And now I would like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility, Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, foreign area care, perioperative services, and pain management. Prior to joining COPIC, she served as the Director of Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. And she is licensed to practice law in Colorado and in California. We are so thankful that you're here with us today, Laura, we invite you to get us started. All right. Thank you, Lindsay. And welcome, everyone. As Lindsay mentioned, we're talking today about dietary standards. You wouldn't think that that was so important. You know, we feed them, they get well, they go home. But that diet really impacts their overall health and well-being and can really hit their recovery. Because years and years ago, when we had patients who were in the intensive care unit, they were there for so long, we didn't even think about it. And then finally, we started to recognize these folks aren't getting the nutrition they needed in order to recover and again, get better and go home. And so that's why I'm so glad we are now covering this topic, because we don't look at it enough. And that's why we need to. I have on slide number two, the email addresses for CMS. Now, granted, there's a lot going on right now in Washington, DC. But surprisingly, they are answering questions. I sent one off Friday, and I already have my response. Late last night, it came in. So bear with them, they do respond to them. Just keep that response when you do get it. I always include a disclaimer that my program today, it's informational only. It is not meant to provide legal advice or establish that attorney-client relationship. Please reach out to your own in-house counsel, attorney, legal representative, whoever that happens to be, when you need advice on a specific situation within your hospital, because there may be a state law that will impact it that I would not have access to. I would like to do just a really short, brief introduction on why we do these and why Georgia Hospital Association puts these programs on, so you don't get one of these. That is the statement of deficiencies, and then we have to do that plan of correction. And of course, no facility wants to be notified they've been involuntarily terminated from that Medicare or Medicaid agreement, because that can happen if you don't do a response for that plan of correction. If the response doesn't address those issues, those deficiencies they found, or you simply don't let them in the front door, any of those can easily lead to a termination of that agreement, and again, huge financial impact to a facility or a provider. I always like to talk about some of the deficiencies on the topic that I talk about and why CMS looks at these, because yes, they are. Well, one is they didn't have the required policies. One of the other things, and I'm going to talk about that, is they don't even follow their own policies that are there. The policies haven't been reviewed. So again, not having those required policies. They didn't get a consult on nutrition from a registered dietitian, and the policy spelled out, not following their own policies. No plan of care regarding the nutritional needs of patients. Here, the physician wasn't notified that the patient wasn't eating, and this patient, of course, was dependent on the staff to feed him, give him the fluid, give him the snacks and that nutrition. They didn't make sure nutritional needs were met, according to dietary practices. They didn't do QAPI on a contracted employee, and that is, of course, that quality assurance performance improvement, where every hospital has to do it for every service, including those under contract. Patient was not given the right diet. No policy on that nursing assessment. In other words, where we're starting off when that patient's admitted. What's their history? What's their allergies? How is their clinical condition? Do they look cascadic? Here, the patient had a gluten problem, and they weren't put on a gluten-free diet. No quality data for the department itself. Just a few more, a non-diabetic was put on a diabetic diet. No temperature checks. Trays not delivered timely. They didn't follow their own safe food handling requirements. They didn't label stored food. Who knows what was in that container? They put dried food debris. They noticed that the mixer had it within the body and on the blade, so it had been cleaned properly. And then they didn't ensure that administrative technical personnel could do their job in handling the food correctly. Here, we put gravy into a plastic salad dressing container. It melted. Gloves not changed. They weren't changed with hands washed after using a marker. And no quality checks that were done to make sure warm food was at the patient's bedside. Now, does this seem like such a catastrophe? Well, again, we have to make foods at the right temperature. So that's why I'm going to start right off with these conditions and with a quick question. Lindsay, would you put that up for us? I sure will. Okay, you should see this first question on your screen that says that our dietary and food service, the first option here is very responsive to changes or last minute needs, is usually very good, but lately has been slower to respond to special requests, needs help, or possibly prefer not to answer here. I'll give you just a couple of seconds to put in those responses. For those of you who joined us over the last few minutes here, as we have a few of these following questions come up on the screen, if you have any questions for Laura throughout the presentation, we will take this time to address those questions. You can click on that Q&A option there at the bottom of your Zoom window and type in your questions at any time. We'll make sure to address those throughout the presentation as well. Okay, we've got some good responses here. And get some of these are just simply polling questions to find out what's going on within your facility. And I commend those who did answer, we need some help. And so thank you very much to all of you. So that's good. Most of you are being very responsive, or at least the service is being responsive. So let's start off right at the back. Now, I want to show one thing on my slides. You're going to see in the upper right hand corner, a letter and four digits. That is the tag number that we're associating this with. In previous programs, the tag number hadn't been in there. But now that CMS is kind of tightening up some of their specialty deficiency notices, I've included the letter and the four digit tag number. If you don't have four digits and the tag number, you're probably going