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.

Historically nursing homes were almshouses turned money-generating enterprises (thanks to government funding) that housed the elderly. To improve their image and attract more residents nursing homes began to establish the hospital model of patient care instead of home.  When the OBRA regulations were published systems were developed to provide efficient, compliant care, often overlooking the personal choices of the elder being cared for.

The OBRA regulations were needed.  They positively impacted the care elders received. Menus were planning in advanced to provide nutritious food served three times per day seven days per week. The select menu was virtually non-existent, but the elder received safe, wholesome food. Residents were given rights that previously were non-existent.

Today organizations such as Pioneer Network are working with CMS to further the regulations and their intent of quality of life for every resident through choice, individuality, and dignity. They are trying to put the ‘home’ back in nursing home.

Makes sense to me.

One of the most ingenious regulations developed by CMS for nursing homes is F281 Professional Standards.  The regulation basically states CMS requires clinicians (doctors, nurses, dietitians, pharmacists, etc) to abide by professional standards.  The regulation goes on to say CMS is not qualified to develop professional standards for clinicians, therefore they will defer to the standards developed by professional organizations such as the “American Dietetic Association‘s Standards of Practice and Standards of Professional Performance for Registered Dietitians (competent, proficient, and expert) in Extended Care Settings.”

Pioneer Network, an advocate for elder rights, is working towards a culture of aging that supports the care of elders in settings where individual voices are heard and individual choices are respected — whether it is in the nursing home, transitional care setting or wherever home and community may be.  Pioneer Network in conjunction with CMS recently convened the Food & Dining Clinical Task Force.  This 2-day event hosted representatives from professional organizations as they 1) discussed ways to make dining a more person centered experience and 2) examined each association’s position or recommendation of nutrition and diet.

I represented the American Dietetic Association on the Food & Dining Clinical Task Force. It was a profound experience to interact and share nutrition and dining ideas with representative members of the health care team, knowing the choices we made in that room would significantly impact elders and professionals throughout the industry.

Karen Shoeneman

This meeting of health care professionals was the brainchild of Karen Shoeneman former Deputy Director of LTC Division, CMS.  Her vision, bring together representatives from various professional organizations to talk and agree upon dining standards.  Ingenious, again! Why?  F281. CMS does not develop professional standards but defers to the standards of professional organizations.  The New Dining Practice Standards have been reviewed, amended, and approved by multiple professional organizations.

The New Dining Practice Standards specifically reference positions/publications of the American Dietetic Association, American Medical Directors Association, CMS, and others to support the Recommended Course of Practice. . .

Diet is to be determined by the person and in accordance with his/her informed choices, goals, and preferences, rather than exclusively by diagnosis.

Assess the condition of the person, include quality of life markers such as satisfaction with food, meal time service, level of control and independence.

When a person makes a ‘risky’ decision, the plan of care will be adjusted to honor informed choice and provide support available to mitigate risk

These are just a sampling from the the New Dining Practice Standards that are scheduled for release shortly.  I anticipate surveyors across the country will be trained on enforcement of these Standards. RDoffice.net will post these Standards upon release and take the reader through some of the key concepts and practice standards.

In the mid-west summer means roadside stands overflowing with sweet corn-on-the-cob, tomatoes, cucumbers, zucchini, green beans, onions, and other fabulously fresh produce.  Each bite of this tender harvest sends the taste buds into a wild frenzy.  Fresh garden fare is so flavorful that my husband, a manufactured-food foodie, can’t wait to pop a raspberry or 10 in his mouth just for the pure enjoyment of its raspberry-ness.

In mid-July an employee of a mid-sized nursing home in Central Illinois proudly shared fresh zucchini from her backyard garden. “My husband used a little too much Miracle Grow this year, so we have plenty to share,” she explained when asked how she had enough to feed 115 residents. The dining services department washed, cleaned, and cooked fresh zucchini not delivered in a big truck, but in the back seat of a car. Without exception everyone enjoyed the seasoned zucchini, except perhaps regulators.

Living with Regulations

Fresh Garden Vegetables

In 2009 an updated CMS regulation F371 stated “food must be procured from approved sources.” The intent of the regulation is to prevent food borne illness from eating potentially hazardous food not maintained at the proper temperature or eating improperly canned foods. Potentially hazardous food (PHF), such as shrimp, requires time/temperature control. The average Louisianan may take a chance with their health when buying roadside shrimp, but for an elder – pathogens multiplying in the shrimp could be deadly. So it makes sense that a PHF be purchased from an approved source.

But what makes sense on paper does not always make sense in practice. Providers enforcing this rule had to ask family members to stop brining food to their loved ones. Needless to say this interpretive guidance was not well accepted by residents, family, or providers.  In response CMS published  CMS Memo 09-39, dated May 29,2009 stating the intent of the regulations allows residents to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices.

But what about residents without guests or residents of our Central Illinois nursing home? The fresh, non-PHF zucchini was donated by an employee.  The residents were not given a choice between  garden fresh zucchini or food distributor zucchini – everyone selecting zucchini got the garden variety. Well it turns out the facility was within regulatory compliance. According to  Wisconsin Department of Health Services in a F325 & F371 Q&A Document, “uncut produce is an agricultural item and agricultural items are not regulated therefore uncut produce does not have to be purchased from approved sources.”  The document goes on to say that  nursing home gardens are ok if fertilizers and pesticides used follow manufacturer’s recommendations. Each state is different so check your local regulations before planting and serving garden fresh vegetables at your nursing home.

Who knew that growing and serving fresh zucchini to elders living in nursing homes could be so complicated?