Donna Manring DTR
revised surveyor guidance for surveying Nutrition (F325) and Sanitary
Conditions (F371) requirements in long-term care facilities became
effective on September 1, 2008. The revised guidance clarifies areas
such as assessment, care planning, and interventions related to
nutrition and sanitary conditions for nursing home and long-term care
residents. However, since these revisions deal with food, food
handling and the prevention of foodborne illnesses, they will have an
affect on almost everyone in your facility.
The remainder of
this article will outline the basic intent, protocols, and deficiency
categorizations of these revisions. It will also offer some ways for
you to achieve and maintain compliance.
With regard to the revised guidance F325 Nutrition, there
have been significant changes. Specifically, F325 and F326 were
merged. The intent of this guidance is to ensure that facilities
maintain acceptable parameters of nutritional status, such as body
weight and protein levels; unless the resident's clinical condition
demonstrates that this is not possible. Every resident must also
receive a therapeutic diet when there is a nutritional problem.
The protocol below will be
used by surveyors for each sampled resident:
To determine if
residents maintained acceptable parameters of nutritional status,
relative to his/her comprehensive assessment.
For a resident
who did not maintain acceptable parameters of nutritional status, to
determine if the facility assessed and intervened (e.g., therapeutic
diet) to enable the resident to maintain acceptable parameters of
nutritional status, unless the resident's clinical condition
demonstrated that this was not possible.
For a resident who is
at nutritional risk, to determine if the facility has identified and
addressed risk factors for, and causes of, impaired nutritional
status, or demonstrated why they could not or should not do
include the following examples of severity determinations:
4 - Immediate Jeopardy
Substantial and ongoing decline in food
intake resulting in significant unplanned weight loss due to dietary
restrictions or downgraded diet textures (e.g., mechanic soft,
pureed, etc.) provided by the facility against the resident's
Development of life-threatening
symptoms or the development of continuation of severely impaired
nutritional status due to repeated failure to assist a resident who
required assistance with meals.
Level 3 - Actual Harm that
is Not Immediate Jeopardy
Loss of weight from declining food
and fluid intake due to the facility's failure to assess and address
the resident's use of medications that affect appetite and food
Decline in function related to poor food/fluid intake
due to the facility's failure to accommodate documented resident food
dislikes and provide appropriate substitutes.
Level 2 - No
Actual Harm with Potential for More than Minimal Harm that is Not
Failure to obtain accurate weights and to
verify weights as needed.
Poor intake due to the facility's
intermittent failure to provide required assistance with eating,
however, the resident met identified weight goals.
provide additional nourishment when ordered for a resident, however,
the resident did not experience significant weight loss.
1 - No Actual Harm with Potential for Minimal Harm
of the facility to provide appropriate care and services to maintain
acceptable parameters of nutritional status and minimize negative
outcomes places residents at risk for more than minimal harm.
Therefore, Severity Level 1 does not apply for this regulatory
Taking a Team Approach to Tackle Tag
Although many nursing homes and long term care facilities
hand the management of nutritional issues to dietitians, this revised
guidance makes the point that nutrition management should address
those issues that affect eating and nutrition, which encompasses
facets and processes beyond just the dietitian. Therefore, your
facility should identify key individuals who should participate in
the assessment and evaluation of nutritional status and related
causes and consequences. For example, nursing staff can provide
details about the resident's nutritional intake. Healthcare
practitioners (e.g., physicians and nurse practitioners) can help
define the nature of the problem (e.g., whether the resident has
anorexia or sarcopenia), identify the causes, and tailor
interventions to the resident's specific causes and situation.
Consultant pharmacists can help the staff and practitioners identify
medications that affect nutrition by altering taste or causing dry
mouth, lethargy, nausea, confusion, etc. Qualified dieticians should
still help to identify nutritional risk factors and recommend
nutritional interventions, based on each resident's medical
condition, needs, desires, and goals.
Whichever staff members
you designate to address resident/patient nutrition, to remain
compliant with this revised guidance, you should abide by these four
Nutritional assessment: It's critical to
identify a resident's desirable weight range and identify any weight
loss or gain. Determine if the resident's weight and nutritional
status were assessed in the context of his/her overall condition and
prognosis, if nutritional requirements and risk factors were
identified, and if causes of the resident's nutritional risks or
impairment were sought. In addition, you need to determine whether
there have been significant changes in the resident's overall intake.
