General Information
Where can I find the nursing home state operations manual that everyone keeps talking about?
The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities can be downloaded from http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf
This manual provides guidance for surveyors on how to interpret the federal law. It can help you understand what you need to have in place for quality care and service for your residents. There is a wealth of information contained in the manual, and anyone working with nursing facilities should review it carefully.
Where can I find information about JCAHO standards for a hospitalized patient?
For information about The Joint Commission you can visit www.jcaho.org
Documentation
I would like some information regarding the MDS forms. What is the difference of 5 days, 30 days, 60 days, 90 days? How do you distinguish from all of these and how does one know what belongs to which resident? Does everyone need to be seen within 48 hours?
Your Minimum Data Set (MDS) coordinator will help you keep all of this straight. There are also many manuals you can refer to such as the Minimum Data Set/Resident Assessment Instrument (MDS/RAI) User's Manual. The MDS generates information for the reimbursement to the facility for care. For Medicare patients, assessment dates for the resident are for a specific time frame of 5/14/30/60/90 days of admission. All residents in LTC will need to be assessed by the dietetics professional by the 5th day of admission. The resident should be visited for food preferences and desires within the first 48 hours of admission.
Food Safety
Do eggs have to be pasteurized to be served in a nursing home? If you make them fried hard, poached hard, hard boiled or egg salad should it cause a problem with state?
If eggs are cooked all the way through and held at the proper temperature, then no, they do not have to be pasteurized. Pasteurized eggs can be convenient for those people who want soft cooked eggs.
If you make jello with no fruit in it, can you keep it for 8 days or is that past the limit?
We advise people to keep leftover foods for no more than 3 days (and then they must be reheated to 165 degrees F for a minimum of 15 seconds). However, the National Restaurant Association allows a longer period of time. My recommendation would be to make only what you need and avoid leftovers.
Feeding Assistants
Where can I find the feeding assistant's rule? I am very interested, as I have been trying to get more people involved in the meal services, 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.
F Tag 373 Nursing Home use of Paid Feeding Assistants was effective 8-17-07. Surveyors will determine noncompliance in any of the following cases: The feeding assistant has not completed a state-approved training program; or is not properly supervised. The facility has not selected an appropriate resident to receive paid feeding assistance; and/or has not maintained records indicating all paid feeding assistants have completed a training course. Each state must determine if it will follow the federal rule as written, or if it will adjust it (add, not take away) for the state. Detailed information on this tag can be found in the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf
Meal Times
Is there a reference that spells out appropriate spacing of meals in LTC? 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?
The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, tag F368 Frequency of meals states that 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 regulations.
Menu Guidelines
I am revising the menus for a nursing home but the director did not give me any guidelines to go by. Does anyone here know where I can find the guidelines for therapeutic menus
for a nursing home?
The CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities can be found here: http://www.cms.hhs.gov/GuidanceforLawsAndRegulations/12_NHs.asp (See F363 Menus and Nutritonal Adequacy).
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, or 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 RD 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 substitutions. If special diets are included in substitutions, the RD should approve the special diet spread sheets in advance. All menu substitutions should be documented and reviewed for patterns. If substitutions are made frequently, the RD should assess for potential problems (purchasing or delivery issues, food use issues, resident dislikes, etc.). Our Policy & Procedure Manual would be of great help with pulling all of this together.
Survey Preparation
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 clinical documentation? Are there any other things I should be focusing on?
It will be important to know the federal and state regulations for Nursing Homes. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities as noted in the question above will help with the federal regulations and will give you the F Tags for federal guidelines as well as the Investigative protocols for the survey process. In addition, each state has their own specific regulations for compliance. If you are doing the clinical component only, you will need a list of the residents at nutrition at in the facility. Significant weight changes, all pressure ulcers, and enteral 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, food/fluid intake goals etc.
4. If on tube feeding, make sure that nutritional 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 in order to meet the individual needs.
6. If forms are in place are they clear, concise and identify the nutritional concerns?
7. Is the MDS information 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, goals, needs?
10. Have the dietitians followed best practice guidelines for the clinical documentation?
Therapeutic Diets and Person-Centered Dining
Hi Becky, I was wondering if you had any suggestions for the following: I work at a nursing facility where we put salt, pepper, and sugar/sugar sub on tables in dining room. If a resident at the table is on a no added salt diet and chooses to use salt shaker, can the state tag us for that? If so, what is a suggestion for this type of situation? Do most facilities put salt/pepper shakers on tables in dining rooms ?
Having condiments on the table provides a more homelike environment which is part of what most facilities are trying to achieve when it comes to culture change and person centered dining. The resident’s right to choose versus physician diet orders can be a gray area, but there are some things you can do.
If you have residents on special diets that are using condiments inappropriately, your responsibility would be to educate them. Explain the diet that the physician has prescribed, and the risks/benefits of following/not following the diet. If the person understands the education and still chooses to use the condiments inappropriately for their diet order, you might try to counsel again, and also carefully document that you provided education/counseling and the person still chooses to use the condiments. Documentation will be the key to avoiding citations for this situation.
If the person is not competent to understand or follow your diet guidance, then supervision by staff during meals may be needed to remind the person they should not use salt. For someone with dementia, simple phrases like “salt is not good for your blood pressure” might help them understand why. However, it is still their right to use the salt if they choose. Again, education, supervision and documentation will be key to avoiding survey citations.