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Nutrition Fundamentals and Medical Nutrition Therapy
Participate in Regulatory Surveys
Corresponds with LEARNING PLAN 17Copyright 2016 Association of Nutrition and Foodservice Professionals
17
Objectives
Identify regulatory standards
Develop an appropriate plan of correction
Demonstrate professional interaction with surveyors
Use regulatory agencies as professional resources
Explain how regulations influence the quality management process
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Regulatory/Accrediting Agencies
Centers for Medicare & Medicaid Services (CMS)» Branch of Department of Health and Human Services (HHS)» Administers the Medicare program» Federal survey guidelines» Oversees HIPAA» Review regulations in CMS State Operations Manual
(SOM)
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Regulatory/Accrediting Agencies
State licensing requirements
Facility is held to the strictest state or federal regulatory requirement
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
CMS Regulations Specific to Nutrition Quality of Care
» 483.25 (c) Pressure sores» 483.25 (i) Nutrition» 483.25 (j) Hydration
Dietary Services» 483.35 (a) Staffing» 483.35 (d) Food» 483.35 (e) Therapeutic diets
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Brain Break
Why is it important to review CMS regulations?
» The operations manual contains helpful information other than regulations. Since CMS provides guidance for surveyors, reviewing the regulations can help dining services be better prepared for the survey.
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
CMS Regulations Specific to Nutrition F-tag = specific guidance for long-term care
» F501 Medical Director and the requirements for effective nutrition policies and oversight
» F520 Quality Assessment and Assurance and the requirements for developing and monitoring effective client nutrition maintenance systems
A-tag = specific guidance for hospitals
C-tag = small rural hospital or critical care hospital
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Voluntary Accreditation
The Joint Commission (TJC)» Originally only accredited hospitals» Now also works with long-term care» Subject to CMS requirements
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Survey Process for Long-Term Care
Both TJC and CMS use surveys as part of their accreditation effort
CMS Quality Indicator Survey (QIS)» Survey process focuses on quality indicators
- MDS, observations, interviews, clinical record reviews» May include a detailed tour of dietary areas» CDM should accompany a surveyor and cooperate fully
Be “survey ready” at all times
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Survey Process Conclusion
Survey team will note any deficiencies and reference F-Tag numbers
Deficiency is a finding that the facility is not in compliance with guidelines» Categorized by the level of risk/harm that may occur
Deficiencies must be followed up promptly and effectively
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Assuring Quality
Policy may be called a number of names
Recognition that quality is an essential element of organizational strategy, not a single initiative» Focus on what client wants and needs, not staff tasks» Use an interdepartmental team approach» Use and evaluate data» Be proactive and continuous» Include a performance improvement segment
‘Outcome’ is most important» Quality Indicators (QIs) = measures of outcomes
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Brain Break
What does it mean to be “survey ready” at all times and how is it achieved?
» It means that regardless of when the survey is conducted, dining services staff can readily answer surveyor questions, necessary documentation is available, and the kitchen is clean and sanitary.
» Regular reviews of what information is expected; maintaining all required documentation; using checklists for kitchen cleanliness and sanitation; use a quality assurance process
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Process for Implementing QA
FOCUS» F = Find a process to improve» O = Organize to improve a process» C = Clarify what is known» U = Understand variation» S = Select a process improvement
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Process for Implementing QA
PDCA» P = Plan» D = Do» C = Check» A = Act
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
QAPI
Quality Assessment and Performance Improvement
Both hospital and long-term care regulations require» Develop, implement and maintain a quality assessment
program- Involves all departments- Focuses on indicators related to improved health outcomes
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17
Brain Break
Why is it important for the CDM to understand the regulations for all departments and the facility’s QA process?
» Often the CDM is the most accessible person during a survey
» CMS regulations are not divided up by department and handed out
» CDM plays a pivotal role in the lives of the clients
Nutrition Fundamentals and Medical Nutrition Therapy • Participate in Regulatory Surveys • Learning Plan 17