Long Term Care Food Service Management

Bid Packet LaSalle County Nursing Home Long Term Food Service 30 Sealed Bids Accepted Until: 7/9/21 2:00pm Senay Rican REQUEST FOR BID Long Term Food Service Management at LaSalle County Nursing Home The LaSalle County Board, through the LaSalle County Nursing Home & VAC, is hereby requesting bids for long term care food service management at the facility located at 1380 North 27th Road, Ottawa, Illinois. All bidders must attend a mandatory live WebEx meeting (Details regarding meeting will be in Bid Packet) on June 17th, 2021 at 10:30am to discuss any questions you may have and to tour the dining service area. WebEx Information: Call: 415-655-0001 Access Code: 173 812 2511## Bid Packets will be available online at www.lasallecounty.org website under the tab Bids/RFP. Sealed Bids shall be received at the LaSalle County Board Office (707 E. Etna Road #245, Ottawa, IL) until 2:00 pm on July 9th, 2021. Bids

will thereafter be opened at LaSalle County Nursing Home & VAC Committee meeting at 9:00 a.m. on July 12th, 2021 at the LaSalle County Governmental Complex, 707 E. Etna Rd., Room #250, Ottawa, Illinois, or as soon thereafter as possible. NO FAXES OR EMAILS OF BIDS WILL BE ACCEPTED AND WILL BE GROUNDS FOR AUTOMATIC ELIMINATION FOR CONSIDERATION Two (2) Original Bids are to be submitted (with agreement/contract signed in blue ink) along with Eleven (11) copies, and one electronic copy on a cd/flash drive for the permanent records of the County of LaSalle and LaSalle County Nursing Home. The selected bidder shall provide certificate of insurance establishing compliance with LaSalle County Resolution No. 10-141 A Resolution Imposing Minimum Insurance Requirements. (A copy of said resolution will be included in Bid Packet). LaSalle County reserves the right to reject any and all proposals, to waive any irregularities in the process, and to award the contract as may be determined to be in LaSalle Countys best interests. For further information regarding this request for Bid, contact Nursing Home Administrator, Carrie Becker at 815-434-0476. LaSalle County Board LaSalle County Nursing Home & VAC Committee http://www.lasallecounty.org/ BID REQUEST FOR: LONG TERM FOOD SERVICE MANAGEMENT LASALLE COUNTY, ILLINOIS LaSalle County Nursing Home & VAC Committee 1380 North 27th Road Ottawa, IL. 61350 (815) 433-0476 2 Bid Request for Long Term Food Service Management Request Issued By: LaSalle County Nursing Home & VAC Committee Contact Person: Carrie Becker Title Administrator Address: 1380 North 27th Road City/State/Zip Ottawa, IL 61350 Phone Number 815-433-0476 SEALED BIDS WILL BE ACCEPTED UNTIL: Date : July 9th, 2021 Time: 2:00 pm Number of Copies of BID: Number of Copies of Bids Response to be Submitted: Twelve (12) and 1 CD/Flash drive BID OPENING DATE: Date : July 12th, 2021 Time: 9:00 am or as soon thereafter as possible BID RECOMMENDED DATE: Date : August 9, 2021 BID AWARD DATE: Date : August 12th or September 13, 2021 Time: 1:00 pm or as soon thereafter as possible PROJECT START DATE: Start Date: December 1, 2021 Sealed Bids for providing long term food services described in the Bid Request Packet will be available at www.lasallecounty.org website under Bids/RFP . Any bid received thereafter and any bid received who did not attend the mandatory WebEx tour will be returned unopened. http://www.lasallecounty.org/ 3 BID REQUIREMENTS - Long Term Care Food Services Management INTRODUCTION The LaSalle County Board, through the LaSalle County Nursing Home & VAC, is hereby requesting bids for its facility with a 79 bed capacity located at 1380 North 27th Road, Ottawa, Illinois, for the retention of a long term food service management company to provide management and culinary services for a high quality, cost effective, nutrition service system. The successful bidder will be responsible for food procurement, food preparation, maintaining supply inventory and staffing for all administrative and operational functions described herein. The Bid seeks an initial contract for a period of one (1) year with a tentative commencement date of December 1, 2021. Two (2) one-year extensions beyond the initial term will be subject to the mutual agreement of the County and the successful Bidder. For the purposes of this BID, the Successful Bidder will be referred to as a Contractor and LaSalle County, Illinois shall be referred to as the LaSalle County Nursing Home. BID PRICE LaSalle County Nursing Home requires a financial bid to manage its nutrition services operations. LaSalle County Nursing Home is open to a variety of financial structures that will best meet the needs of the facility and the County of LaSalle. Bid Price to be based on below: Average Daily Census Monthly Service Fee Yearly Service Fee Total 41-60 61-80 This tier may be billed by Average Daily Resident Census for the month. BID EVALUATION LaSalle County Nursing Home will accept the bid it deems to be in the best interest of the LaSalle County Nursing Home based on all factors stated herein, and not solely on cost. LaSalle County Nursing home reserves the right to reject any or all bids. The Bid award shall be based on, but not necessarily limited to, the following factors: Adherence to all conditions and requirements of the Bid General reputation and experience of the Contractor Bidders ability to service LaSalle County Nursing Home The nature and extent of the companys knowledge of Illinois and the Federal regulatory standards for Long-Term Care Facilities/Nursing Homes. The quantity and quality of merchandise offered Experience in providing long term food service management services in a healthcare environment Failure to meet a material requirement of the Bid request documents will constitute sufficient reason for rejection of any bid. LaSalle County Nursing Home reserves the right to waive any informality or minor defect where the acceptance, rejection, or waiving of such is in the best interests of LaSalle County Nursing Home. 4 LaSalle County Nursing Home reserves the right to disqualify any Bid, before or after opening, upon evidence of collusion, intent to defraud, or any other illegal practice on the part of the bidder. OBJECTIVES To select a professional long term food service management firm and enter into a contract that will meet the following objectives: A. To deliver high quality long term food service that meets or exceeds the Standards of Illinois and Center for Medicare/Medicaid Services (CMS) regulatory standards as well as the expectations of LaSalle County Nursing Home and provides wholesome, healthy meals per the dietary requirements of all residents. B. To operate as an Independent Contractor in a cost-effective manner with the reporting and accountability to the administrator or his/her designee. C. To maintain a cooperative, collaborative relationship with the administration and staff of the LaSalle County Nursing Home. D. To maintain complete and accurate records of meals served and expenses for the purpose of providing a monthly report and invoice to The Administration of the LaSalle County Nursing Home. QUALIFICATIONS To be considered for award of this contract, the following minimum qualifications must be met and fully outlined and explained in the Bid: A. The Contractor must be organized for the purpose of providing long term food service management within healthcare facilities and must have previous experience with proven effectiveness in the installation and maintenance of high quality services similar to that required as described herein. B. The Contractor must have a proven ability as evidenced by past performance and current resources and personnel to execute a contract for services beginning on or about December 1, 2018. The Contractor firm must have a central office that is capable of providing satisfactory provisions of services to the onsite operations. C. The Contractor must possess and maintain in force all required licenses, permits, or certificates required by law. D. The Contractor must be able to provide a minimum of three references where healthcare long term food service is provided in similar facilities. 5 SCOPE OF WORK Long Term Food Service The successful bidder will be expected to provide the following services as part of the long term food service management program: 1) Management Staff Contractor will provide all necessary staff for the length of the contract. Staffing is defined as all management/supervisory and hourly personnel to execute the daily service requirements. This will include a qualified Director for the Dining Services Department. The Director for the Dining Services will work at a minimum of 40 hours each week. The Director shall be either a dietitian or a dietetic service supervisor and shall meet all the requirements of the Illinois Administrative Code, Title 77, Chapter I, Subchapter c, Part 300, Section 300.2010, for a Director of Long Term Food Services. 2) Meals LaSalle County Nursing Home currently serves three (3) meals per day to its long term care and rehabilitation care population. Resident meals are served in one dining room. Provide three (3) meals a day to residents and/or guests/staff breakfast, lunch and dinner as well as supplements, nourishments and floor stocks as needed. Meal delivery shall be set at a time mutually agreed upon between the bidder and nursing home administration. Meal program shall be a hot breakfast, hot lunch and a hot dinner meeting all nutritional requirements. Meals must be nutritionally balanced, tasteful and aesthetically appealing. Special diets are often medically required for residents; the Contractor will be required to accommodate those special diets and shall have proven systems and processes in place to implement and monitor such diets. Contractors shall identify if needed additional costs for such special diets. Sealed Bids must include sample menus to be served for a period of at least four (4) weeks. 3) Billing The Contractor shall issue one invoice on a monthly basis to be submitted to the attention of the Administrator specifying the number of meals provided and management related expenses. After approval and verification of a submitted invoice, payment will be made within thirty (30) days. 4) Equipment and Facilities LaSalle County Nursing Home will provide, maintain and permit the Contractor to use the capital equipment owned by LaSalle County Nursing Home. The Contractor shall take all reasonable measures necessary to assure LaSalle County Nursing Home that its equipment is being properly used and maintained. The Contractor will be responsible for repair or replacement of any damaged equipment due to negligence its employees. LaSalle County Nursing Home will provide preventative maintenance and repair service on all LaSalle County Nursing Home owned equipment. 5) Supplies The Contractor shall procure all supplies for the preparation of meals through Contractors group purchasing agreement. Equipment deemed necessary to prepare meals will be supplied by LaSalle County Nursing Home. The Contractor is responsible for the small ware: knives, glasses, cups, etc. 6 6) Security Contractor employees will follow established security procedures and will take direction from the long term care staff in emergency situations. 7) Sanitation The Contractor will obey all Federal, State and local laws and ordinances regarding health, sanitation and safety. 8) State of Illinois Regulatory Standards The Contractor shall assure that the nutrition services operation is in compliance with the standards set by the State of Illinois and the Centers for Medicare& Medicaid Services (CMS). Documentation of menus as they are actually served must be maintained and submitted on a regular cycle per regulatory requirements. 