CMS and
Culture Change
&
Artifacts of
Culture Change
LONG-TERM CARE SURVEY MANUAL
PREPARED BY MU NHA CONSULTANT
SECTION 3 - CMS, CULTURE CHANGE, ARTIFACTS OF CULTURE CHANGE
CMS and Culture Change and Artifacts of Culture Change - The traditional nursing home
regulatory approach has created tensions between providers and surveyors. Culture change is
movement to transform a facility to a home, a resident to a person, and a schedule to a choice.
States and the federal government have worked over the years to examine regulations to evolve
them into a more responsive regulatory system. Documents below are offered to home nursing
homes to work with their regulators to change the environment of their homes while meeting the
regulations. Missouri has set a 100% compliance goal for facilities filling out the on-line version
of The Artifacts of Culture Change. (www.artifactsofculturechange.org)
SECTION
CMS Nursing Home Culture Change Regulatory
Compliance Questions and Answers
Artifacts of Culture Change
The First 24 Hours and Beyond
New Dining Practice Standards
The Food and Dining Side of the Culture Change Movement:
Identifying Barriers and Potential Solutions to Furthering
Innovation in Nursing Homes
National Long-term Care Life Safety Task Force: Summary
of Proposals Approved by NFPA
Updated January 2015
PAGE #
3.2-3.5
3.6-3.16
3.17-3.18
Appendix 3-A
Appendix 3-B
Appendix 3-C
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-12-25
Baltimore, Maryland 21244-1850
Center for Medicaid and State Operations/Survey and Certification Group
Ref: S&C-07-07
DATE:
December 21, 2006
TO:
State Survey Agency Directors
FROM:
Director
Survey and Certification Group
SUBJECT:
Nursing Home Culture Change Regulatory Compliance Questions and Answers
Memorandum Summary
This memorandum provides the State Survey Agencies and CMS regional offices with:
1. Responses we have made to inquiries concerning compliance with the long-term care health
and life safety code requirements in nursing homes that are changing their cultures and adopting
new practices;
2. Summarizes questions and answers from a June, 2006 CMS Pic-Tel conference with leaders of
the Green House Project (Attachment A); and
3. Provides information about an upcoming series of 4 CMS culture change satellite webcasts
(Attachment B).
Following are regulatory questions that have been sent from culture change organizations from
2004 to date, along with our answers:
Question 1: Tag F368 (Frequency of Meals): You request a clarification that the regulation language at
this Tag that “each resident receives and the facility provides at least three meals daily” does not require
the resident to actually eat the food for the facility to be in compliance. You also ask for clarification
about the regulatory language specifying that there must be no more than 14 hours between supper and
breakfast (or 16 hours if a resident group agrees and a nourishing snack is provided). You state that some
believe this language means all of the residents must actually eat promptly by the 14th hour, which makes
it difficult for the facility to honor a specific resident’s request to refuse a night snack and then sleep late.
Response 1: The regulation language is in place to prevent facilities from offering less than 3 meals per
day and to prevent facilities from serving supper so early in the afternoon that a significant period of time
elapses until residents receive their next meal. The language was not intended to diminish the right of any
resident to refuse any particular meal or snack, nor to diminish the right of a resident over their sleeping
and waking time. These rights are described at Tag F242, Self-determination and Participation. You are
correct in assuming that the regulation language at F368 means that the facility must be offering meals
and snacks as specified, but that each resident maintains the right to refuse the food offered. If surveyors
encounter a situation in which a resident or residents are refusing snacks routinely, they would ask the
resident(s) the reason for their customary refusal and would continue to investigate this issue only if the
resident(s) complains about the food items provided. If a resident is sleeping late and misses breakfast,
surveyors would want to know if the facility has anything for the resident to eat when they awaken (such
as continental breakfast items) if they desire any food before lunch time begins.
3.2
Question 2: F370 (Approved Food Sources): You ask if the regulatory language at this Tag that the
facility must procure food from approved sources prohibits residents from any of the following: 1)
growing their own garden produce and eating it; 2) eating fish they have caught on a fishing trip; or 3)
eating food brought to them by their own family or friends.
Response 2: The regulatory language at this Tag is in place to prohibit a facility from procuring their food
supply from questionable sources, in order to keep residents safe. It would be problematic if the facility is
serving food to all residents from the sources you list, since the facility would not be able to verify that
the food they are providing is safe. The regulation is not intended to diminish the rights of specific
residents to eat food in any of the circumstances you mention. In those cases, the facility is not procuring food.
The residents are making their own choices to eat what they desire to eat. This would also be the case if a
resident ordered a pizza, attended a ball game and bought a hot dog, or any similar circumstance. The right to
make these choices is also part of the regulatory language at F242, that the resident has the right to, “make
choices about aspects of his or her life in the facility that are important to the resident.” This is a key right that
we believe is also an important contributing factor to a resident’s quality of life.
Question 3: Tag F354 (Registered Nurse): “Can the traditional DON role be shared with several registered
nurses with each nurse responsible for one or more households or clusters?”
Response 3: The interpretive guidelines (i.e., Guidance to Surveyors) already contain this language: “The
facility is required to designate an RN to serve as DON on a full time basis. This requirement can be met when
RNs share the position. If RNs share the DON position, the total hours per week must equal 40. Facility staff
must understand the shared responsibilities.” Thus, the position can be shared; however, a comprehensive set
of duties and responsibilities of a DON is not specified in the regulations or interpretive guidelines. We
interpret this role to encompass not only general supervision of nursing care for the facility, but oversight of
nursing policies and procedures, overall responsibility for hiring/firing of nursing staff, ensuring sufficient
nursing staff (F353), ensuring proficiency of nurse aides (F498), active participation in the quality assurance
committee (see Tag F520), and responsibility to receive and act on communications from the pharmacy
consultant about medication problems (Tags F429 and F430). A facility that desires to have various people
share the DON position would need to consider how these DON duties will be fulfilled in a shared position. As
long as these duties are fulfilled, we would consider the facility in compliance with F354, whether or not the
position is being shared.
Question 4: Tag F521 (Quality Assessment and Assurance): You ask whether the regulatory responsibility
for this committee to “meet” can be fulfilled if the physician member is not physically present, but is
participating through alternate means, “such as conference calls or reading minutes/issues and giving input.”
Response 4: Yes, participation can be achieved through means of telephone conferencing, however, we do not
accept the alternative of the physician merely reading documents before or after the meeting. We believe the
purpose of these meetings is to provide a forum for discussion of issues and plans, which cannot be adequately
fulfilled if the physician is merely reading and commenting on documents, since this does not allow for the
interchange of ideas.
Question 5: (HIPAA and Principles of Documentation): You express concern that the Statement of
Deficiencies that surveyors write, which is a publicly posted document, may violate a resident’s right to
privacy, since the details may identify a specific resident to the public.
Response 5: We have received other comments on this issue, and have provided guidance to our State Survey
Agencies and CMS regional offices on our interpretation of this issue in our Survey and Certification (S&C)
3.3
memorandum #04-18. All our S&C memoranda are stored on the CMS website for public access at
http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
Question 6 (Handrails): Could the interpretive guidelines explain that handrails are not necessary at the very
ends of the hallways on the very small sides of the door? This would allow for filling these unused areas with
live plants, for instance, without obstructing egress and handrails would still be available up to the end of each
hallway.
Response 6: The purpose of the handrail requirements at Tag F468 is to assist residents with ambulation
and/or wheelchair navigation. They are a safety device as well as a mobility enhancer for those residents who
need assistance. The survey team onsite would need to observe the responses of residents to the placement of
objects that block the portion of the handrails that is at the end of a hallway. They would also interview
residents to gain their opinion as to whether the objects in question are interfering with their independence in
navigating to the places they wish to go.
Question 7 (Resident Call system): Could the resident call system (F463) regulation that requires calls to be
able to be received at the nurses’ station be changed to also include nurses’ work areas and direct care workers,
as well as the nurses’ stations? Many homes moving away from the institutional model are replacing nurses’
stations with normal kitchens, living room and dining room areas, and using systems whereby resident calls
connect directly to caregivers’ radio/pagers. Because it is harder to change the text of regulation, could the
phrase “at the nurses’ station” be removed from the following sentence in the Interpretive Guidelines: “The
intent of this requirement is that residents, when in their rooms and toilet and bathing areas, have a means to
directly contact staff at the nurses’ station.”
Response 7: We agree that it is desirable for residents and/or their caregivers or visitors to be able to quickly
contact nursing staff when they need help. To meet the intent of the requirement at F463, it is acceptable to use
a modern pager/telephone system which routes resident calls to caregivers in a specified order in an organized
communication system that fulfills the intent and communication functions of a nurse’s station. We will make a
change in the Interpretive Guideline to reflect this position.
Question 8 (Posting of Survey Results): Would CMS consider adding to the posting requirements at Tag
F156 [42 CFR 483.10(b)(10)], text similar to that stated in Tag F167 about posting of survey results, “...or a
notice of their availability?” Although this may just be trading one posting for several, some homes really want
to create a homey environment without so many postings and many homes are placing postings into a photo
album or binder to minimize the institutional look of so many postings.
Response 8: The purpose of the posting requirements at both F156 and F167 is for residents and any other
interested parties to be able to know the information exists, and to easily locate and read the information
without needing to ask for it. What you request above, namely one posting that advises the public of what
information is available to meet requirements of both Tags, is acceptable, as long as the information itself is in
public and easily accessible, such as in a lobby area in a marked (titled) notebook or album. This includes the
following information:
•
“A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups
such as the State survey and certification agency, the State licensure office, the State ombudsman
program, the protection and advocacy network, and the Medicaid fraud control unit;.” (F156)
•
“Written information about how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments covered by such benefits;” (F156) and
3.4
•
The facility, “must make the results available for examination in a place readily accessible to residents
and must post a notice of their availability.” (F167)
Question 9 (Hallway Width): Does the 8 feet requirement (at LSC Tag K39) continue to be necessary since
evacuations are no longer done via wheeling a person out of the building in a bed? Could 6 feet meet the
requirement? If 6 feet sufficed, this would again refer back to our question regarding the requirement for
handrails when something else such as a bench might take up the other
2 feet.
Response 9: The 8 foot corridor width is a requirement of the Life Safety Code (LSC). Corridors remain a
route to use in internal movement of residents in an emergency situation to areas of safety in different parts of
the facility. This movement may be by beds, gurney or other methods which may require the full width of the
corridor. We do not believe it would be in the best interests of the residents to reduce the level of safety in a
facility.
Question 10 (Tag K72 and Exits): In regard to LSC Tag K72 (no furnishings, decorations, or other objects
are placed to obstruct exits or visibility of exits), can secured unit doors be disguised or masked with murals,
etc.? Staff typically will be the ones to use these doors in the case of emergency and will know where they
are. By disguising exit doors, resident anxiety of wanting to go out them may decrease.
Response 10: The life safety code allows some coverings on doors, but not concealment. The code also
specifically forbids the use of mirrors on a door. It is a judgment call by the survey team as to what would be
considered concealment of the door, but in general the door must still be recognizable by a non-impaired
person (such as a visitor). The code does not allow the removal or concealment of exit signs, door handles, or
door opening hardware.
Question 11 (Dining Together): Is it permissible for staff and residents to dine together?
Response 11: There is no federal requirement that prohibits this. We applaud efforts of facilities to make the
dining experience less institutional and more like home. Our concern would be for the facility to make sure
that residents who need assistance receive it in a timely fashion (not making residents wait to be assisted until
staff finish their meals).
Question 14 (Candles): Can candles be used in nursing homes under supervision, in sprinklered facilities.
Response 14: Regarding the request to use candles in sprinklered facilities under staff supervision, National
Fire Protection Association data shows candles to be the number one cause of fires in dwellings. Candles
cannot be used in resident rooms, but may be used in other locations where they are placed in a substantial
candle holder and supervised at all times while they are lighted. Lighted candles are not to be handled by
residents due to the risk of fire and burns. If you would like to discuss this issue, you may contact James
Merrill at 410-786-6998, or via email at [email protected].
Question 15 (Tablecloths): Are cloth tablecloths and napkins permissible in nursing homes?
Response 15: There is no regulation that prohibits it and, in fact, the use of these items is greatly preferable to
the use of bibs, as bibs can detract from the homelike attractiveness of the dining room setting.
3.5
Artifacts of Culture Change - Online Version (www.artifactsofculturechange.org)
Pioneer Network is host to this web-based version of the Artifacts of Culture Change. By registering and
completing the Artifacts of Culture Change, providers are able to input, score and store their data online.
Providers will be able to access current and historical data and are encouraged to:



Complete the tool at a minimum of twice a year. Quarterly updating is recommended, because for
many homes, organizational reporting occurs quarterly. Adding Artifacts to a quarterly reporting
schedule can also help to better analyze incremental changes in benchmark reporting;
Create high involvement of staff, family and residents in completing the tool and solicit
feedback from varying perspectives (see below);
Although assessments of responses can be approximates (e.g. responders do not need to count
every adaptive handle), providers are encouraged to provide close approximate estimates to ensure
the best possible measurements of longitudinal change.
Tips for High Involvement (By Peggy Bargmann, R.N., B.S.N)
Start by gathering the Culture Change Leadership Team. This team should consist of the administrator,
the director of nursing, and representatives from each department in the organization. In order to have
complete representation of the home, it is important that there be representatives from all levels of the
organization. Be sure to include direct care staff members, and at least one family member and one
resident. The team is usually comprised of 15 – 20 people.
Once the team is gathered, have them divide up into groups of 3 – 4 and ask each group to complete the
tool ensuring that everyone has input. Once all the groups have completed the tool, a facilitator can bring
the large group back together and start down through the tool enlisting input from all groups to form a
final consensus score. For some questions, there will be common agreement on the score. For other
questions, there will be a wide variance and the resulting discussion will be lively. By listening, there is
much that can be learned during these discussions. The facilitator will need to be sure that all voices in the
room have equal input – be sure to be listening to the input from direct care staff, residents, and families.
As an example, question # 11 states, "Residents can get a bath/shower as often as they would like." The
staff may feel that all residents have choice in their bathing times, until a resident informs them that when
she moved in she was told what days she was "scheduled" for her shower, and didn't realize that she could
ask for other days. This could lead to a discussion of how residents are informed and how choice is
encouraged and what impact that has on the day-to-day operations.
The process for completing the tool and facilitating the robust discussion can take up to three hours. It is a
great way for the Culture Change Leadership Team to assess where the home is on its culture change
journey, celebrate their accomplishments and, as a result of the group discussion, generate goals and
action plans for their culture change journey. The Team can decide how often they want to repeat this
process (e.g., every 6 months or annually) in order to assess their progress, celebrate their successes and
revise their goals and action plans, as necessary, to continue on their culture change journey.
3.6
Artifacts of Culture Change - PLEASE complete the Online Version
(http://www.artifactsofculturechange.org/)
Home name ________________________________ Date ______________
City ______________________ State ________ Current number of residents ________
Care Practice Artifacts
1. Percentage of residents who are offered
any of the following styles of dining:
 Restaurant style where staff take
residents’ orders;
 Buffet style where residents help
themselves or tell staff what they
want;
 Family style where food is served
in bowls on dining tables where
residents help themselves or staff
assist them;
 Open dining where meal is
available for at least 2 hours time
period and residents can come
when they choose;
 24 hour dining where residents
can order food from the kitchen 24
hours a day.
2. Snacks/drinks available at all times to
all residents at no additional cost, i.e., in a
stocked pantry, refrigerator or snack bar.
_____________Enter the actual percentage % in your home
3. Baked goods are baked on resident
living areas.
____________Enter the actual number of days in your home
Convert your home's figure based on the below scale:
100-81 % (5 points)
80-61 % (4 points)
60-41 % (3 points)
40-21 % (2 points)
20-1 % (1 point)
0% (0 points)
_____ All residents (5 points)
_____ Some residents (3 points)
_____ Not a current practice (0 points)
Convert your home's figure based on the below scale:
4. Home celebrates residents’ individual
birthdays rather than, or in addition to,
celebrating resident birthdays in a group
each month.
5. Home offers aromatherapy to residents
by staff or volunteers.
6. Home offers massage to residents by
staff or volunteers.
All days of the week (5 points)
2-6 days/week (3 points)
< 2 days/week (0 points)
____ All residents (5 pts)
____ Some residents (3 pts)
____ Not a current practice (0 pts)
____ All residents (5 pts)
____ Some residents (3 pts)
____ Not a current practice (0 pts)
____ All residents (5 pts)
____ Some residents (3 pts)
____ Not a current practice (0 pts)
3.7
Care Practice Artifacts (cont.)
7. Home has dog(s) and/or cats(s).
8. Home permits residents to bring own
dog and/or cat to live with them in the
home.
9. Waking time/bedtimes chosen by
residents.
10. Bathing Without a Battle techniques
are used with residents.
11. Residents can get a bath/shower as
often as they would like.
12. Home arranges for someone to be with
a dying resident at all times (unless they
prefer to be alone) – family, friends,
volunteers or staff.
13. Memorials/remembrances are held for
individual residents upon death.
14. “I” format care plans, in the voice of
the resident and in the first person, are
used.
_____ At least one dog or one cat lives on premises (5 pts)
_____ The only animals in the building are when staff bring them
during work hours (3 pts)
_____ The only animals in the building are those brought in for
special activities or by families (1 pt)
_____ None (0 pts)
_____ Yes (5 pts)
_____ No (0 pts)
_____ All residents (5 pts)
_____ Some residents (3 pts)
_____ Not a current practice (0 pts)
_____ All residents (5 pts)
_____ Some residents (3 pts)
_____ Not a current pratice (0 pts)
_____ All residents (5 pts)
_____ Some residents (3 pts)
_____ Not a current practice (0 pts)
____ All residents (5 pts)
____ Some residents (3 pts)
____ Not a current practice (0 pts)
____ All residents (5 pts)
____ Some residents (3 pts)
____ Not a current practice (0 pts)
____ All care plans (5 pts)
____ Some (3 pts)
____ Not a current practice (0 pts)
Care Practice Artifacts Total (Out of
70 possible points)
Environment Artifacts
15. Percent of residents who live in
households that are self-contained with
full kitchen, living room and dining room.
______Enter the actual percentage % in your home
Convert your home's figure based on the below scale:
100-81 % (100 points)
80-61 % (80 points)
60-41 % (60 points)
40-21 % (40 points)
20-1 % (20 points)
0 % (0 points)
3.8
Environment Artifacts (cont.)
