It’s cold and snowy outside. It’s lunchtime, and I just ate a bowl of homemade lentil soup accompanied by a hunk of fresh bread and a glass of iced tea.  It was yummy and chocked full of vitamins, minerals, and fiber. How much? Don’t know, don’t care . . . but then I have that luxury when it comes to my personal food intake!

It pains me to think that the pleasure of a bowl of hot soup and bread my not be an option for me when I’m in the nursing home due to individual interpretation of F363 Menu Planning (individualized) and F366 Substitutes (equal nutritional value).

One of my clients wanted to transition from a select menu to a rotating substitute menu of a daily soup and sandwich plus chips – per resident request.  Sounds like a typical Zoup! or Panera pick-2 menu item. So what’s the big deal? It is a big deal in the long-term care arena of regulatory requirements.

My immediate response from years of conditioning was, NO you cannot due that! a) The State requires a substitute of equal nutrition value, b) Illinois surveyors prefer regulatory compliance as a substitute of a hot food for hot food and cold for cold, and c) it may not please all the residents.

Now of course the only person centered consideration was c) it many not please all the residents, but as a consultant I have to consider the other two as well.

The Dining Services Manager, Menu Planner, and I debated the idea through email and finally talked via conference call on New Year’s Eve to discuss how to move forward with the resident request and regulatory compliance.

Our final plan was to comply with the resident’s preferences and offer a substitute of soup, sandwich, and chips at each meal, in addition a few ‘hot’ items were made available for individuals not wanting a sandwich.  We also evaluated each meal to ensure the substitutes were as nutritious as the planned menu. When they were not the menu was adjusted, such as adding potato salad to replace the chips.

Another key part of the plan was to ensure this was what the residents wanted.  Preferences were documented in the Resident Council Meeting minutes and the RD conducted a resident satisfaction survey. There were mixed reviews, but overall residents were satisfied with the choices.

The final test for success was making it through survey. I believed we had the documentation we needed to show the survey team this was a resident preference, not a facility preference. As predicted the survey team identified the soup and sandwich option as an issue.  They talked to residents, they talked to staff, and they reviewed documentation.  In the end the surveyors did not cite the facility for substitutes.*

The key to success with person-centered care is to identify what the resident’s want/prefer and identify regulatory compliant methods to make it happen. This must be tied up with a ribbon of documentation supporting policy, procedure, and resident preference.

*Endnote: In my practice I have witnessed multiple facilities attempt to reduce the cost of meals by substituting a lunchmeat sandwich – a couple slices of a poor quality lunchmeat on two slices of white bread.  The lunchmeat didn’t come close to meeting nutritional requirements. The type of sandwich was repetitive (cheese or peanut butter) and there were no hot alternatives. So I understand the surveyor’s reluctance, at first glance, to embrace the facility’s substitute menu. Our goal was to make it a true choice and preference of the residents that met basic nutritional requirements.

Person Centered Care
Those Pioneers certainly started something big more than a decade ago. Personal choice, with the full backing of CMS, will continue to make headway in eating decisions such as when to eat, which dining room, what foods, and how much. The average American snacks two to three times per day.

Short-term rehab
Providers vying for a larger market share are offering short-term rehab accommodations similar to a 5-star hotel. Restaurant style dining will be available in richly appointed dining rooms. Look for patients to prefer the privacy of room service during their rehab stay. These baby boomers will be seeking heart-healthy antioxidant-rich selections such as salmon, green tea, sweet potatoes, dark leafy greens, berries, and whole grains.

Food pricing
The cost of food is going to increase by 4% to 5% this year after the drought of last year. Look for more efficient use of food versus a decrease in food quality.

Sustainability
Go green by decreasing food waste. The National Resources Defense Council reports 40% of the food in the US goes uneaten. The excess may be from over purchasing, over production, or over portioning. Take steps this year to analyze your menu, recipes, and personal choices of your elders to prevent food waste.

Hospital Readmissions
Preventing hospital readmissions will be a priority for rehab centers and their census.  Congestive Heart Failure is the current disease targeted by CMS. Nutrition therapy for CHF, 2-gram sodium diet, yuk!  Look for RDs to be education these patients on healthful choices.  Look for more scratch cooking in rehab units since this is the only way an honest 2 gm sodium diet is palatable. Perhaps treatment of congestive heart failure will go the way of diabetes, more medication less diet.

The overall theme for 2013 will be doing more with less. Medicare is decreasing reimbursement by 10%, food costs are rising by 5%, and government is looking to further decrease health care costs.  Dining & Nutrition Services will weather the storm by listening to their patients and implementing sound suggestions.

No Gloves?