9) Nutritional Requirements Menus shall be received and approved by the Contractors Registered Dietitian experienced with healthcare menus and will be adjusted according to the recommended dietary allowances stated by the State of Illinois. 10) Special Diets Therapeutic diets shall be available upon medical authorization. Specific diets shall be prepared and served to residents according to the orders of the responsible health authority. Special diets for religious reasons will be accommodated as directed by the policies of the nursing home. 11) Dietitian Services Contractor will provide, as needed, clinical dietitian services; in addition the LaSalle County Nursing Home may contract the services of a clinical dietitian at its own cost to review dietary services of the LaSalle County Nursing Home. GENERAL REQUIREMENTS Standard Terms and Conditions SPECIFICATIONS: The specifications in this request are the minimum acceptable. LaSalle County Nursing Home shall be the sole judge of equivalency. Bidders are cautioned to avoid bidding alternates to the specifications which may result in rejection of their Bid. DEVIATIONS AND EXCEPTIONS: Deviations and exceptions from terms, conditions, or specifications shall be described fully, on the Bidders letterhead, signed and attached to the request. In the absence of such statement, the Bid shall be accepted as in strict compliance with all terms, conditions, and specifications and the Bidder shall be held liable. ACCEPTANCE-REJECTION: LaSalle County Nursing Home reserves the right to accept or reject any or all bids, to waive any technicality in any Bid submitted and to accept any part of a bid as deemed to be in the best interests of LaSalle County Nursing Home. SEALED BID MUST be received on or before the date and time as set forth above. Bids received after dated and time stamped will be rejected. Receipt of a bid by the mail system does not constitute receipt of a bid by LaSalle County Nursing Home. SEALED BID shall be submitted on Bidders letterhead and signed by an officer of the company. SEALED BID shall be marked on the outside Long Term Food Service Management Services BID, Attention: LaSalle County Nursing Home Administrator and include Company Name, Contact Name and phone number. 7 ENTIRE AGREEMENT: These Standard Terms and Conditions shall apply to any contract or order awarded as a result of this request except where special requirements are stated elsewhere in the request; in such cases, the special requirements shall apply. Further, the written contract shall constitute the entire agreement and no other terms and conditions in any document, acceptance or acknowledgement shall be effective or binding unless expressly agreed to in writing by the contracting authority. APPLICABLE LAW: The Contractor shall at all times comply with and observe all federal and state laws, local laws, ordinances and regulations which are in effect during the period of this contract and which in any manner affect the work of its conduct. This contract shall be interpreted in accordance with the laws of the State of Illinois. The parties shall agree that venue for any legal action brought under this agreement shall be brought only in the LaSalle County Circuit Court, Thirteenth Judicial Circuit, Ottawa, Illinois. ASSIGNMENT: No right or duty in whole or in part of the Contractor under this contract may be assigned or delegated without the prior written consent of LaSalle County Nursing Home. SUBCONTRACTORS: If subcontractors are planned to be used, this should be clearly explained in the Bid. LaSalle County Nursing Home reserves the right to reject any subcontractor. However, the primary Contractor will be responsible for contract performance whether or not subcontractors are used. NONDISCRIMINATION: In connection with the performance of work under this agreement, the successful bidder agrees not to discriminate against any employees, applicant for employment, or actual or potential recipients of services because of age, race, religion, color, marital status, sexual orientation, sex, handicap, as defined in Section 504 and the American with Disabilities Act (ADA) developmental disability, or national origin. BACKGROUND CHECKS: Any employees of said Contractor must complete criminal background checks in compliance with Illinois Department of Public Health Rules and Regulations. It will be the responsibility of the Contractor to assure that said background checks have been performed. The information obtained from said background checks must indicate that the employee would not pose a risk when working with vulnerable adults. SAFETY REQUIREMENTS: All materials, equipment and supplies provided to LaSalle County Nursing Home must comply fully with all safety requirements as set forth by the Illinois Administrative Code, Rules of the Industrial Commission on Safety, and all applicable OSHA standards. HOLD HARMLESS: Contractor shall indemnify Client, its Elected County Officials, Employees, Agents, and Assigns (Client Group) against any loss, damage, injury or death caused by Contractors negligent acts or omissions of Contractors agents or employees, or losses, damages, injuries or death caused by Contractors negligence including those arising out of the consumption or use of the products sold; and Client shall defend and indemnify Contractor for losses, damages, injuries or death arising out of the negligence of Client Group. Contractors obligation to hold Client harmless pursuant to the Agreement shall be dependent upon Client promptly notifying Contractor in writing of any such claims or lawsuits against either Contractor or Client and forwarding to Contractor the summons, complaint and all other documents which relate to said claim or lawsuit. 8 INSURANCE RESPONSIBILITY: The Contractor performing services for LaSalle County Nursing Home shall comply with the insurance requirements contained herein. Selected bidder shall provide a Certificate of Insurance establishing compliance with LaSalle County Resolution No. 10- 141 A Resolution Imposing Minimum Insurance Requirements. Contractor shall provide its own insurance, countersigned by an insurer licensed to do business in the State of Illinois, covering the period of the agreement/contract indicating that Contractor is insured under professional liability insurance in an amount not less than minimum amount required by Resolution #10-141. CANCELLATION: LaSalle County Nursing Home reserves the right to cancel any contract in whole or in part without penalty due to non-appropriation of funds, or for failure of the Contractor to comply with the terms, conditions and specifications of this contract. AUDIT: During the term of the contract, the Contractor shall, upon the request of LaSalle County Nursing Home, make available at reasonable times and places such information as may be required for the purpose of auditing submitted bills for the service provided under the contract. INDEPENDENT CONTRACTOR STATUS: The relationship between Contractor and LaSalle County Nursing Home/County of LaSalle shall, at all time, be that Contractor is an independent contractor of the LaSalle County Nursing Home/County of LaSalle. Employees of the Contractor are not and shall not be deemed to be employees of the LaSalle County Nursing Home/County of LaSalle for any purpose. Employees of the LaSalle County Nursing Home/County of LaSalle are not, nor shall they be deemed to be, employees of the Contractor for any purpose. PROPRIETARY INFORMATION: Any restrictions on the use of data contained within a request must be clearly stated in the Bid itself. Proprietary information submitted in response to a request will be handled in accordance with applicable LaSalle County Nursing Home procurement regulations and the Illinois public record laws. TERMINATION FOR DEFAULT: LaSalle County Nursing Home reserves the right to terminate the contract for default if, after twenty days written notice to cure default, Contractor fails to satisfactorily cures the default. CLARIFICATION OF REQUIREMENTS Bidders are strongly encouraged to read the requirements carefully prior to the submission of a bid. Any and all questions regarding specifications, requirements, competitive procurement process, etc., must be directed to the contact person as indicated on the first page of this Bid. Bidders are cautioned not to contact representatives from LaSalle County Nursing Home during the competitive procurement and evaluation processes other than the stated contact person. Any attempt to contact will automatically disqualify a Bid. The bidder is advised that the only official position of LaSalle County Nursing Home is a position which is stated in writing and issued by the contact person. No other means of communication, whether oral or written, shall be construed as a formal or official response or statement. 9 SUBMISSION REQUIREMENTS A title page, showing the name of the individual/firm submitting this information and proposing to perform the work on this project. List the name, title and telephone number and email addresses of that principal who will serve as the point of contact. Such an individual must be empowered to speak for the individual/firm on policy and contractual matters and should be familiar with the programs and procedures of the individual/firm. Provide a comprehensive resume of the individual(s) who will be assigned primary responsibility and/or other key personnel to serve as project manager on this project. A table of contents A letter of transmittal including the following: o A brief statement of understanding of the services to be provided o A commitment to perform the work if awarded the contract o A statement indicating the period for which the bid is a firm and irrevocable offer A profile of the firm, detailing the experience of the firm and the experience and qualifications for serving the healthcare marketplace. Provide the name and telephone number of at least three healthcare organizations where similar work is provided. Any additional information not specifically requested that the bidder considers essential to this bidder. EVALUATION PROCESS After determining that a Bid satisfies the mandatory requirements stated in the Bid Request, the comparative assessment of the relative benefits and deficiencies of the Bid in relationship to the published evaluation criteria shall be made and the Bid awarded in the best interests of the LaSalle County Nursing Home. After an initial screening process, an interview may be conducted with selected firms, to clarify or verify the Contractors Bid and to develop a comprehensive assessment of the Bid. Only firms which LaSalle County Nursing Home determines to meet its criteria will be invited to the interview. LaSalle County Nursing Home reserves the right to consider historic information, whether gained from the Contractors Bid, question and answer conferences, references or any other source in the evaluation process. The Contractor is cautioned that it is the Contractors sole responsibility to submit information and that LaSalle County Nursing Home is under no obligation to solicit such information if it is not included with the Contractors Bid. Failure of the Contractor to submit such information may cause an adverse impact on the evaluation of the Contractors Bid. 10 Submission of a Bid constitutes acceptance by the individual/firm of the conditions contained in this