16. Percent of residents in private rooms.
______Enter the actual percentage % in your home
Convert your home's figure based on the below scale:
17. Percent of residents in privacy
enhanced shared rooms where residents
can access their own space without
trespassing through the other resident’s
space. (This does not include the
traditional privacy curtain.)
18. No traditional nurses’ stations or
traditional nurses’ stations have been
removed.
19. Percent of residents who have a direct
window view not past another resident’s
bed.
100-81 % (50 points)
80-61 % (40 points)
60-41 % (30 points)
40-21 % (20 points)
20-1 % (10 points)
0 % (0 points)
______Enter the actual percentage % in your home
Convert your home's figure based on the below scale:
100-81 % (25 points)
80-61 % (20 points)
60-41 % (15 points)
40-21 % (10 points)
20-1 % (5 points)
0 % (0 points)
_____ No traditional nurses’ stations (25 pts)
_____ Some traditional nurses’ stations have been removed
(15 pts)
____ Traditional nurses’ stations remain in place (0 pts)
_____Enter the actual percentage % in your home
Convert your home's figure based on the below scale:
_____ 100 – 68% (5 pts)
_____ 67 – 34% (3 pts)
_____ 33 – 0 % (0 pts)
20. Resident bathroom mirrors are
wheelchair accessible and/or adjustable in
order to be visible to a seated or standing
resident.
21. Sinks in resident bathrooms are
wheelchair accessible with clearance
below sink for wheelchair.
_____ All resident bathroom mirrors (5 pts)
_____ Some (3 pts)
_____ None (0 pts)
22. Sinks used by residents have
adaptive/easy-to-use lever or paddle
handles.
_____ All sinks (5 pts)
_____ Some (3 pts)
_____ None (0 pts)
23. Adaptive handles, enhanced for easy
use, for doors used by residents (rooms,
bathrooms and public areas).
_____ All resident-used doors (5 pts)
_____ Some (3 pts)
_____ None (0 pts)
24. Closets have moveable rods that can
be set to different heights.
_____ All closets (5 pts)
_____ Some (3 pts)
_____ None (0 pts)
_____ All resident bathroom sinks (5 pts)
_____ Some (3 pts)
_____ None (0 pts)
3.9
Environment Artifacts (cont.)
25. Home has no rule prohibiting, and
residents are welcome, to decorate their
rooms any way they wish including using
nails, tape, screws, etc.
26. Home makes available extra lighting
source in resident room if requested by
resident such as floor lamps, reading
lamps.
27. Heat/air conditioning controls can be
adjusted in resident rooms.
_____ Yes (5 pts)
_____ No (0 pts)
_____ Yes (5 pts)
_____ No (0 pts)
_____ All resident rooms (5 pts)
_____ Some (3 pts)
_____ None (0 pts)
28. Home provides or invites residents to
have their own refrigerators.
_____ Yes (5 pts)
_____ No (0 pts)
29. Chairs and sofas in public areas have
seat heights that vary to comfortably
accommodate people of different heights.
_____ Chair seat heights vary by 3” or more (5 pts)
_____ Chair seat heights vary by less than 3”(3 pts)
_____ Chair seat heights do not vary (0 pts)
30. Gliders which lock into place when
person rises are available inside the home
and/or outside.
31. Home has store/gift shop/cart available
where residents and visitors can purchase
gifts, toiletries, snacks, etc.
32. Residents have regular access to
computer/Internet and adaptations are
available for independent computer use
such as large keyboard or touch screen.
_____ Yes (5 pts)
_____ No (0 pts)
33. Workout room available to residents.
_____ Yes (5 pts)
_____ No (0 pts)
34. Bathing rooms have functional and
properly installed heat lamps, radiant heat
panels or equivalent.
_____ All bathing rooms (5 pts)
_____ Some (3 pts)
_____ None (0 pts)
35. Home warms towels for resident
bathing.
_____ All residents (5 pts)
_____ Some residents (3 pts)
_____ Not a current practice (0 pts)
36. Accessible, protected outdoor
garden/patio provided for independent use
by residents. Residents can go in and out
independently, including those who use
wheelchairs, e.g. residents do not need
assistance from staff to open doors or
overcome obstacles in traveling to patio.
37. Home has outdoor, raised gardens
available for resident use.
____ Available to all residents (5 pts)
____ Available for some residents (3 pts)
____ Not available (0 pts)
_____ Yes (5 pts)
_____ No (0 pts)
_____ Both Internet access & adaptations (10 pts)
_____ Access without adaptations (5 pts)
_____ Neither (0 pts)
____ Available to all residents (5 pts)
____ Available for some residents (3 pts)
____ Not available (0 pts)
3.10
Environment Artifacts (cont.)
38. Home has outdoor walking/wheeling
path which is not a city sidewalk or path.
39. Pager/radio/telephone call system is
used where resident calls register on
staff’s pagers/radios/telephones and staff
can use it to communicate with fellow
staff.
40. Overhead paging system has been
turned off or is only used in case of
emergency.
41. Personal clothing is laundered on
resident household/neighborhood/unit
instead of in a general all-home laundry,
and residents/families have access to
washer and dryer for own use.
Environment Artifacts Total (Out of
320 possible points)
____ Available to all residents (5 pts)
____ Available for some residents (3 pts)
____ Not available (0 pts)
_____ Yes (5 pts)
_____ No (0 pts)
_____ Yes (5 pts)
_____ No (0 pts)
_____ Available to all residents (5 pts)
_____ Available to some residents (3 pts)
_____ None (0 pts)
Family & Community Artifacts
42. Regularly scheduled intergenerational
program in which children customarily
interact with residents.
_____ Weekly (5 pts)
_____ Monthly or less frequently (3 pts)
_____ No (0 pts)
43. Home makes space available for
community groups to meet in home with
residents welcome to attend.
44. Private guestroom available for
visitors at no, or minimal cost for
overnight stays.
45. Home has café/restaurant/
tavern/canteen available to residents,
families and visitors at which residents
and family can purchase food and drinks
daily.
46. Home has special dining room
available for family use/gatherings which
excludes regular dining areas.
47. Kitchenette or kitchen area with at
least a refrigerator and stove is available to
families, residents, and staff where cooling
and baking are welcomed.
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
_____ Yes (5 pts)
_____ No (0 pts)
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
Family and Community Artifacts Total
(Out of 30 possible points)
3.11
Leadership Artifacts
48. CNAs attend resident care
conferences.
_____ All care conferences (5 pts)
_____ Some (3 pts)
_____ Not a current practice (0 pts)
49. Residents or family members serve on
home quality assessment and assurance
(QAA, QI, CQI, QA) committee.
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
50. Residents have an assigned staff
member who serves as a “buddy”, case
coordinator, Guardian Angel, etc. to check
with the resident regularly and follow up
on any concerns. (This is in addition to an
assigned social service staff.)
51. Learning Circles or equivalent are
used regularly in staff and resident
meetings in order to give each person the
opportunity to share their opinion/ideas.
52. Community Meetings are held on a
regular basis bringing staff, residents and
families together as a community.
_____ All new residents (5 pts)
_____ Some (3 pts)
_____ Not a current practice (0 pts)
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
Leadership Artifacts Total (Out of 25
possible points)
Workplace Practice Artifacts
53. RNs consistently work with the
residents of the same
neighborhood/household/unit (with no
rotation).
54. LPNs consistently work with the
residents of the same
neighborhood/household/unit (with no
rotation).
55. CNAs consistently work with the
residents of the same
neighborhood/household/unit (with no
rotation).
56. Self-scheduling of work shifts. CNAs
develop their own schedule and fill in for
absent CNAs. CNAs independently handle
the task of scheduling, trading shifts/days,
and covering for each other instead of a
staffing coordinator.
_____ All RNs (5 pts)
_____ Some (3 pts)
_____ Not a current practice (0 pts)
_____ All LPNs (5 pts)
_____ Some (3 pts)
_____ Not a current practice (0 pts)
_____ All CNAs (5 pts)
_____ Some (3 pts)
_____ Not a current practice (0 pts)
_____ All CNAs (5 pts)
_____ Some (3 pts)
_____ Not a current practice (0 pts)
3.12
Workplace Practice Artifacts (cont.)
57. Home pays expenses for nonmanagerial staff to attend outside
conferences/workshops, e.g. CNAs, direct
care nurses. Check yes if at least one nonmanagerial staff member attended an
outside conference or workshop paid by
home in past year.
58. Staff is not required to wear uniforms
or “scrubs”.
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
59. Percent of other staff cross-trained and
certified as CNAs in addition to CNAs in
the nursing department.
_____Enter the actual percentage % in your home
60. Activities, informal or formal, are led
by staff in other departments such as
nursing, housekeeping or any departments.
61. Awards given to staff to recognize
commitment to person-directed care, e.g.
Culture Change award, Champion of
Change award. This does not include
Employee of the Month.
62. Career ladder positions for CNAs, e.g.
CNA II, CNA III, team leader, etc. There
is a career ladder for CNAs to hold a
position higher than base level.
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
63. Job development programs, e.g. CNA
to LPN to RN to NP.
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
64. Day care onsite available to staff
_____ Yes (5 points)
_____ Not a current practice (0 points)
65. Home has on staff a paid volunteer
coordinator in addition to activity director.
_____ Full time (30 hours/week or more) (5 pts)
_____ Part time (15-30 hrs/week) (3 pts)
_____ No paid volunteer coordinator (0 pts)
66. Employee evaluations include
observable measures of employee support
of individual resident choices, control and
preferred routines in all aspects of daily
living.
_____ All employee evaluations (5 points)
_____ Some (3 points)
_____ Not a current practice (0 points)
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
Convert your home's figure based on the below scale:
_____100–81 % (5 pts)
_____ 80 – 61% (4 pts)
_____ 60 – 41% (3 pts)
_____ 40 – 21% (2 pts)
_____ 20 – 1% (1 point)
_____ 0 (0 pts)
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
_____ Yes (5 pts)
_____ Not a current practice (0 pts)
Workplace Practice Artifacts Total (Out
of 70 possible points)
3.13
Staffing Outcomes and Occupancy
67. Average longevity of CNAs (in any
position).
Add length of employment in years of
permanent CNAs and divide by number of
CNA staff.
Convert your home's figure based on the below scale:
Above 5 years (5 points)
3-5 years (3 points)
Below 3 years (0 points)
_______ Enter your home's average years.
68. Average longevity of LPNs (in any
position).
Add length of employment in years of
permanent staff LPNs and divide by the
number of LPN staff.
Convert your home's figure based on the below scale:
Above 5 years (5 points)
3-5 years (3 points)
Below 3 years (0 points)
_______ Enter your home's average years.
69. Average longevity of RN/GNs (in any
position).
Add length of employment in years of
permanent staff RNs/GNs and divide by
the number of RN/GN staff.
_______ Enter your home's average years.
70. Longevity of the Director of Nursing
(in any position).
_______ Enter your home's figure in
years.
71. Longevity of the Administrator (in any
position).
_______ Enter your home's figure in
years.
72. Turnover rate for CNAs.
Number of CNAs who left, voluntary or
involuntary, in previous 12 months
divided by the total number of CNA's
employed in the previous 12 months.
_______ Enter your home's percentage.
Convert your home's figure based on the below scale:
Above 5 years (5 points)
3-5 years (3 points)
Below 3 years (0 points)
Convert your home's figure based on the below scale:
Above 5 years (5 points)
3-5 years (3 points)
Below 3 years (0 points)
Convert your home's figure based on the below scale:
Above 5 years (5 points)
3-5 years (3 points)
Below 3 years (0 points)
Convert your home's figure based on the below scale:
0-19 % (5 points)
20-39 % (4 points)
40-59 % (3 points)
60-79 % (2 points)
80-99 % (1 point)
100% and above (0 points)
3.14
Staffing Outcomes and Occupancy
(cont.)
73. Turnover rate for LPNs.
Convert your home's figure based on the below scale:
Number of LPNs who left, voluntary or
involuntary, in previous 12 months
divided by the total number of LPNs
employed in the previous 12 months.
_______ Enter your home's percentage.
0-12 % (5 points)
13-25 % (4 points)
26-38 % (3 points)
39-51 % (2 points)
52-65 % (1 point)
66 % and above (0 points)
74. Turnover rate for RNs.
Convert your home's figure based on the below scale:
Number of RNs who left, voluntary or
involuntary, in previous 12 months
divided by the total number of RNs
employed in the previous 12 months.
_______ Enter your home's percentage.
0-12 % (5 points)
13-25 % (4 points)
26-38 % (3 points)
39-51 % (2 points)
52-65 % (1 point)
66 % and above (0 points)
75. Turnover rate for DONs.
Convert your home's figure based on the below scale:
_______ Enter number of DONs in the
last 12 months
1 (5 points)
2 (3 points)
3 or more (0 points)
Convert your home's figure based on the below scale:
76. Turnover rate for Administrators.
_______ Enter number of NHAs in the
last 12 months
1 (5 points)
2 (3 points)
3 or more (0 points)
77. Percent of CNA shifts covered by
agency staff over the last month.
Total number of CNA shifts (all shifts
regardless of hours in a shift) in a 24 hour
period;
Multiplied by the number of days in the
last full month;
Of this number, number of shifts covered
by an agency CNA
Convert your home's figure based on the below scale:
0 % (5 points)
1-5% (3 points)
Over 5% (0 points)
_______Enter your percentage (agency
shifts divided by total number multiplied
by days multiplied by 100)
3.15
Staffing Outcomes and Occupancy
(cont.)
78. Percent of nurse shifts covered by
agency staff over the last month.
Total number of nurse shifts (all shifts
regardless of hours in a shift) in a 24 hour
period;
Multiplied by the number of days in the
last full month;
Of this number, number of shifts covered
by an agency nurse.
Convert your home's figure based on the below scale:
0 % (5 points)
1-5% (3 points)
Over 5% (0 points)
_______Enter your percentage (agency
shifts divided by total number multiplied
by days multiplied by 100)
79. Current occupancy rate.
Convert your home's figure based on the below scale:
_______ Enter your home’s occupancy
rate
Above average 86-100 % (5 points)
Average 83-85 % (3 points)
Below average 0-82 % (0 points)
Staffing Outcomes and Occupancy
Total (Out of 65 possible points)
Artifacts Sections
Care Practices
Environment
Family and Community
Leadership
Workplace Practice
Staffing Outcomes and Occupancy
Artifacts of Culture Change
Potential Points
Score
70
320
30
25
70
65
580
Developed by the Centers for Medicare and Medicare Services and Edu-Catering, LLP.
ACC-FL adapted with permission.
3.16
The First 24 Hours and Beyond
My name is: ______________________________
Preferred time to arise:
Prior to 6:00am
Between 6:00am and 7:00am
Between 7:00am and 8:00am
Between 8:00am and 9:00am
Between 9:00am and 10:00am
Between 10:00am and 11:00am
Between 11:00am and 12:00pm
Afternoon
Specific Time: ___________
I prefer to be called: ___________________________________
Wake up preference:
I wake up on my own
Have staff wake me up
I use an alarm clock
Nap preference:
I prefer a nap at ____________
I don’t take naps
My nap lasts for _____________
Whenever I awake but not past _____
Sleeping aids:
Television on
Radio on
Extra pillows
Blankets on
Blankets off
No pillows
Snack prior to bed
Room lights on
Night light on
Lamp on
All lights off
Other: _____________________
Bathing preference:
Bathing day(s) preferred:
Bathing time(s) preferred:
Shower
Bath
Sponge Bath
Shower or bath
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Before breakfast at __________
After breakfast at ___________
Before lunch at _____________
After lunch at ______________
Before dinner at ____________
After dinner at _____________
Before bed at ______________
When do you normally take your
medications?
Before breakfast at __________
After breakfast at ___________
Before lunch at _____________
After lunch at ______________
Before dinner at ____________
After dinner at _____________
Before bed at ______________
Do you normally eat three meals a
day?
Bedtime or morning routine you are
comfortable with:
______________________________
______________________________
______________________________
______________________________
______________________________
Food/Special diet preferences:
Foods I dislike:
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
Breakfast
yes or no
Lunch
yes or no
Dinner
yes or no
Other: _____________
3.17
Group size preference:
Please remember:
I don’t like:
Things that comfort me:
Large groups
Small groups
Individual
Independent
Community programs
Other: _____________________
I am hard of hearing in R/L/both
I wear a hearing aid in R/L/both
I wear glasses
I wear dentures
I use a wheelchair/walker/cane
Other: ______________________
Noise
Being cold
Being hot
Being touched
Being with people
Bright lights
Dim lights
Loud noise / music
Talking about: _________________
Activities such as: ______________
_____________________________
Other: _______________________
Being in my room
Being touched
Being with people
Calling family/friends
Humor
Music
Religion
Sports
TV
Reading
Talking about: ________________
Comfort food: ________________
Other: ______________________
Snacks preferred:
Important events you typically
celebrate throughout the year?
Drinks: ______________________
____________________________
Snacks: _____________________
____________________________
Favorite dessert: ______________
Time you prefer snack: _________
(please give brand name as well)
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
Other things you need to know:
3.18
Appendix 3-A
Introduction
Food
and
dining
requirements
are
core
components
of
quality
of
life
and
quality
of
care
in
nursing
homes.
Research
also
shows
that:
50%‐70%
of
residents
leave
25%
or
more
of
their
food
uneaten
at
most
meals
and
both
chart
documentation
of
percent
eaten
and
the
MDS
are
notoriously
inaccurate,
consistently
representing
a
gross
under‐estimate
of
low
intake.
1,
2
60%‐80%
of
residents
have
a
physician
or
dietitian
order
to
receive
dietary
supplements.3
25%
of
residents
experienced
weight
loss
when
research
staff
conducted
standardized
weighing
procedures
over
time.
4,
5
The
American
Dietetic
Association
(ADA)
reports
that
under‐nutrition
adversely
affects
the
quality
and
length
of
life,
and
therefore,
has
aroused
the
concern
of
geriatric
health
professionals.
The
prevalence
of
protein
energy
under‐nutrition
for
residents
ranges
from
23%
to
85%,
making
malnutrition
one
of
the
most
serious
problems
facing
health
professionals
in
long
term
care.
Malnutrition
is
associated
with
poor
outcomes
and
is
an
indicator
of
risk
for
increased
mortality.
