks at bedtime daily. When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the next day if a resident group agrees to this meal span and a nourishing snack is served. Nourishing snack is defined as a verbal offering of items, single or in combination from the basic food groups. Adequacy of the nourishing snack will be determined both by resident interviews and by evaluation of the overall nutritional status of residents in the facility. You may also want to check your state regs.
 
Do you have a specific formula that can be used to determine appropriate staffing levels for dietary? We have found an older formula that used 11-13 minutes per resident for meal preparation. What are your thoughts?
We have used very general formulas also. One is for every 5 meals prepared, 1 labor hour will be used in a long-term care facility which averages out to 12 minutes per resident and is the same as you use! A very general rule of thumb is 0.5 hours per resident, i.e. a 50 bed facility would need 25 total labor hours per day. Of course these formulas do not consider the type of meal service, type of menu, or type of food preparation so be sure to ask those questions also.
 
can oral supplements be billed for (bill insurance coor bill the resident?)
This is a very complicated topic and we can only give generalities as each facility is unique in how they approach this. If you mean a milk shake/health shake or puddings and such those usually are included in meal costs. Some oral supplements such as 2 cal products or modulars may be covered similar to a tube feeding reimbursement based on need with supportive documentation . Many private pay individuals pay for their own supplements out of pocket. It depends on the policy of the facility and the agreement it has with the individual upon admission. Check with your Administrator, Admissions, and/or your billing department to find how this works in your facility.