Dietary, Food and Nutrition Services; Meeting the CMS Hospital and CAH CoPs, DNV Healthcare and TJC Requirements

Product Id : HE255
Instructor : Sue Dill Calloway
Feb 03, 2020 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 90 Minutes

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Come learn about the CMS hospital CoPs on dietary, food, and nutrition services.  CMS previously made 3 changes to the dietary guidelines for hospitals and rewrote all the dietary guidelines for critical access hospitals that went into effect April 1, 2015 with an amendment November 29, 2019. Some hospitals are still working to ensure compliance.

This program will discuss the CMS hospital conditions of participation requirements for dietary and food and nutrition services. It is an important part of the CMS survey and this area has received increased scrutiny of their standards especially in the area of Infection control.

CMS has issued a deficiency report. This program will cover the common deficiencies received by hospitals from CMS in this area. Do you know which ones are the top problematic standards?

CMS will now permit the Medical Staff and Board to credential and privilege qualified dieticians and qualified nutritional specialists to order the patient’s diet. This includes therapeutic diet, supplemental feeding and enteral nutrition. CMS has provided additional information about the C&P process for dieticians and this issue will be discussed in detail.

This program will also cover the Joint Commission provision of care chapter standards related to dietary and the TJC dietary tracer information. The tracer is used to assess and determine the degree of compliance with standards and elements of performance related to nutrition care. The tracer used through dietetic and food services covers some of the same issues discussed during the CMS survey.

This webinar will discuss the DNV Healthcare dietary standards.

CMS Food and Dietetic Services CoP Topics

  • Final regulations on credentialing and privileging qualified dieticians and qualified nutritional specialist
    • C&P to order patient diets
    • Can be with or without appointment to the MS
    • State law and hospital policy
    • State scope of practice
    • Must be C&P by MS and board
  • How to obtain current copy of CoP manual
  • Proposed  changes rea dieticians ordering patient diet
  • Ways to keep up with CMS changes
  • Starts at tag number 618
  • 3 tag numbers changes and one deleted (Tag 628, 929, and 630)
  • Organized dietary services
  • Director and qualified dietary staff required
  • Must meet nutritional needs of patients
  • Policies required
    • Diet manual availability, frequency of meals served, system for diet ordering and tray delivery, accommodation of non-routine occurrence, acceptable hygiene practices, kitchen sanitation etc.
  • Same standards whether or not by contracted services
  • Director who is full time and qualified
    • List of responsibilities to include in job description
    • Approve patient menus and nutritional supplements, patient dietary counseling, collaborating with other staff, maintaining patient data to recommend, prescribe, or modify therapeutic diets etc.
  • Policies and procedures include
    • Safety practices for food handling, emergency food supplies, orientation, work assignments, menu planning, purchasing of foods and supplies etc.
  • Survey procedure questions
  • Diets and menus to meet the needs of patients
  • Therapeutic dies and guidelines
  • Nutritional needs in accordance with recognized dietary practices
  • Current therapeutic diet manual approved by MS and dietician
  • CMS third revised hospital worksheet on infection control
  • Infection control important in dietary

TJC Provision of Care Standards related to Dietary

  • Nutritional Screen
  • Time frame for screens
  • Food and nutrition
  • Person responsible for food and nutrition services
  • Proper sanitation, temperature, etc of food and nutrition
  • What to do if patient refuses food
  • Accommodation of special diets
  • Accommodation of ethnic food and nutrition preferences
  • Storage of food and nutrition
  • Therapeutic diet manual
  • Patient education on nutritional interventions, diets, supplements

Topics Discussed Throughout the Patient Tracer Activity

  • Assessment, care planning
  • Instructions by qualified staff
  • Identification and nutrition risk
  • Nutrition screening criteria
  • Time frames for nutrition assessment and re-evaluation
  • Measuring food consumption
  • Special population needs such as NPO, on vents, in isolation, getting hyperalimentation
  • Procedure to follow if patient refuses meals
  • Discharge education and referrals
  • Communications between dietician and food services

Dietary and food services day to day operation information

  • Director of dietary qualifications
  • Responsibilities of dietary and food services leaders
  • Emergency/disaster plans
  • Hospital diets and menus
  • Food preparation and storage
  • Safe food handling and health of food service staff
  • Contracts for services, food, nutrition support supplies and formulas
  • Sanitation and infection control (pest control, chemicals)
  • Quality improvement activities etc.

Who Should Attend:

  • Dietary staff
  • Joint Commission liaison or accreditation director DNV Healthcare
  • CMS or regulatory staff
  • Dieticians

Director of dietary

  • Compliance officer
  • Chief Operating Officer
  • Chief Nursing Officer
  • Nurses and nurse managers
  • Nurse educator
  • Chief Medical Officer
  • Medical staff  and MS department staff
  • Anyone else responsible for complying with the CMS, DNV Healthcare or Joint Commission standards that affect dietary and nutrition services
Speaker Profile:

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of legal services at a community hospital in addition to being the privacy officer and the compliance officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well-known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.

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