MOCK SURVEY FOR DIETARY SERVICES (HOSPITALS AND NURSING HOMES)
Provided by Linda Handy, MS, RD
Retired Dietitian Surveyor/Trainer CA Dept of Public Health
DIETARY MOCK BASED UPON NEW MANUAL:
MASTERING TITLE 22, CA CODES, AND NEW SURVEY PROCEDURES IN DIETARY SERVICES (obtain at website: www.handydietaryconsulting.com)
QUESTIONS TO EVALUATE YOUR NEED FOR A MOCK SURVEY:
1. A hospital’s or Nursing Home’s Governing Body has ultimate responsibility to ensure that all departments are compliant with the regulatory requirements. There is a great deal of pressure, whether Dietary Services is “self op” or a “Contract Services” to ensure compliance. (A 83)The governing body has the responsibility for assuring that hospital services are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice, irrespective of whether the services are provided directly by hospital employees or indirectly by contract. The governing body must take actions through the hospital’s QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.
2. Are you prepared to answer this question: How does dietary leadership (you) “report up” to Quality/Governing Body on how you are meeting ALL the acceptable standards of practice and benchmarking for performance improvement?
3. Is your facility’s Quality/Governing Body prepared to answer this question: How do you provide oversight, monitoring, and ensuring compliance with all regulatory requirements in dietary services?
4. State: New “Hospital” Relicensing Survey Procedures (for CA Codes) 2016 applicable to Dietary Services (applicable to dietary services in Nursing Homes):
a. Do approved policies, inservice training, and monitoring of staff cover the survey areas?
b. Is staff competent and prepared to answer all questions of surveyors?
c. Is there ongoing QAPI: Performance Improvement for weak areas?
Example: (Surveyor Procedure)
Request a list of transferred or discharged patients with a length of stay of 4-7 days. Review for inclusion of pertinent dietary records upon discharge. Instructions should include the most recent diet order, nutrition assessment, or any pertinent diet education. Suggested diagnoses may include: newly diagnosed or out of control diabetic, dialysis, bariatric surgery, head/neck cancer. Choose 2 – 3 discharge patient records from this list to review.
NOTE: Most discharge planners are NOT sending RD assessments/speech evaluations, education documentation, and the care plans for a continuum of care expectation to the next level of care, esp Nursing Homes. This is now a focus on surveys and deficiencies are expected with this new procedure.
There is also discussion that IF there is decline and negative outcome because the hospital did not send important discharge info to the Nursing Home, it may become an issue in an investigation or review.
a. How much do you know about the requirements of the CMS “A” tags or the validation survey process for acute care hospitals? Often dietary leadership have prepared for a Joint Commission survey (a voluntary accreditation survey), but know very little about the federal CMS Validation Survey required for federal certification funds or the many resources available from CMS.
b. Have you see the CMS Hospital Patient Safety Initiative/Pilot (2011-2013) for aggressively training surveyors on how to survey your hospital and prevent “adverse events” in three focus areas: Quality/Performance Improvement, Infection Control, Discharge Planning? Are you and your staff prepared?
c. CMS is demanding a more thorough accountability during survey on the Condition of Participation for Dietary Services: Dietary staff competency and effective dietary systems, especially ensuring nutrition care, food safety or prevention of Food Borne Illness (A 618-622)
d. Dietary Services can no longer work in “silo” but must demonstrate collaboration with other departments. CMS is demanding a demonstration of facility wide involvement in Quality Assessment and Performance Improvement (QAPI), not just in clinical & patient satisfaction areas, but also in dietary services areas. Does Dietary Department have an emphasis on effective systems for preventing even the “potential” of an adverse event, including Food Borne Illness, Nutrition Decline, Wrong Therapeutic Diets (Patient decline/ Choking Deaths), etc. Are front line staff involved in QAPI? (A 269-311)
e. Can you demonstrate specific collaboration between dietary leadership and the facility’s Infection Control Preventionist /Committee ( A 749) for food safety including the staff training, monitoring (in kitchen observations), employee health (training on reportable symptoms, return to work policies for staff working with highly susceptible population) , and determining weak areas & performance improvement. No longer can ‘Food Safety’ be just a responsibility of the Dietary Leadership Team.
f. Have you studied the deficiencies being given during CMS Validation Surveys? These can help you prepare to demonstrate your compliance.
6. Would you benefit from a GAP ANALYSIS between where you are with regulatory compliance and where you need to be to ensure that your surveys go well?
WHAT WOULD A MOCK SURVEY INCLUDE?
1. CUSTOMIZED FOR YOUR NEEDS: Depends upon size, acuity, levels of care (hospital, subacute, rehab, LTC), and goals
2. POLICY AND PROCEDURE REVIEW (Est. 3 hrs): When deficiencies are found, the surveyors are taught to “investigate further” by reviewing P & P and training. How detailed was the P & P? Were there coordinated policies with Infection Control, Nursing, Med Ex, and Pharmacy? Was it “evidenced based” for acceptable standards of practice, including detailed manufacturer’s guidance? The next step would be to observe/interview to see if staff receive training and monitoring on the approved P & P.