It
has
been
found
that
most
residents
with
evidence
of
malnutrition
were
on
restricted
diets
that
might
discourage
nutrient
intake.6
CMS
notes
that
the
most
frequent
questions
and
concerns
received
by
their
staff
focus
on
the
physicalenvironment
and
dining/food
policies
in
nursing
homes.
Therefore,
in
2010
the
Pioneer
Network
and
CMS
held
their
second
co‐sponsored
national
symposium
Creating
Home
II
National
Symposium
on
Culture
Change
and
the
Food
and
Dining
Requirements
,
sponsored
by
the
Hulda
B.
&
Maurice
L.
Rothschild
Foundation.
The
Symposium
brought
together
a
wide
diversity
of
stakeholders,
including
nursing
home
staff,
regulators,
provider
leadership,
researchers,
registered
dietitians,
vendors,
and
advocates
for
culture
change.
1
Simmons
SF
&
Reuben
D.
(2000).
Nutritional
intake
monitoring
for
nursing
home
residents:
A
comparison
of
staff
documentation,
direct
observation,
and
photography
methods.
Journal
of
the
American
Geriatrics
Society,
48(2):209‐213.
2
Simmons
SF,
Lim
B
&
Schnelle
JF.
(2002).
Accuracy
of
Minimum
Data
Set
in
identifying
residents
at
risk
for
undernutrition:
Oral
intake
and
food
complaints.
Journal
of
the
American
Medical
Directors’
Association,
3(May/June):140‐145.
3
Simmons
SF
&
Patel
AV.
(2006).
Nursing
home
staff
delivery
of
oral
liquid
nutritional
supplements
to
residents
at
risk
for
unintentional
weight
loss.
Journal
of
the
American
Geriatrics
Society,
54(9):1372‐1376.
4
Simmons
SF,
Garcia
ET,
Cadogan
MP,
Al‐Samarrai
NR,
Levy‐Storms
LF,
Osterweil
D
&
Schnelle
JF.
(2003).
The
Minimum
Data
Set
weight
loss
quality
indicator:
Does
it
reflect
differences
in
care
processes
related
to
weight
loss?
Journal
of
the
American
Geriatrics
Society
51(10):1410‐1418.
5
Simmons
SF,
Peterson
E
&
You
C.
(2009).The
accuracy
of
monthly
weight
assessments
in
nursing
homes:
Implications
for
the
identification
of
weight
loss.
Journal
of
Nutrition,
Health
&
Aging,
13(3):284‐288.
6 ADA
Position
Paper
Liberalization
of
the
Diet
Prescription
Improves
Quality
of
Life
for
Older
Adults
in
Long‐
Term
Care
2005.
2
Appendix 3-A
The
Pioneer
Network
is
a
growing
coalition
of
organizations
and
individuals
from
across
the
nation,
changing
the
culture
of
aging
and
long
term
care.
Pioneer
Network
is
dedicated
to
making
fundamental
changes
in
values
and
practices
to
create
a
culture
of
aging
that
is
life‐affirming,
satisfying,
humane
and
meaningful.
It
advocates
for
public
policy
change,
creates
communication,
networking
and
learning
opportunities;
builds
and
supports
relationships
and
community;
identifies
and
promotes
transformation
in
practice,
services,
public
policy
and
research;
develops
and
provides
access
to
resources
and
leadership;
and
hosts
a
national
conference
to
bring
together
interested
parties
with
a
desire
to
propel
this
important
work.
The
Hulda
B.
&
Maurice
L.
Rothschild
Foundation
is
the
only
national
philanthropy
exclusively
focused
on
improving
the
quality
of
life
for
elders
in
nursing
homes
throughout
the
United
States.
One
of
its
key
strategies
is
to
work
together
with
significant
stakeholders
in
order
to
modify
existing
regulations,
such
that
they
better
support
new
models
of
aging
in
long
term
care.
Currently,
the
Foundation
has
initiated
and
is
supporting
a
number
of
such
efforts:
• The
National
Life
Safety
Task
Force
convened
by
Pioneer
Network
that
has
revisions
pending
to
the
National
Life
Safety
Code.
• The
Center
for
Health
Design
expert
panel
that
is
developing
recommendations
for
the
guidelines
which
govern
the
Design
and
Construction
of
Healthcare
Facilities.
• The
American
Intitute
of
Architects
Design
for
Aging
Community
that
is
drafting
a
Proposal
for
Changes
to
Accessibility
Standards
for
Nursing
Home
&
Assisted
Living
Residents
in
Toileting
and
Bathing
under
the
Americans
with
Disabilities
Act.
• At
the
specific
request
of
the
regulatory
community,
the
Foundation
has
supported
the
University
of
Minnesota
in
building
a
free
website,
NHRegsPlus,
which
provides
a
cross‐indexed
compendium
of
all
state
nursing
home
regulations.
Food
and
dining
are
an
integral
part
of
individualized
care
and
self‐directed
living
for
several
reasons,
including:
(1)
the
complexity
of
food
and
dining
requirements
when
advancing
models
of
culture
change;
(2)
the
importance
of
food
and
dining
as
a
significant
element
of
daily
living,
and
(3)
the
most
frequent
questions
and
concerns
CMS
receives
from
regulators
and
providers
consistently
focus
on
dining
and
food
policies
in
nursing
homes.
Therefore,
we
believe
this
area
is
one
most
in
need
of
national
dialogue
if
we
are
to
improve
quality
of
life
for
persons
living
in
nursing
homes
while
maintaining
safety
and
quality
of
care.
In
order
to
gather
input
from
the
many
key
stakeholders,
the
Creating
Home
II
National
Symposium
on
the
Food
and
Dining
Requirements
and
Culture
Change
was
co‐sponsored
by
Pioneer
Network
and
CMS,
in
collaboration
with
the
American
Health
Care
Association.
A
set
of
research
papers
were
commissioned
with
a
wide
variety
of
experts
as
well
as
a
3
Appendix 3-A
series
of
webinars,
hosted
by
Carmen
Bowman
under
contract
with
CMS,
and
all
were
posted
online.
This
process
allowed
many
members
of
interested
organizations,
associations,
regulatory
departments,
and
others
to
participate.
The
Hulda
B.
&
Maurice
L.
Rothschild
Foundation
supported
a
Stakeholder
Workshop
on
May
14,
2010
that
was
attended
by
83
national
leaders,
which
reviewed
the
feedback
from
all
stakeholders,
expert
speakers
and
individual
participants.
Two
of
the
numerous
recommendations
at
the
Creating
Home
II
symposium
for
future
consideration
were:
National
stakeholder
workgroup
develop
guidelines
for
clinical
best
practice
for
individualization
in
long
term
care
living
to
provide
regulatory
overview
and
interpretive
protocol
and
investigative
guidance,
and
prepare
related
education
materials
to
facilitate
implementation.
Each
profession
serving
elders
in
long‐term
care
develop
and
disseminate
standards
of
practice
for
their
professional
accountability
that
addresses
proper
training,
competency
assessment,
and
their
role
as
an
active
advocate
for
resident
rights
and
resident
quality
of
life
from
a
wellness
perspective
in
addition
to
quality
of
care
from
a
medical
perspective.
These
recommendations
were
acted
upon
at
least
in
part
thanks
to
the
generous
funding
of
the Hulda
B.
and
Maurice
L. Rothschild
Foundation
to
the
Pioneer
Network
in
2011
by
forming
the
Food
and
Dining
Clinical
Standards
Task
Force.
The
Food
and
Dining
Clinical
Standards
Task
Force
is
comprised
of
symposium
experts,
representatives
from
Centers
for
Medicare
and
Medicaid
Services
Division
of
Nursing
Homes,
the
US
Food
and
Drug
Administration
and
the
Centers
for
Disease
Control
and
Prevention
as
well
as
national
standard
setting
groups.
The
Food
and
Dining
Clinical
Standards
Task
Force
made
a
significant
effort
to
obtain
evidence
and
thus
the
New
Dining
Practice
Standards
document
reflects
evidence‐based
research
available
to‐date.
The
document
also
reflects
current
thinking
and
consensus
which
are
in
advance
of
research.
Therefore
the
Current
Thinking
portions
of
each
section
of
the
New
Dining
Practice
Standards
document
represent
a
list
of
recommended
future
research.
4
Appendix 3-A
GOAL
STATEMENT:
Establish
nationally
agreed
upon
new
standards
of
practice
supporting
individualized
care
and
self‐directed
living
versus
traditional
diagnosis‐focused
treatment.
Organizations
Agreeing
to
the
New
Dining
Practice
Standards
• American
Association
for
Long
Term
Care
Nursing
(AALTCN)
• American
Association
of
Nurse
Assessment
Coordination
(AANAC)
• American
Dietetic
Association
(ADA)
• American
Medical
Directors
Association
(AMDA)
• American
Occupational
Therapy
Association
(AOTA)
• American
Society
of
Consultant
Pharmacists
(ASCP)
• American
Speech‐Language‐Hearing
Association
(ASHA)
• Dietary
Managers
Association
(DMA)
• Gerontological
Advanced
Practice
Nurses
Association
(GAPNA)
• Hartford
Institute
for
Geriatric
Nursing
(HIGN)
• National
Association
of
Directors
of
Nursing
Administration
in
Long
Term
Care
(NADONA/LTC)
• National
Gerontological
Nursing
Association
(NGNA)
Note
to
reader:
5
Appendix 3-A
Regular
diet
is
referred
to
often
in
this
document.
Regular
diet
is
defined
as
what
should
be
prepared
and
offered
to
meet
nutritional
needs
in
accordance
with
the
current
recommended
dietary
allowances
of
the
Food
and
Nutrition
Board
of
the
National
Research
Council,
National
Academy
of
Sciences,
used
as
a
standard
meal
planning
guide
while
residents
have
the
right
to
make
choices.
Whenever
physician
is
referred
to
in
this
document,
it
is
recognized
that
medical
care
may
be
delivered
by
a
physician,
or
a
nurse
practitioner,
or
a
physician
assistant
under
the
direction
of
a
physician
in
accordance
with
state
licensure
law.
Borrowing
from
CMS
interpretive
guidance
and
probe
language
at
Tag
F280
and
Tag
F281:
Tag
F280:
“Interdisciplinary”
means
that
professional
disciplines,
as
appropriate,
will
work
together
to
provide
the
greatest
benefit
to
the
resident.
The
physician
must
participate
as
part
of
the
interdisciplinary
team,
and
may
arrange
with
the
facility
alternate
methods
other
than
attendance
at
care
planning
conferences,
of
providing
his/her
input,
such
as
one‐on‐one
discussions
and
conference
calls.
Some
interdisciplinary
professional
disciplines
include
the
occupational
therapist,
dietitian
and
speech
therapist
as
the
Probes
at
Tag
F280
indicate:
Was
interdisciplinary
expertise
utilized
to
develop
a
plan
to
improve
the
resident’s
functional
abilities?
a. For
example,
did
an
occupational
therapist
design
needed
adaptive
equipment
or
a
speech
therapist
provide
techniques
to
improve
swallowing
ability?
6
Appendix 3-A
b. Do
the
dietitian
and
speech
therapist
determine,
for
example,
the
optimum
textures
and
consistency
for
the
resident’s
food
that
provide
both
a
nutritionally
adequate
diet
and
effectively
use
oropharyngeal
capabilities
of
the
resident?
c. Is
there
evidence
of
physician
involvement
in
development
of
the
care
plan
(e.g.,
presence
at
care
plan
meetings,
conversations
with
team
members
concerning
the
care
plan,
conference
calls)?
Tag
F281:
“Professional
standards
of
quality”
means
services
that
are
provided
according
to
accepted
standards
of
clinical
practice.
Standards
may
apply
to
care
provided
by
a
particular
clinical
discipline
or
in
a
specific
clinical
situation
or
setting.
Standards
regarding
quality
care
practices
may
be
published
by
a
professional
organization,
licensing
board,
accreditation
body
or
other
regulatory
agency.
Recommended
practices
to
achieve
desired
resident
outcomes
may
also
be
found
in
clinical
literature.
Possible
reference
sources
for
standards
of
practice
include:
•
Current
manuals
or
textbooks
on
nursing,
social
work,
physical
therapy,
etc.
•
Standards
published
by
professional
organizations
such
as
the
American
Dietetic
Association,
American
Medical
Association,
American
Medical
Directors
Association,
American
Nurses
Association,
National
Association
of
Activity
Professionals,
National
Association
of
Social
Work,
etc.
•
Clinical
practice
guidelines
published
by
the
Agency
of
Health
Care
Policy
and
Research.
•
Current
professional
journal
articles.
Similarly,
whenever
“interdisciplinary
team”
is
referred
to
in
this
document,
it
can
and
is
recommended
that
it
include
extended
technical,
support
,
and
administrative
team
members
such
as
Certified
Nursing
Assistants,
(CNAs),
Patient
Care
Technicians
(PCTs),
directors
of
food
service
(including
Certified
Dietary
Managers
(CDMs)
&
Dietetic
Technicians,
Registered
(DTRs),
cooks,
housekeepers,
and
cross
trained/blended
workers.
This
document
comprises
numerous
quotations
from
many
professional
organizations,
thus
a
variety
of
nomenclature
is
used.
There
has
been
no
effort
to
edit
or
standardize
the
nomenclature
referring
to
people
who
live
in
long
term
care
settings,
e.g.
elders,
residents,
clients,
patients
or
to
describe
where
they
live,
e.g.
facilities,
nursing
homes,
homes
and
communities.
7
Appendix 3-A
Contents
Standard
of
Practice
regarding
Individualized
Nutrition
Approaches/Diet
Liberalization
8
Standard
of
Practice
for
Individualized
Diabetic/Calorie
Controlled
Diet
12
Standard
of
Practice
for
Individualized
Low
Sodium
Diet
15
Standard
of
Practice
for
Individualized
Cardiac
Diet
Standard
of
Practice
for
Individualized
Altered
Consistency
Diet
18
20
Standard
of
Practice
for
Individualized
Tube
Feeding
Standard
of
Practice
for
Individualized
Real
Food
First
Standard
of
Practice
for
Individualized
Honoring
Choices
25
29
33
Standard
of
Practice
for
Shifting
Traditional
Professional
Control
to
Individualized
Support
of
Self
Directed
Living
42
New
Negative
Outcome
Patient
Rights
and
Informed
Consent/Refusal
across
the
Healthcare
Continuum
Mayo
Clinic
Proceedings
2005
References
8
Appendix 3-A
45
51
58
Standard
of
Practice
for
Individualized
Nutrition
Approaches/Diet
Liberalization
Basis
in
Current
Thinking
and
Research
American
Medical
Directors
Association
(AMDA):
Weight
loss
is
common
in
the
nursing
home
and
associated
with
poor
clinical
outcomes
such
as
the
development
of
pressure
ulcers,
increased
risk
of
infection,
functional
decline,
cognitive
decline
and
increased
risk
of
death.
One
of
the
frequent
causes
of
weight
loss
in
the
long‐term
care
setting
is
therapeutic
diets.
Therapeutic
diets
are
often
unpalatable
and
poorly
tolerated
by
older
persons
and
may
lead
to
weight
loss.
The
use
of
therapeutic
diets,
including
low‐salt,
low‐fat,
and
sugar‐restricted
diets,
should
be
minimized
in
the
LTC
setting.7
Attending
physicians
are
encouraged
to
consider
liberalizing
dietary
restrictions
(e.g.,
calorie
limitation,
salt
restrictions)
that
are
not
essential
to
the
resident’s
well
being,
and
that
may
impair
quality
of
life
or
acceptance
of
diet.8
Patients
and
families
who
have
become
accustomed
to
dietary
restrictions
while
at
home
or
in
the
acute
care
setting
may
need
to
be
educated
about
this
change
in
thinking.
Swallowing
abnormalities
are
common
but
do
not
necessarily
require
modified
diet
and
fluid
textures,
especially
if
these
restrictions
adversely
affect
food
and
fluid
intake.9
American
Dietetic
Association
(ADA):
It
is
the
position
of
the
American
Dietetic
Association
that
the
quality
of
life
and
nutritional
status
of
older
residents
in
long‐term
care
facilities
may
be
enhanced
by
liberalization
of
the
diet
prescription.
Medical
nutrition
therapy
must
balance
medical
needs
and
individual
desires
and
maintain
quality
of
life.
The
recent
paradigm
shift
from
restrictive
institutions
to
vibrant
communities
for
older
adults
requires
dietetics
professionals
to
be
open‐minded
when
assessing
risks
versus
benefits
of
therapeutic
diets,
especially
for
frail
older
adults.
Food
is
an
essential
component
of
quality
of
life;
an
unacceptable
or
unpalatable
diet
can
lead
to
poor
food
and
fluid
intake,
resulting
in
weight
loss
and
undernutrition
and
a
spiral
of
negative
health
effects.10
Although
limited
evidence
supporting
a
medicalized
diet
in
select
older
adults
does
exist,
it
is
also
important
to
note
that
these
diets
are
often
less
palatable
and
poorly
tolerated
and
can
lead
to
weight
loss.
Weight
loss
is
a
far
greater
concern
to
the
often
frail
nursing
home
American
Medical
Directors
Association
Clinical
Practice
Guideline:
Altered
Nutritional
Status.
2009.
AMDA
Synopsis
of
Federal
Regulations
in
the
Nursing
Home:
Implication
for
Attending
Physicians
and
Medical
Directors
2009.
9
AMDA
Clinical
Practice
Guideline:
Diabetes
Management
in
the
Long‐Term
Care
Setting
2008.
10
ADA
Position
Paper
Liberalization
of
the
Diet
Prescription
Improves
Quality
of
Life
for
Older
Adults
in
Long‐Term
Care
2005.
7
8
9
Appendix 3-A
resident
and
easily
outweighs
the
potential
modest
benefits
a
medicalized
diet
can
only
sometimes
offer.11
It
is
the
position
of
the
American
Dietetic
Association
that
the
quality
of
life
and
nutritional
status
of
older
adults
residing
in
health
care
communities
can
be
enhanced
by
individualization
to
less‐restrictive
diets.
Although
therapeutic
diets
are
designed
to
improve
health,
they
can
negatively
affect
the
variety
and
flavor
of
the
food
offered.
Individuals
may
find
restrictive
diets
unpalatable,
resulting
in
reducing
the
pleasure
of
eating,
decreased
food
intake,
unintended
weight
loss,
and
undernutrition
–
the
very
maladies
health
care
practitioners
are
trying
to
prevent.
In
contrast,
more
liberal
diets
are
associated
with
increased
food
and
beverage
intake.