bid. There is no expressed or implied obligation for LaSalle County Nursing Home to reimburse responding firms for any expenses incurred in preparing Bids in response to this request. Any award of a contract resulting from this Request for Bid will be made only by written authorization from the LaSalle County Nursing and LaSalle County Board. COST The Contractor must provide individual/firm cost Bid data for the services required from this contract. In the evaluation of the Contractors Bid, LaSalle County Nursing Home reserves the right to consider the value of money and other economic impact factors as deemed appropriate and in the best interests of LaSalle County Nursing Home. LaSalle County Nursing Home seeks an initial contract for a period of one (1) year with a tentative commencement date of December 1, 2021 and ending on November 30, 2022. Two (2) one-year extensions beginning December 1 and ending November 30th beyond the initial term will be subject to the mutual agreement of LaSalle County Nursing Home and the successful Contractor. Cost Bids Must Be Placed In A Separate Sealed Envelope Marked Long Term Food Service Management, Cost Bid. REPUTATION AND RELIABILITY Reputation and reliability of the bidders organization are considered in the evaluation process. Therefore, the bidder is advised to submit any information which documents successful and reliable experience in past performance related to the requirements of this Request for Bid. The qualifications of the personnel proposed by the Contractor to perform the requirements of this Request for Bid will be considered in the evaluation. Therefore, the Contractor should submit information related to the experience and qualifications of the staff proposed. PROPOSED METHOD OF PERFORMANCE The Contractor will be expected to be extremely responsive to the programmatic needs of LaSalle County Nursing Home. 11 COST BID/SIGNATURE FORM The submission of a Bid shall be considered as a representation that the bidder has carefully investigated all conditions, has full knowledge of the scope, nature and quality of work required. The proper submission of this form by the bidder will be considered as the bidders offer to enter into a contract in accordance with the provisions herein set forth. If the Bid is accepted and a contract issued, then this Bid Request and all documents attached hereto including any amendments, the Contractors price Bids and any other written offers/clarifications made by the Contractor and accepted by LaSalle County Nursing Home, will be incorporated into the entire contract between LaSalle County Nursing Home and the Contractor and it shall contain all the terms and conditions agreed on by the parties hereto, and no other agreement regarding the subject matter of this Bid shall be deemed to exist or bind any of the parties hereto. Acceptance will take place only upon award by LaSalle County Nursing Home, execution of this document by the proper County official(s), and delivery of the fully executed contract to the successful bidder. The contract may only be amended by written agreement by the Contractor and LaSalle County Nursing Home. Any terms or conditions that the Contractor wishes to propose in a final contract must be included in the Bid, or they shall not be considered upon final award. Any final contract must be acceptable to the county and is subject to review by the county for legal sufficiency and compliance with the terms and conditions of this Request for Bid. ATTACH YOUR COST BID TO THIS FORM AND RETURN THE ORIGINAL WITH COPIES IN ACCORDANCE WITH THE INSTRUCTIONS AS NOTED IN THE REQUEST FOR BID. (Cost Bids must be placed in a separate sealed envelope marked Long Term Food Service Management, Cost Bid.) Contractor (to be signed by the person authorized to legally bind your firm to this contract). All Bid conditions and prices submitted shall remain firm for 90 calendar days following opening. Contactors Company Address City, State & Zip Telephone No. FAX No. E-mail: Web Site BY: ________________________________________ (Manual signature required) NAME: _____________________________________ (Typed or printed) TITLE: _____________________________________ Standards of Illinois and Center for Medicare/Medicaid Services (CMS) Joint Committee on Administrative Rules ADMINISTRATIVE CODE Joint Committee on Administrative Rules ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER ec: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE SUBPART J: FOOD SERVICE Section 300.2010 Director of Food Services Section 300.2020 Dietary Staff in Addition to Director of Food Services Section 300.2030 Hygiene of Dietary Staff Section 300.2040 Diet Orders Section 300.2050 Meal Planning Section 300.2060 Therapeutic Diets (Repealed) Section 300.2070 Scheduling Meals Section 300.2080 Menus and Food Records Section 300.2090 Food Preparation and Service Section 300.2100 Food Handling Sanitation Section 300.2110 Kitchen Equipment, Utensils, and Supplies Joint Committee on Administrative Rules ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE Section 300.2010 Director of Food Services a) b) A full-time person, qualified by training and experience, shall be responsible for the total food and nutrition services of the facility. This person shall be on duty a minimum of 40 hours each week. 1) This person shall be either a dietitian or a dietetic service supervisor. 2) The person responsible for the food service may assume some cooking duties but only if these duties do not interfere with the responsibilities of management and supervision. If the person responsible for food service is not a dietitian, the person shall have frequent and regularly scheduled consultation from a dietitian. Consultation, given in the facility, shall include training, as needed, in areas such as menu planning and review, food preparation, food storage, food service, safety, food sanitation, and use of food equipment. Clinical management of therapeutic diets shall also be included in consulting, covering areas such as tube feeding; nutritional status and requirements of residents, including weight, height, hematologic and biochemical assessments; physical limitations; adaptive eating equipment; and clinical observations of nutrition, nutritional intake, resident's eating habits and preferences, and dietary restrictions. 1) Intermediate care facilities: A minimum of eight hours of consulting time per month shall be provided for facilities with 50 or fewer residents. An additional four minutes of consulting time per month shall be provided per resident over 50 residents, based on the average daily census for the previous year. 2) Skilled nursing facilities: A minimum of eight hours of consulting time per month shall be provided for facilities with 50 or fewer residents. An additional five minutes of consulting time per month shall be provided per resident over 50 residents, based on the average daily census for the previous year. (Source: Amended at 23 Ill. Reg. 8106, effective July 15, 1999) Section 300.2020 Dietary Staff in Addition to Director of Food Services There shall be sufficient number of food service personnel employed and on duty to meet the dietary needs of all persons eating meals in the facility. Their working hours shall be scheduled to meet the total dietary needs of the residents. All dietary employees' time schedules and work assignments shall be posted in the kitchen. Dietary duties and job procedures shall be available in the dietary department for employees' knowledge and use. (B) (Source: Amended at 13 III. Reg. 4684, effective March 24, 1989) Joint Committee on Administrative Rules ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER ec: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE Section 300.2030 Hygiene of Dietary Staff Food service personnel shall be in good health, shall practice hygienic food handling techniques, and good personal grooming. (B) (Source: Amended at 13 Ill. Reg. 4684, effective March 24, 1989) Section 300.2040 Diet Orders a) Two or more copies of a current diet manual shall be available and in use. One copy shall be located in the kitchen for use by dietary personnel. Other copies shall be located at each nurses' station for use by physicians when prescribing diets. b) Physicians shall write a diet order, in the medical record, for each resident indicating whether the resident is to have a general or a therapeutic diet. The diet shall be served as ordered. c) A written diet order shall be sent to the food service department when each resident is admitted and each time that the resident's diet is changed. Each change shall be ordered by the physician. The diet order shall include, at a minimum, the following information: name of resident, room and bed number, type of diet, consistency if other than regular consistency, date diet order is sent to dietary, name of physician ordering the diet, and the signature of the person transmitting the order to the food service department. d) The resident shall be observed to determine acceptance of the diet, and these observations shall be recorded in the medical record. e) A therapeutic diet means a diet ordered by the physician as part of a treatment for a disease or clinical condition, to eliminate or decrease certain substances in the diet (e.g., sodium) or to increase certain substances in the diet (e.g., potassium), or to provide food in a form that the resident is able to eat (e.g., mechanically altered diet). f) All therapeutic diets shall be medically prescribed and shall be planned or approved by a dietitian. g) The kinds and variations of prescribed therapeutic diets shall be available in the kitchen. If separate menus are not planned for each specific diet, diet information for each specific type, in a form easily understood by staff, shall be available in a convenient location in the kitchen. h) All oral liquid diets shall be reviewed every 48 hours. Medical soft diets, sometimes known as transitional diets, shall be reviewed every three weeks. All other therapeutic and mechanically altered diets, including commercially prepared formulas that are in liquid form and blenderized liquid diets, shall be reviewed as needed, or at least every three months. (Source: Amended at 23 Ill. Reg. 8106, effective July 15, 1999) Joint Committee on Administrative Rules ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE Section 300.2050 Meal Planning Each resident shall be served food to meet the resident's needs and to meet physician's orders. The facility shall use this Section to plan menus and purchase food in accordance with the following Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. a) Milk and Milk Products Group: 16 ounces or more of Grade A whole or low fat pasteurized milk where milk is used for fluid consumption. Calcium equivalents for eight ounces of milk: 1) 1% ounces natural cheese, 2) Two ounces processed cheese, 3) One cup yogurt, or one cup frozen yogurt, 4) One cup cottage cheese, or 5) 1% cups ice cream or ice milk. b) Meat Group: A total of 6 ounces (by weight) of good quality protein to provide 38 to 42 grams of protein daily. To ensure variety, food items repeated within the same day shall not be counted as meeting a required serving. The following are examples of one serving. 1) Three ounces (excluding bone, fat and breading) of any cooked meat such as whole or ground beef, veal, pork or lamb; poultry; organ meats such as liver, heart, kidney; prepared luncheon meats. 2) Three ounces (excluding skin and breading) of cooked fish or shell fish or % cup canned fish. 3) Three ounces of natural or processed cheese or %4 cup cottage cheese. 