DIET TIP SHEET FOR DIABETIC. COUNTING CARBS IS EASY 1 serving = about 15 grams of carbohydrate

Transcription

1

2

3 TIP SHEET FOR Carbohydrates (starch, sugar, white flour) are the main nutrients that, when digested, have the biggest effect on blood glucose. Understanding the amount of carbohydrates in foods is an important first step in diabetic meal planning. -Diane Hall, RD SOME SUGGESTIONS FOR CONTROLLING BLOOD SUGAR Medication or insulin dose should be prescribed at optimum times, which should be in accordance to individual eating routines. ü Eat the same number of meals and snacks each day. ü Eat three meals a day, roughly 4-6 hours apart. ü A mid-morning, afternoon and/ or evening snack may be beneficial. ü Try to always eat the same amount of carbs at each meal and snack. ü Do some daily physical activity. ü Consume foods that have fiber, such as whole grains, legumes (kidney, pinto, black, lima beans, etc.) and vegetables. ü Include a source of protein and fat to balance out meals and snacks. ü Choose healthy foods. ü Do not skip meals. Grains 1 slice bread 1 tortilla (6 inch) ¼ large bagel 2 taco shells (5-inch size) ½ hamburger or hot dog bun ¾ cup cereal ½ cup cooked cereal 4-6 small crackers ½ cup cooked pasta or rice ¾ ounce pretzels, potato chips, or tortilla chips 3 cups popcorn MILK 1 cup milk 1 cup soy milk 1 cup yogurt, plain or sweetened w/sugarfree sweetener Other Foods Count 1 cup of casserole or similar foods as 2 servings. Count 1 cup raw veggies or ½ cup cooked non-starch veggies as free foods. DIABETIC DIET COUNTING CARBS IS EASY 1 serving = about 15 grams of carbohydrate Starchy Vegetables ½ cup beans, peas, corn, sweet potatoes, winter squash, or mashed or boiled potatoes 1 sm. baked potato Sweets and Desserts 2-inch square cake (unfrosted) 2 small cookies ¼ cup sherbet/sorbet ½ cup ice cream/ frozen yogurt 1 popsicle 1 Tbsp syrup, jam, jelly, sugar, honey 2 Tbsp light syrup ½ cup soft drink 1 cup Gatorade Fruit 1 small fresh fruit ½ cup canned fruit ¼ cup dried fruit 17 small grapes 1 cup melon/berries 2 Tbsp raisins, ½ cup fruit juice Most adults aim for 3-5 servings of carbs with meals and 1-2 servings with snacks.

4 NEW DINING PRACTICE STANDARDS Excerpts from Pioneer Network Food and Dining Clinical Standards Task Force Phone:

5 Recommended Course of Practice Diet is to be determined with the person and in accordance with his/her informed choices, goals and preferences, rather than exclusively by diagnosis. Recommended Course of Practice Ensure that the physician and consultant pharmacist are aware of resident food and dining preferences so that medication issues can be addressed and coordinated i.e. medication timing and impact on appetite. Liberalized Diet Current Thinking and Research AMDA: One of the frequent causes of weight loss in the long-term care setting is therapeutic diets. Therapeutic diets are often unpalatable and poorly tolerated by older persons and may lead to weight loss. The use of therapeutic diets, including low-salt, lowfat, and sugar-restricted diets, should be minimized in the LTC setting. ADA: It is the position of the American Dietetic Association that the quality of life and nutritional status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets. For many older adults residing in health care communities, the benefits of less-restrictive diets outweigh the risks. CMS: Elderly nursing home residents with diabetes can receive a regular diet that is consistent in the amount and timing of carbohydrates, along with proper medication to control blood glucose levels. Diabetic Diet Current Thinking and Research AMDA: An individualized regular diet that is well balanced and contains a variety of foods and a consistent amount of carbohydrates has been shown to be more effective than the typical treatment of diabetes. ADA: There is no evidence to support prescribing diets such as no concentrated sweets or no sugar added for older adults in living in health care communities, and these restricted diets are no longer considered appropriate. CMS: Elderly nursing home residents with diabetes can receive a regular diet that is consistent in the amount and timing of carbohydrates, along with proper medication to control blood glucose levels. Reference American Medical Directors Association Clinical Practice Guideline: Altered Nutritional Status ADA Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long-Term Care 2005 Leible and Wayne, The Role of the Physician s Order, paper written for CHII 2010 Reference AMDA Clinical Practice Guideline: Diabetes Management in the Long-Term Care Setting 2008 ADA Position Paper Individualized Nutrition Approaches for Older Adults in Health Care Communities 2010 Leible and Wayne, The Role of the Physician s Order, paper written for CHII

