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The American Health Care Association Melissa Temkin, Director of Membership and Regulatory Relations [email protected] , 202-898-2822. AHCA/NCAL Annual Meeting. October 4-7, 2009 McCormick Place, Chicago, IL 13 tracks, including Care Practice, Quality, Survey, etc.

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The American Health Care Association

Melissa Temkin, Director of Membership and Regulatory Relations

[email protected], 202-898-2822

CD Network


Ahca ncal annual meeting
AHCA/NCAL Annual Meeting

  • October 4-7, 2009

  • McCormick Place, Chicago, IL

  • 13 tracks, including Care Practice, Quality, Survey, etc.

  • Sessions can be listed in ADA’s activity log for CEUs

  • For more information, go to www.ahcancal.org

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The quality indicator survey qis and nutrition is sponsored by the cd network and provide nutrition

The Quality Indicator Survey(QIS) and Nutritionis sponsored by the CD Network and Provide Nutrition

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The consultant dietitian network cd network
The Consultant Dietitian Network(CD Network)

  • Who We Are

    • Registered, licensed dietitians who provide nutrition consulting and food service management services across the United States.

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

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The quality indicator survey qis and nutrition

The Quality Indicator Survey(QIS) and Nutrition

Presented by: Pam Brummit, MA, RD, LD

Brenda Richardson, MA, RD, LD, CD

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Qis development
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

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Purpose and objectives of the qis
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

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Qis purpose and objectives cont
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

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Preliminary results
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.

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The Good NewsThe survey process has changed, but the F-Tags and Interpretive Guidelines are the same.

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Qis survey two stage computer assisted survey process which includes 9 tasks
QIS SURVEYTwo-stage computer-assisted survey process, which includes 9 Tasks

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Stage i process
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.

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Stage i process continued
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

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Stage ii process
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

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Stage i

STAGE I

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Task 1 off site survey preparation
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.

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Task 2 on site entrance conference
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

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Task 2 concurrent activities
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

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Task 3 initial tour
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

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Task 3 initial tour cont
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.

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Task 4 sample selection
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

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Task 4 mds sample
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

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Task 4 admission sample review
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.

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Task 4 admission sample review1
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

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Task 4 admission sample review continued
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

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Task 4 admission sample review continued1
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)

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Task 4 census sample review
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

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Task 4 census sample review1
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

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Task 4 census sample review continued
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.

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Task 4 census sample review continued1
TASK 4: CENSUS SAMPLE REVIEW - continued

Resident Observations

  • Collect and record resident-specific information which takes into account situation and time of day

  • Multiple observations may be made

    Resident Interviews

  • Interview those residents assessed as interviewable by the QIS DCT

  • Questions asked as they are written

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Task 4 census sample review continued2

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

TASK 4: CENSUS SAMPLE REVIEW - continued

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Task 4 census sample review continued3

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)

TASK 4: CENSUS SAMPLE REVIEW - continued

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Task 4 census sample review continued4

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

TASK 4: CENSUS SAMPLE REVIEW - continued

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Task 4 census sample review continued5
TASK 4: CENSUS SAMPLE REVIEW - continued

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

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Task 4 census sample review continued6
TASK 4: CENSUS SAMPLE REVIEW - continued

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?

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Task 4 census sample review continued7
TASK 4: CENSUS SAMPLE REVIEW - continued

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)

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Task 4 census sample review continued8
TASK 4: CENSUS SAMPLE REVIEW - continued

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.

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Task 4 census sample review continued9
TASK 4: CENSUS SAMPLE REVIEW - continued

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

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Task 4 census sample review continued10
TASK 4: CENSUS SAMPLE REVIEW - continued

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

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Task 4 surveyor initiated 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

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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

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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?