For
many
older
adults
residing
in
health
care
communities,
the
benefits
of
less‐restrictive
diets
outweigh
the
risks.12
Centers
for
Medicare
and
Medicaid
Services
(CMS):
Liberalized
diets
should
be
the
norm,
restricted
diets
should
be
the
exception.
Generally
weight
stabilization
and
adequate
nutrition
are
promoted
by
serving
residents
regular
or
minimally
restricted
diets.13
Research
suggests
that
a
liberalized
diet
can
enhance
the
quality
of
life
and
nutritional
status
of
older
adults
in
long‐term
care
facilities.
Thus,
it
is
often
beneficial
to
minimize
restrictions,
consistent
with
a
resident’s
condition,
prognosis,
and
choices
before
using
supplementation.
It
may
also
be
helpful
to
provide
the
residents
their
food
preferences,
before
using
supplementation.
This
pertains
to
newly
developed
meal
plans
as
well
as
to
the
review
of
existing
diets.
Dietary
restrictions,
therapeutic
(e.g.,
low
fat
or
sodium
restricted)
diets,
and
mechanically
altered
diets
may
help
in
select
situations.
At
other
times,
they
may
impair
adequate
nutrition
and
lead
to
further
decline
in
nutritional
status,
especially
in
already
undernourished
or
at‐risk
individuals.
When
a
resident
is
not
eating
well
or
is
losing
weight,
the
interdisciplinary
team
may
temporarily
abate
dietary
restrictions
and
liberalize
the
diet
to
improve
the
resident’s
food
intake
to
try
to
stabilize
their
weight.
Sometimes,
a
resident
or
resident’s
representative
decides
to
decline
medically
relevant
dietary
restrictions.
In
such
circumstances,
the
resident,
facility
and
practitioner
collaborate
to
identify
pertinent
alternatives
(CMS
Tag
F
325
Nutrition).14
Current
Thinking
Given
that
most
nursing
home
residents
are
at
risk
for
malnutrition
and
may
in
fact
have
different,
therapeutic
targets
for
blood
pressure,
blood
sugar
and
cholesterol,
a
regular
or
liberalized
diet
which
allows
for
resident
choice
is
most
often
the
preferred
initial
choice.
11
Gardner
CD,
Coulston
A,
Chatterjee
L,
Rigby
A,
Spiller
G,
Farquhar
JW,
The
effect
of
a
plant‐based
diet
on
plasma
lipids
in
hypercholesterolemic
adults:
a
randomized
trial.
Intern
Med.
2005;142
(9):725.
12
ADA
Liberalization
of
the
Diet
Prescription
Improves
Quality
of
Life
for
Older
Adults
in
Long‐Term
Care
2005.
13
CMS
Satellite
Broadcast
From
Institutional
to
Individualized
Care:
Case
Studies
in
Culture
Change,
Part
III,
2007
available
from
the
Pioneer
Network
www.pioneernetwork.net.
14
State
Operations
Manual
for
LTC
Facilities,
Appendix
PP,
483.25(i)
F
325
Nutrition,
2008
Guidance.
10
Appendix 3-A
As
with
any
medical
issue,
residents
should
be
monitored
for
desired
outcomes
as
well
as
for
potential
adverse
effects.15
Some
homes
have
actually
made
the
“regular”
diet
with
ranges
of
consistency
modifications
such
as
"puree
to
mechanical
soft"
their
only
available
option,
then
honored
the
resident's
choice
to
eliminate
"not
recommended"
foods
from
his/her
diet
by
choice,
then
monitored
his/her
clinical
outcomes
and
made
changes
as
necessary.
That
being
said,
homes
with
transitional
care
units
or
that
serve
younger
disabled
people
may
choose
to
offer
the
more
restrictive
diets
as
an
option
for
long
term
health.16
All
persons
moving
into
a
nursing
home
receive
a
regular
diet
unless
there
is
a
strong
medical
historical
reason
to
initiate/continue
a
restricted
diet.
Those
who
require
medicalized
diets
can
be
assessed
by
the
dietitian,
physician,
and
if
necessary
the
speech
therapist
for
appropriate
individualized
modification.
There
needs
to
be
continuous
monitoring
of
the
usage
of
all
medicalized
diets
to
ensure
that
they
continue
to
be
medically
indicated,
much
the
same
way
the
usage
of
urinary
catheters
or
other
medical
devices
are
monitored.
When
potential
interventions
have
the
ability
to
both
help
and
harm,
such
as
medicalized
diets
and
thickened
liquids,
the
interventions
should
be
reviewed
by
the
interdisciplinary
team
in
a
holistic
fashion
and
discussed
with
the
resident
and/or
their
family/POA
prior
to
their
implementation.
Residents
and/or
their
families/POA
should
be
educated
regarding
these
interventions
and
the
care
plan
monitored
for
both
safety
and
effectiveness.
The
physician
and
interdisciplinary
team
should
treat
asymptomatic
disease
PROVIDED
it
is
consistent
with
the
resident’s
goals
for
care,
is
SUPPORTED
by
the
literature
and
DOES
NOT
DECREASE
QUALITY
OF
LIFE.17
Relevant
Research
Trends
See
below
for
relevant
research
to
each
specific
diet.
15
Leible
and
Wayne,
The
Role
of
the
Physician’s
Order,
paper
written
for
CHII
2010.
16
Bump,
Linda.
Clinical
Standards
Task
Force
communication,
2011.
17
Leible
and
Wayne,
The
Role
of
the
Physician’s
Order,
paper
written
for
CHII
2010.
11
Appendix 3-A
Recommended
Course
of
Practice
• Diet
is
to
be
determined
with
the
person
and
in
accordance
with
his/her
informed
choices,
goals
and
preferences,
rather
than
exclusively
by
diagnosis.
• Assess
the
condition
of
the
person.
Include
quality
of
life
markers
such
as
satisfaction
with
food,
meal
time
service,
level
of
control
and
independence.
• Assess
the
condition
of
the
person.
Assess
and
provide
the
person's
preferred
context
and
environment
for
meals,
in
other
words
the
person's
preferences,
patterns
and
routines
for
socialization
(i.e.
eating
alone
or
with
others),
physical
support
(i.e.
adapted
eating
utensils,
assistance
with
cartons/cutting
or
adapted
w/c
positioning),
timing
of
meals
(i.e.
typical
community
or
unique
meal
times)
and
personal
meaning/value
of
the
dining
experience
(i.e.
for
one
who
does
not
eat
breakfast,
breakfast
is
not
important
but
perhaps
an
early
lunch
is).
Include
quality
of
life
markers
such
as
satisfaction
with
food,
service
received
during
meals,
level
of
control
and
independence.
• Unless
a
medical
condition
warrants
a
restricted
diet,
consider
beginning
with
a
regular
diet
and
monitoring
how
the
person
does
eating
it.
• Empower
and
honor
the
person
first,
and
the
whole
interdisciplinary
team
second,
to
look
at
concerns
and
create
effective
solutions.
• Support
self‐direction
and
individualize
the
plan
of
care.
• Ensure
that
the
physician
and
consultant
pharmacist
are
aware
of
resident
food
and
dining
preferences
so
that
medication
issues
can
be
addressed
and
coordinated
i.e.
medication
timing
and
impact
on
appetite.
• Monitor
the
person
and
his/her
condition
related
to
their
goals
regarding
nutritional
status
and
their
physical,
mental
and
psychosocial
well‐being.
• Although
a
person
may
have
not
been
able
to
make
decisions
about
certain
aspects
of
their
life,
that
does
not
mean
they
cannot
make
choices
in
dining.
• When
a
person
makes
“risky”
decisions,
the
plan
of
care
will
be
adjusted
to
honor
informed
choice
and
provide
supports
available
to
mitigate
the
risks.
• Most
professional
codes
of
ethics
require
the
professional
to
support
the
person/client
in
making
their
own
decisions,
being
an
active,
not
passive,
participant
in
their
care.
• When
caring
for
frail
elders
there
is
often
no
clear
right
answer.
Possible
interventions
often
have
the
potential
to
both
help
and
harm
the
elder.
This
is
why
the
physician
must
explain
the
risks
and
benefits
to
both
the
resident
and
interdisciplinary
team.
The
information
should
be
discussed
amongst
the
team
and
resident/family.
The
resident
then
has
the
right
to
make
his/her
informed
choice
even
if
it
is
not
to
follow
recommended
medical
advice
and
the
team
supports
the
person
and
his/her
decision,
mitigating
risks
by
offering
support,
i.e.
offering
foods
of
natural
pureed
consistency
when
one
refuses
recommended
tube
feeding.
It
is
when
the
team
makes
decisions
for
the
person
without
acknowledgement
by
all
that
problems
arise.
The
agreed
upon
plan
of
care
should
then
be
monitored
to
make
sure
the
community
is
best
meeting
the
resident's
needs.
• All
decisions
default
to
the
person.
12
Appendix 3-A
Standard
of
Practice
for
Individualized
Diabetic/Calorie
Controlled
Diet
Basis
in
Current
Thinking
and
Research
AMDA:
“…intensive
treatment
of
diabetes
may
not
be
appropriate
for
all
individuals
in
the
LTC
setting.
To
improve
quality
of
life,
diagnostic
and
therapeutic
decisions
should
take
into
account
the
patient’s
cognitive
and
functional
status,
severity
of
disease,
expressed
preferences,
and
life
expectancy.”18
An
individualized
regular
diet
that
is
well
balanced
and
contains
a
variety
of
foods
and
a
consistent
amount
of
carbohydrates
has
been
shown
to
be
more
effective
than
the
typical
treatment
of
diabetes.19
ADA:
There
is
no
evidence
to
support
prescribing
diets
such
as
no
concentrated
sweets
or
no
sugar
added
for
older
adults
in
living
in
health
care
communities,
and
these
restricted
diets
are
no
longer
considered
appropriate.
Most
experts
agree
that
using
medication
rather
than
dietary
changes
to
control
blood
glucose,
blood
lipid
levels,
and
blood
pressure
can
enhance
the
joy
of
eating
and
reduce
the
risk
of
malnutrition
in
older
adults
in
health
care
communities.20
CMS:
Nothing
specific
to
diabetes
was
found,
however,
CMS
has
stated
much
about
liberalizing
diets,
see
Diet
Liberalization
section
as
well
as
each
specific
diet
section.
Current
Thinking
If
a
person
with
diabetes
chooses
not
to
eat
breakfast,
for
example,
that
decision
should
be
made
and
communicated
before
a
dose
of
regular
insulin
is
administered
in
the
morning.
While
we
agree
that
people
should
be
given
as
much
freedom
as
possible
in
choice
of
diets
and
foods,
it
may
be
more
appropriate
in
many
cases
to
liberalize
the
treatment
goals
or
targets
(such
as
hemoglobin
A1C
or
cholesterol)
rather
than
add
more
medication.21
The
only
benefit
to
sliding
scale
insulin
is
with
a
new
diagnosis
where
the
clinician
is
attempting
to
estimate
daily
dosage
of
insulin.
For
this
reason,
insulin
sliding
scale
should
be
used
sparingly
if
at
all,
and
glucose
monitoring
should
be
done
no
more
than
once
daily
in
stable
diabetics,
more
frequently,
albeit
temporary,
if
actively
adjusting
the
regimen.22
More
than
once
daily
blood
sugars
in
stable
diabetic
patients
should
be
discouraged
(Ibid).
18
AMDA
Clinical
Practice
Guidelines:
Diabetes
Management
in
the
Long‐Term
Care
Setting
2008.
19
AMDA
Clinical
Practice
Guideline:
Diabetes
Management
in
the
Long‐Term
Care
Setting
2008.
20
ADA
Position
Paper
Individualized
Nutrition
Approaches
for
Older
Adults
in
Health
Care
Communities
2010.
21
Food
and
Dining
Clinical
Standards
response,
3/23/11
American
Society
of
Consultant
Pharmacists.
22
Leible
and
Wayne,
The
Role
of
the
Physician’s
Order,
paper
written
for
CHII
2010.
13
Appendix 3-A
Elderly
nursing
home
residents
with
diabetes
can
receive
a
regular
diet
that
is
consistent
in
the
amount
and
timing
of
carbohydrates,
along
with
proper
medication
to
control
blood
glucose
levels
(Ibid).
Relevant
Research
Trends
The
traditional
treatment
of
diabetes
of
a
“no
concentrated
sweets”
and
a
liberal
diabetic
diet
have
not
been
shown
to
improve
glycemic
control
in
nursing
home
residents.23
Recent
studies
have
failed
to
show
that
tight
glycemic
control
prevents
heart
attacks
and
strokes
in
diabetics
and
may
in
fact
worsen
outcome.
24
Tighter
glycemic
control
may
prevent
long
term
complications
of
diabetes
such
as
retinopathy,
neuropathy
and
nephropathy
in
newly
diagnosed
diabetics
however
these
conditions
take
years
to
develop
and
few,
if
any,
older
adults
would
benefit
from
this
approach.25
Given
the
lack
of
clear
evidence
to
guide
treatment
in
the
older
adult
population,
AMDA
recommends
individualizing
the
treatment
plan
based
on
a
resident’s
underlying
medical
condition
and
associated
co‐morbidities
and
has
stated
a
target
hemoglobin
AIC
between
7
and
8
is
reasonable.26
Little
evidence
supports
the
use
of
sliding
scale
insulin
as
it
is
reactive
in
nature
and
fails
to
meet
the
physiologic
needs
of
the
person
(Ibid).
Recommended
Course
of
Practice
• Diet
is
to
be
determined
with
the
person
and
in
accordance
with
his/her
informed
choices,
goals
and
preferences,
rather
than
exclusively
by
diagnosis.
• Assess
the
condition
of
the
person.
Assess
and
provide
the
person's
preferred
context
and
environment
for
meals,
in
other
words
the
person's
preferences,
patterns
and
routines
for
socialization
(i.e.
eating
alone
or
with
others),
physical
support
(i.e.
adapted
eating
utensils,
assistance
with
cartons/cutting
or
adapted
w/c
positioning),
timing
of
meals
(i.e.
typical
community
or
unique
meal
times)
and
personal
meaning/value
of
the
dining
experience
(i.e.
for
one
who
does
not
eat
breakfast,
breakfast
is
not
important
but
perhaps
an
early
lunch
is).
Include
quality
of
life
markers
such
as
satisfaction
with
food,
service
received
during
meals,
level
of
control
and
independence.
• Unless
a
medical
condition
warrants
a
restricted
diet,
consider
beginning
with
a
regular
diet
and
monitoring
how
the
person
does
eating
it.
23
Tariq
SH,
Karcic
E,
Thomas
DR,
et
al.
The
use
of
no‐concentrated
sweets
diet
in
the
management
of
type
2
diabetes
in
nursing
homes.
J
Am
Dietetic
Assoc
2001;
101(12):1463‐1466.
24
Tariq
SH,
Karcic
E,
Thomas
DR,
et
al.
The
use
of
no‐concentrated
sweets
diet
in
the
management
of
type
2
diabetes
in
nursing
homes.
J
Am
Dietetic
Assoc
2001;
101(12):1463‐1466
25
Effects
of
intensive
glucose
lowering
in
type
2
diabetes.
N
Engl
J
Med
2008;
358(24):2545‐255
26
AMDA
Clinical
Practice
Guideline:
Diabetes
Management
in
the
Long‐Term
Care
Setting
2008.
14
Appendix 3-A
• Empower
and
honor
the
person
first,
and
the
whole
interdisciplinary
team
second,
to
look
at
concerns
and
create
effective
solutions.
• Support
self‐direction
and
individualize
the
plan
of
care.
• Ensure
that
the
physician
and
consultant
pharmacist
are
aware
of
resident
food
and
dining
preferences
so
that
medication
issues
can
be
addressed
and
coordinated
i.e.
medication
timing
and
impact
on
appetite.
• Monitor
the
person
and
his/her
condition
related
to
their
goals
regarding
nutritional
status
and
their
physical,
mental
and
psychosocial
well‐being.
• Although
a
person
may
have
not
be
able
to
make
decisions
about
certain
aspects
of
their
life,
that
does
not
mean
they
cannot
make
choices
in
dining.
• When
a
person
makes
“risky”
decisions,
the
plan
of
care
will
be
adjusted
to
honor
informed
choice
and
provide
supports
available
to
mitigate
the
risks.
• Most
professional
codes
of
ethics
require
the
professional
to
support
the
person/client
in
making
their
own
decisions,
being
an
active,
not
passive,
participant
in
their
care.
• When
caring
for
frail
elders
there
is
often
no
clear
right
answer.
Possible
interventions
often
have
the
potential
to
both
help
and
harm
the
elder.
This
is
why
the
physician
must
explain
the
risks
and
benefits
to
both
the
resident
and
interdisciplinary
team.
The
information
should
be
discussed
amongst
the
team
and
resident/family.
The
resident
then
has
the
right
to
make
his/her
informed
choice
even
if
it
is
not
to
follow
recommended
medical
advice
and
the
team
supports
the
person
and
his/her
decision,
mitigating
risks
by
offering
support,
i.e.
offering
foods
of
natural
pureed
consistency
when
one
refuses
recommended
tube
feeding.
It
is
when
the
team
makes
decisions
for
the
person
without
acknowledgement
by
all
that
problems
arise.
The
agreed
upon
plan
of
care
should
then
be
monitored
to
make
sure
the
community
is
best
meeting
the
resident's
needs.
• All
decisions
default
to
the
person.
15
Appendix 3-A
Standard
of
Practice
for
Individualized
Low
Sodium
Diet
Basis
in
Current
Thinking
and
Research
AMDA:
Such
dietary
restrictions
may
benefit
some
individuals,
but
more
lenient
blood
pressure
and
blood
sugar
goals
in
the
frail
elderly
may
be
desirable
while
a
less
palatable
restricted
diet
may
lead
to
weight
loss
and
its
associated
complications.27
ADA:
The
relationship
between
congestive
heart
failure,
blood
pressure,
and
sodium
intake
in
the
elderly
population
has
not
been
well
studied.
The
American
Heart
Association
recommends
that
older
adults
attempt
to
control
blood
pressure
through
diet
and
lifestyle
changes
and
recommends
a
sodium
intake
of
2
to
3
g/day
for
patients
with
congestive
heart
failure.
However,
a
randomized
trial
of
adults
aged
55
to
83
years
found
that
a
normal‐sodium
diet
improved
congestive
heart
failure
outcomes.