to get lost. And you'll be in an area where you did not tend to be if you're looking at those deficiencies. Well, let's go ahead and just start. Of course, we have to have an organized service. And you have to have someone who directs it. And that you have enough qualified folks to provide the service, do their jobs. If you are contracting out this service, you can't do that. Nonetheless, you still have to have a dietician. You have to keep minimum standards, even though it's contracted out. Somebody else is doing it. And there has to be someone that acts as a liaison with the medical staff on any dietary policies, and especially any recommendations. Now, there is contract management standards. They're in the tag numbers under governing body. I'm not going to cover those today. But as far as what goes into a contract, who's responsible, who works with them, who signs off on them. That's in those four tag numbers. Well, of course, the service has to be organized. And you want to have to make sure that these needs are being met for that patient. We're following orders and, of course, standards of practice. So what about those standards of practice? Who sets those? CMS does not. These come from your professional organizations. Academy of Nutrition and Dietetics, also known as A&D. They actually have a code of ethics for nutrition and dietetic professionals. That asterisk indicates I have that resource in the appendix for you. This particular area, they talk about competence and use of evidence-based practice, which, of course, CMS requires on anything, any requirement that they have out there. You also have to work with others and practice within their scope of practice, which is, again, required by CMS. So the dietician has to act within their scope of practice. Now, the academy, again, they have four principles and standards. I'm just going to list them here. Competence and professional development in the practice. And this is for your dietician and anybody working in dietetics. Integrity and personal and organizational behavior and practices. Professionalism, social responsibility. Now, these seem very basic. You could apply this to anybody across the board. But those are the ones that they have especially put out for the dietary area. All right. Here's the seven policy and procedures. Now, a couple of years ago, it was a must. CMS kind of loosened up. And now you should have the following written policy and procedures. I would urge any facility, have these handy. Have them there. Make sure they're reviewed and updated. The first one, availability of your manual, your diet manual, and also your therapeutic, excuse me, memos. Sometimes called nutritional care manual, pediatric nutritional care, because that's going to be different than what you have for us older folk. How often are you going to serve your meals? What do you have for diet ordering and then delivery of their trays? How fast is that diet order going to get down? How are you going to do any non-routine occurrences? Let's say you have a patient who is out in surgery. They're coming back late, and yet you need to get a tray to them. Or maybe they're admittedly, and they need something to eat. They've been in the emergency department. What are you going to do for those individuals who you may have to board until you get a bed available? TPN, other peripheral nutrition, and then changes in the order. I'm going from a soft diet to a full diet. How is that going to happen? That's what your policy needs to spell out. Of course, integrated into QAPI. Not only that, but infection prevention and control programs. There are number six, guidelines on hygiene practices of your folks who work in dietary. And then kitchen sanitation. Not only are we trying to protect from germs, but you also have to keep in mind vermin that might make their way into your hospital. Whether it's coming in through packaging, or the door is left open, and a mouse can slip in. One in six Americans are going to have some type of foodborne illness. There were 800 outbreaks in one year, and 3,000 of those folks died. So this is pretty serious that CMS is really looking at it. For dietary, just overall, we have to comply with all state and federal laws. That's why I always mention, check with your in-house counsel if there's a specific state law on any particular sanitation rule. Sanitation rule. And this applies whether you do it, again, directly or through contracts. So if you have a contractor coming in with their own staff, you have to make sure they're following those rules. And that they're evaluated through your performance improvement process. Maybe these trays are constantly late. Or maybe the right food isn't being delivered and prepared. Okay, why is that happening? They should be consistent with your national standards. I've got a few of them here. Some position papers that you can tap into. That's the link you will have to copy and paste that to your surf engine. Unfortunately, I can't make the links work. And then, of course, CDC has a lot to do with foodborne illnesses. How those outbreaks can really affect not just one person, but multiple individuals. The Kitchen and Food Service, they actually have an observation tool. It's a 14-page document. It's called CMS Form 255. Now, this is based on long-term care. But like a lot of the forms, they can translate and be used within your hospital. Storage. Not only food storage, but the temperatures. That the surveyor, during initial tour, they're going to find out maybe there's something that's going on here that isn't done appropriately. They'll watch for hand washing. Hand washing. Is it done appropriately and for the length of time you're supposed to do it? Items in the refrigerator. They're labeled. They're dated. Temperature is 41 degrees or less. And that food is stored in sanitary conditions. Again, do we have, you know, vermin droppings laying around? How high up is it stacked? Are you doing rotation of those food products so that, you know, last in is last out, etc. And who's responsible for watching those dates? So that's what the tool looks like and how you would access, be able to access it. Again, it's a good way if you want to do just a self-assessment. And you can tap into that. Can you work for either a critical access or an acute hospital? It doesn't matter. So back to the tag numbers. We have to have a full-time employee who is the director of the service. They are ones that are overseeing the daily operations of this overall service. Now, this is not someone who has to be a dietitian. It can be someone who has education, experience, training in doing a diet food service. That's what they're used to. They are given the authority