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Task 4 nutrition hydration tube feeding quality of care indicators using sampled residents
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)

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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)

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Task 4 relevent findings
TASK 4 : RELEVENT FINDINGS

  • Document:

    • Observed problems

    • Areas of concern

    • Date, time, and source

    • Person interviewed and title

  • IDRs WILL BE DIFFICULT

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The cd network and provide nutrition would like to introduce brenda richardson ma rd ld cd
The CD Network and Provide Nutrition would like to introduceBrenda Richardson, MA, RD, LD, CD

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Task 5 facility level survey areas
TASK 5: FACILITY-LEVEL SURVEY AREAS

Survey tasks to be completed:

  • Demand billing

  • Dining observation

  • Infection control

  • Kitchen/Food Service Observation

  • Med Pass

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Task 5 facility level survey areas continued
TASK 5: FACILITY-LEVEL SURVEY AREAS - continued

  • QAA Review

  • Resident Council president interview

  • Abuse prohibition review*

  • Admission, transfer, discharge review*

  • Environmental Observations*

  • Nursing services, sufficient staffing*

  • Personal funds*

    * completed only if triggered by complaints or Stage I interviews, observations or record reviews.

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Task 5 dining observation
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

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Task 5 dining observation continued
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.

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Task 5 dining observation continued1
TASK 5: DINING OBSERVATION - continued

  • 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.

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Task 5 dining observation continued2
TASK 5: DINING OBSERVATION - continued

  • 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.

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Task 5 dining observation continued3
TASK 5: DINING OBSERVATION - continued

  • 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

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Task 5 dining observation continued4
TASK 5: DINING OBSERVATION - continued

  • 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.

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Task 5 dining observation continued5
TASK 5: DINING OBSERVATION - continued

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.

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Task 5 dining observation continued6
TASK 5: DINING OBSERVATION - continued

  • 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.

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Task 5 dining observation continued7
TASK 5: DINING OBSERVATION - continued

  • 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.

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Task 5 dining observation continued8
TASK 5: DINING OBSERVATION - continued

  • 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.

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Task 5 dining observation continued9
TASK 5: DINING OBSERVATION - continued

  • 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?

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Task 5 dining observation continued10
TASK 5: DINING OBSERVATION - continued

  • 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.

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Task 5 kitchen food service observation
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.

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Task 5 kitchen food service observation continued
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?

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Task 5 kitchen food service observation continued1
TASK 5: KITCHEN/FOOD SERVICE OBSERVATION -continued

  • 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?

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Task 5 kitchen food service observation continued2
TASK 5: KITCHEN/FOOD SERVICE OBSERVATION -continued

  • 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?

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President of resident council is interviewed
PRESIDENT OF RESIDENT COUNCIL IS INTERVIEWED

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

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Task 6 transition from stage i to stage ii
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

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This cd network and provide nutrition presentation returns to pam
This CD Network and Provide Nutrition Presentation returns to Pam

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Stage ii

STAGE II

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Task 7 care areas and critical elements
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.

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Nutrition hydration tube feeding status 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

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Task 7 critical element pathways
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

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Task 7 critical element pathways continued
TASK 7: CRITICAL ELEMENT PATHWAYS - continued

Critical Element Pathways:

  • Activities

  • ADLs and/or ROM

  • Behavioral/Emotional Status

  • Bowel & Bladder/Catheters

  • Communication/Sensory Problems

  • Dental Status/Services

  • Dialysis

  • General

  • Hospice/Palliative Care

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Task 7 critical element pathways continued1
TASK 7: CRITICAL ELEMENT PATHWAYS - continued

  • Hospitalization or Death

  • Nutrition, Hydration, Tube Feeding Status

  • Pain Management

  • Psychoactive Medications

  • Physical Restraints

  • Pressure Ulcers

  • Rehab/Community Discharging

  • Ventilators

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Nutrition hydration tube feeding status care area1
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

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Task 7 nutrition hydration tube feeding observations
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

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Task 7 nutrition hydration tube feeding observations1
TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING – OBSERVATIONS

  • 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?

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Task 7 nutrition hydration tube feeding observations2
TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING – OBSERVATIONS

  • 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?

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Task 7 nutrition hydration tube feeding observations3
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?

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Task 7 nutrition hydration tube feeding observations4
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?

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Task 7 nutrition hydration tube feeding observations5
TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING – OBSERVATIONS

  • 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.