4) Three eggs (minimum weight 21 ounces per dozen, considered a medium egg). Note: If one egg is served at a meal, a protein food of good quality may be reduced from six to five ounces for the remaining meals. If two eggs are served at a meal, a minimum of two ounces of good quality protein shall be served at each of the remaining meals. 5) 14 cups cooked dried peas or beans, six tablespoons of peanut butter, or one cup nuts, not more than twice a week and provided that eggs, milk or lean meat is served at the same meal. 6) Three ounces of soy protein containing not less than 21 grams of protein or in combination with other sources of quality protein to equal 21 grams of protein, provided that it is acceptable to the resident population. 7) Combinations of all above examples are acceptable, provided that the minimum standard of six ounces of a good quality protein food is served daily and provided that the combinations do not conflict with eye appeal or palatability. 8) The content of meat alternative products shall be listed on the menu. Joint Committee on Administrative Rules ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE Cc) Vegetable and Fruit Group: Five or more servings of fruits or vegetables. 1) A serving consists of: A) 2 cup chopped raw, cooked, canned or frozen fruit or vegetables; B) cup fruit or vegetable juice; or C) One cup raw leafy vegetable. 2) The five or more servings shall consist of: A) Sources of vitamin C i) One serving of a good source of vitamin C (containing at least 60 mg of vitamin C); or ii) Two servings of a fair source of vitamin C. This may be more than one food item and shall contain a total of at least 65 mg of vitamin C. B) One serving of a good source of vitamin A at least three times a week supplying at least 1000 micrograms retinol equivalent (RE) of vitamin A. C) Other fruits and vegetables, including potatoes, that may be served in 4 cup or larger portions. 3) To ensure variety, food items repeated within the same day shall not be counted as meeting a required serving. d) Bread, Cereal, Rice and Pasta Group: Six or more servings of whole grain, enriched or restored products. One serving equals: 1) One slice of bread, 2) Y% cup of cooked cereal, rice, pasta, noodles, or grain product, 3) % cup of dry, ready-to-eat cereal, 4) '% hamburger or hotdog bun, bagel or English muffin, 5) One 4-inch diameter pancake, 6) One tortilla, 7) Three to four plain crackers (small), 8) % croissant (large), doughnut or danish (medium), 9) 1/16 cake, 10) Two cookies, or 11) 1/12 pie (2-crust, 8"). ) Butter or Margarine: To be used as a spread and in cooking. f) Other foods shall be served to round out meals, satisfy individual appetites, improve flavor, and meet the individual's nutritional and caloric needs. Joint Committee on Administrative Rules ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER ec: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE g) Meals for the day shall be planned to provide a variety of foods, variety in texture and good color balance. The following meal patterns shall be used. 1) Three meals a day plan: A) Breakfast: Fruit or juice, cereal, meat (optional, but three to four times per week preferable), bread, butter or margarine, milk, and choice of additional beverage. B) Main Meal (may be served noon or evening): Soup or juice (optional), entree (quality protein), potato or potato substitute, vegetable or salad, dessert (preferably fruit unless fruit is served as a salad or will be served at another meal), bread, butter or margarine, and choice of beverage. C) Lunch or Supper: Soup or juice (optional), entree (quality protein), potato or potato substitute (optional if served at main meal), vegetable or salad, dessert, bread, butter or margarine, milk, and choice of additional beverage. 2) Other meal patterns may be used if facilities are able to meet residents needs using such plans. (Source: Amended at 23 III. Reg. 8106, effective July 15, 1999) Section 300.2060 Therapeutic Diets (Repealed) (Source: Repealed at 23 Ill. Reg. 8106, effective July 15, 1999) Section 300.2070 Scheduling Meals a) A minimum of three meals or their equivalent shall be served daily at regular times with no more than a 14 hour span between a substantial evening meal and breakfast. The 14 hour span shall not apply to facilities using the "four or five meal-a-day" plan, provided the evening meal is substantial and includes, but is not limited to, a good quality protein, bread or bread substitute, butter or margarine, a dessert and a nourishing beverage. b) Bedtime snacks of nourishing quality shall be offered. Snacks of nourishing quality shall be offered between meals when there is a time span of four or more hours between the ending of one meal and the serving of the next, or as otherwise indicated in the resident's plan of care. Cc) If a resident refuses food served, reasonable and nutritionally appropriate substitutes shall be served. (Source: Amended at 16 III. Reg. 17089, effective November 3, 1992) Joint Committee on Administrative Rules ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE Section 300.2080 Menus and Food Records a) b) g) Menus, including menus for "sack" lunches and between meal or bedtime snacks, shall be planned at least one week in advance. Food sufficient to meet the nutritional needs of all the residents shall be prepared for each meal. When changes in the menu are necessary, substitutions shall provide equal nutritive value and shall be recorded on the original menu, or in a notebook marked "Substitutions", that is kept in the kitchen. Ifa notebook is used to document substitutions, it shall include the date of the substitution; the meal at which the substitution was made; the menu as originally written; and the menu as actually served. The menu for the current week shall be dated and available in the kitchen. Upon the request of the Department, sample menus shall be submitted for evaluation. Menus shall be different for the same day of consecutive weeks and adjusted for seasonal differences. All menus as actually served shall be kept on file at the facility for not less than 30 days. Food label information for purchased prepared food listing food composition and, when available, nutrient content shall be kept on file in the facility for the current menu cycle. Supplies of staple foods for a minimum of a one week period and of perishable foods for a minimum of a two day period shall be maintained on the premises. These supplies shall be appropriate to meet the requirements of the menu. Records of all food purchased shall be kept on file for not less than 30 days. (Source: Amended at 23 II]. Reg. 8106, effective July 15, 1999) Section 300.2090 Food Preparation and Service a) b) c) Foods shall be prepared by appropriate methods that will conserve their nutritive value, enhance their flavor and appearance. They shall be prepared according to standardized recipes and a file of such recipes shall be available for the cook's use. Foods shall be attractively served at the proper temperatures and in a form to meet individual needs. (B) All residents shall be served in a dining room or multi-purpose room except for an individual with a temporary illness, who is too ill, or for other valid reasons. (Source: Amended at 13 IIl. Reg. 4684, effective March 24, 1989) Joint Committee on Administrative Rules ADMINISTRATIVE CODE TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE Section 300.2100 Food Handling Sanitation Every facility shall comply with the Department's rules entitled "Food Service Sanitation" (77 III. Adm. Code 750). (Source: Amended at 13 IIl. Reg. 4684, effective March 24, 1989) Section 300.2110 Kitchen Equipment, Utensils, and Supplies Each facility shall provide an adequate number of dishes, glassware, and silverware of a satisfactory type to serve all the residents in the facility at each meal. (Source: Amended at 14 III. Reg. 14950, effective October 1, 1990) Medicare "Requirements | (SOM Appendix PP) F800 F800 re SSL yi hes eessnnmasovenenmnmm (Effective: [ 1-28-17) $483.60 Food and nutrition services. The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. INTENT 483.60 To ensure that facility staff support the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet. GUIDANCE 483.60 This requirement expects that there is ongoing communication and coordination among and ' between staff within all departments to ensure that the resident assessment, care plan and actual food and nutrition services meet each resident's daily nutritional and dietary needs and choices. While it may be challenging to meet every residents' individual preferences, incorporating a residents preferences and dietary needs will ensure residents are offered meaningful choices in ' meals/diets that are nutritionally adequate and satisfying to the individual. Reasonable efforts to accommodate these choices and preferences must be addressed by facility staff. Also, cite this Tag if there are overall systems issues relating to how the facility manages and executes its food and nutrition services. Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017} 561 (SOM Appendix PP) F801 F801 a el (Effective: 11-28-17) 483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483,70(e) This includes: 562 483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who- (i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iif) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)() and ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. 483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who- (i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a_ national certifying body; or (D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and Regulations and Survey Process for Long-Terin Care Facilities (November 28, 2017) (SOM Appendix PP) F801 (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. INTENT 483.60 (a)(1)-(2) To ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services. DEFINITIONS 483.60(a)(1)-(2) "Full-time" means working 35 or more hours a week. "Part-time" employees typically work fewer hours in a day or during a work week than full-time employees. The U.S. Department of Labor, Bureau of Statistics uses a definition of 34 or fewer hours a week as part-time work. Part-time workers may also be those who only work during certain parts of the year. "Consultants" means an individual who gives professional advice or services. They are generally - not direct employees of the facility and may work either full or part-time. GUIDANCE 483.60(a)(1)-(2) Cite F801 for concerns regarding the qualifications of the dietitian, other clinical nutrition professionals, or the food services director, For concerns regarding support personnel refer to . F802, Sufficient Dietary Support Personnel. In addition, cite F801 if staff, specifically the qualified dietitian or other Clinically qualified nutrition professional did not carry out the functions of the food and nutrition services. While these functions may be defined by facility management, at a minimum they should include, but are not limited to: Assessing the nutritional needs of residents; @ Developing and evaluating regular and therapeutic diets, including texture of foods and liquids, to meet the specialized needs of residents; Developing and implementing person centered education programs involving food and nutrition services for all facility staff: . Overseeing the budget and purchasing of food and supplies, and food preparation, service and storage; and, Participating in the quality assurance and performance improvement (QAPH), as described in 483.75, when food and nutrition services are involved. , The qualified dietitian or other clinically qualified nutrition professional can decide to oversee and delegate some of the activities listed above to the director of food and nutrition services, PROBES 483.60(a)(1)-(2) If the survey team finds concems regarding a resident's food and/or nutritional status determine: * Ifthe practices of the dietitian, nutrition professional, and/or food services director contributed to'the identified concerns. If so how? How facility management ensures that staff have the appropriate competencies and skills sets to carry out the functions of the food and nutrition service? Ifa food services director is employed by the facility, do they have frequent consultations with the dietitian or other nutrition professionals or consultants employed by the facility? Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017} 563 (SOM Appendix PP) F801 564 POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION 483.60(a)(1)-(2) During the investigation of F801, the surveyor may have identified concerns with additional requirements related to outcome, process, and/or structure requirements. The surveyor is advised to investigate these related requirements before determining whether non-compliance: may be present at these other tags. Examples of some of the related requirements that may be considered when non-compliance has been identified include, but are not limited to, the following but are not limited to: @ 483.25(b)(1), F686, Pressure Injury e Determine if the facility identified, evaluated, and responded to a change in a resident's skin integrity. @ 483.25(g)(1)-(3), F692, Nutrition/Eydration Status Determine if the facility identified, evaluated, and responded to a change in nutritional parameters, anorexia, or unplanned weight loss, dysphagia, and/or swallowing disorders in relation to the resident's ability to eat. @ 483.25(g)(4)-(5), F693, Tube Feeding Management @ Determine if the facility identified, evaluated, and responded to the use of a nasogastric and gastrostomy tubes. Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) (SOM Appendix PP) F802 F802 $a gel ae a a Ai (Effective: 11-28-17) 483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e). 483.60({a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. 483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in 483.21(b)(2)ii). DEFINITION 483.60(a)(3)-(b) "Sufficient support personnel" means having enough dietary and food and nutrition staff to safely carry out all of the functions of the food and nutrition services. This does not include staff, such as licensed nurses, nurse aides or paid feeding assistants, involved in assisting residents with eating. PROCEDURES 483.60(a)(3) and (b) Through observations and interviews determine if there are sufficient support personnel to safely and effectively carry out the meal preparation and other food and nutrition services as defined by facility management. @ Observe and interview residents to determine if their needs and preferences are met, if the food is palatable, attractive, served at the proper temperatures and at appropriate times? If concerns are identified, determine if they may be related to insufficient or inadequately trained personnel. @ Do observations and/or interviews indicate there are sufficient staff to prepare and serve meals in a timely manner and to maintain food safety and temperature? @ Determine who represents food and nutrition services at interdisciplinary team meetings: When evaluating timeliness, factors that should be considered include but may not be limited to: Meals or nutritional supplements are provided in accordance with a resident's medication requirements; @ Meals intended to be hot" are served as such and are maintained at the desired temperature when provided to the resident; @ Meals or nutritional supplements are provided to residents within 45 minutes of either a residents request or less depending on the facility's scheduled time for meals. Ifa concern with having sufficient staff is identified, determine if the staffing levels provided were based on the facility assessment. If a concern with the facility assessment is identified, see 483.70(e), F838, Facility Assessment. Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) 565 (SOM Appendix PP) F803 F803 (Effective: 11-28-17) 483.60(c) Menus and nutritional adequacy. Menus must 566 483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; 483.60(c)(2) Be prepared in advance; 483.60(c)(3) Be followed; 483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; 483.60(c)(5) Be updated periodically; 483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and -483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. ; INTENT 483.60(c)(1)-(7) To assure that menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. DEFINITIONS 483.60(c)(1)-(7) "Reasonable effort" mearis assessing individual resident needs and preferences and demonstrating actions to meet those needs and preferences, including reviewing availability of procurement sources of such food items, identifying preparation methods and approaches, and determining whether purchasing and serving such items can occur. "Periodically" means that a facility should update its menus to accommodate their changing resident population or resident needs as determined by their facility assessment. See F838, This includes ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services, GUIDANCE 483.60(c)(1-7) The facility must make reasonable efforts to provide food that is appetizing to and culturally appropriate for residents. This means learning the resident's needs and preferences and responding to them. For residents with dementia or other barriers or challenges to expressing their preferences, facility staff should document the steps taken to learn what those preferences are. It is not required that there be individualized menus for all residents; however, alternatives aligned with individual needs and preferences should be available if the primary menu or immediate selections for a particular meal are not to a resident's liking. Facilities must make reasonable and good faith efforts to develop a menu based on resident requests and resident groups' feedback. Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) (SOM Appendix PP) F803 PROCEDURES 483.60(c)(1-7) If during meal observations, a resident's dietary intake appears inadequate determine through interviews and record review if facility staff made reasonable efforts to review and/or adjust the menu and/or the individual resident's food plan to meet the nutritional, religious, cultural, and ethnic needs, and preferences of the resident. If the survey team observes deviation from a resident's planned menu, review documentation, ie., diet card, medical record and interview the resident, food service manager or dietitian to support reason(s) for deviation from the planned menu. PROBES 483.60(c)(1-7) Through interviews, observations and record reviews determine it: e Residents are receiving food in the amount, type, consistency and frequency to maintain normal body weight and acceptable nutritional values. Resident preferences and needs are incorporated into the development of the individual food plan? e A resident chooses not to consume certain foods or food groups such as the resident is a vegetarian or does not eat dairy, how does the facility ensure the resident's menu and/or the individual resident's food plan meets his or her nutritional needs? e Menus meet basic nutritional needs by providing meals based on individual nutritional ' assessment, the individualized plan of care, and established national guidelines and are periodically updated to mitigate the risk of menu fatigue? Menus are reviewed and revised as needed by a qualified dietitian or other qualified nutrition professional? NOTE: Standard meal planning guides may be used for menu planning and food purchasing. They are not intended to meet the nutritional needs and preferences of residents and must be adjusted to consider individual differences. Some residents will need more due to age, size, gender, physical activity, and state of health, There are many guides , ie, American Diabetes Association, Academy of Nutrition and Dietetics, American Medical Association, or U.S. Department of Agriculture, that are available and appropriate for use when adjusted to meet each resident's needs. DEFICIENCY CATEGORIZATION e Examples of Level 4, immediate jeopardy to resident health and safety, include, but are not limited to: The facility only maintains a one day supply of foods and drink on hand to prepare and serve their planned menus. This supply did not include foods to meet the nutritional needs or choices of residents. Several residents reported that they were often hungry and were told by staff that no snacks or other food was available. Facility staff failed to follow a menu for a resident on a puree diet. The wrong texture of diet was provided which resulted in a choking incident for this resident. This placed the resident at risk for potential death or brain damage due to lack of oxygen from choking. e An example of Level 3, Actual harm (physical or psychological) that is not immediate jeopardy, includes, but is not limited to: Based on a resident's current comprehensive assessment, the resident's nutritional needs changed; however facility staff did not change or updated a menu to meet the nutritional needs of this resident. As a result this resident experienced significant weight. Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) 567 (SOM Appendix PP) F803 e Examples of Level.2 -No actual harm with a potential for more than minimal harm (physical or psychological) that is not immediate jeopardy, include but are not limited to: O The facility failed to ensure the resident's menus and/or the individual resident's food plan met her/his nutritional needs and preferences. Q A repetitive menu was provided to the residents resulting in complaints about the lack of variety in food options. e An example of Level I -No actual harm with a potential for minimal harm includes but is not limited to: While no resident complaints were received during survey, it was observed that food items were being substituted with equally nutritious foods, but not noted or updated on the menu and residents were not notified of the change. Regulations and Survey Process for Long-Term Care Facilities 568 (November 28, 2017) (SOM Appendix PP) F804 F804 LS a SSS SS TS SSS ssi (Effective: 11-28-17) 483.60(d) Food and drink Kach resident receives and the facility provides- 483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; 483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. INTENT 483.60(d)(1)-(2) To assure that the nutritive value of food is not compromised and destroyed because of prolonged: 1. Food storage, light, and air exposure; or 2. Cooking of foods in a large volume of water; or 3. Holding on steam table. DEFINITIONS 483.60(d)(1)-(2) "Food attractiveness" refers to the appearance of the food when served to residents. Food palatability" refers to the taste and/or flavor of the food. "Proper (safe and appetizing) temperature" means both appetizing to the resident and minimizing the risk for scalding and burns. GUIDANCE 483.60(d)(1)-(2) Food should be palatable, attractive, and at an appetizing temperature as determined by the type of food to ensure resident's satisfaction, while minimizing the risk for scalding