6 Recommended Course of Practice Low sodium diets are not shown to be effective in the long term care population of elders for reducing blood pressure or exacerbations of CHF and therefore should only be used when benefit to the individual resident has been documented. Low Sodium Diet Current Thinking and Research ADA: A liberal approach to sodium in diets may be needed to maintain adequate nutritional status, especially in frail older adults. CMS: Dietary restrictions, therapeutic (e.g., low fat or sodium restricted) diets, and mechanically altered diets may help in select situations. At other times, they may impair adequate nutrition and lead to further decline in nutritional status, especially in already undernourished or at-risk individuals. When a resident is not eating well or is losing weight, the interdisciplinary team may temporarily abate dietary restrictions and liberalize the diet to improve the resident s food intake to try to stabilize their weight. Reference ADA Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in LTC 2005 CMS State Operations Manual Appendix P, Tag Nutrition Recommended Course of Practice Cardiac Diet Current Thinking and Research AMDA: Special diets for diabetes, hypertension and heart failure, and hypercholesterolemia have not been shown to improve control or affect symptoms. Reference Low saturated fat (low cholesterol) diets have only a modest effect on reducing blood cholesterol in the long term care elder population and therefore should only be used when benefit has been documented. The effects of the traditional low cholesterol and low fat diets typically used to treat elevated cholesterol vary greatly and, at most, will decrease lipids by only 10-15%. If aggressive lipid reduction is appropriate for the nursing home resident it can be more effectively achieved through the use of medication that provides average reductions of between 30 and 40% while still allowing the individual to enjoy personal food choices. 1 Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S), The Lancet. 1994;344(8934):1383. ² LaRosa JC, Grundy SM, Waters DD, Shear C, Barter P, Fruchart JC, Gotto AM, Greten H, Kastelein JJ, Shepherd J, Wenger NK, Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med. 2005;352(14):1425 3

7 Recommended Course of Practice Altered Consistency Diet Current Thinking and Research Reference ADA: Older adults consuming modified texture diets report an increased need for assistance with eating, dissatisfaction with foods, and decreased enjoyment of eating, resulting in reduced food intake and weight loss CMS: Identification of a swallowing abnormality alone does not necessarily warrant dietary restrictions or food texture modifications. No interventions consistently prevent aspiration and no tests consistently predict who will develop aspiration pneumonia. CMS State Operations Manual Appendix PP, Tag F Nutrition When a person makes risky decisions, the plan of care will be adjusted to honor informed choice and provide supports available to mitigate the risks. The anticipated outcome of solid foods ground or pureed and liquids thickened to nectar or honey thickness is improvement in oral intake and a reduced risk of choking and/or aspiration. However, data on their effectiveness is inconsistent; not all residents with dysphagia aspirate or choke and not all aspiration results in pneumonia. Campbell Taylor 2008 Oropharyngeal Dysphagia in Long-Term Care:Misperceptions of Treatment Efficacy Research shows that there was no simple relationship between prandial liquid aspiration and pneumonia in LTC patients. The consistent removal of plaque from teeth, gums, cheeks, and dentures has been shown to decrease significantly the incidence of pneumonia in LTC. Logeman JA, Gensler G, Robbins, et al. Design, Procedures, Findings, and Issues from the Largest NIH Funded Dysphagia Clinical Trial entitled Randomized Study of Two Interventions for Liquid Aspiration; Short and Long-term Effects. (Protocol 201) Presented at ASHA Annual Conference, November 16-18, Available at omized_studies. Accessed Dec 20, Robbins J, et al. Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence. Ann Int Med 2008; 148: Messinger-Rapport B, et al. Clinical Update on Nursing Home Medicine: J Amer Med Dir Assoc 2009; 10: Data does not support the perceived risk of aspiration. 4