Gloves have got to be one of the most misused commodities in the food service industry. They provide a false sense of food security to the wearer and the customer alike. The butcher has on gloves, unwittingly cross contaminating the ground beef with chicken as he moves from one species to another without changing gloves. No medium burgers with that ground beef. Better cook it to an internal temperature of 165˚F for 15 seconds to kill any salmonella that may have inadvertently been added to the ground beef.

What is the rationale for glove use in a food service establishment? The answer: to prevent bare hand contact with ready-to-eat foods. That’s it. Bare hands may harbor bacteria, therefore the glove works as a barrier between the bacteria and the ready-to-eat food.

An obvious example, Anna is preparing a deli sandwich wearing disposable gloves because she is handling the bread, lunchmeat, cheese, lettuce, and tomato – all ready-to-eat foods. She washes her hands before putting on and after taking off the disposable gloves. Bravo to Anna for proper glove use.

Juan is preparing a baked chicken sandwich, starting with a frozen chicken patty.  Does Juan have to use a gloved hand to remove the frozen patty from the box, place it on a baking pan, and put it in the oven? No. The chicken patty is not ready-to-eat. It will be heated, thus killing the bacteria that may be on the chicken patty.  Juan does have to wash his hands before handling the frozen patty. In practice 9 times out of 10 I see cooks using gloves, a poor choice in the use of resources.

My all time favorite misuse of gloves is when food isn’t handled at all. Dining staffers are preparing plates of food using scoops and tongs while wearing gloves. I don’t get it. What are they protecting, the tongs?

To reduce the risk of food borne illness via contamination the FDA recommends food service workers suffering with diarrhea and/or fever should not handle ready-to-eat foods with bare hands. Ya think!?!  They should be home in bed. The FDA goes on to say a three pronged approach to decreasing food borne illness by the common fecal/oral route (gross) is to restrict sick workers from handling food, washing hands, and using disposable gloves.  So let’s make it easy, if you’re sick with diarrhea and/or fever stay home.  If you use the bathroom, thoroughly wash your hands (especially fingernails) before leaving the bathroom.

My message to the food service workers of Oregon: use proper hand washing techniques, use tongs or tissue paper to handle ready-to-eat foods (minimizing bare hand contact with ready-to-eat food), and stay home if you’re sick. The country will measure your success by the recorded outcomes. In a year we will look at the statistics to discern if the cases of food borne illness increased after the elimination of disposable glove. I’d place money (saved by not buying gloves) on no significant increase in food-borne illness.

For the rest of us, continue to use disposable gloves when handling ready-to-eat foods.  Don’t forget to wash your hands before after putting on  and taking off the gloves. Try to refrain from using gloves when handling food that requires cooking, when handling plates, scoops, or tongs.

Overuse of disposable plastic gloves does not make food safer. It negatively impacts the bottom line, wasting thousands of dollars on unnecessary disposable gloves.  It negatively impacts the environment by adding plastic into our landfills. Today, more than ever, we cannot afford to waste any of our resources.

Resources

US Food Code 2009. Preventing Contamination by Employee, 3-301.11 Preventing Contamination from Hands. Food and Drug Administration:2009. Accessed 8/25/2012  http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/ucm189211.htm

The New Dining Practice Standards Impacting Long Term Care

Linda Roberts

States experiencing budget shortfalls may look to increase revenue in creative ways. Legislative authorization to collect additional revenue from providers is a mechanism to generate new in-state Medicaid funds thus resulting in increased federal dollars.  In return providers may see increased reimbursement in the care of Medicaid patients.

Illinois is currently awaiting CMS approval of a provider tax. Illinois will be reimbursing providers for Medicaid recipients receiving therapeutic diets as scored on the MDS 3.0.

Illinois’ decision guarantees business as usual for Medicaid recipients.  Currently the majority of nursing home residents are on therapeutic diets for treatment of diabetes, congestive heart failure, and heart disease.

While Illinois holds fast to the hospital model of nursing home care other states are moving toward a more home-like model.  Meals are served restaurant or family style allowing residents to select the foods they wish to eat.  Diets are ordered based on personal preference rather than diagnosis. The goal of care for the elder in a nursing home – avoid consequences.

CMS supports the resident’s right to choose. F325 states, “A resident has a right to make informed choices about accepting or declining care and treatment.  The facility can help the resident exercise those rights effectively by discussing with the resident the resident’s condition, treatment options (including risks and benefits, and expected outcomes), personal preferences, and any potential consequences of accepting or refusing treatment.  If a resident declines specific interventions, the facility must address the resident’s concerns and offer relevant alternatives.”