Nutritional diagnosis: Designated healthcare professionals
must identify the significance of any weight changes and suggest the
interventions that are needed.
Nutritional intervention: Once an
intervention is suggested, specific healthcare professionals must
follow through and implement the changes.
Designated professionals should collaborate with other disciplines to
revisit previous steps to reassess, add, or revise nutrition
intervention strategies and/or evaluate additional
Sanitary Conditions - F371
The intent of
this requirement is to ensure that facilities obtain food for
resident consumption from sources approved or considered satisfactory
by federal, state or local authorities. Facilities must also follow
proper sanitation and food handling practices to prevent the outbreak
of food borne illness.
protocol below will be used by surveyors for each sampled
To determine if the facility obtained food safe for
consumption from approved sources.
To determine if the
facility stores, prepares, distributes, and serves food in a sanitary
manner to prevent food borne illness.
To determine if the
facility has systems (e.g., policies, procedures, training, and
monitoring) in place to prevent the spread of food borne illness and
minimize food storage, preparation and handling practices that could
cause food contamination and could compromise food safety.
determine if the facility utilizes safe food handling from the time
the food is received from the vendor and throughout the food handling
processes in the facility.
guidelines include the following examples of severity
Level 4 - Immediate Jeopardy
meat thawing on a plate in the refrigerator had juices overflowing
and dripping onto uncovered raw vegetables on the shelf below. The
contaminated vegetables were not discarded and were used to make
salad for the next meal.
Observations and interviews indicate
that food service staff with gastrointestinal illnesses was permitted
to prepare food.
Level 3 - Actual Harm that is Not
Outbreak of nausea and vomiting occurs in
the facility related to the inadequate sanitizing of dishes and
Level 2 - No Actual Harm with
Potential for More than Minimal Harm that is Not Immediate
During the initial tour of the kitchen, two food
service workers were observed on the loading dock. One was smoking
and the other employee was emptying trash. Upon returning to the
kitchen, they proceeded to prepare food without washing their
A Great Resource for F371
approach to preventing foodborne illness is the use of Hazard
Analysis and Critical Control Point (HACCP) Principles. A HACCP plan
involves identifying hazards (biological, chemical, or physical) at
specific points during food handling and preparation and identifying
how the hazards can be prevented, eliminated or reduced to a safe
level. HACCP focuses attention on the risks that are associated with
foodborne illness by identifying critical control points (CCPs) in
the food preparation processes that, if not controlled, might result
in the food being unsafe to eat. Some operational steps that are
critical to control in long-term care facilities and nursing homes to
prevent or eliminate food safety hazards are cooking, cooling,
holding, reheating of foods, and employee hygienic practices.
sites for additional information regarding HACCP, foodborne illness,
safety recommendations, and FDA (Food and Drug Administration) Food
Code guidelines can be found at:
The United States Food &
Drug Administration Hazard Analysis Critical Control Point Web sites
General Strategies for Both Revisions
addition to the tips above, there are some general strategies you can
follow that will help you to remain compliant:
Make a plan.
Create a plan that details who is responsible for what items. Be sure
to include action steps, deadlines/milestones, and goals. For
example, you could pass out a study guide, (action step) quiz team
members two weeks later (deadline) with the goal of 95 percent or
higher of correct answers (goal).
Provide formal training.
Ensure that all staff members who will participate in surveyor
assessments receive formal training from recognized experts. Also,
ensure they have the most up-to-date instruction manual and revisions
at all times.
Create a team of individual section
specialists. Solicit volunteers among the staff to become the
experts on the various new items. Each of these specialists would
provide additional mentoring and support to other team members with
regard to the specialty item and would act as a resource person on
that item on a continuing basis.
Practice. Conduct mock
interviews and surveys. It will provide you and your team with a
script to use, and it will also help to prepare and inform residents.
Also, it would be wise to time the interviews you do, so you can
begin to have an idea of how long they are going to take. This can be
extremely helpful when your staff needs support and guidance about
Healthcare rules are regulations are
ever-changing. Although you can't always predict what is going to
change and when, you can always prepare yourself and your staff. By
adopting the tips and strategies above, your healthcare staff will be
ready to shine through at survey time.