8 CENTERS OF MEDICARE AND MEDICAID SERVICES LONG TERM CARE FINAL RULES FOR FOOD AND NUTRITION SERVICES What s Changed? excerpts from the CMS Operating Manual effective November 28, 2016 Phone: info@seniornutrition.net

9 Existing Rules are in BLACK (strike-through indicates deletion of previous wording) Changes/Additions to Rules are in RED F360 F800 F361 F Dietary Services Food and nutrition services (a) Staffing FOOD AND NUTRITION SERVICES The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The facility must employ a qualified dietitian either full time, part-time or on a consultant basis. Sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility s resident population in accordance with the facility assessment required at e. [As linked to Facility Assessment, (e), will be implemented beginning November 28, 2017 (Phase 2)] (1) This includes: A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who- (i) Holds a bachelor s or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licen sure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a registered dietitian by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law: (i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or (i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (D) Has an associate s or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management from an accredited institution of higher learning; and Balanced Senior Nutrition info@seniornutrition.net SeniorNutrition.net

10 F362 F (a)(3) Standard Sufficient Staff Support Staff (b) (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in (b)(2)(ii). F363 F (c) Menus and nutritional adequacy Menus must (1) Meet the nutritional needs of residents in accordance recommended dietary allowances of the Food & Nutrition Board of the National Research Council and National Academy of Sciences with established national guidelines. (2) Be prepared in advance (3) Be followed; (4) Reflect, based on a facility s reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; (5) Be updated periodically. (6) Be reviewed by the facility s dietitian or other clinically qualified nutrition professional for nutritional adequacy. (7) Nothing in this paragraph should be construed to limit the resident s right to make personal dietary choices. F364 F804 F365 F805 F366 F806 F Food and drink (d) Each resident receives and the facility provides (1) Food prepared by methods that conserve nutritive value, flavor, and appearance (2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature (d)(3) Food prepared in a form designed to meet individual needs. (4) Substitutes offered of similar nutritive value to residents who refuse food served Food that accommodates resident allergies, intolerances, and preferences. (5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; and (6) Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration. Balanced Senior Nutrition info@seniornutrition.net SeniorNutrition.net

11 F367 F808 F368 F (e) Therapeutic Diets (f) Frequency of Meals (1) Therapeutic diets must be prescribed by the attending physician. (2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident s diet, including a therapeutic diet, to the extent allowed by State law. (1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. (2) There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided in below except when a nourishing snack is offered served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. (3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care. F369 F (g) Assistive devices The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks. F371 F812 F (i) Sanitary Conditions Food safety requirements The facility must (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) (ii) (iii) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food handling practices. This provision does not preclude residents from consuming foods not procured by the facility. (2) Store, prepare, distribute and serve food under sanitary conditions in accordance with professional standards for food service safety. (3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. F372 F (i)(4) Dispose of garbage and refuse properly. Balanced Senior Nutrition info@seniornutrition.net SeniorNutrition.net

