Food & Nutrition Services

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1 Food & Nutrition Services ( ) Presenter: Joan Haskins

2 Summary CMS focus of the food and nutrition services revisions was on the inclusion of person centered care practices that foster choices in diet type, meal times and food preferences.

3 Summary They also set minimum qualifications for dietitians and food service directors to ensure that the quality of resident assessments, care plans, and meal service help residents maintain optimum nutritional status.

4 Previous items Section covers regulations related to Food and Nutrition services previously listed as Dietary Services in

5 Revised items Revisions includes sections for staffing, menus and nutritional adequacy, Food, therapeutic diets, frequency of meals, assistive devices, paid feeding assistants, and sanitary conditions. Goal is to establish minimum health and safety standards that support the nutritional well-being of all residents while respecting their right to make informed choices about their care.

6 F360 The facility must provide each resident with a nourishing palatable, well balanced diet that meets the daily nutritional and special dietary needs of each resident, taking into consideration the preferences of each resident.

7 F361 - Staffing The facility must employ 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-wide assessment.

8 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 --

9 Holds a bachelor s or higher degree granted by a regionally accredited 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 the purpose. Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional

10 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 licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a registered dietician by the Commission on Dietetic Registration or its successor organization, or meets the criteria from the previous slide.

11 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.

12 If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who; 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:

13 A certified dietary manager; or A certified food service manager; or Has similar national certification for food service management and safety from a national certifying body; or 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

14 In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

15 F362 - Support Staff 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 the comprehensive person-centered care plan regulation set.

16 F363 - Menus and Nutritional Adequacy. Menus must Meet the nutritional needs of residents in accordance with established national guidelines.; o Be prepared in advance; o Be followed;

17 o 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; o Be updated periodically; o Be reviewed by the facility s dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

18 o Nothing in this paragraph should be construed to limit the resident s right to make personal dietary choices.

19 F364 - Food and Drink Each resident receives and the facility provides Food prepared by methods that conserve nutritive value, flavor, and appearance; Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

20 F365 - Food and Drink Each resident receives and the facility provides Food prepared in a form designed to meet individual needs.

21 F366 - Food and Drink Each resident receives and the facility provides Food that accommodates resident allergies, intolerances, and preferences; 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.

22 F366 - Food and Drink Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration.

23 F367 Therapeutic Diets Therapeutic diets must be prescribed by the attending physician. 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.

24 F368 - Frequency of Meals 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.

25 F368 - Frequency of Meals There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is 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.

26 F368 - Frequency of Meals Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at nontraditional times or outside of scheduled meal service times, consistent with the resident plan of care.

27 F369 - 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.

28 F371 - Food Safety The facility must Procure food from sources approved or considered satisfactory by federal, state or local authorities. o This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations...and

29 The facility must o This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and foodhandling practices. o This provision does not preclude residents from consuming foods not procured by the facility.

30 F371 - Food Safety The facility must Store, prepare, distribute, and serve food in accordance with professional standards for food service safety. 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.

31 F372 - Food Safety The facility must Dispose of garbage and refuse properly.

32 F373 Paid Feeding Assistants State approved training course A facility may use a paid feeding assistant, if o The feeding assistant has successfully completed a Stateapproved training course that meets the requirements before feeding residents; and o The use of feeding assistants is consistent with State law.

33 F373 Paid Feeding Assistants Supervision o A feeding assistant must work under the supervision of a registered (RN) or licensed practical nurse (LPN) o In an emergency, a feeding assistant must call a supervisory nurse for help.

34 F373 Paid Feeding Assistants Resident selection criteria o A facility must ensure that a feeding assistant provides dining assistance only for residents who have no complicated feeding problems. o Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube or parenteral/iv feedings.

35 F373 Paid Feeding Assistants Resident selection criteria o The facility must base resident selection on the interdisciplinary team s assessment and the resident s latest assessment and plan of care. Appropriateness for this program should be reflected in the comprehensive care plan.

36 Friendly reminder Required Training of Feeding Assistants A facility must not use any individual working in the facility as a paid feeding assistant unless that individual has successfully completed a State-approved training program for feeding assistants.

37 Work group probes Will you have to adjust staffing? Newly hired food service directors must meet minimum criteria specified. Develop plan to bring current food service directors into compliance within 5 years Assess adequacy of current food and nutrition staffing, 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).

38 Work group probes Will you need to develop policy/procedure allowing dietitians to write diet and supplement orders to the extent allowed by state law? (This may take longer to implement) Considering your resident population, do you want to? Might you need to review and modify current menus? to ensure they meet national guidelines, and take into consideration resident religious, ethnic, cultural preferences. Are they being reviewed by the facility s dietitian or other clinically qualified nutrition professional for nutritional adequacy?

39 Work group probes What changes (if any) will need to be done to adjust for the frequency of meals? Or, are they already based on resident needs, preferences, requests and the plan of care? Do you have food options available for those residents that choose to eat at non-traditional meal times? You might consider including and obtaining approval from resident group if time between dinner and breakfast is greater than 14 hours.

40 Work group probes Food and Drink review current interview, assessment, tray card processes to ensure that residents are offered food that accommodates allergies, intolerances, and preferences; and, that residents are offered beverages consistent with their needs and preferences, and in sufficient amounts to maintain hydration Review available meal alternates on the menu; consider a variety of always available items based on resident input. Are alternates available for each food category? Entrée, vegetable, starch? Review meal delivery system to ensure that food is served at appetizing and safe temperatures.

41 Work group probes Food Safety Will you need to modify food procurement policies to include provision for allowing purchasing from local producers or facility community gardens when compliant with safe growing and handling practices. Will need to develop and implement policy on use and storage of foods brought to residents by visitors that allows residents the right to choose these items with appropriate facility guidance on safe food handling practices. Infection control practices????

42 Work group probes Will you need to develop and implement an action plan that will bring them into compliance within appropriate time frames? Some items such as accommodating residents who choose to eat at non-traditional meal times, will have an immediate impact on resident quality of life. Other items may take longer to implement, such as having a food service director that meets the criteria for qualified staff. There is a 5 year grace period to meet this requirement for existing staff, but if a new food service director is hired, they must meet the standards.

43 Work group probes In the end, providers and residents should benefit from more satisfied residents, and regulatory compliance.

44 Implementation Deadlines Food & Nutrition Services Phase 1: November 28, 2016 Except for Linked to a the facility-wide assessment Dietitians designated after the effective date Phase 2: November 28, 2017 Dietitians hired or contracted with prior to effective date Director of Food & Nutrition Services designated to serve prior to effective date Phase 3: November 28, 2019

45 Questions?

46 Resources ards/ Published August October 2010

47 Resources CULTURE CHANGE IN NURSING HOMES: HOW FAR HAVE WE COME? FINDINGS FROM THE COMMONWEALTH FUND 2007 NATIONAL SURVEY OF NURSING HOMES; Michelle M. Doty, Mary Jane Koren, and Elizabeth L. Sturla; May 2008 For CDM, CFPP credentialing questions, visit to review pathways.

Content Edited for Food and Nutrition Services only. F Food and nutrition services

Appendix PP - Regulatory Text Only Content Edited for Food and Nutrition Services only. Ref: S&C 17-07-NH Printed for Training Purpose Only Appendix PP - Full version https://www.cms.gov/regulations-and-guidance/guidance/transmittals/2017downloads/