and delegation by the board and your medical staff to do the operation of that service. So that means they have to provide training to their own staff. They have to make sure policy and procedures are done, that they're being followed. They do daily management of dietary. In other words, they order. They make sure things are being ordered. If it's outdated, you get rid of it. How is that going to be done? Job descriptions. Make sure they're very specific and clearly delineate that authority. And also, who does this person report to? Back to the medical staff or do they go to the governing body? Who is their oversight also? So here's the minimum policy and procedures. And these are the ones, yes, you do have to have. Safety practices on food handling. In other words, keep it warm, wash your hands, wear gloves. Emergency food supplies. You've had some bad weather in that area of the U.S. where what if your food supply is cut off or delayed? Are you going to make sure you can feed your patients and staff when you need to? What is the jobs of your personnel who are working there? Who's going to orient them and supervise them? Menu planning. Who does that? Purchase. I mentioned the purchasing of food and supplies. Keeping all those essential records that you have to have. That's everything from purchasing menus, training records of the personnel, and the reports for QAPI. And then finally, a policy on the QAPI for this direct service. There's a lot of policies, again, that you have to keep. And these are the ones that were cited that hadn't been completed. All right, your director. What does this person have to show? Well, through education, experience, and training, that they are qualified to do this. They can manage that department. And of course, depending on how big you are, what services that you're providing, well, that's how complex or large your food service is going to be. The surveyor will make sure this individual is a full-time employee. They're going to look at the job description, and they want to make sure that that file has the necessary education, experience, and training to manage that dietary. Now, this doesn't have to be a degree. It doesn't. But somewhere along the line, they have to have some education in what is required for that. Again, they won't say they have to have a degree, but they want to look at their education. Now, the dietician. This is different. This is a licensed individual. This is someone who is qualified to oversee and supervise nutritional aspects of the patient's care. They have to approve menus, any supplements that this person, the patient, may need, that there is counseling for both the patient and family when indicated. They then have to perform and document assessments on a patient's nutritional status and needs. They look at the patient's ability to tolerate those diets when it is appropriate. They work with other services like nursing and pharmacy, medical staff, social work when that patient is being discharged. Does this person have issues with obtaining not only the right amount of food for the right food, but the right amount of food? And then they also have to keep data to recommend and then work on prescribed diets. As far as the qualified dietician, this person can be contracted. They can be full-time, part-time, whatever works for your facility. And of course, qualifications is determined here on the education. Yes, they do have to have education. Establish formal education. Experience specialized training for being a dietician. And then whether or not your state requires this individual to be licensed or being registered. Most states do require them to be licensed or registered. If it is not full-time, just make sure they're available for consultations, whether it's from nursing or from the medical staff. That frequency is going to depend on how large you are, how many patients, what are those patients' needs. Like the manager of your dietary services, they are going to look at the personnel folders. They want to make sure they're qualified. Is that licensure, is it current? Are they on suspension with their license? If not full-time, how many hours do they spend working so that they can meet the needs of the patient and that there's adequate coverage. What if that dietician wants to go on vacation or is out ill? How are you going to make sure there's coverage? That's up to the hospital to make that coverage determination. Then we have our staff, those people who are down there preparing the meals, putting them on the trays, getting those trays up. That means you have to have enough, not only administrative, but also technical, and that they do their jobs right, that they're competent, education, experience, and specialized training, if that's what it is. Personnel files, documentation that they are competent. In other words, there's been a demonstration, they've done a return demonstration and done it appropriately. Our menus have to meet our patient's needs. In other words, what are the dietary practices? This can also be your observation patients. They're not inpatients yet, but we just can't leave them there to starve, though we do have to provide something for them. Follow those practices, whether it's USDA food nutrition, they talk about recommended dietary intake. Institute of Medicine, they actually have a food nutrition board. They have a dietary reference intake, and it talks about the values. There are four values that the IOM does reference. Number 1 is the recommended dietary allowance. That's what all of us healthy people, that's the average intake that is recommended for us on a traditional basis. Adequate intake of a particular nutrient. This drills down a little bit more. It is very similar to what they call the estimated safe and adequate daily intake. Here you use this when the recommended dietary allowance can't be determined. That's based on observed intakes of a nutrient by a group of healthy individuals. In other words, how much intake are these healthy individuals taking of vegetables, protein? Maybe it's dairy or fruits and vegetables. Number 3, tolerable uptake. This is one where you can take as much of this particular nutrient and will become toxic to you. Because the higher the level, the more your risk goes up. Think about your kidney patients. Now, they have trouble metabolizing them, or even your liver patients. Perhaps you have those who cannot metabolize a particular nutrient. Therefore, the higher that level, the more toxic it is going to be for them. In my training, we always had those four vitamins, A, D, E, K, where you could actually overdose on those vitamins. They're healthy, they're vitamins. If you can't metabolize them and