and burns. Providing palatable, attractive, and appetizing food and drink to residents can help to encourage residents to increase the amount they eat and drink. Improved nutrition and hydration status can help prevent, or aid in the recovery from, illness or injury. PROCEDURES 483.60(d)(1)-(2) If there are complaints concerning food temperatures, palatability, or attractiveness from residents or through group interviews, observations of food not being eaten, or delay in passing of food trays, request a test tray from the dining area, floor or unit of most concern. In addition; e Review recipes, if needed, to determine if non-compliance exists. e Ifa test tray was obtained, how did it support resident or observed concerns? PROBES 483.60(d)(1)-(2) @ Does food have a distinctly appetizing aroma and appearance, which is varied in color and texture? e Is food generally well-seasoned (use of spices, herbs, etc.) and acceptable to residents? If not, did the facility ensure all ingredients were available to make recipes as instructed for palatability? @ Js food prepared in a way to preserve vitamins? Method of Storage and preparation should cause minimum loss of nutrients. For example, foods are prepared as directed or not held at hot Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) 569 (SOM Appendix PP) F804 570 temperatures for hours prior to meal service because prolonged hot temperatures can result in a loss of vitamins. Is food served at preferable temperature for the resident (hot foods are served hot and cold foods are served cold and in accordance with resident preferences). (Not to be confused with the proper holding temperature. Refer to 483.60(i) food safety requirements. Was the facility aware of the resident(s) complaint(s) about the food through resident council, the grievance/complaint process at the facility, or communication directly with staff? What did facility do to address the complaint(s)? Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) (SOM Appendix PP) F805 F805 LD aa eT ea SS en (Effective: 11-28-17) 483.60(d) Food and drink Each resident receives and the facility provides- 483.60(d)(3) Food prepared in a form designed to meet individual needs. PROCEDURES 483.60(d)(3) @ Observe meals and food preparation to assure the food is prepared and appropriate to meet resident's needs and according to their assessment and care plan. * Are there any observations of residents having difficulty chewing or swallowing their food? @ Is the food cut, chopped, ground, or pureed for individual resident's needs? Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) 57] cor ttt ne A RAR at ALLE RE nt ee RNA RAnAtttnEnen area vie se sen gamtunnennentt et (SOM Appendix PP) F806 F806 (Effective: 11-28-17) 483.60(d) Food and drink Each resident receives and the facility provides- 483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; 483.60(d}(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; and GUIDANCE 483.60 (d)(4)-(5) Facilities should be aware of each resident's allergies, intolerances, and preferences, and provide an appropriate alternative. A food substitute should be consistent with the usual and/or ordinary food items provided by the facility. For example, the facility may, instead of grapefruit juice, substitute another citrus juice or vitamin C rich juice the resident likes. PROCEDURES 483.60(d)(4)-(5) Observe meal services. Ifa resident appears to refuse food or drink items, determine if he or she is offered the opportunity to receive substitutes. PROBES 483.60(d)(4)-(5) e Ask residents how the food meets their preferences, allergies and/or intolerances. Ifresidents who refuse food or drinks, ask them if they are offered substitutes. @ Interview residents or staff to determine how alternate food choices are communicated to the residents? e How are food textures, allergies, intolerances, and preferences accommodated per a resident's assessment, care plan and choice and how is this information communicated to staff? _ POTENTIAL TAGS FOR FURTHER INVESTIGATION 483.60(d)(4)-(5) During the investigation of F806, the surveyor may have identified concerns with additional requirements related to outcome, process, and/or structure requirements. The surveyor is advised to investigate these related requirements before determining whether non-compliance may be present at these other tags. Examples of some of the related requirements that may be considered when non-compliance has been identified include, but are not limited to, the following: 483.20(b), F636, Comprehensive Assessments Determine if the resident's allergies, intolerances, preferences, or need for a therapeutic diet were comprehensively assessed. @ 483.21(b)(1}, F656, Comprehensive Care Plans Determine if a comprehensive care plan was developed to include the resident's allergies, intolerances, preferences, or need for a therapeutic diet. @ 483.21(b)(2), F657, Comprehensive Care Plan Revision Q Determine if the care plan was reviewed and revised by appropriate staff, in conjunction with the interdisciplinary team and with input from the resident or his/her legal Regulations and Survey Process for Long-Term Care Facilities 572 (November 28, 2017) (SOM Appendix PP) F806 representative, to try to address any allergies, intolerances, preferences, or need for a therapeutic diet, 483.21(b)(3)(i), F658, Care provided by Qualified Persons in Accordance with the Plan of Care Determine whether the care plan for a resident with allergies, intolerance, preferences, or a therapeutic diet is adequately and/or correctly implemented. @ 483.25(9)(1)-(3), F692, Nutrition/Hydration Q Determine if the facility has managed the resident's nutritional interventions to meet the resident's nutritional needs, while accommodating the resident's allergies, intolerances, preferences, or need for a therapeutic diet. Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) 573 em pawn arta (SOM Appendix PP) F807 F807 a SS (Effective: 11-28-17) 483.60(d) Food and drink . Each resident receives and the facility provides- $483.60(d)(6) Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration. GUIDANCE 483.60(d)(6) Proper hydration alone is a critical aspect of nutrition among nursing home residents. Individuals who do not receive adequate fluids are more susceptible to urinary tract infections, pneumonia, decubitus ulcers, skin infections, confusion and disorientation.! 23 Other food items may also include items that become a liquid at room temperature, such as popsicles and ice cream. If a concern is identified regarding maintaining a resident's hydration status or about a resident's fluid restriction, see 483.25(g)(1)-(3), F692, Nutrition/Hydration Status. PROBES 483.60(d)(6) e Are drinks and other fluids provided when the resident requests and consistent with the resident's care plan, preferences and choices? Does facility staff provide sufficient drinks that the resident prefers to maintain hydration? @ Are other liquids, such as broth, popsicles, or ice cream, offered to the resident to encourage fluid intake? @ What action does facility staff take to ensure resident hydration is maintained if a resident refuses the fluids offered? POTENTIAL TAGS FOR FURTHER INVESTIGATION 483.60(d)(6) During the investigation of F807, the surveyor may have identified concerns with additional requirements related to outcome, process, and/or structure requirements, The surveyor is advised to investigate these related requirements before determining whether non-compliance may be present at these other tags. Examples of some of the related requirements that may be considered when non-compliance has been identified include, but are not limited to, the following: @ 483.10(c), F552, Right to Make Treatment Decisions Q Determine if the facility addressed the resident's right to refuse treatment, including drinks and thickened fluids. @ 483.20(b), F636, Comprehensive Assessments Q Determine if the resident's hydration status was comprehensively assessed. @ 483.21(b)(1), F656, Comprehensive Care Plans O Determine if a comprehensive care plan was developed to address a resident's hydration needs and fluid preferences. Regulations and Survey Process for Long-Term Care Facilities 574 (November 28, 2017) (SOM Appendix PP) F807 483.21(b)(2), F657, Comprehensive Care Plan Revision Q Determine.if-the care plan was periodically reviewed and revised by appropriate staff, in conjunction with the practitioner and with input from the resident or his/her legal representative, to address resident hydration needs and preferences. $483,25(g)(1)-(3), F692, Assisted Nutrition and Hydration Q Determine if the facility has managed the resident's hydration needs. 483.35(a), F725, Sufficient Staffing Q Determine if the concerns related to providing residents with sufficient liquids i is related to having sufficient nursing assistant staff to meet these needs, 483.10(c), F552, Right to Make Treatment Decisions Determine if the facility addressed the resident's right to refuse treatment, including drinks and thickened fluids. 483.20(b), F636, Comprehensive Assessments Determine if the resident's hydration status was comprehensively assessed. 483.21(b)(1), F656, Comprehensive Care Plans Determine if a comprehensive care plan was developed to address a resident's hydration needs and fluid preferences. 483.21(b)(2), F657, Comprehensive Care Plan Revision Q Determine if the care plan was periodically reviewed and revised by appropriate staff, in conjunction with the practitioner and with input from the resident or his/her legal representative, to address resident hydration needs and preferences. 483.25(g)(1)-(3), F692, Assisted Nutrition and Hydration Determine if the facility has managed the resident's hydration needs. 483.35(a), F725, Sufficient Staffing Q Determine if the concerns related to providing residents with sufficient liquids is related to having sufficient nursing assistant staff to meet these needs. Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) 575 (SOM Appendix PP) Endnotes (F807) Endnotes (F807) ' Chidester, J.C., and Spangler, A.A, "Fluid Intake in the Institutionalized Elderly," Journal of the American Dietetic Associa- tion 97 (1991):23-30. 2 Feinsod, F., Levenson, 8., Rapp, K., Rapp, M., Beechinor, E., Liebmann, L, (2004). "Dehydration in frail, older residents in long-term care facilities." Journal of the American Medical Directors Association, 5(2 Suppl), $35-S41, 3 Gasper, P.M. "Water Intake of Nursing Home Resident." Journal of Gerontologic Nursing. 1999; 25(4):2229. Regulations and Survey Process for Long-Term Care Facilities 576 (Novesnber 28, 2017) (SOM Appendix PP) F808 F808 LL SSS ry Si ho i SSDS! (Effective: ] 1-28-17) 483.60(e) Therapeutic Diets $483.60(e)(1) Therapeutic diets must be prescribed by the attending physician. 483,.