By Linda Handy, MS,RD

                                                                                                                     Retired Surveyor/Trainer, CA DPH

Selected as recommended "Book of the Month" by October 2013 Newsletter!

This manual has been percolating in the author's mind during the last two years of consulting with very difficult CMS Validation surveys in CA Hospitals. It starts with a real example of one facility's journey where the author was asked to join key leadership (CEO, CNO, Food Service Director) in a meeting at the CMS Regional Office after several failed surveys in meeting the regulatory requirements (Condition of Participation) of Dietary Services, and related QAPI and Infection Control regs. The CMS Director wanted a written GAP ANALYSIS of where the facility was and where the facility needed to be for compliance in all requirements. (How would you proceed to develop a GAP Analysis of your facility?) He asked HOW the facility will establish effective objectives? What changes will be made? What will be done differently? How will the facility measure and evaluate performance improvement? How will they now ensure staff competency according to national standards? How will facility provide the assurance to CMS that they will establish improved systems to ensure that the intent of all regulations are met? This is the future of surveying (for hospitals AND nursing homes.) The story does not end here; it actually "begins" here, as this facility's staff embraced basic QAPI principles (Study the detailed QAPI Hospital Regulations A 263-317 on Pg. 53): Defined objectives (based upon industry standards/regulations), measured delivery of objectives, and demonstrated/documented the continuing improvement in those weak areas of meeting objectives. Dietary leadership could no longer be "silo", but had to learn how to effectively "collaborate" with other departments (Nursing, Quality Leadership, and Infection Control Officers to meet the intent of the regulations.)

The manual's goals are stated as:
First, what are the federal (CMS) regulation, Surveyor Interpretive Guidance (IG), and survey process in Dietary Services and related tags for Hospitals (General Acute Care Hospitals) and Long Term Care/Nursing Homes? How can LTC/Nursing learn from the new, demanding CMS Hospital Patient Safety Initiative (for training Surveyors)?

Second, how can your facility meet the intent and expectations of QAPI, with the CMS emphasis on HOW you demonstrate the prevention or potential of Adverse Events?

Third, what are examples of deficiencies that have been given? NOTE: There are many QAPI examples are from hospital CMS Validation Surveys (Food Safety and Nutrition.) The new revised LTC/NH QAPI tag, implemented 11/29/16 has similar requirements.

Fourth, how can you establish proactive, preventative systems to help staff become effective "self-surveyors", thus providing excellent patient/resident care, preventing adverse events, and preventing survey deficiencies? How can you develop QAPI procedures to strengthen your defense: that you are identifying all potential adverse events and aggressively, vigilantly demonstrating how you are preventing them?

This manual with is pending re-approval for 6 CPEs from CDR for RDs and DTRs and has current approval for 6 CEU from ANFP for CDMs.

Price: $40.00