you get too much of that in your system, you're going to be in trouble. You're going to become toxic. Then number 4, what is the estimated average requirement? This makes half of the estimated requirement of a nutrient for half of the people. Here is that reference intake. This just gives you an example of what that looks like. It takes into account children, males, females, pregnancy, or lactating. It's a very comprehensive one and it really covers all of these nutrients that we might need. Or what is our upper level? For those of you who might get folks in who take a lot of supplements, keep this one handy for your physicians. If you get a person who's admitted and they come in and say their zinc is just way off the charts, why is that? Why is your zinc level so high? Well, that could be one of the reasons. It's one of those supplements that they have taken. Those are not FDA approved. That's the one thing we have to keep an eye on. Now, the good thing is there is actually an interactive tool and tables that you can tap into also. They're trying to make this as easy for us or as convenient so that it's also readily available. Well, therapeutic diet. This is one that's part of their treatment program to help them with their disease or their condition and what we're trying to do is take out certain substances in the diet through this therapeutic diet. For example, maybe we want to help them unload some of that sodium, or maybe they're way over on their potassium because their kidneys aren't working and somehow we have to bring that potassium level down, which we know can affect their cardiovascular, especially their cardiac conduction system. The other one is simply a mechanically altered, they're edentulous or perhaps they have difficulty swallowing. One of our sons had to have some surgery to where he was on a liquid diet for about two weeks and then he had to go on to a soft diet. For those two weeks, he worked with a dietician to make sure he's getting the right nutrients in that liquid form so that he could continue to recover. We know as nurses, we assess the patient on admission. How does this person look? Are they looking anorexic, cascadic? Do they look dehydrated? What is it about them? Now, there are patients who will have certain dietary needs. Here's just some of those examples, those who have to have two feed-ins, whether it's a day two or however, a JPEG. Again, that medical or surgical intervention, something where they can't either ingest or simply digest and absorb nutrients. Think about those who have colon resections, especially small bowel resections. A lot of metabolism goes on in that area, and that's why we have to be careful with those individuals. Those who may be anorexic or bulimia have that compromised nutritional status or something that simply impacts the uptake of those nutrients, whether it's diabetes, maybe it's CHF, that we have to keep an eye on. Brings me to question 2, Lindsay. Okay. Let's get that one up here on the screen for you. You should now see this question that says, we assess the following patients for the nutritional status or needs. All patients, only those over the age of 70, ages 10-16, and then over age 70, only those under 18, only those patients who appear malnourished or severely underweight. Not sure who is assessed, the last question there. You might have to scroll down to see that last option. Laura, this one question has come into the chat asking, does this education also apply to critical access hospitals? Yep. Yes, it does. Yes. Please use this for criticals. Now, there's a little bit more, I don't want to say loose, it's more understanding that critical access hospital may not have all of the resources, but you really need to look at these for your critical access hospitals. Again, it's not as involved in the requirements, but they're going to look at how are you feeding your patients. A lot of you will contract it out, but you still have to meet those same requirements. I think we touch on criticals as we go through here. I think that's my next section. Perfect. I'll go ahead and end this poll and show those results. Great. All patients, wonderful. Only those who appear malnourished. Again, thank you to those who do say, this is what we got and what we're working with. The care plan. Care plan has to address if this person has any special nutritional needs. How are we going to monitor their dietary intake? How are we going to make sure we're meeting that nutritional status? If patient simply refuses to eat or the food that we're giving them. Again, the care plan has to address any substitutes of equal value to meet those basic needs. Also, how often are we going to monitor this person? Weights. That's a good way to start. Are we gaining? Are we losing? What about intake and output? Lab values. Are lab values indicating this person is very dehydrated? Are we actually getting rid of that sodium? Or do they have CHF? Now, watch out for that potassium, so that if we're giving them diuretics or something to help shed some of that that we're not also taking away the potassium. These are just some of the ways that we can do it. It's not all inclusive by all means. Here's an example of just one of those nutritional assessment forms. What's your weight? What's your height? How is your BMI look in relation to your age, your height, and your weight? The surveyor wants to talk to the dietician. How do you meet the nutritional needs and how do your menus do that? Are you relying on any particular format to make those menus, like DRIs or recommended daily allowance? Then they're talking to the staff within the dietary. How are patients assessed? How are you monitoring them? How do you identify those with specific needs? Now, this will probably be nursing. That's who they're really focused on at this point in time. Then they'll go through the charts. They want to look for any therapeutic diet. Also, have we identified those patients who need special nutritional needs? Now, what are we doing for those? Maybe this person is coming in with ulcerative colitis, that it is so bad that they cannot retain any nutrition within their intestinal tract and they are losing weight rapidly. Those who are at risk for malnutrition, I did find an article, one out of every three patients are at risk for malnutrition. They don't eat enough in the hospital and that slows their recovery. That's why this particular article did use that malnutrition screening tool. They found over half, just 51 percent of the patients ate half or less of their food. There, they did have a higher risk of death because they just weren't getting that nutritional value to fight off the infection or fight off the illness