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law. INTENT 483.60()(1)-(2) To assure that residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his her goals and preferences. GUIDANCE 483.60()(1)-(2) If the residents' attending physician delegates this task he or she must supervise the dietitian and remains responsible for the resident's care even if the task is delegated. The physician would be able to modify a diet order with a subsequent order, if necessary. NOTE: The terms "attending physician" or "physician" also includes a non-physician provider (physician assistant, nurse practitioner, or clinical nurse specialist) involved in the management of the resident's care. , DEFINITIONS 483.60(e)(1)-(2) "Therapeutic Diet" means a diet ordered by a physician or delegated registered or licensed dietitian as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet, (e.g., sodium) or to increase specific nutrients in the diet (e.g., potassium), or to provide food the resident is able to eat (e.g., a mechanically altered diet). Mechanically altered diet" means one in which the texture of a diet is altered. When the texture is modified, the type of texture modification must be specific and part of the physicians' or delegated registered or licensed dietitian order. PROBES 483.60(e)(1)-(2) * Ifa resident is receiving a therapeutic diet, is the diet prescribed by the attending physician or delegated registered or licensed dietitian? e Ifa registered or licensed dietitian has written the order, is this delegation by the physician allowed by State law? e Ifa resident has inadequate nutrition or nutritional deficits that manifest into and/or are a product of weight loss or other medical problems, determine if there is a therapeutic diet that is medically prescribed. POTENTIAL TAGS FOR FURTHER INVESTIGATION 483.60(e)(1)-(2) During the investigation of F808, the surveyor may have identified concerns with additional requirements related to outcome, process, and/or structure requirements. The surveyor is advised to investigate these related requirements before determining whether non-compliance may be Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) 577 578 (SOM Appendix PP) F808 present at these other tags. Examples of some of the related requirements that may be considered when non-compliance has been identified include, but are not limited to, the following: @ 483.30(e)(2), F715, Physician Delegation to Dietitians Determine if concerns are identified with the physician delegation/supervision of a registered or licensed dietitian @ 483.25()(1)-(3), F692, Assisted Nutrition and Hydration. Determine if concems are identified regarding a resident's nutritional status Regulations and Survey Process for Long-Term Care Facilities {November 28, 2017) (SOM Appendix PP) F809 F809 ev re isi ri yy SRP (Effective: 11-28-17) 483.60(f) Frequency of Meals $483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times cemparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. 483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span, 483.60()(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat af non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care, DEFINITIONS 483.60(f)(1)-(3) A "Nourishing snack" means items from the basic food groups, either singly or in combination with each other. "Suitable and nourishing alternative meals and snacks" means that when an alternate meal or snack is provided, it is of similar nutritive value as the meal or snack offered at the normally scheduled time and consistent with the resident plan of care. GUIDANCE 483.60(f)\(1)-(3) Facility staff must ensure meals and snacks are served at times in accordance with resident's needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Adequacy of the nourishing snack" will be determined both by resident interviews and by evaluation of the overall nutritional status of residents in the facility, (for example: Is the offered snack usually satisfying?) This regulation is not intended to require facilities to provide a 24-hour-a-day full service food operation or an on-site chef. Suitable alternatives may be meals prepared in advance that can be appropriately served by appropriately trained facility staff at non-traditional times. PROCEDURES 483.60()(1)-(3) Observe meal times and schedules and determine if they are offered at regular times comparable to normal times found in the community. Interview residents to get their input on meal service schedules to determine if they meet their choices and their input regarding eating at nontraditional times and the availability of snacks throughout the day. PROBES 483.60(0(1)-(3) e Are three meals offered at regular times? @ Are snacks and meals available for residents at non-traditional times or outside of scheduled meal service times, or upon request? Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) 579 (SOM Appendix PP) F809 e Ask residents if they are offered snacks at bedtime. If snacks are not offered, would they want them? Regulations and Survey Process for Long-Term Care Facilities 580 (November 28, 2017) (SOM Appendix PP) F810 F810 A eter (Effective: 11-28-17) 483.60(g) Assistive devices The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks, GUIDANCE 483.66(g) The facility must provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat or drink independently, for example, improving poor grasp by enlarging silverware handles with foam padding, aiding residents with impaired coordination or tremor by installing plate guards, or specialized cups. The facility must also provide the appropriate staff assistance to ensure that these residents can use the assistive devices when eating or drinking. For concerns regarding the use of other types of assistive devices, such as postural supports for head, trunk and arms, please see guidance under F676 and F677 for ADL care and services. PROCEDURES 483.60(g) Review sampled residents' comprehensive assessment and plan of care for their capacity/ability to eat independently: Determine if recommendations were made for adaptive eating equipment and utensils. If they were, determine if these utensils are available and utilized by residents. @ Ifrecommended but not used, determine if this is by resident's choice. * If eating equipment and utensils are not being utilized, determine when these were recommended and how their use is being monitored by the facility and if the staff is developing alternative recommendations and monitoring ongoing assessments. e Observe whether staff competently assists residents who use assistive devices. Regulations and Survey Process for Long-Term Care Facilities (Novernber 28, 2017) 581 (SOM Appendix PP) F811 F811 a ia eT a eT deanna (Effective: 11-28-17) 483.60(h) Paid feeding assistants 483.60(h)(1) State approved training course. A facility may use a paid feeding assistant, as defined in 488.301 of this chapter, if- (i) The feeding assistant has successfully completed a State-approved training course that meets the requirements of 483.160 before feeding residents; and (ii) The use of feeding assistants is consistent with State law. 483.60(h)(2) Supervision. (i) A feeding assistant must work under the supervision of a registered nurse (RN) or licensed practical nurse (LPN). (ii) In an emergency, a feeding assistant must call a supervisory nurse for help. 483.60(h)(3) Resident selection criteria. (i) A facility must ensure that a feeding assistant provides dining assistance only for residents who have no complicated feeding problems. , (ii) Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube or parenteral/TV feedings. (iii) The facility must base resident selection on the interdisciplinary team's assessment and the resident's latest assessment and plan of care. Appropriateness for this program should be reflected in the comprehensive care plan, NOTE: Paid feeding assistants must complete a training program with the following minimum content as specified at 483.160. a, Minimum training course contents. A State-approved training course for paid feeding assistants must include, at a minimum, 8 hours of training in the following: (1) Feeding techniques; (2) Assistance with feeding and hydration; (3) Communication and interpersonal skills; (4) Appropriate responses to resident behavior; (5) Safety and emergency procedures, including the Heimlich maneuver; (6) Infection control; (7) Resident rights; and (8) Recognizing changes in residents that are inconsistent with their normal behavior and the importance of reporting those changes to the supervisory nurse, b. Maintenance of records. A facility must maintain a record of all individuals, used by the facility as feeding assistants, who have successfully completed the training course for paid feeding assistants. Regulations and Survey Process for Long-Tenn Care Facilities 582 (November 28, 2017) (SOM Appendix PP) F811 INTENT 483.60(h)(1)-(3) To ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. The use of paid feeding assistants is intended to supplement certified nurse aides, not substitute for nurse aides or licensed nursing staff. DEFINITIONS 483.60(h)(1)-G) "Paid feeding assistant" is defined in the regulation at 42 CFR 488.301 as "an individual who meets the requirements specified at 42 CFR 483.60(h)(1)(i) and who is paid by the facility to feed residents, or who is used under an arrangement with another agency ot organization." NOTE: The regulation uses the term paid feeding assistant." While we are not using any other term, facilities and States may use whatever term they prefer, such as dining assistant, meal assistant, resident assistant, nutritional aide, etc. in order to convey more respect for the resident. Facilities may identify this position with other titles; however, the facility must be able to identify those employees who meet the requirements under the paid feeding assistant regulation. While the facility is still responsible for ensuring the safety and care of all residents, this regulation does not apply to family members or to volunteers. GUIDANCE 483.60(h)(1)-(3) NOTE: The regulation requires that paid feeding assistants must work under the supervision of an RN or LPN, and they must call the supervisory nurse in case of an emergency. Therefore, a facility that has received a waiver and does not have either an RN or LPN available in the building cannot use paid feeding assistants during those times. Interdisciplinary Team Assessment of Resident Eligibility for Feeding Assistance When determining whether a resident may be assisted by a paid feeding assistant facility staff must base resident selection on the interdisciplinary team's current assessment of the resident's condition and the resident's latest comprehensive assessment and plan of care. Appropriateness should be reflected in the resident's comprehensive care plan. Paid feeding assistants are only permitted to assist residents who have no complicated eating or drinking problems as determined by their comprehensive assessment. Examples of residents that a paid feeding assistant may assist include residents who are independent in eating and/or those who have some degree of minimal dependence, such as needing cueing or partial assistance, as long as they do not have complicated eating or drinking problems. Paid feeding assistants are not permitted to assist residents who have complicated eating problems, such as (but not limited to) difficulty swallowing, recurrent lung aspirations, or who receive nutrition through parenteral or enteral means, Nurses or nurse aides must continue to assist residents who require the assistance of staff with more specialized training to eat or drink. Paid feeding assistants may assist eligible residents to eat and drink at meal times, snack times, or during activities or social events as needed, whenever the facility can provide the necessary supervision. Supervision of Paid Feeding Assistants - Paid feeding assistants must work under the supervision of an RN or LPN. While we are not prescribing the exact means by which facility RNs and LPNs assert their supervisory responsibilities, we expect that facilities will do so in a way that avoids negative outcomes for their residents, If a facility chooses to use paid feeding assistants, it is the facility's responsibility to ensure that adequate supervisory nursing staff are available