the american health care association - ahca/ncal · august 12, 2009 cd network 11 the american...
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August 12, 2009August 12, 2009 CD NetworkCD Network 11
The American Health Care The American Health Care
AssociationAssociation
Melissa Temkin, Director of Membership Melissa Temkin, Director of Membership and Regulatory Relationsand Regulatory Relations
[email protected]@ahca.org, 202, 202--898898--28222822
August 12, 2009August 12, 2009 CD NetworkCD Network 22
AHCA/NCAL Annual MeetingAHCA/NCAL Annual Meeting
�� October 4October 4--7, 20097, 2009�� McCormick Place, Chicago, ILMcCormick Place, Chicago, IL�� 13 tracks, including Care Practice, 13 tracks, including Care Practice,
Quality, Survey, etc.Quality, Survey, etc.�� Sessions can be listed in ADASessions can be listed in ADA’’ss
activity log for CEUsactivity log for CEUs�� For more information, go to For more information, go to
www.ahcancal.orgwww.ahcancal.org
August 12, 2009August 12, 2009 CD NetworkCD Network 33
TheThe Quality Indicator SurveyQuality Indicator Survey
(QIS) and Nutrition(QIS) and Nutritionis sponsored by the CD Network and Provide Nutritionis sponsored by the CD Network and Provide Nutrition
August 12, 2009August 12, 2009 CD NetworkCD Network 44
The Consultant Dietitian NetworkThe Consultant Dietitian Network(CD Network)(CD Network)
�� Who We AreWho We Are•• Registered, licensed dietitians who Registered, licensed dietitians who
provide nutrition consulting and food provide nutrition consulting and food service management services across service management services across the United States.the United States.
•• We provide services to all aspects of the We provide services to all aspects of the healthcare industry with a special healthcare industry with a special emphasis on Longemphasis on Long--Term Care.Term Care.
August 12, 2009 CD Network 5
The Quality Indicator
Survey
(QIS) and Nutrition
Presented by: Pam Brummit, MA, RD, LD
Brenda Richardson, MA, RD, LD, CD
CD Network 6August 12, 2009
QIS DEVELOPMENT�University of Colorado, University of
Wisconsin, Maverick Systems, and Alpine Technology� Development from 1998-2005
� Field tests by research, CMS staff, CO, IA, MD, NJ and WI
� Demonstration and evaluation by CA, CT, KS, LA, OH 2006
CD Network 7August 12, 2009
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
CD Network 8August 12, 2009
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
CD Network 9August 12, 2009
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.
CD Network 10August 12, 2009
CD Network 11August 12, 2009
The Good NewsThe survey process has changed, but the F-Tags
and Interpretive Guidelines are the same.
CD Network 12August 12, 2009
QIS SURVEYTwo-stage computer-
assisted survey process,
which includes 9 Tasks
CD Network 13August 12, 2009
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.
CD Network 14August 12, 2009
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
CD Network 15August 12, 2009
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
August 12, 2009 CD Network 16
STAGE I
CD Network 17August 12, 2009
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.
CD Network 18August 12, 2009
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
CD Network 19August 12, 2009
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
CD Network 20August 12, 2009
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
CD Network 21August 12, 2009
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.
CD Network 22August 12, 2009
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
CD Network 23August 12, 2009
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
CD Network 24August 12, 2009
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.
CD Network 25August 12, 2009
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
CD Network 26August 12, 2009
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
CD Network 27August 12, 2009
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)
CD Network 28August 12, 2009
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
CD Network 29August 12, 2009
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
CD Network 30August 12, 2009
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.
CD Network 31August 12, 2009
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 madeResident Interviews� Interview those residents assessed as
interviewable by the QIS DCT�Questions asked as they are written
CD Network 32August 12, 2009
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
CD Network 33August 12, 2009
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)
CD Network 34August 12, 2009
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
CD Network 35August 12, 2009
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
CD Network 36August 12, 2009
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?
CD Network 37August 12, 2009
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)
CD Network 38August 12, 2009
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.
CD Network 39August 12, 2009
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
CD Network 40August 12, 2009
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
CD Network 41August 12, 2009
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
CD Network 42August 12, 2009
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
CD Network 43August 12, 2009
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?