A
liberal
approach
to
sodium
in
diets
may
be
needed
to
maintain
adequate
nutritional
status,
especially
in
frail
older
adults.28
CMS:
Dietary
restrictions,
therapeutic
(e.g.,
low
fat
or
sodium
restricted)
diets,
and
mechanically
altered
diets
may
help
in
select
situations.
At
other
times,
they
may
impair
adequate
nutrition
and
lead
to
further
decline
in
nutritional
status,
especially
in
already
undernourished
or
at‐risk
individuals.
When
a
resident
is
not
eating
well
or
is
losing
weight,
the
interdisciplinary
team
may
temporarily
abate
dietary
restrictions
and
liberalize
the
diet
to
improve
the
resident’s
food
intake
to
try
to
stabilize
their
weight.29
Relevant
Research
Trends
The
typical
two
gram
sodium
diet
that
is
often
recommended
for
individuals
with
hypertension,
has
been
shown
to
reduce
systolic
blood
pressures,
on
average,
by
only
5
mmHg,
and
diastolic
blood
pressures
by
only
2.5
mmHg
making
this
diet’s
effect
on
blood
pressure
modest
at
best
and
has
not
actually
been
shown
to
improve
cardiovascular
outcomes
in
the
nursing
home
resident30.
Guidelines
for
blood
pressure
targets
for
older
adults
differ
from
those
for
younger
people.
For
older
adults,
current
literature
supports
intervention,
with
medication
and/or
diet,
only
for
systolic
blood
pressures
over
160
mmHg
and
targets
a
systolic
blood
pressure
of
less
than
150mmHg.31
AMDA
The
Role
of
the
Medical
Director
in
Person‐Directed
Care
White
Paper,
Mar.
2010,
3.
ADA
Liberalization
of
the
Diet
Prescription
Improves
Quality
of
Life
for
Older
Adults
in
LTC
2005.
29 CMS
State
Operations
Manual
Appendix
P,
Tag
325
Nutrition
30 Dickinson,
HO,
Mason,
JM,
Nicolson,
DJ,
et
al.
Lifestyle
interventions
to
reduce
raised
blood
pressure:
a
systematic
review
of
randomized
controlled
trials.
J
Hypertens
2006;
24:215.
31
Beckett,
NS,
Peters,
R,
Fletcher,
AE,
et
al.
Treatment
of
hypertension
in
patients
80
years
of
age
or
older.
N
Engl
J
Med
2008;
358:1887.
27
28
16
Appendix 3-A
Lowering
systolic
blood
pressures
below
120
to
130mmHg
and
diastolic
pressures
below
65mmHg
may
increase
mortality
in
the
elderly.32
Limiting
salt
intake
in
individuals
with
congestive
heart
failure
is
felt
to
be
of
benefit
by
limiting
fluid
retention,
but
the
clinical
experience
of
two
medical
directors
of
numerous
nursing
homes
shows
that
this
is
necessary
in
only
a
minority
of
nursing
home
patients,
usually
those
who
are
salt
sensitive
and
often
have
advanced
disease.33
Older
people
have
the
same
taste
preferences
as
they
have
had
all
of
their
life,
and
thus
low
sodium,
low
fat
meals
are
not
always
as
appetizing
as
the
normal
version
of
a
food
with
naturally
high
fat
and
sodium
content.34
Recommended
Course
of
Practice
Low
sodium
diets
are
not
shown
to
be
effective
in
the
long
term
care
population
of
elders
for
reducing
blood
pressure
or
exacerbations
of
CHF
and
therefore
should
only
be
used
when
benefit
to
the
individual
resident
has
been
documented.
Recommended
Course
of
Practice
• Diet
is
to
be
determined
with
the
person
and
in
accordance
with
his/her
informed
choices,
goals
and
preferences,
rather
than
exclusively
by
diagnosis.
• Assess
the
condition
of
the
person.
Assess
and
provide
the
person's
preferred
context
and
environment
for
meals,
in
other
words
the
person's
preferences,
patterns
and
routines
for
socialization
(i.e.
eating
alone
or
with
others),
physical
support
(i.e.
adapted
eating
utensils,
assistance
with
cartons/cutting
or
adapted
w/c
positioning),
timing
of
meals
(i.e.
typical
community
or
unique
meal
times)
and
personal
meaning/value
of
the
dining
experience
(i.e.
for
one
who
does
not
eat
breakfast,
breakfast
is
not
important
but
perhaps
an
early
lunch
is).
Include
quality
of
life
markers
such
as
satisfaction
with
food,
service
received
during
meals,
level
of
control
and
independence.
• Unless
a
medical
condition
warrants
a
restricted
diet,
consider
beginning
with
a
regular
diet
and
monitoring
how
the
person
does
eating
it.
• Empower
and
honor
the
person
first,
and
the
whole
interdisciplinary
team
second,
to
look
at
concerns
and
create
effective
solutions.
• Support
self‐direction
and
individualize
the
plan
of
care.
• Ensure
that
the
physician
and
consultant
pharmacist
are
aware
of
resident
food
and
dining
preferences
so
that
medication
issues
can
be
addressed
and
coordinated
i.e.
medication
timing
and
impact
on
appetite.
32
Oates
DJ,
Berlowitz
DR,
Glickman
ME,
Silliman
RA,
Borzecki
AM.
Blood
pressure
and
survival
in
the
oldest
old.
J
Am
Geriatr
Soc
2007;
55(3):383‐8.
33
Leible
and
Wayne,
The
Role
of
the
Physician
Order,
paper
written
for
CHII
2010.
34 Calverley,
D.
“The
Food
Fighters.”
Nursing
Standard,
Vol.
22,
2007,
20‐21.
17
Appendix 3-A
• Monitor
the
person
and
his/her
condition
related
to
their
goals
regarding
nutritional
status
and
their
physical,
mental
and
psychosocial
well‐being.
• Although
a
person
may
have
not
be
able
to
make
decisions
about
certain
aspects
of
their
life,
that
does
not
mean
they
cannot
make
choices
in
dining.
• When
a
person
makes
“risky”
decisions,
the
plan
of
care
will
be
adjusted
to
honor
informed
choice
and
provide
supports
available
to
mitigate
the
risks.
• Most
professional
codes
of
ethics
require
the
professional
to
support
the
person/client
in
making
their
own
decisions,
being
an
active,
not
passive,
participant
in
their
care.
• When
caring
for
frail
elders
there
is
often
no
clear
right
answer.
Possible
interventions
often
have
the
potential
to
both
help
and
harm
the
elder.
This
is
why
the
physician
must
explain
the
risks
and
benefits
to
both
the
resident
and
interdisciplinary
team.
The
information
should
be
discussed
amongst
the
team
and
resident/family.
The
resident
then
has
the
right
to
make
his/her
informed
choice
even
if
it
is
not
to
follow
recommended
medical
advice
and
the
team
supports
the
person
and
his/her
decision,
mitigating
risks
by
offering
support,
i.e.
offering
foods
of
natural
pureed
consistency
when
one
refuses
recommended
tube
feeding.
It
is
when
the
team
makes
decisions
for
the
person
without
acknowledgement
by
all
that
problems
arise.
The
agreed
upon
plan
of
care
should
then
be
monitored
to
make
sure
the
community
is
best
meeting
the
resident's
needs.
• All
decisions
default
to
the
person.
18
Appendix 3-A
Standard
of
Practice
for
Individualized
Cardiac
Diet
Basis
in
Current
Thinking
and
Research
AMDA:
Routine
dietary
restrictions
are
usually
unnecessary
and
can
be
counterproductive
in
the
LTC
setting.
Special
diets
for
diabetes,
hypertension
and
heart
failure,
and
hypercholesterolemia
have
not
been
shown
to
improve
control
or
affect
symptoms.
When
a
patient
is
at
risk
or
has
unintended
weight
loss,
the
presence
of
one
of
diagnoses
alone
is
insufficient
justification
for
continuing
dietary
restrictions.
The
reasons
for
any
dietary
restrictions
that
are
ordered
should
be
clearly
stated
in
the
patient’s
record.35
ADA:
The
Dietary
Approaches
to
Stop
Hypertension
(DASH)
eating
pattern
is
known
to
reduce
blood
pressure
and
may
also
reduce
rates
of
heart
failure.
The
DASH
diet
is
low
in
sodium
and
saturated
fat
but
also
high
in
calcium,
magnesium,
and
potassium.
The
nutrition
care
plan
for
older
adults
with
cardiac
disease
should
focus
on
maintaining
blood
pressure
and
blood
lipid
levels
while
preserving
eating
pleasure
and
quality
of
life.
Using
menus
that
work
toward
the
objectives
of
the
Dietary
Guidelines
for
Americans
and/or
the
DASH
diet
can
help
achieve
those
goals.36
CMS:
Dietary
restrictions,
therapeutic
(e.g.,
low
fat
or
sodium
restricted)
diets,
and
mechanically
altered
diets
may
help
in
select
situations.
At
other
times,
they
may
impair
adequate
nutrition
and
lead
to
further
decline
in
nutritional
status,
especially
in
already
undernourished
or
at‐risk
individuals.
When
a
resident
is
not
eating
well
or
is
losing
weight,
the
interdisciplinary
team
may
temporarily
abate
dietary
restrictions
and
liberalize
the
diet
to
improve
the
resident’s
food
intake
to
try
to
stabilize
their
weight.37
Relevant
Research
Trends
The
effects
of
the
traditional
low
cholesterol
and
low
fat
diets
typically
used
to
treat
elevated
cholesterol
vary
greatly
and,
at
most,
will
decrease
lipids
by
only
10‐15%.
If
aggressive
lipid
reduction
is
appropriate
for
the
nursing
home
resident
it
can
be
more
effectively
achieved
through
the
use
of
medication
that
provides
average
reductions
of
between
30
and
40%
while
still
allowing
the
individual
to
enjoy
personal
food
choices.38,
39
35
AMDA Clinical
Practice
Guideline
for
Alteration
in
Nutritional
Status,
2010,
20.
36
ADA
Position
Paper
Individualized
Nutrition
Approaches
for
Older
Adults
in
Health
Care
Commun.
2010.
CMS
State
Operations
Manual
Appendix
P,
Tag
325
Nutrition
Randomised
trial
of
cholesterol
lowering
in
4444
patients
with
coronary
heart
disease:
the
Scandinavian
Simvastatin
Survival
Study
(4S),
The
Lancet.
1994;344(8934):1383.
39
LaRosa
JC,
Grundy
SM,
Waters
DD,
Shear
C,
Barter
P,
Fruchart
JC,
Gotto
AM,
Greten
H,
Kastelein
JJ,
Shepherd
J,
Wenger
NK,
Treating
to
New
Targets
(TNT)
Investigators.
Intensive
lipid
lowering
with
atorvastatin
in
patients
with
stable
coronary
disease.
N
Engl
J
Med.
2005;352(14):1425.
37
38
19
Appendix 3-A
Recommended
Course
of
Practice
Low
saturated
fat
(low
cholesterol)
diets
have
only
a
modest
effect
on
reducing
blood
cholesterol
in
the
long
term
care
elder
population
and
therefore
should
only
be
used
when
benefit
has
been
documented.
Recommended
Course
of
Practice
• Diet
is
to
be
determined
with
the
person
and
in
accordance
with
his/her
informed
choices,
goals
and
preferences,
rather
than
exclusively
by
diagnosis.
• Assess
the
condition
of
the
person.
Assess
and
provide
the
person's
preferred
context
and
environment
for
meals,
in
other
words
the
person's
preferences,
patterns
and
routines
for
socialization
(i.e.
eating
alone
or
with
others),
physical
support
(i.e.
adapted
eating
utensils,
assistance
with
cartons/cutting
or
adapted
w/c
positioning),
timing
of
meals
(i.e.
typical
community
or
unique
meal
times)
and
personal
meaning/value
of
the
dining
experience
(i.e.
for
one
who
does
not
eat
breakfast,
breakfast
is
not
important
but
perhaps
an
early
lunch
is).
Include
quality
of
life
markers
such
as
satisfaction
with
food,
service
received
during
meals,
level
of
control
and
independence.
• Unless
a
medical
condition
warrants
a
restricted
diet,
consider
beginning
with
a
regular
diet
and
monitoring
how
the
person
does
eating
it.
• Empower
and
honor
the
person
first,
and
the
whole
interdisciplinary
team
second,
to
look
at
concerns
and
create
effective
solutions.
• Support
self‐direction
and
individualize
the
plan
of
care.
• Ensure
that
the
physician
and
consultant
pharmacist
are
aware
of
resident
food
and
dining
preferences
so
that
medication
issues
can
be
addressed
and
coordinated
i.e.
medication
timing
and
impact
on
appetite.
• Monitor
the
person
and
his/her
condition
related
to
their
goals
regarding
nutritional
status
and
their
physical,
mental
and
psychosocial
well‐being.
• Although
a
person
may
have
not
be
able
to
make
decisions
about
certain
aspects
of
their
life,
that
does
not
mean
they
cannot
make
choices
in
dining.
• When
a
person
makes
“risky”
decisions,
the
plan
of
care
will
be
adjusted
to
honor
informed
choice
and
provide
supports
available
to
mitigate
the
risks.
• Most
professional
codes
of
ethics
require
the
professional
to
support
the
person/client
in
making
their
own
decisions,
being
an
active,
not
passive,
participant
in
their
care.
• When
caring
for
frail
elders
there
is
often
no
clear
right
answer.
Possible
interventions
often
have
the
potential
to
both
help
and
harm
the
elder.
This
is
why
the
physician
must
explain
the
risks
and
benefits
to
both
the
resident
and
interdisciplinary
team.
The
information
should
be
discussed
amongst
the
team
and
resident/family.
The
resident
then
has
the
right
to
make
his/her
informed
choice
even
if
it
is
not
to
follow
recommended
medical
advice
and
the
team
supports
the
person
and
his/her
decision,
mitigating
risks
by
offering
support,
i.e.
offering
foods
of
natural
pureed
consistency
when
one
refuses
recommended
tube
feeding.
It
is
when
the
team
makes
decisions
for
the
person
without
acknowledgement
by
all
that
20
Appendix 3-A
problems
arise.
The
agreed
upon
plan
of
care
should
then
be
monitored
to
make
sure
the
community
is
best
meeting
the
resident's
needs.
• All
decisions
default
to
the
person.
21
Appendix 3-A
Standard
of
Practice
for
Individualized
Altered
Consistency
Diet
An
altered
consistency
diet
is
usually
prescribed
due
to
swallowing
difficulties,
or
dysphagia,
which
is
not
a
diagnosis
but
rather
a
symptom
commonly
associated
with
conditions
such
as
stroke,
dementia
or
Parkinson’s
disease.
Basis
in
Current
Thinking
and
Research
AMDA:
Swallowing
abnormalities
are
common
but
do
not
necessarily
require
modified
diet
and
fluid
textures,
especially
if
these
restrictions
adversely
affect
food
and
fluid
intake.40
Provide
foods
of
a
consistency
and
texture
that
allow
comfortable
chewing
and
swallowing.
A
resident
who
has
difficulty
swallowing
may
reject
pureed
or
artificially
thickened
foods
but
may
eat
foods
that
are
naturally
of
a
pureed
consistency,
such
as….
mashed
potatoes,
….puddings,
….and
yogurt,
finely
chopped
foods
may
retain
their
flavor
and
be
equally
well
handled
(Ibid).
ADA:
The
registered
dietitian
should
collaborate
with
the
speech‐language
pathologist
and
other
healthcare
professionals
[such
as
the
occupational
therapist]
to
ensure
that
older
adults
with
dysphagia
receive
appropriate
and
individualized
modified
texture
diets.
Older
adults
consuming
modified
texture
diets
report
an
increased
need
for
assistance
with
eating,
dissatisfaction
with
foods,
and
decreased
enjoyment
of
eating,
resulting
in
reduced
food
intake
and
weight
loss.41
CMS:
In
deciding
whether
and
how
to
intervene
for
chewing
and
swallowing
abnormalities,
it
is
essential
to
take
a
holistic
approach
and
look
beyond
the
symptoms
to
the
underlying
causes.
Excessive
modification
of
food
and
fluid
consistency
may
unnecessarily
decrease
quality
of
life
and
impair
nutritional
status
by
affecting
appetite
and
reducing
intake.
Many
factors
influence
whether
a
swallowing
abnormality
eventually
results
in
clinically
significant
complications
such
as
aspiration
pneumonia.
Identification
of
a
swallowing
abnormality
alone
does
not
necessarily
warrant
dietary
restrictions
or
food
texture
modifications.
No
interventions
consistently
prevent
aspiration
and
no
tests
consistently
predict
who
will
develop
aspiration
pneumonia.42
40
AMDA
Clinical
Practice
Guideline
for
Alteration
in
Nutritional
Status
2010,
20.
ADA
Unintended
Weight
Loss
Guideline
2009.
42 CMS
State
Operations
Manual
Appendix
PP,
483.25
Tag
F325
Nutrition.
41
22
Appendix 3-A
Relevant
Research
Trends
Disease
states
which
affect
muscle
strength
and
coordination
alter
the
ability
for
one
to
successfully
complete
a
swallow
and/or
protect
the
airway
resulting
in:
1)
choking,
where
food
partially
or
fully
obstructs
a
resident’s
airway;
or
2)
aspiration
or
inhalation
of
food/liquids,
oral
secretions
or
gastric
secretions
into
the
airway
and
lungs
which
may
result
in
pneumonia
or
pneumonitis.43
In
addition,
problems
with
swallowing
efficiency
(weakness/fatigue/limited
endurance)
may
lead
to
residue
in
the
oral
tract,
incomplete
swallowing
and
reduced
intake.44,
45
The
anticipated
outcome
of
solid
foods
ground
or
pureed
and
liquids
thickened
to
nectar
or
honey
thickness
is
improvement
in
oral
intake
and
a
reduced
risk
of
choking
and/or
aspiration.
However,
data
on
their
effectiveness
is
inconsistent;
not
all
residents
with
dysphagia
aspirate
or
choke
and
not
all
aspiration
results
in
pneumonia.46,
47,
48
While
a
modified
barium
swallow
may
show
that
thickened
liquids
reduce
the
risk
of
aspiration
acutely,
there
is
little
to
no
long
term
evidence
that
this
intervention
prevents
aspiration
pneumonia49,
50,
51.
There
is
evidence
that
improved
oral
care
can
reduce
the
risk
of
developing
aspiration
pneumonia
in
the
elderly.
52,
53
In
addition,
oral
care
can
impact
clinical
issues
such
as
dehydration.