3. MOCK SURVEY ONSITE (16-24 hrs):
a. Review of trayline and delivery systems
b. Review of effective systems and staff competency during Kitchen Observation and food operations. The Infection Control Preventionists & other staff are welcomed to further their knowledge and role in food safety monitoring. Training from Handy self study manual: Is Your Staff Competent and Survey Ready in Food Safety? Includes sections written specifically for Infection Control Preventionists, their role in the regulatory requirements for “surveillance” and the prevention of “adverse event” of Food Borne Illness, and how they can collaborate with & support dietary management, and strengthen Food Safety/prevent CMS deficiencies. Has 50 Huddle topics for weekly inservices.
c. Review of Therapeutics and Nutrition Care Systems. Evaluation of dietitian participation on key hospital committees, P & T, Nursing Collaborations, and Wound Care. Evaluation of Nutrition Assessment and Care Planning, Timely Response to Dietitian’s Recommendations, Drug & Nutrient systems, qualifications and competency of Registered Dietitian /Dietary Manager; Discharge planning/continuum of care; End of Life; Quality of Life and Patient/Resident Rights for Decision Making (right to refuse or not to follow a restricted diet or therapy.)
d. Evaluation and training on Performance Improvement and how to “report up” to Quality/Governing Body. This is a pro-active, preventative approach versus a retrospective/reactive approach AFTER deficiency findings and the required aggressive Plan of Correction. Assist Hospital/Nursing home leadership demonstrate how they are meeting regulatory requirements by providing oversight, monitoring, and sustainability of compliance with all regulations (in dietary services.) Training from Handy self study manual (packed resources with many deficiency examples): Dietary Services: Mastering Survey & Mastering QAPI
4. GAP ANALYSIS: WRITTEN SUMMARY AND RECOMMENDATIONS (3 hrs) This support can continue with follow up visits and email/phone support as needed.
SAMPLING OF ENDORSEMENTS FOR LINDA HANDY CONSULTING
(more upon request)
10/31/16 Linda recently visited our facility, St Jude Medical Center, and shared her insights with our team. With our industry and Title 22 ever changing, Linda was the right person with her longstanding knowledge and experience of survey practices. The first day she was here, she took an extensive tour of our kitchen and cafeteria. As she toured and evaluated the areas, she challenged our staff members the way a surveyor would, and took the time to explain to our staff the correct way to answer a surveyor. She gave us insight on best practices from the many other facilities she worked with which was very helpful. The second day of her visit, she worked very closely with some of our dietitians and toured the NICU and formula room. She did not leave until she was positive all of our questions had been answered and all staff were briefed on her findings and advice. The whole time Linda was here, she actively engaged our management team with the pertinent and personalized information she provided. We are very happy with her service and would strongly recommend her to any facility.
Brianna Heeger, Manager, Food operations
101 E. Valencia Mesa Drive, Fullerton, CA 92835 T: (714) 992-3000 ext. 4083 C: (714)853-4252
To Whom It May Concern, 8/1/2016
As we prepared to open our new kitchen after a large scale remodel and prepared ourselves to open a new 245 bed medical center on the same campus, we decided to reach out to Linda to ensure that we were ready for surveyors and we are very happy we took that step. Linda’s knowledge of regulations and food service operations provided us with the confidence that we are ready for the licensing process to begin. She was able to learn our operational processes and to provide direction to the areas of concern from a regulatory perspective.
Although, we believed that we had turned over every stone in our planning we found we had some areas for improvement. It was a positive experience to have Linda on-site with us, for her to share her knowledge of regulatory requirements and I felt it was a great learning experience for my management team that have never been through a survey process. They came away from the process with a strong understanding of the expectations during a survey and with more confidence in their ability to participate in a positive manner in our upcoming surveys. Thank you.
Chris McCracken, R.D., M.B.A
Director of Nutrition Services
University of California San Diego Health
April 29, 2013
Re: Linda Handy, MS, RD Consulting Services. Retired Specialty Surveyor/Trainer, CA Dept. Public Health
To Whom It May Concern:
Linda Handy was tremendously helpful in preparing us for the recent CMS Validation survey of the dietary department. My only regret is that I didn’t have her consult more. CMS is demanding a more thorough accountability during survey. Linda was instrumental in helping me understand the federal A Tags for the Conditions of Participation for Dietary Services. There must be demonstration of facility wide involvement in Quality Assurance and Performance Improvement, not just in clinical & patient satisfaction areas, but also in dietary services areas, with an emphasis in food safety. CMS is looking for alliance between dietary leadership and the facility’s Infection Prevention /Committee. Food safety deficiencies also impact the A Tags for Infection Prevention. Areas of emphasis Linda can make stronger are: food safety practices, staff training, monitoring and policies and procedures.
Linda’s experience as a Retired CA Dept. Public Health and as a Registered Dietitian is invaluable. She has surveyed hundreds of hospitals and nursing homes and trained surveyors on how to survey for the dietary services requirements. She knows what is being surveyed for.