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Task 7 nutrition hydration tube feeding observations6
TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING – OBSERVATIONS

  • 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.

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Task 7 nutrition hydration tube feeding interviews
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.

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Task 7 nutrition hydration tube feeding interviews1
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?

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Task 7 nutrition hydration tube feeding assessment
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?

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Task 7 nutrition hydration tube feeding assessment1
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

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Task 7 nutrition hydration tube feeding care plan
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?

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Task 7 general critical element pathways
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

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Task 7 general critical element pathways1
TASK 7: GENERAL CRITICAL ELEMENT PATHWAYS

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

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Task 8 analysis decision making and integration of information
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

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Task 9 exit conference
TASK 9: EXIT CONFERENCE INFORMATION

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

  • Will provide list of residents if facility requests

  • Report finalization

  • Revisit if needed

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Cd network and provide nutrition now return you to brenda
CD Network and INFORMATIONProvide Nutrition now return you to Brenda

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Current trends future plans
CURRENT TRENDS & FUTURE PLANS INFORMATION

  • 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

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Personal experiences with qis
Personal Experiences with QIS: INFORMATION

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

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Personal experiences with qis cont
Personal Experiences with QIS: (cont) INFORMATION

  • 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

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Personal experiences with qis1
Personal Experiences with QIS: INFORMATION

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.

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Tools and resources for proactive readiness
TOOLS AND RESOURCES FOR PROACTIVE READINESS INFORMATION

  • 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.

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Tools and resources for proactive readiness1
TOOLS AND RESOURCES FOR PROACTIVE READINESS INFORMATION

  • 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.

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Tools and resources for proactive readiness cont
TOOLS AND RESOURCES FOR PROACTIVE READINESS (CONT) INFORMATION

  • 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

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Tools and resources for proactive readiness cont1
TOOLS AND RESOURCES FOR PROACTIVE READINESS (CONT) INFORMATION

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

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

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Thank you
THANK YOU!!! INFORMATION

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Thank you to the sponsors
Thank You to the Sponsors INFORMATION

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Cd network services
CD Network Services INFORMATION

  • Cost Analysis and Control

  • Quality Nutrition Care

  • Regulatory Compliance/Crisis Management

  • Menu and Purchasing Systems

  • Interim Staffing by Dietetics Professionals

  • National Coverage with Regional Expertise

  • Professional Presentations – Webinars, Teleconferences or Onsite

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Cd network members
CD Network Members INFORMATION

Abshire Dietary Consultants, Inc.

Mary Abshire, MS, RD, LD

Becky Dorner & Associates, Inc.

Becky Dorner, RD, LD

Brummit & Associates, Inc.

Pam Brummit, MS, RD, LD

Carolina Nutrition Consultants, Inc.

Edna Cox, RD, CSG, LD

C L Gerwick & Associates, Inc.

Cheryl Carson, RD, LD

C S Johnson & Associates

Candace Johnson, MS, RD, LD

Dietary Consultants, Inc.

Carolyn Breeding, MS, RD, LD

Dietitian Consulting Services, LLC

Terri Raymond, MS, RD, LD

Dietary Directions, Inc.

Mary Vester-Toews, RD

Nutrition Systems, Inc.

Lynn Carpenter Moore, RD

Nutritious Lifestyles

Janet McKee, MS, RD, LD

Steffen & Associates, Inc.

Marolyn Steffen, RD, LD


Www cdnetworkonline com
www.cdnetworkonline.com INFORMATION

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When provide liquid protein came on the market the competition listened
When INFORMATIONProvide Liquid Protein came on the market, the competition listened.

  • They lowered their price

    • By over 20%

  • They adjusted their taste

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

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Provide protein powder
Provide INFORMATIONProtein Powder

  • Whey Isolate base

  • Agglomerated powder for fast-acting dispersion in liquids

  • Three flavors – Chocolate, Vanilla, and Natural

  • 12 grams of protein in 4 oz. serving

  • 32 servings per container

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

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It’s what we do… INFORMATION

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