or help them recover. Adults who didn't eat any of their food, six times higher rate of death. Now, only 11 percent of these, only 11 percent were given a supplement. This was back in January of 22 with this article. How come we're not meeting their needs? Well, we have to have an order for everything and that includes our diet. Now, who does that? Well, that depends on what your state allows, what your medical staff and board have said you can do. Is it going to be only a physician, an advanced practice provider, or if, again, your state and everything allows it, can your registered dietician or nutritional professional write those orders? But this has to be authorized in the bylaws from the medical staff and then consistent with state law. Now, I found a couple of resources on finding out about state licensure within your state. Though there's a link you would want to tap up and then just put your cursor over your particular state. It will tell you where's the statute and you can click the link to the statute. Now, some states are working and partnering with actually the Department of Defense and Academy of Nutrition and Dietetics. They're really trying to support the ability of dieticians to work within a compact. We have it for nursing, we have it for medicine, and PAs, and nurse practitioner, etc. Now, they're trying to get this for dieticians, where the dieticians can go across state lines much more efficiently. If you're living on a border state city, this is very, very beneficial. Unfortunately, we only have three states right now where it is enacted. Three of them are pending in it. Otherwise, the majority of us simply do not have that at this time. I'm hoping that over the next couple of years, they'll see the benefit to this where you can get folks easily licensed or they can cross state lines in order to write these orders. When we talked about the patient assessment, of course, we base our diet on that patient assessment. What do they need? But it has to be in the record. Whoever does that, usually it's going to be the nurse will start it on admission and then perhaps your dietician will come in and take over. Also, how are they tolerating it? I don't know if any of you have ever tried the no salt, no added salt, low salt diet. That leaves a lot to be desired. They really do as far as flavor. That's what we want to watch for. Yes, it's beneficial to them. Is there any way we can maybe make it more tasty? Granted, they're losing weight, but it's because they're not eating or because we're actually getting that extra fluid off of them. The board can allow the medical staff to give privileges to dieticians. If the state law permits it, and again, the medical staff, it's going back to the board saying, these folks know these diets inside and out. They know how the patient can respond and the nutrients that you need. Let's give them the authority to be granted privileges to write orders. Of course, they have to make sure they're qualified before they even do this. State law will determine what is a qualified. That may be a registered dietician with a private organization, but they can also say, there's going to be more requirements that we want to have for our dieticians in order to do this. That's up to the state if that's what they feel is needed. Here are some of the standards, scope of practice for registered dieticians. This was revised just last year. If you're interested, you can link it there and then download it. What if you're bored and your medical says, no, we're not going to do that. We're not going to be privileging and credentialing these individuals. Even though the state says you can, well, then it's up to the practitioner to write that order because they're responsible for their care. They can still do an assessment, that dietician can still do the assessment, make recommendations, but that's where it ends. Then the physician or the provider has to write that order. The surveyor will make sure, of course, we have a diet, and if it is the dietician writing the order, then they're going to go back and make sure through their file, they are privileged and credentialed and appointed to do so. They're going to ask you, the hospital, whoever that would be, usually, it's COO or CEO, or maybe the dietician. What nutritional standards are you using to make these orders and make the menus? They'll look through your records. They want to make sure diet orders are there, that they have been prescribed by someone who's taking care of the patient. Also, nutritional needs are met and that you're watching their intake and their status. We are monitoring it, whether it's good or bad, at least we're keeping an eye on that patient's status. Here we have to have a manual. It's a therapeutic diet manual, readily available, and that's for everybody, whether it's the physicians to find out, okay, what can this person have, nursing, also food service. Don't forget, they have to know, okay, what do we send up? You may have a couple of copies of this within your hospital, but it's one that's approved by the dietician and the medical staff. Regardless if the dietician is privileged and credentialed to write orders. No more than five years old, you're following standards and all types of diets that are routinely ordered, and then following any guidance for ordering and preparing of diets. Because there may be a certain way that we have to prepare a food in order to meet that nutritional need. Also take into account, and it's not in the conditions, just as a suggestion, any cultural requirements for those diets that you have to take into account. That's why, again, your dietician is a really great resource for you. If not, you can always consult with their local cultural person on what is necessary for this person's diet. The one who asked about critical access, yes, we are going to be covering critical access. Now here, your tag numbers begin with the letter C. I'm including it here, some previous guidelines because when CMS redid the manual back in 2020, they changed a few things and they didn't include the interpretive guidelines. Now, there are some of them that are still out there. You can still follow them. It gives you something to go on because they haven't done that yet. Hopefully, again, this year, they will get around to it. Here's my third question, Lindsay. You should now see this question on your screen and that says, our critical access hospital, and this question, you can select all options that apply to your organization, prepares patient meals in-house, has had some concerns with in-house preparations, contracts with a local restaurant for patient meals, has had some concerns with quality of patient meals