Dealing with deficiencies a recipe for success.

It's 9:30 a.m. on a Tuesday and the survey team has just pulled into the parking lot. Word of its arrival spreads quickly through the facility. The question is whether the staff is fully prepared or is standing with chills down its collective spine.

For the food and nutrition services department, the survey entails a thorough inspection of the kitchen and selected medical records. In the kitchen, surveyors observe overall sanitation, safe food practices in production areas, therapeutic diets and portion control. For the clinical staff, the survey process is more daunting with a scrupulous review of medical records to ensure that assessments are accurate, timely and that clinical judgement is optimal in each case. Standing up to the rigors of this annual process presents a challenge, unless you are ready for it every day of the year.

The food and nutrition services industry has recipes for everything, but not all facilities have recipes for successfully completing the annual recertification survey of the kitchen and facility. Following such policies enables the facility to improve production efficiency, maintain product consistency and quality, and save on food costs and reduce waste.

Such a recipe is of supreme importance since nutrition-related deficiencies are among the most commonly cited nationwide. Every year, nutritional deficiencies make the list of the top 10 deficiencies cited at U.S. long term care facilities. The recipe for keeping your facility from repeating such deficiencies requires an approach similar to successfully completing the audit process.

The national top 10 deficiencies list has not changed too dramatically over the past several years. Pressure ulcers, food safety and sanitation, therapeutic diets not meeting assessed needs, and hydration issues are hot targets of both state and federal surveyors. The old saying of "an ounce of prevention is worth a pound of cure" sums up the best plan of action to avoid these and all other deficiencies.

There are three major ingredients in the survey success recipe: a strong evaluation/quality improvement program, staff education and communication. Digna Cassens, a corporate dietitian with Country Villa Health Services in southern California explained, "Survey readiness is not a temporary, one-time event. You have to be ready 365 days a year, 24 hours a day."

From the top administrator down throughout the leadership chain, a facility works hard to maintain compliance with policies and procedures on a 24/7 basis. From the proper cooling of a top round of beef, assessing nutritional needs of a resident with a stage III pressure ulcer, or to the proper fire safety protocols, in doing things the right way it will be habit and require little thought as to what the proper steps are.

Inconsistencies in recorded temperatures, nutrition assessments, and verbal answers can lead to deficiencies. Survey readiness should be an ongoing process, as your facility needs to be in order at all times. The process should include copious staff education, and scrupulous evaluation with the most critical eye.

The number of facilities that "gear up" for surveys can surprise even the most experienced consultant. What is not a surprise, however, is that these facilities generally do not fare well on surveys. A facility cannot undo 11 months of mistakes in one month of "gearing up" for the big day.

Thorough assessment. For survey success, "one must be very critical of one's own systems," said Valerie K. Smith, dietitian of Charlotte Hall Veteran's Home in Maryland. Smith went on to say that self-auditing and knowing your weaknesses is of extreme importance. Facilities must be using the MDS, care planning, quality indicators and quality measures proactively, not reactively. These tools were created to help those of us in the industry, as well as the potential consumers of our services.

Identifying your facility's weak areas and doing something about them internally is a boost survey teams can offer. If they find a problem that you didn't know you had, you are dead in the water. However, most survey teams will acknowledge the problem in a lighter manner or not at all if they know you have identified both the problem and a course of action to correct it. "Presurvey audits and educating staff on the survey process and expectations can go a long way to building confidence during the stressful times," said Anita Sigmon, consultant dietitian at Britthaven of Morganton in North Carolina.

Staff education. It is important that staff know the ramifications of surveys--both good and bad--and that they also know what is expected of them during the visit. Staff education is an ongoing process as the job turnover rates can be particularly high for foodservice workers. While food service workers do not need an in-depth course on the survey process and each of the regulations, they do need to know how the regulations translate into each of the steps and jobs they carry out throughout the day.

The best way to convey this is with concrete examples and the reason behind each step. For example, the top round of beef needs to be properly thawed, cooked, quartered, cooled, portioned and reheated, to reach and maintain the proper temperatures for each step to prevent food-borne illness, and to assure a quality product, at the point of service, to meet the nutritional needs of the residents.

Attempting to teach without giving the reason for the action will not drive home the importance of the action so that it will be done repetitively in the correct way. Regardless of whether we are training food service workers, clinicians or other nursing home staff, having an understanding

of why things need to be done in a certain way will greatly improve the level of compliance to that policy or procedure.

Communication. The last ingredient in the recipe for success is communication. It has been estimated that 99 percent of all deficiencies have roots in miscommunication. One of the most common miscommunications that occurs with nursing facilities is when policies are revised and not everyone who needs to know is made aware. There are simple steps that can be put into place to assure communications are complete, but no system is fail-proof. It is best to be on the alert for the potential for this to occur to reduce the chance, and to have one person responsible for the main communication of policy changes and updating policy books with the revised copies.

Through quality improvement audits of the MDS and care plans, medical record audits guided by the quality indicators and quality measures for your facility, education and observation of the staff in action, and communication you can decrease staff anxiety and improve outcomes. The table below provides some key points in avoiding nutrition related deficiencies. For further direction, consult your state operations manual for the guidance to surveyors. This information is most useful as it is what the surveyors will use to determine your level of compliance to the regulations.

PREVENTING NUTRITION-RELATED DEFICIENCIES

* Review policy and procedure manuals annually;

* Train staff regularly on correct procedures or on any policy that has changed;

* Enforce proper policies/protocols and back up with disciplinary action as needed;

* Have foodservice employees who are food safety and sanitation certified;

* Have ordering, receiving, storing, thawing, cooking, serving, and cooling protocols in place;

* Use standardized recipes;

* Have menus and spreadsheets for therapeutic diets reviewed by the registered dietitian;

* Follow the planned menu and note when substitutions occur and why;

* Keep records of freezer, cooler and dishmachine temperatures;

* Serve meals in an attractive manner at the appropriate temperatures and with proper portions and garnishes;

* Offer substitutions and alternatives that are nutritionally equivalent to the main meal;

* Make sure assessments reflect the current status of the resident and are updated as necessary;

* Make sure the residents who need adaptive devices or assistance with meals get it--and in a timely manner;

* Have assessment policies that are in accordance with accepted guidelines;

* Complete assessments, MDS's and careplans in a timely manner

* Have a fortified food program;

* Have documentation for meal, fluid, supplement and HS snack consumption available;

* Have a hydration risk assessment and intervention program;

* Have a nutrition risk assessment and intervention program;

* Be sure that everyone knows who is on any high risk program;

* Update care plans with any change in resident status or interventions;

* If interventions aren't working, change them;

* Always be prepared--for anything.--CH