to supervise these assistants, Reguiations and Survey Process for Long-Term Care Facilities (November 28, 2017) 583 (SOM Appendix PP) F811 384 Adequate supervision by a supervising nurse does not necessarily mean constant visual contact or being physically present during the meal/snack time, especially if a feeding assistant is assisting a resident to eat in his or her room. However, in the event that an emergency should occur, the feeding assistant must be aware of and know how to access the supervisory nurse immediately and the nurse must be located close enough to the resident that he or she can promptly respond. Should an emergency arise, a paid feeding assistant must immediately call a supervisory nurse for help. Supervisory nurses should monitor the provision of the assistance provided by paid feeding assistants to evaluate on an ongoing basis: e Their use of appropriate feeding techniques; e Whether they are assisting assigned residents according to their care planned eating and drinking needs; @ Whether they are providing assistance in recognition of the rights and dignity of the resident; and @ Whether they are adhering io safety and infection control practices. Use of Existing Staff as Paid Feeding Assistants ~ Facilities may use existing staff, Le., licensed nurses, certified nursing assistants, to assist residents in feeding. However, other employees for example, administrative, clerical, housekeeping, dietary staff, or activity specialists, etc. must have successfully completed a State-approved training course for paid feeding assistants, as required in 483.160. Maintenance of Training Records - The facility must maintain a record of all employees used as paid feeding assistants. The record should include verification that they have successfully completed a State-approved training course as required in 483.160. Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) (SOM Appendix PP) Investigative Protocal -Use of Paid Feeding Assistants Investigative Protocol -Use of Paid Feeding Assistants NN Le aT a er a Ge x rare Objectives - To determine if: e Individuals used as paid feeding assistants successfully completed a State-approved training course; Sampled residents who were selected to receive assistance from paid feeding assistants were assessed and determined to be eligible to receive these services based on the latest assessment and plan of care; e Paid feeding assistants are supervised by an RN or LPN; and, Paid feeding assistants know how to obtain assistance in emergencies. Use - When through observation, record review, or interview(s) with residents, family, or staff, a surveyor identifies concerns that the facility may not be following the requirements regarding paid feeding assistants, including proper training and supervision, and proper assessment and selection of residents for feeding assistance, Procedures - Review the resident's comprehensive assessment and interdisciplinary care plan to guide observations and interviews. Observations ~ If a concer was discovered through resident or family interview(s), observe the resident while he or she is being assisted to eat and drink by a paid feeding assistant. Determine if the assistant is using proper feeding technique and is providing the type of assistance specified in the resident's care plan. Note the resident's condition and observe for the presence of complicated feeding problems that may require the assistance of a nurse aide or licensed nursing staff. The use of paid feeding assistants is intended to supplement, not substitute for, nursing staff. Also during observation note whether: e A paid feeding assistant was observed assisting 4 resident in a location without a call system available or other means of emergency notification; A resident who was assessed as ineligible for services due to complicated eating/drinking problems, or a resident who has not been assessed for eligibility, is being assisted by a paid feeding assistant; and, e RN or LPN staff members assigned to supervise paid feeding assistants were observed to be unavailable (for example, not available in case of emergency). If the concern was discovered through observations that were already made, only conduct additional observations if necessary to complete the investigation. Resident and Family Interviews - If a resident is selected for this protocol through surveyor observation that he or she is having difficulties in eating or drinking and he or she is being assisted by a paid feeding assistant, interview the resident if the resident is interviewable. Ask questions to gain information about why the resident is receiving these services and the resident's experience with receiving assistance to eat and drink. If concerns are identified, inquire if the resident has reported these problems to a nurse. If the resident is not interviewable, ask these questions of a family member or the resident's representative. If the concern was discovered through resident, resident representative or family interviews already conducted, focus any additional interview on questions specific to complete the investigation, Paid Feeding Assistant Interviews - Interview paid feeding assistants assisting the selected resident. Determine whether there are concerns with their training, supervision, or the selection of the resident such as: @ What training did you successfully complete in providing feeding assistance? ' @ What information did you receive about this resident's needs for assistance (type of assistance needed, any precautions)? @ In what manner and by whom are you supervised while assisting residents? Regulations and Survey Process for Long-Term Care Facilities (November 28, 2017) 585 (SOM Appendix PP) Investigative Protocol -Use of Paid Feeding Assistants What issues/problems do you report (such as coughing, choking, changes in the resident's usual responses, or level of alertness) and to whom do you report? What would you do if an emergency occurred while you were assisting a resident to eat or drink? Who would you contact and how would you contact them? Interdisciplinary Team Interview - Interview the nurse or other member(s) of the interdisciplinary team responsible for assessing if the resident is eligible and appropriate to receive assistance by a paid feeding assistant. Ask: , e How they determined that this resident has no complicated feeding problems and is eligible to be assisted by a paid feeding assistant? e Ifa resident is appropriate to receive assistance from a paid feeding assistant, how is this resident's needs reflected in his or her comprehensive care plan? How they determine that each eligible resident remains free of emergent complicated feeding problems? e Who supervises paid feeding assistants and how is the supervision accomplished? @ Describe the processes in place to handle emergencies when a supervisor is not present in the area where paid feeding assistants are assisting residents. Review of Resident Assessment of Eligibility to Receive Assistance from a Paid Feeding Assistant - Determine whether the resident's assessment regarding his or her ongoing eligibility to be assisted by a paid feeding assistant is based on identification of the current condition of the resident and any additional or new risk factors or condition changes that may impact on the resident's ability to eat or drink. This information may be contained in the RAI or in other supporting documents such as progress notes, etc. The assessment of eligibility to receive assistance from a paid feeding assistant is ongoing and should be reflected in a resident's comprehensive care plan. Requirements for Training of Paid Feeding Assistants - Determine how the facility identifies that paid feeding assistants have successfully completed a State-approved training course that meets the requirements at 42 CFR 483.160 before they are allowed to assist eligible residents with eating and drinking. If the facility uses temporary (agency) staff as paid feeding assistants, request documentation that these staff have met the minimum training requirements at 42 CFR 483.160. Review facility's records for all employees used as paid feeding assistants to verify their completion of a State approved training course (it is recommended the survey team coordinator assign one surveyor to obtain and verify these records). NOTE: If the facility has not ensured any paid feeding assistant has completed a State-approved training course, do not cite here. Cite 42 CFR 483.95(h), F948, Required training of feeding assistants. POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION 483.60(h)(1)-(3) During the investigation of F811, the surveyor may have identified concerns with additional requirements related to outcome, process, and/or structure rquirements. The surveyor is cautioned to investigate these related requirements before determining whether non-compliance may be present at these other tags. Examples of some of the related requirements that may be considered when non-compliance has been identified include, but are not limited to, the following: 483.10, F550, Resident Rights Q Determine if staff are attentive and responsive to the resident's requests, and if they provide assistance to eat in a manner that respects the resident's dignity, meets needs in a timely manner, and minimizes potential feelings of embarrassment, humiliation, and/or isolation related to inability to assist themselves with food or fluid intake. Regulations and Survey Process for Long-Term Care Facilities 586 (November 28, 2017) (SOM Appendix PP) Investigative Protocol -Use of Paid Feeding Assistants @ 483.10(c), F552 and F578, Planning and Implementing Care OQ Determine if the facility addressed the resident's right to choose or refuse treatment, including receiving assistance to eat or drink by a paid feeding assistant. 483.20(b), F636, Comprehensive Assessinents ; Q Review whether facility staff initially and periodically conducted a comprehensive, accurate assessment of the resident's ability to eat and drink with or without assistance and/ or identified a condition that makes the resident ineligible for this service. e 483.21(b)(1), F656, Comprehensive Care Plans QO Review whether facility staff developed or implemented a comprehensive care plan that was based on the assessment of the resident's conditions, needs, and behaviors, and was consistent with the resident's goals in order to provide assistance with nutrition and hydration as necessary. 483.21(b)(2)(iii), F657, Comprehensive Care Plan Revision Q Determine if the care plan was reviewed and revised periodically, as necessary, related to eligibility to eat and drink with assistance of a paid feeding assistant. @ 483.25(g)(1)-(3), F692, Nutrition/Hydration Status Review if facility staff had identified, evaluated, and responded to a change in nutritional parameters, anorexia, or unplanned weight loss, dysphagia, and/or swallowing disorders in relation to the resident's ability to eat. Q Review if facility staff had identified, evaluated, and responded to a change in the resident's ability to swallow liquids. @ 483.25 (b)(4), F676, ADL Assistance for Dependent Residents Q Determine if staff identified and implemented appropriate measures to provide food and fluids for the resident who cannot perform relevant activities of daily living. @ 483.35(a), F725, Sufficient Staff Determine if the facility has qualified staff in sufficient numbers to provide assistance to eat or drink to those residents who require such assistance. For residents who are not eligible to receive assistance from paid feeding a