provided by a contractor, or finds patient meals provided by the contractor to be very tasty. I'm going to give you a couple of seconds to put in your responses there. Again, just a reminder, if you have any questions for Laura, make sure that you're typing those into that Q&A option there at the bottom of your Zoom window or if for some reason you don't see that, you can, of course, type your comments there in the chat. We'll address those as well. I'm going to say the decision to use a contract, totally up to your board. It may be more economical for them to use an outside contractor rather than having a full kitchen to prepare and staff it. That may just be more economical for the critical access hospital than rather having the entire system, the entire department. One hospital I worked with did do that. They had a local restaurant that provided the meals. Even the staff said their meals are 10 times more tastier than the ones we fixed here. It was a win-win for everybody that the meals tasted better, they still met the requirements, and everybody was happier and it was less expensive. Perfect, I'm going to end this and share the results there. Okay, yeah, great. Most of you are preparing your meals in-house. All right, that's great. Again, a lot of these are simply informational only. All right, the standards, what I covered in A, they're very, very similar to what's required for you, but they're shorter. In fact, you don't have a separate section that's called dietary services, as does ACUTE. It's in the provision of services chapter. It applies to all inpatients, including swing bed patients because that's part of your census, is your swing beds. again, policy and procedures in place to make sure we're meeting our patient's nutritional needs, following those accepted, recognized dietary practices. All diets, including therapeutic, have to be ordered by a practitioner, taking care of the patient, or again, the qualified dietician, if your state law and your medical staff say, yes, we're going to use those folks. You're not required to prepare meals. You don't have to do that. You can use a contract, but just be aware, infection prevention and control is hit hard here. So you both, whether it's an acute or a critical, you may be cited deficiencies in both areas. And if it's a huge issue, they may do more of a deep dive into infection prevention and control than what you would hope they do. Here we have all of our new requirements and interpretive guidelines, the survey procedures, they're all pending, but I have included what was there before. I have a feeling they're going to be very similar to what Appendix A has said. So here are the interpretive guidelines. These are the ones from before, no longer on the website. You might want to keep an eye on these slides just to have them handy. Staff to make sure needs are met, a qualified director, again, education, experience, training. This is somebody who may need to be licensed by your state. So keep an eye on that. If swing beds, same thing, that we're following the parameters for nutritional status, like body weights and protein, we got them that far to swing beds, we don't want them to get sick and have to go back to inpatient. And as a swing bed, they also have to get that therapeutic diet if it's required. Follow all of those practices. Institute of Medicine, those four referenced. Again, it's the same interpretive guidelines that we covered in the acute. RDA, adequate intake, tolerable intake level, estimated average requirement. All of those were the same as for the acute. Patients have to be assessed. Do we need a therapeutic diet? Are there any nutritional deficiencies we weren't aware of? Any conditions or status, physical status, that they can't digest and absorb the nutrients? Signs and symptoms. Are they at risk for malnutrition? Is there a condition that affects their intake? Now, I wanna take one other thing you might wanna keep in mind here. Don't forget your social worker when you're developing some of these plans, because when they go home, how are we going to be able to maintain that nutritional status for them? And is food at issue, getting the availability of food access for them? So we're gonna be done really quickly today, so you guys will have a little extra time. I'm gonna just go into some of the professional organizations, their position statements, their guidelines. Your dieticians probably know this inside and out. Just make sure that if they're new to the role, that this is available. So here's the Academy of Nutrition and Dietetics at A&D. It talks about what they need to do, and their website is actually eatright.org. They have position and practice papers that you can download and utilize. Also, they talk about Nutritional Care Manual, covers 100 diseases and conditions. It includes pediatrics, our kiddos. Sports Nutrition Care Manual. If you have a lot of high schoolers that are coming in, and maybe they've had a really bad break in an extremity, what type of diet do we have that we can make sure we're getting that bone remodeling done? Practice papers, registered dietician, and privileges, examples of those privileges that perhaps you can tap into. There's an evidence analysis library, even evidence-based practice guidelines. So it's a really good resource for you. Another one is the Society for Nutritional Education, or SNEB. This one will give you just some of the resources for education for your patients and others. They even have it for food service professionals. So this would be that director of the food service, and the staff working down there. And the Society for Nutrition. Again, there's multiple resources out here. American Society for Parental and Adulteral Nutrition, when they can't eat, and it's gotta be some other resource. Healthy Plate. This is a really good one to use with your patients, and kind of tap them into this resource. Now, what do I need to help me get to be where I want to be? And just simply eat smart and eat right, what's available out there. So again, we're gonna be done way early today, Lindsay. So again, great for you folks, get you back to what you need to be doing. So here we have an 80-bed hospital, 10-bed behavioral health unit. This unit specializes in eating disorders. Our patients go from five to 60, and this is in the behavioral health unit. We have a patient admitted for anorexia and bulimia, six one and about 104 pounds. They have oral lesions, bleeding gums, absolutely refuse all food. Nope, not gonna eat. They did consent to a central line for TPN. All diet orders are done by qualified registered dieticians, state laws fine on it, everything. Well, sure enough, the surveyor shows up. Well, at that