I would highly recommend that all healthcare organizations that are held accountable for dietary services utilize Linda’s service for not just one visit to review policies, but to observe all of the dietary practices and assist with development of training programs so that staff are able to demonstrate and verbalize proper procedures. Further, while Linda is able to assist after a survey on development of plans of corrections it is more beneficial to have her do this before the survey(s) to prepare and avoid deficiencies in the first place.
I close by stating that it is evident that Linda’s goal is to not only help us prepare for survey but by doing so we become a better and a more safe service for our patients.
Lesa L. Blake, MBA-HCM, RD Corporate Director Support Services Operations Hoag Memorial Hospital Presbyterian One Hoag Drive PO Box 6100 Newport Beach CA 92658-6100 (949) 764-8198 Lesa.Blake@hoag.org
As a Food Service Director in Healthcare, the thought of CMS coming to our facility sent chills down my spine. I was very familiar with Joint Commission, but heard and read that the CMS “Full Book Reviews” were very different and would have a dietary component unlike anything we had experienced. We knew that CMS was headed our way, and were quick to review the Conditions of Participation as a guide to evaluating how prepared we were (or thought we were.) I thought working for a contract food service company with great systems and standards and being in the healthcare industry for 25 years were enough to put us on the right path toward success with CMS. Boy was I wrong!
I approached the hospital to see if they would approve us bringing in a mock auditor who could help us gage where we were at with compliance to CMS standards. Enter Linda Handy! We spent two days reviewing policies, practices, opportunities and gaining a better idea of what to expect and how to prepare. After she left, we worked like crazy to shore up our systems and standards and invited her out one more time to help us make any course corrections.
CMS came, spent three days in our dietary department, and we had a very successful CMS survey, with only two minor items deficiencies noted in the CMS-2567 report. We were prepared and did very well, and I cannot say enough about Linda’s role in our success. She really helped us understand what CMS was looking for and how to position ourselves for success. Being proactive with getting her involved ahead of time was the key to our success, and helped make our department stronger and our relationships with the hospital staff and administration more solid.
Joyce Solis, CEC, CDM
General Manager Food & Nutrition Services
Saint John’s Health Center
Santa Monica, CA
RE: MOCK Survey for Dietary Services
To Any Food Service Director in Healthcare,
I am writing this letter to help you with all the challenges we as directors have in meeting the regulations we are faced with. I attended a lecture by Linda Handy, MS, RD and immediately got nervous about all I needed to do to meet the CMS regulations in food service. Linda Handy is a retired surveyor/trainer for California Department of Public Health and has written many manuals to help food service directors in Acute Care & Long Term Care.
Linda Handy does MOCK surveys and we invited her our hospital to do a survey to help us identify where we needed to focus. During the survey she included our infection control nurses and PI staff. We are now working as a team to comply with the regulations. She followed our tray passers to the floors to see our process; she surveyed the kitchen and made recommendations as she would have as a California State surveyor.
Her expertise was greatly appreciated. We now have a plan of action and many references to help us understand what the standards are and what surveyors are looking for. I would highly recommend inviting Linda Handy to any health care facility dietary dept. to do a MOCK survey to identify, teach and guide you in complying with all the regulations of Title 22 and CMS.
Please feel free to contact me regarding our survey by Linda Handy. We feel that her services are very reasonable for all the help, resources and knowledge she can provide to you and your facility.
Susan Wray, RD
Director of Food Services
Foothill Presbyterian Hospital
250 S. Grand Ave.
Glendora, CA 91741
As Interim Director of the Department of Nutrition and Food Services of a large teaching hospital (2013), I needed guidance and direction in bringing the department into compliance with state regulations and Food Code 2009. Ms. Handy's expertise was crucial to accomplish this as my experience was strong in the clinical area having been a clinical dietitian and a Clinical Nutrition Manager but I was somewhat limited in the food service arena. She taught me about Food Code 2009, its practical applications and how to incorporate the code into our policies and procedures. She helped me in designing a strong Quality Assurance Program for both Food and Clinical Nutrition Services. This included the development of tools for monitoring elements of documentation of medical nutrition therapy. It also included putting into place monitors to ensure adherence to the dress code by food service personnel, proper temperature control of equipment, storage areas, and food preparation, and; developing checklists for food service supervisors. She guided me in developing the Diet Manual for the Hospital and helped to clarify the law when it came to the standards of practice for the dietetic technician, registered with regards to their work in assisting the registered dietitian. This helped in writing a more effective policy and procedure on Nutrition Screening and Assessment. Ms. Handy also gave me tips on what the State Dietitians would be looking for in the nutrient analyses of hospital diets. She also helped to build my confidence in preparation for the state interviews as she shared with me the things she would look for as a former state inspector. Her "Handy Cards" were instrumental in training and building the confidence of food service workers in their ability to do their jobs well, appropriately, and with pride. Ms. Handy was a joy to work with and provided the encouragement to accomplish this daunting task successfully.
Donna Chin, RD
Santa Clara County Medical Center