Our reimbursement structure may preclude a more liberal approach to nutrition care of the elderly in Illinois, but F325 still allows for our elders to select the foods they wish to eat.

References

Health Care Providers and Industry Taxes/Fees. National Conference of State Legislators: November 10, 2011. Available at http://www.ncsl.org/?tabid=14359  Accessed January 04, 2012.

Appendix PP. Centers for Medicare and Medicaid Services. Available at https://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf Accessed January 4, 2012.

New Practice Dining Standards. Pioneer Network: August 2011.  Available at http://pioneernetwork.net/Data/Documents/NewDiningPracticeStandards.pdf  Accessed January 4, 2012.

F276 Quarterly Review states the resident’s assessment is updated at least quarterly.  Keep in mind CMS’ idea of assessment is the MDS, not the assessment piece completed by the RD. The question F276 asks, “ is the quarterly review of the resident’s condition consistent with information in the progress notes, plan of care, and your resident observation and interviews?” In other words, is the MDS completed accurately based on information found in the chart, through resident interview and observation.

Let’s start with observation & interviews.  Bottom line, CMS wants you to observe your residents eating at least once a quarter. Hopefully you’re more attentive than that, but at a minimum have someone take a peek in the dining room every 92 days (don’t forget it’s a 7-day look behind
for section K).  Same goes for talking with the resident, family, and/or staff about nutrition and food preferences.  Document in the medical record what you observed and heard from the resident, family, or other health care professional. If you see a problem refer to the RD.  If you are the RD assess the data and determine if there is a nutritional problem, etc.

The care plan has a measurable goal and multiple approaches intended to move the resident toward the goal.  CMS is saying quarterly take a look at the care plan and see if the resident has met the goal or not.  If the resident has met the goal then document in a nutrition progress note whether the care plan will be d/c’d or continued.  If the resident has not met the goal document that and identify if the goal or approaches will be changed so the resident can achieve the goal.

So bottom line the IDT reviews the health status of each resident quarterly.  Nutrition notes include progress toward goal, changes in care plan, observation of oral intake, tolerance of diet, and interview results.

Most facilities have systems in place to continuously identify and refer residents at increased nutritional risk to the RD.  The quarterly review is just another opportunity to identify at risk residents. Typically there is a 7-day look behind for most MDS items. Chart at the end of the 7-day look behind and document in the medical record using current data that supports the MDS. Remember weight has a 30-day and 180 day look-back.

Who should complete the Quarterly Review for nutrition?  Someone qualified by experience and education.  CMS does not mandate the RD complete the Quarterly Review. In today’s economic climate excessive paperwork, like a 13-page quarterly nutrition assessment completed by the RD, is an expensive luxury most facilities can no longer afford.

Linda Roberts

A few years ago one of my clients had such a bad survey the state health department assigned a Monitor to the building. The purpose of the Monitor was to assist and guide the facility toward regulatory compliance. The State identified a deficiency in the facility’s ability to identify residents with poor oral fluid and food intake.

In an effort to find the solution I developed a magnificent Food & Fluid Intake Record. The intake record was so thorough it would put every other Food Intake Record to shame.  It was the Food Intake Record to end all Food Intake Records!

The Monitor took one look at my perfect Food Intake Record and said, “This form is setting the facility up for failure. This is like completing a calorie count on each person at each meal.” She explained the nursing home must have a system in place to identify individuals that are eating poorly or consuming less than normal so staff can identify the cause and begin interventions as needed. Traditional food intake records, although commonly used, are not required. This is probably a good thing since many of the Food Intake Records I’ve seen have been completed in advance, at the end of the month, and on occasion – daily.

Since that time I have recommended my clients adopt a food intake system that identifies residents eating poorly or less than normal. The  Food Intake Record  consists of a tray ticket and a bucket. Aides place the tray ticket of poor eaters in the bucket.  The Dining Services Manager or designee collects the tickets and follows-up with the resident. Some of my clients hold fast to the three-ring binder. For them I recommend a form that identifies only those residents eating poorly or less than normal. The Dining Services Manager or designee needs to review the binder daily.

No matter what system your nursing home uses ensure the staff is well trained and residents eating poorly get the interventions they need.

Linda Roberts

Garden Fresh

CMS states, “residents can benefit from having a variety of fresh foods for their consumption.”

The facility should follow safe food handling practices once the food is harvested and brought into the kitchen for preparation.

Nursing home gardens are compliant with F371 Sanitary Conditions as long as the facility has & follows policies and procedures for maintaining the gardens. If there is an outbreak of food-borne illness the facility must report it to the local health department.

The role of the Registered Dietitian: make sure there are policies in place. If there are not, write them.

