ANNUAL SURVEY PREPARATION For Year-Long Compliance May 21, 2014 Adam Snyder, RVP, Unidine Jenny Overly, Director of Innovation, Unidine
Objectives: Identify key components of federal & state regulations specific to dining services; Evaluate own operation for areas of potential citation during the annual survey process; Compare examples of survey results to regulations;
Federal Tags: Dining Services F325 Nutrition F360 Dietary Services F361-362 Staffing F363 Menu & Nut l Adequacy F364 Food F365 Modified Menu F366 Substitutes F367 Therapeutic Menu F368 Frequency of Meals F369 Assistive Devices F371 Sanitary Conditions
Federal Tags Impacted by Dining Quality of Care F314 Pressure Sores F322 Feeding Tubes F329 Unnecessary Drugs Quality of Life F246 Accommodation of needs F252 Environment F253 Housekeeping & Maintenance Resident Assessment F272 Comprehensive Assessment F279 Comprehensive Plan of Care Administration F492 Compliance with Laws F495 Competency F516 Confidentiality F517 Emergency & Disaster Plan
Top 10 Most Common Citations 1.F309: Provide necessary care for highest practicable well-being; 2.F371: Store/prepare/distribute food under sanitary conditions; 3.F281: Services provided meet professional standards; 4.F324: Supervision/devices to prevent accidents; 5.F323: Facility is free of accident hazards; 6. F253: Housekeeping and Maintenance Services; 7. F279: Develop comprehensive care plans; 8. F314: Proper treatment to prevent/heal pressure sores; 9. F514: Clinical records meet professional standards; 10. F225: Not employ persons guilty of abuse
Michigan Tags: Dietary Services Michigan Survey Regulations are part of the annual survey process during the even year The survey process essentially remains the same except a few key items will be reviewed to qualify for State Re- Certification If deficiencies are identified in a state regulation, the federal regulation can be cited as well State regulations do not supersede the federal, only make the federal regulation more definitive
Michigan Tags: Dietary Services Qualifications of Dietary Supervisor Policies and Procedures Nutritional Needs of Patients Menus: Posting & Filing Meal Census & Food Record
Surveyor Routine Kitchen Visits Upon entering the building, a surveyor reports directly to the kitchen First Impressions Count! Initial walk-through often brief Follow-up Visits: Check Food Temperatures Test Tray Check Dish Machine and Monitoring Reminders Surveyors collect information through: Observation Record Review Resident & Staff Interview Don t neglect off-shift times, surveyor may start at times other than usual business hours
Resident Interview Surveyors conduct resident interviews either one-on-one or during resident council: Is the flavor and appearance of your food satisfactory? Do you receive food here you like to eat? If you ever refused a particular food, did the center provide you with something else? Is the temperature of your hot and cold foods appropriate? About what time do you receive your meals? Are the meals generally on time or late? What are you offered for a bedtime snack? If you ever shared your concerns about the food with staff, how did they respond?
Typically Requested Items Meal Times Resident Menu Specific past dates Current week s menu Number of residents ordered mechanically altered diet Number of residents with significant weight loss
Year-Long Survey Preparation Prepare, prepare, prepare. Monthly Planner Monthly Audits Food Service & Clinical Resident Interviews Dining Room & Operational Observations Survey-Ready Binder Survey Preparation Checklist Federal State
Year-Long Survey Preparation Create a Monthly Planner Completion of Quality Monitoring Test Trays & Tray Accuracy Diet Accuracy Audit Routine Staff In-Servicing Observe the Dining Room & Kitchen through the eyes of a surveyor CMS Forms Resident Interview Culinary Council Meal Rounds
Create a Monthly Planner Incorporate Surveyor Forms Surveyor Observation Forms Developed by: Department of Health and Human Services Centers for Medicare & Medicaid Services Dining Observations Kitchen & Food Service Observation Critical Elements for Nutrition, Hydration, and Tube Feeding Status Critical Elements for Pressure Ulcers
Year-Long Survey Preparation Survey-Readiness Binder Menus: Week at Glance for Regular, Mechanical, & Therapeutic Diets Signed by Registered Dietitian Meal Times for all Dining Locations Emergency Plans: Water Agreement Letter Emergency Water Supply P&P Emergency Menu