CD Network 44August 12, 2009
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)
CD Network 45August 12, 2009
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)
CD Network 46August 12, 2009
TASK 4 : RELEVENT FINDINGS
� Document:�Observed problems� Areas of concern� Date, time, and source� Person interviewed and title
� IDRs WILL BE DIFFICULT
CD Network 47August 12, 2009
The CD Network and Provide Nutrition would
like to introduce
Brenda Richardson, MA, RD, LD, CD
CD Network 48August 12, 2009
TASK 5: FACILITY-LEVEL SURVEY AREAS
Survey tasks to be completed:1. Demand billing2. Dining observation3. Infection control4. Kitchen/Food Service Observation5. Med Pass
CD Network 49August 12, 2009
TASK 5: FACILITY-LEVEL SURVEY AREAS - continued
6. QAA Review7. Resident Council president interview8. Abuse prohibition review*9. Admission, transfer, discharge review*10. Environmental Observations*11. Nursing services, sufficient staffing*12. Personal funds*
* completed only if triggered by complaints or Stage
I interviews, observations or record reviews.
CD Network 50August 12, 2009
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
CD Network 51August 12, 2009
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.
CD Network 52August 12, 2009
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.
CD Network 53August 12, 2009
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.
CD Network 54August 12, 2009
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
CD Network 55August 12, 2009
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.
CD Network 56August 12, 2009
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.
CD Network 57August 12, 2009
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.
CD Network 58August 12, 2009
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.
CD Network 59August 12, 2009
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.
CD Network 60August 12, 2009
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?
CD Network 61August 12, 2009
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.
CD Network 62August 12, 2009
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.
CD Network 63August 12, 2009
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?
CD Network 64August 12, 2009
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?
CD Network 65August 12, 2009
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?
CD Network 66August 12, 2009
PRESIDENT OF RESIDENT COUNCIL IS INTERVIEWED
� May be questioned about food satisfaction, cold food complaints, poor quality, sanitation, service, honoring preferences, etc.
CD Network 67August 12, 2009
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
CD Network 68August 12, 2009
This CD Network and Provide Nutrition Presentation
returns to Pam
August 12, 2009 CD Network 69
STAGE II
CD Network 70August 12, 2009
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.
CD Network 71August 12, 2009
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
CD Network 72August 12, 2009
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
CD Network 73August 12, 2009
TASK 7: CRITICAL ELEMENT PATHWAYS - continued
Critical Element Pathways:1. Activities2. ADLs and/or ROM3. Behavioral/Emotional Status4. Bowel & Bladder/Catheters5. Communication/Sensory Problems6. Dental Status/Services7. Dialysis8. General9. Hospice/Palliative Care
CD Network 74August 12, 2009
TASK 7: CRITICAL ELEMENT PATHWAYS - continued
10. Hospitalization or Death11. Nutrition, Hydration, Tube Feeding Status12. Pain Management13. Psychoactive Medications14. Physical Restraints15. Pressure Ulcers16. Rehab/Community Discharging17. Ventilators
CD Network 75August 12, 2009
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
CD Network 76August 12, 2009
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
CD Network 77August 12, 2009
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?
CD Network 78August 12, 2009
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?
CD Network 79August 12, 2009
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?
CD Network 80August 12, 2009
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?
CD Network 81August 12, 2009
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.
CD Network 82August 12, 2009
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.
CD Network 83August 12, 2009
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.
CD Network 84August 12, 2009
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?
CD Network 85August 12, 2009
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?
CD Network 86August 12, 2009
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
CD Network 87August 12, 2009
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?
CD Network 88August 12, 2009
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
CD Network 89August 12, 2009
TASK 7: GENERAL CRITICAL ELEMENT PATHWAYS
� Based on identified concerns with related outcomes, further investigation may include other tags
CD Network 90August 12, 2009
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
CD Network 91August 12, 2009
TASK 9: EXIT CONFERENCE
�Surveyors will use a potential citation report to guide the exit
�Will provide list of residents if facility requests
�Report finalization�Revisit if needed
CD Network 92August 12, 2009
CD Network and Provide Nutrition now return you
to Brenda
CD Network 93August 12, 2009
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
CD Network 94August 12, 2009
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
CD Network 95August 12, 2009
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
CD Network 96August 12, 2009
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.
CD Network 97August 12, 2009
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.
CD Network 98August 12, 2009
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.
CD Network 99August 12, 2009
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
CD Network 100August 12, 2009
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
CD Network 101August 12, 2009
THANK YOU!!!
CD Network 102August 12, 2009
Thank You to the Sponsors
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CD NetworkCD Network MembersMembersAbshire Dietary Consultants, Inc.Abshire Dietary Consultants, Inc.Mary Abshire, MS, RD, LDMary Abshire, MS, RD, LD
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