For
example,
residents
with
swallowing
problems
may
be
able
to
have
water
Marik
PE.
Aspiration
Pneumonitis
and
Aspiration
Pneumonia.
N
Eng
J
Med
2001;
344;
9:
665‐671.
Kays,
S.
&
Robbins,
J.
2009.
The
application
of
tongue
endurance
measures
to
functional
dining.
Perspectives
on
Swallowing
and
Swallowing
Disorders
(Dysphagia),
18,
61‐67.
45 Kays,
S.A.,
Hind,
J.A.,
Gangnon,
R.E.,
&
Robbins,
J.
2010.
Effects
of
dining
on
tongue
endurance
and
swallowing‐related
outcomes.
Journal
of
Speech,
Language,
and
Hearing
Research,
53,
898‐907.
46
Logeman
JA,
Gensler
G,
Robbins,
et
al.
Design,
Procedures,
Findings,
and
Issues
from
the
Largest
NIH
Funded
Dysphagia
Clinical
Trial
entitled
Randomized
Study
of
Two
Interventions
for
Liquid
Aspiration;
Short
and
Long‐term
Effects.
(Protocol
201)
Presented
at
ASHA
Annual
Conference,
November
16‐18,
2006.
Available
at
http://www.dysphagassist.com/major_randomized_studies.
Accessed
Dec
20,
2009.
47
Robbins
J,
et
al.
Comparison
of
2
Interventions
for
Liquid
Aspiration
on
Pneumonia
Incidence.
Ann
Int
Med
2008;
148:509‐518.
48
Messinger‐Rapport
B,
et
al.
Clinical
Update
on
Nursing
Home
Medicine:
2009.
J
Amer
Med
Dir
Assoc
2009;
10:
530‐553.
49
Logeman
JA,
Gensler
G,
Robbins,
et
al.
Design,
Procedures,
Findings,
and
Issues
from
the
Largest
NIH
Funded
Dysphagia
Clinical
Trial
entitled
Randomized
Study
of
Two
Interventions
for
Liquid
Aspiration;
Short
and
Long‐term
Effects.
(Protocol
201)
Presented
at
ASHA
Annual
Conference,
Nov.
16‐18,
2006.
Available
at
http://www.dysphagassist.com/major_randomized_studies.
Accessed
Dec
20,
2009.
50
Robbins
J,
et
al.
Comparison
of
2
Interventions
for
Liquid
Aspiration
on
Pneumonia
Incidence.
Ann
Int
Med
2008;
148:509‐518.
51 Messinger‐Rapport
B,
et
al.
Clinical
Update
on
Nursing
Home
Medicine.
J
Amer
Med
Dir
Assoc
2009;
10:
530‐553.
52
Sarin
J,
Balasubramaniam
R,
Corcoran
AM,
et
al.
Reducing
the
risk
of
aspiration
pneumonia
among
elderly
patients
in
long‐term
care
facilities
through
oral
health
interventions.
J
Am
Med
Dir
Assoc.
2008;9:128–135
53
Yoon,
M.N.
&
Steele,
C.M.
(2007).
The
oral
care
imperative:
The
link
between
oral
hygiene
and
aspiration
pneumonia.
Topics
in
Geriatric
Rehabilitation,
23,
280‐288.
43
44
23
Appendix 3-A
throughout
the
day
(i.e.
the
Frazier
free
water
protocol),
as
long
as
good
oral
care
is
provided.
54
Recent
information
also
raises
the
concern
that
these
at
risk
residents
become
more
at
risk
for
dehydration
and
malnutrition
caused
by
the
unpalatable
and
visually
unappealing
modified
dysphagia
diets.55
Management
of
all
geriatric
conditions
involves
some
risks.
No
known
evaluations
or
interventions
can
guarantee
that
someone
will
not
aspirate.
It
is
important
to
note
that
many
elderly
individuals
with
swallowing
abnormalities
and
aspiration
risk
do
not
get
aspiration
pneumonia.
In
fact,
there
is
evidence
that
altered
consistency
diets
may
increase
the
risk
of
nutrition
and
hydration
deficits.
Thickened
liquids
and
pureed
foods
are
often
poorly
tolerated.56
While
there
are
currently
no
published
studies
that
show
that
tube
feeding
prevents
aspiration,
one
study
found
that
orally
fed
patients
with
dysphagic
disorders
had
significantly
less
aspiration
than
tube‐fed
patients.57
Current
Thinking
Given
the
complexity
of
the
swallow
mechanism
and
the
multitude
of
problems
that
can
arise,
it
is
essential
that
the
physician
is
involved
in
the
evaluation
of
swallowing
disorders.
A
thorough
history
and
physical
examination
is
required
to
determine
potential
causes
of
the
swallowing
dysfunction.
While
the
most
common
processes
causing
dysphagia
in
long
term
care
are
related
to
identified,
co‐morbid
conditions,
it
is
important
to
consider
other
disease
states
or
pathology
such
as
previously
undiagnosed
mass
lesions,
gastroesphogeal
reflux,
or
cancer.58
...the
interdisciplinary
team
should
assess
dysphagia
in
the
context
of
the
whole
individual.
It
is
essential
to
understand
who
the
resident
is,
and
how
he/she
is
doing
medically,
functionally
and
psychosocially.59
If
a
medical
evaluation
identifies
oral‐pharyngeal
dysphagia
as
a
concern,
a
bedside
swallow
evaluation
should
be
performed.
This
evaluation
may
provide
valuable
information
regarding
the
resident’s
swallowing
function
and
efficiency.
Results
of
this
Panther,
K.
2005.
The
Frazier
free
water
protocol.
Perspectives
on
Swallowing
and
Swallowing
Disorders
(Dysphagia),
14,
4‐9.
55
Steele
C.
Food
for
Thought:
Primum
Non
Nocere:
The
Potential
for
Harm
in
Dysphagia
Intervention.
Perspectives
on
Swallowing
and
Swallowing
Disorders
(Dysphagia).
2006:
15:
19‐23.
56
Levenson,
Steven.
“Changing
Perspectives
on
LTC
Nutrition
&
Hydration.”
Caring
for
the
Ages.
September
2002,
Vol.
3,
No.
9,
pp.
10‐14.
www.amda.com/publications/caring/september2002/nutrition.cfm
57
Feinbert
MJ,
Knebl
J,
Tully
J.
Prandial
aspiration
and
pneumonia
in
an
elderly
population
followed
over
three
years.
Dysphagia
1996;
11;
104‐109.
58
Leible
and
Wayne,
The
Role
of
the
Physician
Order,
paper
written
for
CHII
2010.
59
Levenson,
S.
The
Basis
for
Improving
and
Reforming
Long‐Term
Care,
Part
3:
Essential
Elements
for
Quality
Care,
J
Amer
Med
Dir
Assoc,
2009:
10:
597‐606.
54
24
Appendix 3-A
evaluation
should
be
considered
by
the
interdisciplinary
team
and
recommendations
regarding
swallowing
management,
including
diet
modifications,
should
be
made
based
upon
concerns
that
have
been
raised
and
discussion
with
the
resident
and/or
their
family/POA
regarding
risks
and
benefits.60
The
use
of
videofluoroscopy
or
other
instrumental
swallowing
assessments
in
long
term
care
should
be
used
only
when
clinically
indicated.
When
used
appropriately,
these
assessments
can
provide
useful
information
about
where
problems
are
arising
and
potential
modifications
that
may
be
of
assistance
to
the
resident.
The
results
of
these
tests
should
be
used
in
assisting
the
interdisciplinary
team
in
discussing
further
options
with
the
resident
and
or
their
family/Power
of
Attorney
(POA).
If
the
testing
will
not
add
new
information
or
aid
in
adjusting
the
resident’s
plan
of
care
then
the
value
of
the
additional
test
needs
to
be
reconsidered
(Ibid).
Interdisciplinary
team
members,
including
health
care
practitioners,
should
be
involved
in
balancing
the
risks
of
aspiration
against
the
potential
benefits
of
more
liberal
diets
and
food
consistency,
and
deciding
whether
there
are
viable
alternatives.
There
should
be
a
discussion
of
the
patient’s
progress,
goals
and
objectives.
Often,
aspiration
risks
must
be
tolerated
because
of
other,
more
immediate
or
probable
risks
such
as
nutrition
or
hydration
deficits.61
(For
this
purpose
of
this
document,
healthcare
practitioners
refers
to
advanced
practice
nurses,
physician
assistants
and
physicians.)
Some
physicians
are
writing
orders
for
modified
consistencies
in
ranges
that
accommodate
each
resident’s
differing
acceptance/tolerance
at
different
times
of
day,
to
different
food
groups
such
as
"puree
to
mechanical
soft"
or
"mechanical
soft
to
soft."62
A
comprehensive
and
thorough
assessment
of
the
resident
includes
everything
from
medication
side
effects
that
reduce
appetite
to
depression
and
beyond
to
ensure
that
the
standard
of
care
related
to
nutrition
is
provided.
When
all
is
ruled
out
and
documented
and
the
resident
or
family
persists
in
refusal‐‐‐this
becomes
the
standard
of
care
for
that
person.
Ensuring
thorough
ongoing
reassessment
is
of
utmost
importance
in
order
to
continually
challenge
the
highest
practicable
level
of
functioning
repeatedly
over
time,
especially
in
the
months
following
the
original
diagnosis
as
well
as
capturing
that
what
a
person
wants
can
and
does
change
over
time
(Ibid).
The
risk
of
choking
needs
to
be
compared
and
weighed
to
the
slow
process
of
wasting
away.
We
need
to
stop
letting
the
risk‐benefits
default
to
the
special
diet.
We’re
weighted
on
that
side
and
not
looking
at
that
the
person
might
waste
away
(CHII
Recommendation).
Recommended
Course
of
Practice
60
Leible
and
Wayne,
The
Role
of
the
Physician
Order,
paper
written
for
CHII
2010.
61
Levenson,
Steven.
“Changing
Perspectives
in
LTC
Nutrition
and
Hydration.”
Caring
for
the
Ages.
9.3
2002
10‐14.
62
Bump,
Linda.
Clinical
Standards
Task
Force
communication,
2011.
25
Appendix 3-A
• Diet
is
to
be
determined
with
the
person
and
in
accordance
with
his/her
informed
choices,
goals
and
preferences,
rather
than
exclusively
by
diagnosis.
• Assess
the
condition
of
the
person.
Assess
and
provide
the
person's
preferred
context
and
environment
for
meals,
in
other
words
the
person's
preferences,
patterns
and
routines
for
socialization
(i.e.
eating
alone
or
with
others),
physical
support
(i.e.
adapted
eating
utensils,
assistance
with
cartons/cutting
or
adapted
w/c
positioning),
timing
of
meals
(i.e.
typical
community
or
unique
meal
times)
and
personal
meaning/value
of
the
dining
experience
(i.e.
for
one
who
does
not
eat
breakfast,
breakfast
is
not
important
but
perhaps
an
early
lunch
is).
Include
quality
of
life
markers
such
as
satisfaction
with
food,
service
received
during
meals,
level
of
control
and
independence.
• Unless
a
medical
condition
warrants
a
restricted
diet,
consider
beginning
with
a
regular
diet
and
monitoring
how
the
person
does
eating
it.
• Empower
and
honor
the
person
first,
and
the
whole
interdisciplinary
team
second,
to
look
at
concerns
and
create
effective
solutions.
• Support
self‐direction
and
individualize
the
plan
of
care.
• Ensure
that
the
physician
and
consultant
pharmacist
are
aware
of
resident
food
and
dining
preferences
so
that
medication
issues
can
be
addressed
and
coordinated
i.e.
medication
timing
and
impact
on
appetite.
• Monitor
the
person
and
his/her
condition
related
to
their
goals
regarding
nutritional
status
and
their
physical,
mental
and
psychosocial
well‐being.
• Although
a
person
may
have
not
be
able
to
make
decisions
about
certain
aspects
of
their
life,
that
does
not
mean
they
cannot
make
choices
in
dining.
• When
a
person
makes
“risky”
decisions,
the
plan
of
care
will
be
adjusted
to
honor
informed
choice
and
provide
supports
available
to
mitigate
the
risks.
• Most
professional
codes
of
ethics
require
the
professional
to
support
the
person/client
in
making
their
own
decisions,
being
an
active,
not
passive,
participant
in
their
care.
• When
caring
for
frail
elders
there
is
often
no
clear
right
answer.
Possible
interventions
often
have
the
potential
to
both
help
and
harm
the
elder.
This
is
why
the
physician
must
explain
the
risks
and
benefits
to
both
the
resident
and
interdisciplinary
team.
The
information
should
be
discussed
amongst
the
team
and
resident/family.
The
resident
then
has
the
right
to
make
his/her
informed
choice
even
if
it
is
not
to
follow
recommended
medical
advice
and
the
team
supports
the
person
and
his/her
decision,
mitigating
risks
by
offering
support,
i.e.
offering
foods
of
natural
pureed
consistency
when
one
refuses
recommended
tube
feeding.
It
is
when
the
team
makes
decisions
for
the
person
without
acknowledgement
by
all
that
problems
arise.
The
agreed
upon
plan
of
care
should
then
be
monitored
to
make
sure
the
community
is
best
meeting
the
resident's
needs.
• All
decisions
default
to
the
person.
Standard
of
Practice
for
Individualized
Tube
Feeding
Basis
in
Current
Thinking
and
Research
26
Appendix 3-A
AMDA:
Tube
feeding
may
be
clinically
appropriate
in
certain
circumstances,
but
it
should
not
be
an
automatic
next
step
when
other
feeding
strategies
have
failed.
Before
deciding
to
initiate
tube
feeding,
the
interdisciplinary
care
team
should
meet
with
the
patient
and
family
to
carefully
consider
the
risks
and
benefits
of
tube
feeding
and
the
patient’s
preferences.
Contrary
to
what
many
people
think,
tube
feeding
does
not
ensure
the
patient’s
comfort
or
reduce
suffering;
it
may
cause
diarrhea,
abdominal
pain,
and
local
complications
and
may
increase
the
risk
of
aspiration.63
ADA:
Enteral
nutrition
may
not
be
appropriate
for
terminally
ill
older
adults
with
advanced
disease
states,
such
as
terminal
dementia,
and
should
be
in
accordance
with
advanced
directives.
The
development
of
clinical
and
ethical
criteria
for
the
nutrition
and
hydration
of
persons
throughout
the
life
span
should
be
established
by
members
of
the
health
care
team,
including
the
registered
dietitian.64
CMS:
In
deciding
whether
and
how
to
intervene
for
chewing
and
swallowing
abnormalities,
it
is
essential
to
take
a
holistic
approach
and
look
beyond
the
symptoms
to
the
underlying
causes.
Excessive
modification
of
food
and
fluid
consistency
may
unnecessarily
decrease
quality
of
life
and
impair
nutritional
status
by
affecting
appetite
and
reducing
intake.
Many
factors
influence
whether
a
swallowing
abnormality
eventually
results
in
clinically
significant
complications
such
as
aspiration
pneumonia.
Identification
of
a
swallowing
abnormality
alone
does
not
necessarily
warrant
dietary
restrictions
or
food
texture
modifications.
No
interventions
consistently
prevent
aspiration
and
no
tests
consistently
predict
who
will
develop
aspiration
pneumonia.
For
example,
tube
feeding
may
be
associated
with
aspiration,
and
is
not
necessarily
a
desirable
alternative
to
allowing
oral
intake,
even
if
some
swallowing
abnormalities
are
present.65
Relevant
Research
Trends
Feeding
tubes
have
not
been
shown
to
reduce
the
risk
of
aspiration
or
prolong
survival
in
residents
with
end
stage
dementia.66
Oral
secretions
and/or
gastric
content
are
often
the
source
of
aspiration
pneumonia
or
pneumonitis
and
thus
will
not
be
resolved
with
the
placement
of
a
tube.67
63
AMDA Clinical
Practice
Guideline
for
Alteration
in
Nutritional
Status,
2010,
22.
64
ADA
Unintended
Weight
Loss
Guideline,
2009.
CMS
State
Operations
Manual
Appendix
PP,
483.25
Tag
F325
Nutrition
Casarett
D,
Kapo
J,
Kaplan
A.
Appropriate
Use
of
Artificial
Nutrition
and
Hydration‐Fundamental
Principles
and
Recommendations.
N
Eng
J
Med
2005;
353;24:
2607‐2612.
67
Leible
and
Wayne,
The
Role
of
the
Physician
Order,
paper
written
for
CHII
2010.
65
66
27
Appendix 3-A
Arguments
for
placing
a
tube
for
feeding
include
improving
nutritional
status.
Studies
in
the
elderly
with
dementia
have
shown
little
to
no
improvement
in
weight.
In
situations
when
there
was
improvement
in
weight,
there
was
no
improvement
in
clinical
outcome
for
the
residents.
Enteral
feeding
is
also
considered
for
wound
care
as
a
means
to
improve
wound
healing.
Data
over
a
6
month
follow
up
has
shown
no
impact
on
pressure
ulcers
or
on
infections
such
as
cellulitis
associated
with
wounds68,
69.
Percutaneous
endoscopic
gastrostomy
(PEG)
and
Percutaneous
Endoscopic
Jejunostomy
(PEJ)
tubes
do
not
improve
a
resident’s
quality
of
life.
There
are
associated
physical
and
psychosocial
discomforts
related
to
the
feedings
themselves
such
as
abdominal
distension,
diarrhea,
and
restriction
of
free
movement
if
attached
to
an
infusion
device.
Additionally,
the
resident
is
deprived
of
the
social
experience
of
mealtime
that
is
valued
by
many.
Placing
a
PEG
tube
in
residents
with
advanced
dementia
should
be
strongly
discouraged,
and
placement
in
other
individuals
should
take
goals
of
care
into
account.70
A
systematic
literature
search
of
13
controlled
trials
on
the
use
of
supplements
with
people
with
dementia
and
12
controlled
trials
testing
assisted
feeding
showed
high
calorie
supplements
and
other
oral
feeding
options
can
help
people
with
dementia
to
gain
weight
as
an
alternative
to
tube
feeding.71
Due
to
a
focus
on
food
and
their
aromas
“half
a
dozen
residents
have
traded
in
their
g‐tubes
for
a
place
at
the
table”
at
Idylwood
Care
Center
in
Sunnyvale,
California.72
Methicillin‐resistant
Staphylococcus
aureus (MRSA)
colonization
is
more
likely
to
be
identified
in
residents
with
pressure
ulcers
or
fecal
incontinence
or
who
are
bed
bound
or
require
feeding
tubes
or
urinary
catheters.73
Issues
related
to
tube
feeding
are
captured
in
this
story
from
a
family
member:
Rose
had
a
stroke
when
she
was
82
leaving
her
immobile,
unable
to
speak
clearly
or
feed
herself.