time they noted three other eating disorder patients were not improving. They weren't getting any better. And during the record review, sure enough, DS's record is pulled. And here's what they found. Physician wasn't even aware of the reference to TPN in the note. Now, how that happens, I can't answer. Neither could the hospital. No nursing assessment. In short, there were no I's and O's, no weights being done on this patient daily. There were no documentation, any communication between pharmacy and dietary. Now, I couldn't understand how that could happen because if the dietician is writing the orders for TPN, why wasn't there any other additional communication other than that order? Just to make sure everybody's on the right page, this is a severely cascadic individual. How they're still standing, I don't know. But at six some and only 100 pounds, that's a concern for just their health and wellbeing. What citations should they receive or could they receive, I should say? So while you're thinking about some of this, I do wanna let you know, I have 36 pages of resources. I'm not going through all 36 for you, but a lot of it is some of those I referenced. Get your dieticians, they probably already have some of these, but having a backup never hurts in case there's another avenue that they need to look at. So Lindsay, record time, is there any questions or how would you like to handle this last one? Perfect, no problem at all. I'm sure everybody will appreciate having some time to go back to your morning. I don't see any questions at this time. If you do have any questions related to the presentation for Laura, go ahead and be typing those in to either that Q&A option or the chat. We do have time to address those questions. And then if you would like to put any comments in the chat regarding this discussion question, I encourage you to go ahead and do that as well. So we'll wait and see if we have any questions here. Okay, I'd also be curious to see how many attendees have patients who, you can tell there's a food insecurity going on with these individuals, whether these are working class people or just working individuals who still have that food insecurity, or if that hasn't swayed one way or another, if there's not much change. And I only bring it up because now with some of the changes, our food bank here in my area has had to cut back on what they can make available. And I've been in that food bank and it's phenomenal how huge it is in the number of people they actually serve. And these are folks who desperately need this food just simply to survive, let alone be well and healthy. So I'd just be kind of curious if that is an issue with some of the attendees on just food insecurity within their communities and their patient populations. And if you have any comments related to that, go ahead and type that into the chat for us. I do see one question that came in, Laura, asking if there are any limitations with remote registered dieticians assessments and or recommendations. Nope, nope, they haven't made it. Just somebody needs to put eyes on them and make those assessments. Whether you do it by video, you can do it. I mean, CMS has not prohibited that, but someone has to do that assessment. That's why having that dietician, if it's remote by video, okay, they can do it just like a physician. No, there's no limitation on that that CMS has come out with. They just want it done. Perfect. Another question that just came in asking if there are any guidelines as to how long a patient can remain in POs. Nope, that's up to your physician. Because yeah, that's interesting. I know those of us who enjoy our meals, I am totally one of them. I'm worse than my cat. If I'm not fed at a certain hour, I'm going to get cranky, angry. I think it's the phrase. I haven't scratched, yeah, I haven't scratched, bit or meowed at anybody lately, but no, I know, I've heard about those diets where they talk about intermittent fasting and I learned the hard way. That's not me. I couldn't do it. No, I had to be fasting for some blood work and I got lightheaded. So yeah, I won't be doing that routine. Yeah. Okay, I don't see any other questions. Do you want to maybe go over this final discussion question here and then we'll do some closing comments. They got tapped on quite a few of them. Number one, of course, was the nursing care plan. The nursing assessment hadn't been done and then the care plan hadn't also been really updated. It was a very loose nursing care plan to begin with. As far as the physician not being made aware of that, this is the one where, again, the RD could go ahead and write the order, but she forgot to tell the physician that, oh yeah, this is what we're doing for TP. And I think the physician could read the chart and read it themselves, but really it's important to have that communication. Both of them are taking care of the patient and there needs to be that communication. So they did tap them on that one also. And the same with pharmacy. Why aren't you folks talking to each other? What is it? Pick up the phone, whatever it has to be that you can have that conversation with the pharmacist who's directing preparation of that TPN because there was no, that no one was aware other than what was in the chart. This patient wasn't getting better. And why was that? Why was that TPN not working? Did we need to do something different with that TPN? So they got about four or five citations that they did have to go back and work on the plan of correction. It was just a lot of it, an issue of communication that they hadn't been talking or communicating with each other that this is not happening. Now on the nursing care plan, that was just something that hadn't been done. That was just flat out, hadn't been done. We don't have time. Well, CMS doesn't like that excuse. They want you to have it done. It needs to be completed. And how long does it take to get a wait? Surely not very long. So they did have some, they did actually come back in six months for a repeat visit because with the number of patients, three, there was not a very large behavioral health unit, but with three patients, they were really concerned. So they did come back for another visit. So again, on some of these resources in the appendix is very basic on how to find the manual and keep up with things. And also I believe I put in here how you can find the deficiencies, yes. So if anyone needs help with that, Lindsay, have them reach out to you and then I'll kind of walk through on what needs to be done or any additional questions. Because yeah, that manual can be confusing at times. So thank you everyone. Thank you, Lindsay, for your help. I appreciate it. And- There are a