Year-Long Survey Preparation Survey-Readiness Binder Certifications: RD CDM ServSafe, etc Nutrition: Nutrition at Risk P&P High Risk Lists: Significant weight loss x 30 days, Tube Feeding, Dialysis, & Wounds Weight Monitoring P&P Unit Pantry & Resident Refrigerator Responsibility Community Policy and Procedure
Year-Long Survey Preparation Survey-Readiness Binder Work Orders Submitted to Community Maintenance and Outside Vendors Current Cleaning Schedule Thermometer Calibration Annual Survey Results Adaptive Equipment List
Year-Long Survey Preparation Survey-Readiness Binder Food Allergies Departmental In-Service Schedule Past 6 Months of. Pest Control Service Hood Cleaning Verification Chemical Partner (Eco Lab) Audit Copy of Signature Page of Approved Diet Manual
Year-Long Survey Preparation Survey Preparation Checklist Incorporate a checklist for all pertaining federal and state regulations Complete checklist & identify areas of concern Create a plan of action Re-evaluate readiness
Survey Preparation Checklist F325 Nutrition Assessment Nutrition at Risk Policy & Procedure * Meeting sign-in sheets Meeting notes for past 3 months Weight Policy & Procedure Who is responsible for weighing Timeframe to obtain admit & monthly wts Process to identify re-weights Who is responsible to calibrate scales When are scales calibrated Scale calibration documentation *Survey Ready Binder Item
Survey Preparation Checklist F325 Nutrition Assessment Residents at High Nutritional Risk List of residents with significant weight change past 30 days * Documentation standards for High Risk List of residents ordered sliding scale insulin Estimated needs re-estimated with declines and/or resolution of risk issues Communication of issues with RD for timely documentation *Survey Ready Binder Item once window opens
Survey Preparation Checklist F361 & 362 and MI 801 & 802 Staffing Federal Checklist Credentials * Call-in Procedure * Master Schedule & Position Description * In-Service Records for past year * Michigan Checklist Credentials * Certified Dietary Manager In-Service Records for past year * *Survey Ready Binder Item
Survey Preparation Checklist F363 and MI 804 Menu Federal Checklist Approved Menu * Substitution Log Recipes 100% for all items served Michigan Checklist Menu Posting Menu as Served Nutritional Adequacy *Survey Ready Binder Item
Survey Preparation Checklist F363 & F367 Menu & Therapeutic Diets Diet Manual Signed Face Sheet * Nutritional Adequacy P&P * when window opens List of Residents Ordered Pureed Diet * Test Trays & Tray Accuracy Audits *Survey Ready Binder Item
Survey Preparation Checklist F363 & F367 and MI 803 Menu & Therapeutic Diets Federal Checklist Diet Order Policy & Procedure * Community Specific Diet Guide Diet Order Accuracy Processing of diets Michigan Checklist Complete Diet Order Includes all supplements, portion changes, enriched, etc. *Survey Ready Binder Item
Survey Preparation Checklist F368 & F369 Frequency of Meals & Adaptive Equipment HS Snack Community-wide Policy & Procedure * Meal Times * Adaptive Equipment when window opens Updated List * Tray Accuracy *Survey Ready Binder Item
Survey Preparation Checklist F371 Sanitation Temperatures (Logs x 3 months) Dish Machine Temperatures Pot & Pan Sanitation Log Refrigerator & Freezer Storage Temp Logs Tray Line / Satellite Serving Area Logs Calibration of Thermometers Re-Heating Food Cooling Log *Survey Ready Binder Item
Survey Preparation Checklist F371 Sanitation Date Marking Policy & Procedure * Included in In-Service Schedule Routine Monitoring Within and outside of Dining Service Operation Daily Routine of Staff Kitchen Walk-Through Air Gap Storage Under Sinks *Survey Ready Binder Item
Survey Preparation Checklist MI 805: Meals & Food Usage A meal census, to include patients, personnel, and guests, for the preceding 3 months shall be kept on file in the home A record of the kind and amount of food used for the preceding 3 months shall be kept on file in the home
Survey Preparation Checklist MI 806: Food Acceptance Record The food acceptance of a patient shall be recorded as follows: For a period of 14 days immediately following admission. For a period of 14 days immediately following initiation of a change in diet, unless otherwise ordered by a physician. Under any other circumstances, such as abnormal weight loss, for a period ordered by a physician. Food acceptance records shall be retained in the facility.
Miscellaneous Items Staff questioned regarding: Resident Abuse What do you do when you witness resident abuse? What do you do if you suspect resident abuse? Who do you report incidence of abuse to? What is a catastrophic reaction? What to do in the event of a fire? Surveyor request for background checks on Dining Service managers
Questions?