It
was
found
that
she
was
aspirating
upon
swallowing
and
of
course
her
physician
strongly
recommended
a
permanent
feeding
tube.
Despite
her
losses,
Rose
was
very
mentally
clear
and
strongly
indicated
she
wanted
no
tubes!
Her
sister/power
of
attorney
defended
her
choices
and
the
physician
reluctantly
discharged
her
to
skilled
care
with
no
tubes.
Rose
was
hand
fed
pureed
food
and
she
did
die
of
aspiration
…
7
years
later.74
68
Sampson
EL,
Candy
B,
Jones
L.
Enteral
tube
feeding
for
older
people
with
dementia.
Cochrane
Database
2009
April
15;
(2):
CD007209.
69
Finucane
T,
Christmas
C,
Travis
K.
Tube
Feedings
in
Patients
with
Advanced
Dementia:
A
Review
of
the
Evidence.
JAMA,
Oct
1999;
1365‐1370.
70
Leible
and
Wayne,
The
Role
of
the
Physician
Order,
paper
written
for
CHII
2010.
71
Hanson,
L.C.,
Ersek,
M.,
Gilliam,
R.,
and
Carey,
T.
S.
Oral
Feeding
Options
for
People
with
Dementia:
A
Systematic
Review,
JAGS
59:
463‐472,
2011.
72
Schaeffer,
Keith.
Nourish
the
Body
and
Soul,
Action
Pact
Publishing,
2008.
73
Bradley
S.
Issues
in
the
management
of
resistant
bacteria
in
long‐term
care
facilities.
Infect
Control
Hosp
Epidemiol
1999;20:362‐6.
74
Anna
Ortigara,
anecdotal
family
story,
4‐2011.
28
Appendix 3-A
Recommended
Course
of
Practice
When
there
is
weight
loss
and
functional
decline
in
an
elder
with
multiple
comorbidities
or
with
end
stage
disease
the
default
should
not
be
to
place
a
g‐tube
for
nutrition
and
hydration.
The
interdisciplinary
team
including
the
elder’s
primary
care
physician
should
meet
to
address
the
elder’s
and
or
POA
goals
for
care
and
develop
a
care
plan
that
meets
the
changing
needs
of
the
elder.
This
may
include
a
discussion
regarding
palliative
care
or
hospice
with
the
elder
and
the
family.
• Diet
is
to
be
determined
with
the
person
and
in
accordance
with
his/her
informed
choices,
goals
and
preferences,
rather
than
exclusively
by
diagnosis.
• Assess
the
condition
of
the
person.
Assess
and
provide
the
person's
preferred
context
and
environment
for
meals,
in
other
words
the
person's
preferences,
patterns
and
routines
for
socialization
(i.e.
eating
alone
or
with
others),
physical
support
(i.e.
adapted
eating
utensils,
assistance
with
cartons/cutting
or
adapted
w/c
positioning),
timing
of
meals
(i.e.
typical
community
or
unique
meal
times)
and
personal
meaning/value
of
the
dining
experience
(i.e.
for
one
who
does
not
eat
breakfast,
breakfast
is
not
important
but
perhaps
an
early
lunch
is).
Include
quality
of
life
markers
such
as
satisfaction
with
food,
service
received
during
meals,
level
of
control
and
independence.
• Unless
a
medical
condition
warrants
a
restricted
diet,
consider
beginning
with
a
regular
diet
and
monitoring
how
the
person
does
eating
it.
• Empower
and
honor
the
person
first,
and
the
whole
interdisciplinary
team
second,
to
look
at
concerns
and
create
effective
solutions.
• Support
self‐direction
and
individualize
the
plan
of
care.
• Ensure
that
the
physician
and
consultant
pharmacist
are
aware
of
resident
food
and
dining
preferences
so
that
medication
issues
can
be
addressed
and
coordinated
i.e.
medication
timing
and
impact
on
appetite.
• Monitor
the
person
and
his/her
condition
related
to
their
goals
regarding
nutritional
status
and
their
physical,
mental
and
psychosocial
well‐being.
• Although
a
person
may
have
not
be
able
to
make
decisions
about
certain
aspects
of
their
life,
that
does
not
mean
they
cannot
make
choices
in
dining.
• When
a
person
makes
“risky”
decisions,
the
plan
of
care
will
be
adjusted
to
honor
informed
choice
and
provide
supports
available
to
mitigate
the
risks.
• Most
professional
codes
of
ethics
require
the
professional
to
support
the
person/client
in
making
their
own
decisions,
being
an
active,
not
passive,
participant
in
their
care.
• When
caring
for
frail
elders
there
is
often
no
clear
right
answer.
Possible
interventions
often
have
the
potential
to
both
help
and
harm
the
elder.
This
is
why
the
physician
must
explain
the
risks
and
benefits
to
both
the
resident
and
interdisciplinary
team.
The
information
should
be
discussed
amongst
the
team
and
resident/family.
The
resident
then
has
the
right
to
make
his/her
informed
choice
even
if
it
is
not
to
follow
recommended
medical
advice
and
the
team
supports
the
person
and
his/her
decision,
mitigating
risks
by
offering
support,
i.e.
offering
foods
of
natural
pureed
consistency
when
one
refuses
recommended
tube
feeding.
It
is
when
the
team
makes
decisions
for
the
person
without
acknowledgement
by
all
that
29
Appendix 3-A
problems
arise.
The
agreed
upon
plan
of
care
should
then
be
monitored
to
make
sure
the
community
is
best
meeting
the
resident's
needs.
• All
decisions
default
to
the
person.
Please
see
the
appendix
as
it
includes
an
ethical
case
study
involving
tube
feeding
and
a
superb
document
regarding
informed
choice
and
who
ultimately
decides.
30
Appendix 3-A
Standard
of
Practice
for
Individualized
Real
Food
First
Basis
in
Current
Thinking
and
Research
AMDA:
Provide
foods
of
a
consistency
and
texture
that
allow
comfortable
chewing
and
swallowing.
A
resident
who
has
difficulty
swallowing
may
reject
pureed
or
artificially
thickened
foods
but
may
eat
foods
that
are
naturally
of
a
pureed
consistency,
such
as
…
mashed
potatoes,
...puddings,
…
and
yogurt,
finely
chopped
foods
may
retain
their
flavor
and
be
equally
well
handled.75
ADA:
Research
suggests
that
the
goal
of
food
service
should
be
to
create
a
meal
situation
as
natural
and
independent
as
possible,
comparable
with
eating
at
home;
making
choices
from
a
wide
range
of
menu
items
tailored
to
the
resident’s
wants;
and
seeking
input
from
residents,
family
and
staff.
Stringent
diet
restrictions
limiting
familiar
foods
and
eliminating
or
modifying
seasonings
may
contribute
to
poor
appetite;
decreased
food
intake;
and
increased
risk
of
illness,
infection
and
weight
loss.76
CMS:
With
any
nutrition
program,
improving
intake
via
wholesome
foods
is
generally
preferable
to
adding
nutritional
supplements.77
CMS
answers
regarding
choice
to
eat
food
out
of
a
garden
in
the
Survey
and
Certification
memo
S&C
‐07‐07
December
21,
2006:
Question
2:
(370)
Approved
Food
Sources:
You
ask
if
the
regulatory
language
at
this
Tag
that
the
facility
must
procure
food
from
approved
food
sources
prohibits
residents
from
any
of
the
following:
1)
growing
their
own
garden
produce
and
eating
it;
2)
eating
fish
they
have
caught
o
a
fishing
trip;
or
3)
eating
food
brought
to
them
by
their
own
family
or
friends.
Response
2:
The
regulatory
language
at
this
Tag
is
in
place
to
prohibit
a
facility
from
procuring
their
food
supply
from
questionable
food
sources,
in
order
to
keep
residents
safe.
It
would
be
problematic
if
the
facility
is
serving
food
to
all
residents
from
the
sources
you
list,
since
the
facility
would
not
be
able
to
verify
that
the
food
they
are
providing
is
safe.
The
regulation
is
not
intended
to
diminish
the
rights
of
specific
residents
to
eat
food
in
any
of
the
circumstances
you
mention.
In
those
cases,
the
facility
is
not
procuring
food.
The
residents
are
making
their
own
choices
to
eat
what
they
desire
to
eat.
This
would
also
be
the
case
if
a
resident
ordered
a
pizza,
attended
a
ball
game
and
bought
a
hot
dog,
or
any
similar
circumstance.
The
right
to
make
these
choices
is
also
part
of
the
regulatory
language
at
F242,
that
the
75
AMDA
Clinical
Practice
Guideline
for
Alteration
in
Nutrition,
2010.
ADA
Liberalization
of
the
Diet
Prescription
Improves
Quality
of
Life
for
Older
Adults
in
LTC,
2005.
77
CMS
State
Operations
Manual
Appendix
PP
483.25(i)
Tag
F325
Nutrition
2008
Revised
Guidance.
76
31
Appendix 3-A
resident
has
the
right
to,
“make
choices
about
aspects
of
his
or
her
life
that
are
important
to
the
resident.”
This
is
a
key
right
that
we
believe
is
also
an
important
contributing
factor
to
a
resident’s
quality
of
life.
Relevant
Research
Trends
An
expectation
of
OBRA
since
1987,
choosing
food
before
supplements,
and
food
before
medication
is
a
natural
decision
in
culture
change.
With
choice,
accessibility
and
individualization,
our
residents
eat
foods
of
choice
throughout
the
day,
and
even
during
the
night
if
need
be,
eliminating
the
need
for
costly,
and
often
refused,
commercial
supplements.
Similarly,
the
need
for
laxatives
is
reduced
and
often
eliminated
with
increased
fluid
intake
and
increased
opportunities
for
fiber
rich,
bowel
stimulating
foods
of
choice.
Even
the
need
for
medication
for
behavioral
management
can
be
reduced
when
foods
of
choice
are
available
at
times
of
choice
and
places
of
choice.78
Homes
eliminating
commercial
supplements
have
found
a
significant
increase
in
food
consumption
and
reduced
incidence
of
weight
loss
(Ibid).
Oral
supplements……
often
go
wasted
or
conflict
with
medications.
Improving
taste
is
one
of
the
best
and
simplest
ways
of
improving
nutrition.79
An
11
week
randomized
controlled
intervention
study
with
121
people
living
in
nursing
homes
found
improved
nutrition
and
function
with
a
multifaceted
intervention
of
chocolate,
homemade
supplements,
group
exercise
and
oral
care.80
Oral
liquid
nutrition
supplements
have
been
shown
to
be
only
moderately
successful
in
increasing
energy
intake,
which
has
also
been
shown
to
be
related
to
the
limited
time
staff
can
devote
to
getting
the
supplements
delivered
and
giving
verbal
encouragement
to
consume
them.81
A
randomized,
controlled
trial
in
three
nursing
homes
with
sixty
three
residents
found
offering
residents
a
choice
among
a
variety
of
foods
and
fluids
twice
per
day
may
be
a
more
effective
nutrition
intervention
than
oral
liquid
nutrition
supplementation.
Also
found
was
that
snack
options
are
a
more
cost‐effective
nutrition
intervention
relative
to
supplements
based
on
staff
time,
resident
refusal
rates,
caloric
intake
and
waste.82
Bump,
Linda.
Food
for
Thought.
Action
Pact
Publishing.
2004‐2005.
Webster,
Clint.
Preventing
Malnutrition
in
the
Elderly.
Final
Research
Papers,
Winter
2008,
March
4,
2008.
80
Beck,
A.
M.,
Damkajaer,
K.
and
Beyer,
N.
Multifaceted
nutritional
intervention
among
nursing
home
residents
has
a
positive
influence
on
nutrition
and
function.
Nutrition,
24,
2008,1073‐1080.
81
Schlettwein‐Gsell,
D.
“Nutrition
and
the
quality
of
life:
A
measure
for
the
outcome
of
nutritional
intervention?”
American
Journal
of
Clinical
Nutrition,
Vol.
556,
1992,
pp.
12635‐12665.
82 Simmons,
Sandra
F.,
Zhuo,
X.,
Keeler,
E.
Cost‐effectiveness
of
Nutrition
Interventions
in
Nursing
Home
Residents:
a
pilot
intervention.
The
Jour
of
Nut,
Health
and
Aging
Vol.
14
No.
5
2010
367‐372.
78
79
32
Appendix 3-A
Historically,
it
has
been
shown
that
giving
people
foods
they
like
to
eat
minimizes
the
use
of
supplements
and
can
reduce
costs.
For
example,
Eric
and
Margie
Haider,
administrator
and
director
of
nursing
at
Crestview
Nursing
Home
in
Missouri
in
2001,
espoused
that
by
giving
people
foods
they
like
to
eat,
you
can
minimize
the
use
of
supplements
and
calculated
a
savings
of
$1,164.00
per
month
by
serving
real
foods
residents
wanted
to
eat.83
Supplements
at
Crestview
went
from
72
in
1998
to
only
14
by
July
2000.84
One
study
revealed
that
among
100
frail
nursing
home
residents,
oral
protein
supplements
did
not
produce
improvement
in
measures
of
strength
or
function
unless
it
was
combined
with
resistance
strength
training.85
Reducing
the
number
of
medications
that
a
resident
takes
can
also
impact
appetite.
Residents
that
must
take
numerous
pills
or
large
volumes
of
liquid
at
each
med‐pass,
with
bulk
laxatives,
for
example,
can
have
reduced
appetite
at
meal
time.86
Elderly
people
who
have
one
or
more
medical
conditions
and
are
taking
an
average
of
three
medications
show
greater
losses
of
taste
sensitivity
than
healthy,
older
adults.87
Flavor
enhancement
of
nutrient
dense
food
may
compensate
for
taste
losses
and
improve
food
intake.
Flavor
enhancers
are
mixtures
of
odorous
molecules
that
are
extracted
from
natural
products
or
synthesized,
such
as
monosodium
glutamate.
Flavor
enhancement
differs
from
adding
spices,
herbs,
and
salt
because
flavor
enhancement
intensifies
the
flavor
of
food
while
spices
and
herbs
increase
odor
and
taste
sensation.
Studies
involving
frail
elderly
have
shown
that
adding
flavor
enhancers
to
food
improved
intake
and
immune
function
by
increasing
the
total
number
of
lymphocytes,
resulting
in
improved
functional
status.88
Current
Thinking
Before
any
nutritional
supplement
is
offered
let
alone
“ordered,”
providers
and
surveyors
ensure
that
real
foods
were
offered
first
(CHII
Recommendation).
Some
homes
are
finding
alternatives
to
dietary
supplementation
by
engaging
the
elders
in
growing
their
own
garden.
The
elders
choose
what
will
be
grown,
help
with
the
planting,
tending
and
harvesting.
Then
they
help
prepare
and
eat
the
harvest.
Besides
the
83
Bowman,
Carmen
S.
The
Environmental
Side
of
the
Culture
Change
Movement:
Identifying
Barriers
and
Potential
Solutions
to
furthering
Innovation
in
Nursing
Homes.
Background
Paper
to
the
April
3rd,
2008
Creating
Home
in
the
Nursing
Home:
A
National
Symposium
on
Culture
Change
and
the
Environment
Requirements.
Report
of
CMS
Contract
HHSM‐500‐2005‐00076P.
84
Rantz,
Marilyn
J.,
and
Marcia
K.
Flesner.
Person
Centered
Care:
A
Model
for
Nursing
Homes.
American
Nurses
Association:
Washington
D.C.,
2004,
pp.
23,
25.
85
Fiatarone
MA,
O’Neill
MF,
Ryan
ND,
et
al.
Exercise
training
and
nutritional
supplementation
for
physical
frailty
in
very
elderly
people.
N
Engl
J
Med,
1994;
330;
1769‐1775.
86
Martin,
McHenry
Caren.
The
Consultant
Pharmacist’s
Expanded
Role
in
Nutrition
Management.
The
Consultant
Pharmacist.
June
2009.
Vol.
24.
No.
6.
87
Shiffman
SS,
Graham
BG,
Taste
and
smell
perception
affect
appetite
and
immunity
in
the
elderly.
Euro
Clin
Nutr2000;
54,
3:
54‐63.
88
Shiffmann
SS,
Intensification
of
sensory
properties
of
foods
for
the
elderly.
J
Nutr
2000;
130
Suppl
4;
927‐
930.
33
Appendix 3-A
nutritional
benefit,
the
elders
also
have
the
benefit
of
accomplishment
and
contribution
which
affects
their
mood
and
self‐esteem.89
Recommended
Course
of
Practice
Advocate
the
use
of
real
food
before
the
addition
of
dietary
supplements.
Recommend
using
real
food
before
any
modified
foods
including
laxative
mixtures
or
single
source
nutrient
powders/liquids.
Instead
of
artificial
supplements,
extra
protein,
vitamin
and
fiber
powders
can
be
added
to
smoothies,
shakes,
malts
and
other
real
foods
people
like
to
eat.
Use
of
fresh
produce
is
encouraged,
an
example
would
be
produce
from
resident
gardens.
The
dining
experience
should
be
as
natural
as
possible
comparable
to
eating
at
home.
Resident
satisfaction
with
the
quality
of
the
food
and
the
dining
experience
should
be
a
home’s
priority.
89
Hyde,
Denise.
The
Role
of
the
Pharmacist.
Paper
for
CHII.
34
Appendix 3-A
Standard
of
Practice
for
Individualized
Honoring
Choices
Many
homes
are
offering
the
people
who
live
there
more
dining
choices
based
on
the
individual’s
life
patterns,
history
and
current
preferences.
Including
but
not
limited
to
open
dining
times,
choice
from
menus,
buffets,
family
dining
style
with
food
at
the
table
and
snack
bars/accessible
pantries.
Honoring
choice
is
a
complex
issue
including
variables
such
as
balancing
risk
with
benefit,
individual
decision
making
capacity,
and
inclusion
of
resident
advocates.
Honoring
choice
is
born
out
of
relationship,
consistent
resident
staff
relationships
are
essential
to
identifying
and
honoring
individual
choice.