couple other questions that came in, Laura, while we're going through that discussion question. And this first one says, for a critical access hospital swing bed unit, are there guidelines around food being brought in from the outside or should that be allowed? Yeah, you can allow it, sure. As long as it meets with their dietary regime. As long as there's no limitations on their diet, that's fine. Just as long as staff knows it, how are you gonna keep it at the right temperature? Where's it going to be stored? What kind of a refrigerator is it gonna be put in? Is it gonna be put in a separate patient refrigerator? Like some of the nursing homes, they have it that way. They have just for patients, only staff accesses. They put the food in, they label it and it comes back out. And so that we know it maintains that temperature. Same with cooking. Does it have to be warmed up? Who's going to do it? How will that be accomplished? But yeah, as long as it's not prohibited by their dietary requirements or regimen or order, yeah, absolutely. Go ahead and bring it in. Just remember, make sure you're following your infection prevention and control guidelines on keeping it stored and preparing and keeping it warmed up. Perfect, okay. And then this next question asks, our dishroom is needing to be revised. Is there a requirement to physically separate the clean from the dirty side? We currently have a physical wall and want to remove it to allow room to be more efficient. I'm wondering if that's possible. You're gonna, that could be a little tricky. Just think of it like, I always look at it like dirty and clean utility. Be very careful with that. A CMS may kind of look at that with the survey or look at that with a jaundice eye, so to speak. It's like, why is this happening? How can you ensure that division between clean and dirty? How's it going to occur? I'd be very careful if that's what you want to do. You might want to check with your own state on that one before you institute that decision. Okay, and then how do you service an ISO patient when delivering meals to their rooms as a food service contractor? That's a good question. Can they utilize nursing to help with that, to maintain that isolation and that everything is done appropriately? Again, look at your processes, just do a run through and say, where are we slipping on infection prevention and control? Because that's gonna be the big one. Okay, let's see. Usually the RD does not write a TPN order. We usually can recommend and the PharmD will write the orders. That's great. Yeah, that's totally acceptable. Yeah, PharmDs can also write the orders if that's what the hospital wants to do. And the state says they can do that too. We had some really great physicians, but they relied on our RDs, our PharmDs so much on a lot of the orders because they understood the medicine. It was sometimes that nutrition and interaction with the drugs that they needed that help. The patients really, we did see an improvement in our patients when they did start collaborating much more frequently than before. Okay, and then it looks like I have a couple more here. This one says for food service director foul, what type of training is looked for? Yeah, that they didn't spell out, unfortunately. That's why that food service slide, I had one for food service professionals. I would go to that resource and look there. And Lindsey, I can flip back up through the slides just to reorient to that particular, there. Here's your food service professional. There's another question as well that asks if you can give examples of education that they might need to follow. So that's a similar question. And right here, it talks about becoming that certified professional and also the education. It's right in there. I would look to that resource in finding out what education do they want that? What do they want for that director? Because CMS won't tell you. Big help, I know, but that's what they expect. Okay, wonderful. We had some great questions come in. Yes. I'm gonna give a couple of closing comments. So if you're typing a question, go ahead and type it and send it in. And we'll give you just a couple of seconds to do that. As I go over to some closing comments here, just as a reminder that you will receive an email tomorrow morning, but just note that it does come from educationnoreplyatzoom.us. And so if it's coming to you from that Zoom email, it very well may get caught up in your spam, your quarantine, your junk folders, anywhere but your inbox. So if you don't see that in your inbox in the morning, I do first encourage you to check those additional folders if it's still not there and you just like to access the reporting of today. You can, of course, just use the same Zoom link that you used to join us for the live presentation to also go back and access the reporting. And just remember that the recording is available via Zoom for 60 days from today's date. You will need to click on that link. It will ask you to enter your information and that will prompt an email to come to us for approval of that reporting access request. We do approve those very quickly, but we ask you to just give us one business day to grant those access requests. And also included in that email will be a link to the slides that Laura presented for us today. So you'll have all of these additional resources that she's included in that link there as well. And then if you are a member of the Georgia Hospital Association, I do encourage you to pay special attention to that final link that will be in that email in the morning. And that link will take you to the new GHA Learning Academy where you can complete the evaluation and obtain your continuing education credits and certificate of attendance from today's presentation. And if you are joining us as a member or a partner of State Hospital Association, I encourage you to reach out to your contact within your association to obtain any information they have for you regarding CEs as well. Okay, I don't see any other pending questions as Laura mentioned earlier. If you do have any additional questions, you can always reach out to us at education at gha.org. And I'm happy to work with Laura to get those questions over to her and the responses back to you. Thank you, Laura, as always for your time and information that you shared with us. Thank you all for joining us and for your questions. I hope you found the information to be valuable and I hope you all have a wonderful afternoon. Thank you so much, Laura. Thanks everyone. Thank you, Lindsay. Bye-bye.

risk management

patient safety

dietary standards

nutrition

patient recovery

dietician

food handling

healthcare guidelines

nutritional care