Perhaps ‘Common Sense’ is not dead after all.

Linda Roberts

Pioneer Network in conjunction with CMS convened the Food & Dining Clinical Standards Task Force.  The event brought together professionals from multiple clinical disciplines including ADA, AMDA, NADONA, ASHA, AOTA, etc to discuss and agree upon dining practice standards supporting person centered care and culture change values.

It was a humbling experience for me to seated at the table (representing ADA) with professionals from clinical associations making decisions that will impact thousands of elders across the nation.

The New Dining Practice Standards reflects evidence based research meshed with current thinking. There are 10 Standards which can be simplified to the following:

• Individualized Liberal Diets
• Real Food First
• Honoring Food Choices
• Shifting from staff control to individualized support of self-directed care
• New Negative Outcome

Bottom line, elders have the right to choose what they wish to eat, when they wish to eat, and how much they wish to eat.  Our job as health care professionals is to respect their wishes. Another key part of our job is to educate them on choice, beneficial versus detrimental, and allow them to choose. Even those that cannot verbalize reveal their choices each time they refuse a food item.

CMS F281 Professional Standards will catalogue these standards along with the others developed by professional organizations and reference them when necessary.

My last blog, Letting Go of Therapeutic Diets, examines the Individualized Liberal Diets. My next blog will look at Real Food First.

Linda Roberts

Individualized, liberal diets are the foundation of The New Dining Practice Standards published by the Pioneer Network.  And why not? Evidence based research continues to support therapeutic diets are detrimental at worst, neutral at best for the elderly.

This is a very difficult conversion for many practitioners to embrace.  We support the concept, but when it comes down to actually individualizing the majority of diet orders to a less-restrictive diet (General) we flinch.  Admit it, you as a practitioner are having a terrible time letting go of therapeutic diets for the resident with diabetes, cardiac disease, or chronic renal failure.

As with most things in our industry change is regulatory based.  Pioneer Network in conjunction with CMS realized this and so the Food and Dining Clinical Standards Task Force was formed to take the documented positions of professional organizations and validate them via regulatory language. Three cheers for the visionaries.

Since it seems our every move is dictated by the regulations, take a look at them.  This can be tedious for those of us that are not regulators, but it really is worth a look.  The term individualize is sprinkled generously throughout the regulations.  If you don’t believe me pull up the SOM Appendix pp on-line and search “individualize(d).”  This knowledge should help bolster your cache of arguments for diet individualization.

Let’s examine current diet practices in the nursing home using the resident with CKD Stage 5 – dialysis.  Our training and experience dictates this resident must be put on the renal diet we have standardized for our facility.  For the sake of this example we will use a variation of an abbreviated renal diet of a General Diet, No Tomatoes, No Baked Potatoes, No Orange Juice, ½ cup Milk per day.  Now every CKD Stage 5 Dialysis patient will have this diet order and will stay on this diet, regardless of serum potassium or phosphorous, because it is the standard diet of the facility. Where is the individualization that is mentioned in F325, “The care plan . . . identifies resident goals and choices and identifies resident specific interventions?” Going back to our example, how does the standard diet meet the needs of the resident with serum potassium of 3.2 mEq/L? It doesn’t, yet there are countless residents on dialysis receiving the standard renal diet of the facility. Diets are not being modified to meet individual needs and residents are not being allowed to make food choices.

Informed choice is a key phrase that is used throughout The New Dining Practice Standards and the OBRA regulations.  As nutrition practitioners it becomes our duty to educate residents of the consequences (good and bad) of their choices then allow them to make choices.  Most of our residents have been selecting the food they eat for at least 65 years, so why take that basic choice away?  Some of you will argue their choices led them to the nursing home, but it is their right as citizens of the United States (F151 Exercise of Rights) to continue to make personal, informed choices about what they eat.

That leads us to the food from which the residents can select.  During the course of our debates over the Standards I emphasized the need for personnel trained to cook.  So often the food we serve is reheated canned or frozen foods.  Lost is the art of the scratched-cooked meal.  The use of Chefs trained in scratch cooking may enhance the flavor and nutritive value of food while reducing the excessive sodium, potassium, and fat often found in convenience foods. Plus the use of an a la carte menu offers a selection of foods from which the resident can make an informed choice.  The RD working with the Chef in the development of menu choices supported by flavorful, healthful recipes is a win/win for the resident.

Individual, liberal diets will not appear in every nursing home overnight, but The New Dining Practice Standards will support their use via regulatory compliance (F281 Professional Standards).  Embrace the change.  Individualized diets will give our residents a little more control over their lives and may indirectly reduce the number of food complaints.