The American Health Care Association

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• The American Health Care Association
• Melissa Temkin, Director of Membership and
  Regulatory Relations
• mtemkin_at_ahca.org, 202-898-2822

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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 ADAs 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
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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

• Presented by Pam Brummit, MA, RD, LD
• Brenda Richardson, MA, RD, LD, CD

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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

• 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

• 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

• 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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(No Transcript)
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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
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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

• 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

• 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
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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 2ON-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

• 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

• 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.

• 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

• 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
  surveyors individual PCs

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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

• 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 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

• 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 lt 15 days

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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

• 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 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

• 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 - 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 - continued

• 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

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TASK 4 CENSUS SAMPLE REVIEW - continued

• 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)

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TASK 4 CENSUS SAMPLE REVIEW - continued

• 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

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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 facilitys 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 - continued

• Family Interview Questions
• Does the facility honor the residents
  preferences on what he/she eats or drinks?
• Does the facility honor the residents 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 - 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 - 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 - 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 - 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

• 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

• 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

• 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
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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

• 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

• 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

• 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 - 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 - 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 - 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 - 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 - 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 - 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 - 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 - 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 - 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 - 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

• 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

• 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
-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
-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

• 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

• 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
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STAGE II
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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

• 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

• 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

• 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 - 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
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

• 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
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
  residents rights?

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TASK 7 NUTRITION/HYDRATION/ TUBE FEEDING
OBSERVATIONS

• Are proper feeding techniques used for
  positioning, cueing, totally feeding?
• Observe staff response to residents 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
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 -
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 residents preferences honored regarding
  choices, portion sizes, nourishments, fluid
  restrictions?

81
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.

82
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

• 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.

84
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?

85
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?

86
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

87
TASK 7 NUTRITION/HYDRATION/ TUBE FEEDING CARE
PLAN

• Care plan is developed that is consistent with
  residents 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

• 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

89
TASK 7 GENERAL CRITICAL ELEMENT PATHWAYS

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

90
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

91
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

92
CD Network and Provide Nutrition now return you
to Brenda
93
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

94
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
95
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
96
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.

97
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.

98
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.

99
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
100
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

101
THANK YOU!!!

102
Thank You to the Sponsors
103
CD Network Services

• 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

104
CD Network Members

• 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
105
www.cdnetworkonline.com
106
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107
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