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Donna Manring DTR

The 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.

Nutrition - F325
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.

Investigative Protocol
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 so.

Deficiency Categorizations
The guidelines include the following examples of severity determinations:

Level 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 expressed preferences.

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 intake.

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 Immediate Jeopardy
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.

Failure to provide additional nourishment when ordered for a resident, however, the resident did not experience significant weight loss.

Level 1 - No Actual Harm with Potential for Minimal Harm
The failure 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 requirement.

Taking a Team Approach to Tackle Tag F325
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 main processes:

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.

Nutritional monitoring/evaluation: Designated professionals should collaborate with other disciplines to revisit previous steps to reassess, add, or revise nutrition intervention strategies and/or evaluate additional outcomes.

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.

Investigative Protocol
The protocol below will be used by surveyors for each sampled resident:

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.

To 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.

Deficiency Categorization
The guidelines include the following examples of severity determinations:

Level 4 - Immediate Jeopardy
Raw 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 Immediate Jeopardy
Outbreak of nausea and vomiting occurs in the facility related to the inadequate sanitizing of dishes and utensil

Level 2 - No Actual Harm with Potential for More than Minimal Harm that is Not Immediate Jeopardy
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 hands.

A Great Resource for F371
One effective 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.

Web 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 at:

Operator's Manual

Regulator's manual

General Strategies for Both Revisions
In 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 these interviews.

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.

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