12 TUBE FEEDING F322 F693 F325 F (g)(4)(5) Nutrition. Assisted nutrition and hydration (g)(1)(3) Nutrition Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident s comprehensive assessment, the facility must ensure that a resident (i) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (ii) Is offered sufficient fluid intake to maintain proper hydration and health; and 42 C.F.R (iii) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. {(iv) and (v) are F693.} (iv) A resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube enteral methods unless the resident s clinical condition demonstrates that use of a naso-gastric tube was unavoidable; enteral feeding was clinically indicated and consented to by the resident; and (v) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident s comprehensive assessment, the facility must ensure that a resident (1) Maintains acceptable parameters of nutritional status, such as usual body weight and protein levels or desirable body weight range and electrolyte balance, unless the resident s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. (3) Receives Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. F327 F692 F151 F (g)(2) Hydration Assisted nutrition and hydration (b) Exercise of Rights (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident s comprehensive assessment, the facility must ensure that a resident (2) Must provide Is offered sufficient fluid intake to maintain proper hydration and health RESIDENT RIGHTS The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. (1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. (2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. Balanced Senior Nutrition info@seniornutrition.net SeniorNutrition.net

13 F154 F552 F155 F578 F279 F286 F639 F279 F280 F655 F656 F (c) Planning and Implementing Care Right to Refuse Treatment (d) Use (a) Baseline Care Plans The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. (2)(iii) The right to be informed, in advance, of changes to the plan of care. (4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. (5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive USE A facility must maintain all resident assessments completed within the previous 15 months in the resident s active record and use the results of the assessments to develop, review and revise the resident s comprehensive care plan CARE PLANS [ (a) will be implemented beginning November 28, 2017 (Phase 2)] (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-- (i) Be developed within 48 hours of a resident s admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. (2) The facility may develop a comprehensive care plan in place of the baseline care plan. If the comprehensive care plan (i) Is developed within 48 hours of the resident s admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). (3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident s medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. Balanced Senior Nutrition info@seniornutrition.net SeniorNutrition.net

14 483.21(a) Baseline Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at (c)(2) and (c)(3), that includes measurable objectives and timeframes to meet a resident s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident s highest practicable physical, mental, and psychosocial well-being as required under , or ; and (ii) Any services that would otherwise be required under , or but are not provided due to the resident s exercise of rights under , including the right to refuse treatment under (c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident s medical record. (iv)in consultation with the resident and the resident s representative (s) (A) The resident s goals for admission and desired outcomes. (B) The resident s preference and potential for future discharge. Facilities must document whether the resident s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident s representative(s). An explanation must be included in a resident s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Balanced Senior Nutrition info@seniornutrition.net SeniorNutrition.net

15 F280 F553 Right to Participate in Planning Care (c) (2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident s strengths and needs. (iii) Incorporate the resident s personal and cultural preferences in developing goals of care. F281 F658 F282 F (b)(3) Comprehensive Care Plans (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must (i) Meet professional standards of quality. The services provided or arranged by the facility, as outlined by the comprehensive care plan, must (ii) Be provided by qualified persons in accordance with each resident s written plan of care. (iii) Be culturally-competent and trauma informed. [ (b)(iii) will be implemented beginning November 28, 2019 (Phase 3)] QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT F520 F Quality assurance and performance improvement. [ and all subparts will be implemented beginning November 28, 2019 (Phase 3), unless otherwise specified] Each LTC facility, must develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must: Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities; Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation; [ (a)(2) implemented November 28, 2017 (Phase 2)] Balanced Senior Nutrition info@seniornutrition.net SeniorNutrition.net

16 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT F520 F865 (Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and Present documentation and evidence of its on ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request. Program design and scope. A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must: Address all systems of care and management practices; Include clinical care, quality of life, and resident choice; Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF. Reflect the complexities, unique care, and services that the facility provides. Governance and leadership. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. The QAPI program is sustained during transitions in leadership and staffing; The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed; The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. Corrective actions address gaps in systems, and are evaluated for effectiveness; and Clear expectations are set around safety, quality, rights, choice, and respect. Disclosure of information. Balanced Senior Nutrition info@seniornutrition.net SeniorNutrition.net