Basis
in
Current
Thinking
and
Research
AMDA:
Most
residents
will
appreciate
having
these
choices
and
the
team
can
weigh
the
benefits
against
the
risks
and
work
with
the
resident
and/or
family/POA
to
establish
an
effective
individualized
plan
of
care.90
Identifying
the
proper
balance
between
medical
complexity,
which
may
require
medications,
modifications
and
restrictions,
and
allowing
for
personal
choice,
is
the
essence
of
good
medicine.
However,
a
blanket
or
rote
approach
to
these
issues
(for
example,
easing
restrictions
on
everyone
without
regard
to
impact)
is
inconsistent
with
sound
approaches.
Individualized
care
should
seek
to
understand
the
entire
person,
to
focus
attention
on
the
medical,
functional
and
psychosocial
aspects
of
the
resident.
The
interdisciplinary
team
should
consider
the
potential
effects
of
proposed
interventions
on
the
resident,
rather
than
simply
the
treatment
or
protocol’s
effect
on
a
disease.
For
example,
some
residents
who
remain
in
bed
until
they
awake
on
their
own
may
develop
pressure
ulcers
or
lose
weight,
although
most
will
not.
Most
residents
will
appreciate
having
these
choices
and
the
team
can
weigh
the
benefits
against
the
risks
and
work
with
the
resident
and/or
family/POA
to
establish
an
effective
individualized
plan
of
care.
This
approach
is
especially
helpful
in
situations
where
the
benefits
of
the
intervention
are
modest
and
the
risks
significant.91
ADA:
Involving
individuals
in
choices
about
food
and
dining
such
as
food
selections,
dining
locations,
and
meal
times
can
help
them
maintain
a
sense
of
dignity,
control,
and
autonomy.92
Including
older
individuals
in
decisions
about
food
can
increase
the
desire
to
eat
and
improve
quality
of
life
(Ibid).
CMS:
AMDA
The
Role
of
the
Medical
Director
in
Person‐Directed
Care
White
Paper,
Mar.
2010,
3.
AMDA
The
Role
of
the
Medical
Director
in
Person‐Directed
Care
White
Paper,
Mar.
2010,
3.
92 ADA
Position
Paper
Individualized
Nutrition
Approaches
for
Older
Adults
in
Health
Care
Communities,
2010.
90
91
35
Appendix 3-A
Tag
F242
Self‐Determination
and
participation
‐
The
resident
has
the
right
to:
1)
Choose
activities,
schedules,
and
health
care
consistent
with
his/her
interests,
assessments
and
plans
of
care;
2)
Interact
with
members
of
the
community
both
inside
and
outside
the
facility;
and
3)
Make
choices
about
aspects
of
his
or
her
life
that
are
significant
to
the
resident.
Providers
are
to
be
actively
seeking
preferences,
choice
over
schedules
important
to
the
resident
i.e.
waking,
eating,
bathing,
retiring
and
states
if
resident
is
unaware
of
the
right
to
make
such
choices
determine
if
home
has
actively
sought
resident
preference
information
shared
with
caregivers.93
Tag
F280
Participation
planning
care
and
treatment
–
The
resident
has
the
right
to
‐
unless
adjudged
incompetent
or
otherwise
found
to
be
incapacitated
under
the
laws
of
the
State,
participate
in
planning
of
care
and
treatment
or
changes
in
care
and
treatment.
Sometimes,
a
resident
or
resident’s
representative
decides
to
decline
medically
relevant
dietary
restrictions.
In
such
circumstances,
the
resident,
facility
and
practitioner
collaborate
to
identify
pertinent
alternatives.
[The
resident
or
representative]
has
the
right
to
make
informed
choices
about
accepting
or
declining
care
and
treatment.94
The
right
to
make
informed
decisions
means
that
the
patient
or
patient’s
representative
is
given
the
information
needed
in
order
to
make
“informed”
decisions
regarding
his/her
care.95
Relevant
Research
Trends
Nursing
home
residents
value
control
and
choice
on
aspects
of
their
daily
lives
including
food.96,
97,
98
Residents
consumed
a
greater
proportion
of
food
when
they
were
fed
by
CNAs
who
had
less
need
for
power
and
allowed
the
resident
to
control
the
interaction.99
Autonomy
in
relation
to
food
such
as
access
to
food
between
meals
and
having
foods
brought
in
by
family
and
friends
has
a
positive
association
with
quality
of
life
for
residents.100
93
CMS
State
Operations
Manual
Appendix
PP,
483.15(b)
Tag
242
Self‐determination
and
participation.
CMS
State
Operations
Manual
Appendix
PP
483.25(i)
Tag
F325
Nutrition.
CMS
State
Operations
Manual
Appendix
A
Hospitals
Survey
Protocol,
Regulations
and
Interpretive
Guidelines
for
Hospitals,
A‐0049
482.13(b)(2).
96
Kane,
R.A.
et
al.
“Everyday
Matters
in
the
Lives
of
Nursing
Home
Residents:
Wish
for
and
Perception
of
Choice
and
Control,”
Journal
of
the
American
Geriatrics
Society,
45,
No.
9,
1997,
1086‐1093.
97
Evans
BC
and
Crogan
NL.
Using
the
FoodEx‐LTCto
assess
institutional
food
service
practices
through
nursing
home
residents’
perspectives
on
nutrition
care.
J
Gerontol
Med
Sci,
2005,
60A,
125‐128.
98
West
GE,
Oullet
D
&
Oulette
S.
Resident
and
staff
ratings
of
foodservices
in
long‐term
care:
implications
for
autonomy
and
quality
of
life.
J
Appl
Gerontol
2003;
22
(1),
57‐75.
99
Mezey
M,
Fulmer
T,
Amella,
E.
Factors
Influencing
the
Proportion
of
Food
Consumed
by
Nursing
Home
Residents
with
Dementia.
Journal
of
the
American
Geriatrics
Society,
Volume
47,
Issue
7,
Nov.
1999.
94
95
36
Appendix 3-A
When
residents
were
asked
to
make
a
list
of
those
aspects
of
their
lives
that
were
most
important
to
their
quality
of
life,
they
identified
choice
of
dining
companions
and
where
to
eat
their
meals
as
their
top
priorities.101
Bulk
food
service
(steam
table/buffet)
and
a
home‐like
environment
optimize
energy
intake
in
individuals
at
high
risk
for
malnutrition,
particularly
those
with
low
body
mass
index
and
cognitive
impairment.102
Snacking
is
an
important
dietary
behavior
among
older
adults…
(and)
may
ensure
older
adults
consume
diets
adequate
in
energy.
Snacks
provide
over
25%
of
resident
energy
intake
and
14%
of
protein
intake.103
Making
food
available
24
hours
a
day
is
recommended
in
the
2000
Malnutrition
and
Dehydration
in
Nursing
Homes:
Key
Issues
in
Prevention
and
Treatment
research
study
as
one
approach
to
the
prevention
and
treatment
of
malnutrition
and
dehydration
in
nursing
home
residents.104
Persons
with
mild
to
moderate
cognitive
impairment
(i.e.
Mini
Mental
State
Exam
scores
13‐26)
are
able
to
respond
consistently
to
questions
about
preferences,
choices
and
their
own
involvement
in
decisions
about
daily
living,
and
to
provide
accurate
and
reliable
responses
to
questions
about
demographics.105
There
is
no
way
of
knowing
whether
family
surrogates,
formal
or
informal,
accurately
represent
the
wishes
of
the
older
person
with
dementia.106
Family
members’
and
older
100
Carrier
N,
West
GE,
Ouellet
D.
Dining
experience,
foodservices
and
staffing
are
associated
with
quality
of
life
in
elderly
nursing
home
residents.
The
Journal
of
Nutrition,
Health
and
Aging,
Vol.
13,
No.
6,
2009.
565‐
570.
101
Cohn
J
&
Sugar
JA.
Determinants
of
quality
of
life
in
institutions:
perceptions
of
frail
older
residents,
staff
and
families.
In:
Burren
JF,
Lubben
JF,
Rowe
JC
&
Deutschman
DE,
The
concept
and
measurement
of
quality
of
life
in
the
frail
elderly.
Academic
Press,
Inc.
Chapter
2.
102
Desai
et
al,
Changes
in
Types
of
Foodservice
and
Dining
Room
Environment
Preferentially
Benefit
Institutionalized
Seniors
with
Low
Body
Mass
Index,
2007.
103
Zizza,
C.A.,
F.A.
Tayie,
and
M.
Lino.
“Benefits
of
Snacking
in
Older
Americans.”
Journal
of
the
American
Dietetic
Association,
Vol.
107,
2007,
800‐806.
104 Burger,
S.G.
J
Kayser‐Jones
and
J.
P.
Bell
Malnutrition
and
Dehydration
in
Nursing
Homes:
Key
Issues
in
Prevention
and
Treatment
The
Commonwealth
Fund
2000.
105
Feinberg,
Lynn
Friss
and
Carol
J
Whitlatch,
Are
Persons
with
Cognitive
Impairment
able
to
State
Consistent
Choices?
The
Gerontologist,
Vol.
41,
No.
3,
374‐382.
106
Kane,
R.L.
and
R.A.
Kane,
“What
Older
People
Want
from
Long‐Term
Care
And
How
They
Can
Get
It.”
Health
Affairs
Nov./Dec.
2001
37
Appendix 3-A
residents’
ratings
of
the
services
of
both
nursing
homes
and
assisted
living
facilities
reveal
little
congruence.
107,
108
Current
Thinking
Choice
of
food
has
a
tremendous
impact
on
quality
of
life.
Some
might
say
it
defines
quality
of
life.109
Foods
of
choice
are
available
whenever
residents
are
hungry,
not
just
at
scheduled
meal
times.
And
when
they
long
for
a
specific
food,
it
is
available.
Foods
of
choice
are
available
24/7
and
someone
is
available
24/7
to
prepare
them.110
Simply
speaking,
it
is
all
about
choice.
It
is
as
simple
as
asking,
“What
does
the
resident
want?
How
did
they
do
it
at
home?
How
can
we
do
it
here?”
Choice
of
what
to
eat,
when
to
eat,
where
to
eat,
whom
to
eat
with,
how
leisurely
to
eat.
True
choice,
not
token
choice.
Not
the
win‐lose
choice
between
a
hot
breakfast
and
sleeping
to
the
rhythm
of
your
day.
Not
simply
the
choice
of
hot
or
cold
cereal,
but
also
the
raisins
and
brown
sugar
that
make
oatmeal
a
daily
pleasure.
For
dining,
true
choice
is
exemplified
in
point‐of‐service
choice...
(Ibid).
Develop
approaches
to
dining
that
reflect
a
view
of
elders
as
capable
of
making
choices
and
deciding
what,
when,
and
with
whom
to
dine
as
a
mental
wellness
activity
because
it
“exercises”
the
decision
making
circuitry
of
the
brain,
enhances
pleasure,
and
strengthens
memory
encoding
and
retrieval.111
There
needs
to
be
a
new
“red
flag”
or
“assumption”
for
both
surveyors
and
providers
that
a
tray
line
or
set/limited
meal
times
are
now
viewed
as
an
obvious
contradiction
of
choice
and
if
this
lack
of
choice
leads
to
failure
to
thrive
it
would
be
considered
harm
during
the
survey
process
(CH
recommendation).
There
needs
to
be
another
new
“red
flag”
whereby
any
notation
in
a
resident
record
or
care
plan
of
a
resident
as
“non‐compliant”
with
physician
orders
is
viewed
as
an
obvious
contradiction
to
resident
choice
with
a
shift
to
facility
non‐compliance
with
requirements
to
offer
choice
at
tag
242,
right
to
refuse
treatment
at
tag
155
and
right
to
same
rights
as
any
citizen
of
the
United
States
at
Tag
151
(CHII
Recommendation).
Everyone,
provider
community,
all
disciplines,
MDS
Coordinators
identify
in
assessment
and
on
care
plans
a
person’s
preferences
more
so
than
problems,
distinguishing
between
true
medical
problems
and
personal
preferences
using
the
new
guidance
at
Tag
242
107
Kane,
R.A.
et
al,
First
Findings
from
Wave
1
Data
Collection:
Measures,
Indicators
and
Improvement
of
Quality
of
Life
in
Nursing
Homes
(Minneapolis:
Division
of
Health
Services
Research
and
Policy,
School
of
Public
Health,
University
of
Minnesota,
2000..
108
Levin,
C.A.
Resident
and
Family
Perspectives
on
Assisted
Living.
Doctoral
Thesis,
Univ.
of
Minnesota,
2001.
109 Leible
and
Wayne,
The
Role
of
the
Physician
Order,
paper
written
for
CHII
2010.
110 Bump,
Linda.
The
Deep
Seated
Issue
of
Choice,
paper
for
CHII
2010.
111 Ronch,
Judah.
Food
for
Thought
paper
for
CHII
2010.
38
Appendix 3-A
“actively
seeking
preferences”
to
guide
all
of
us.
Create
a
new
standard
of
practice
that
care
plans
identify
familiar
and
meaningful
foods
preferred
(CHII
Recommendation).
The
majority
of
nursing
home
residents
are
able
to
reliably
answer
questions
about
their
satisfaction
with
the
food
service,
regardless
of
cognitive
status,
and
the
presence
of
complaints
is
related
to
poor
meal
intake
and
depressive
symptoms.112
Informed
choice
implies
that
someone
informed
the
person,
this
is
the
facility’s
responsibility:
risks
of
certain
choices,
benefits
of
certain
choices,
education.
However,
it
now
sounds
like
what
we’ve
been
teaching
to
be
the
risks
of
choosing
not
following
a
certain
restricted
diet
may
not
be
true
after
all.
If
there
is
no
evidence
that
restricted
diets
actually
bring
about
the
outcomes
we
thought
they
did,
then
we
really
do
not
know.
Better
yet
would
be
basing
probability
on
what
the
individual’s
baseline
and
history
shows
risk
for
that
person
to
be.113
The
medical
director
should
work
closely
with
the
registered
dietitian,
director
of
nursing
and
the
director
of
food
services
to
develop
a
system
promoting
resident
choice
while
maintaining
quality
of
care.
This
system
should
include
policies
that
promote
routine
use
of
a
regular
diet
while
maintaining
opportunities
for
discussion
of
the
risks
and
benefits
of
diet
choices
that
are
felt,
by
convention,
to
place
the
resident
at
risk.
The
facility
must
provide
evidence
of
the
education
that
was
offered
to
the
resident
and
the
family
as
well
as
documentation
of
the
discussion
of
the
risks.
A
periodic
review
of
the
risks
associated
with
the
resident’s
choices
should
be
conducted
with
the
resident
and
his/her
family.
It
is
imperative
the
resident’s
physician
be
involved
in
these
discussions.114
The
facility
should
attempt
to
offer
less
risky
alternatives
to
food
choices
the
resident
may
request.
Offering
ice
cream
instead
of
a
cookie
may
satisfy
the
desire
for
a
dessert
while
maintaining
a
safer
consistency.
The
facility
must
plan
for
the
resident’s
choice,
noting
ways
to
monitor
and
provide
for
safety,
such
as
offering
to
cut
meat
into
small
pieces
at
meals,
recognizing
the
resident’s
ability
to
decline
the
offer.
An
informed
consent
by
the
resident
does
not
mitigate
the
facility’s
responsibility
to
keep
the
resident
as
safe
as
the
resident
and
his/her
family
allow
based
on
informed
choice
(Ibid).
Defining
Health‐Related
Quality
of
Life
Subjective
Measured
from
the
patient’s
perspective
after
informed
education
about
illness
and
therapy
(emphasis
added)
Multidimensional
sense
of
well‐being
(commonly
agreed
on
by
authors)
Functional
well‐being:
energy
level
and
ability
to
participate
in
activities
of
daily
living,
including
work
and
leisure
112
Simmons,
Sandra
F.,
Patrick
Cleeton,
and
Tracey
Porchak.
“Resident
Complaints
about
the
Nursing
Home
Food
Service:
Relationship
to
Cognitive
Status.”
Journal
of
Gerontology:
Psychological
Sciences,
Vol.
10,
2009.
113
Bowman,
Carmen.
The
Food
and
Dining
Side
of
the
Culture
Change
Movement:
Identifying
Barriers
and
Potential
Solutions
to
furthering
Innovation
in
Nursing
Homes
Background
Paper
for
the
Feb.
2010
CHII.
Report
of
CMS
Contract
HHSM‐500‐2009‐00057P.
114 Leible
and
Wayne,
The
Role
of
the
Physician
Order,
paper
written
for
CHII
2010.
39
Appendix 3-A
Emotional:
comprises
both
positive
(peace
of
mind,
happiness)
and
negative
(depression,
anxiety)
moods
Physical
well‐being:
body
symptoms
of
pain,
dyspnea,
dysphagia,
nausea,
fatigue
Treatment
satisfaction
(emphasis
added):
includes
financial
costs
Social
functioning:
the
ability
to
engage
in
social
activities
Intimacy:
concerns
of
body
image
and
sexuality
Family
well‐being:
ability
to
maintain
communication
and
family
relationships.115
The
elder’s
right
to
have
a
liberalized
diet
or
even
the
elimination
of
caloric
and
other
dietary
restrictions
has
slowly
been
embraced
to
enhance
quality
of
life.
But
many
…
interdisciplinary
team[s]
resist
the
elder’s
right
to
have
an
informed
refusal
of
an
ordered
diet
(texture
modified
or
tube
feeding)
that
might
put
them
at
aspirative
and
choking
risk.
Often
this
is
based
upon
the
long
held,
preconceived
notion
that
federal
regulatory
requirements
(and
possibility
of
a
deficiency
finding)
are
for
safety
first,
and
quality
of
life
decisions
take
a
second
seat
after
that.
It
is
also
based
upon
years
of
NOT
informing
the
resident
that
these
choices
were
his/her
rights
and
NOT
including
the
resident’s
voice
or
preference
in
the
dietary
planning
and
decision
making.
Yet,
the
F
tag
151
federal
requirement
states
its
intent
regarding
the
facility’s
responsibilities
toward
rights:
“Exercising
rights
means
that
residents
have
autonomy
and
choice,
to
the
maximum
extent
possible,
about
how
they
wish
to
live
their
everyday
lives
and
receive
care.”
This
includes
the
right
of
refusal
of
an
ordered
medical
therapy
or
diet.
The
surveyor
is
to
“Pay
close
attention
to
resident
or
staff
remarks
and
staff
behavior
that
may
represent
deliberate
actions
to
promote
or
to
limit
a
resident‘s
autonomy
or
choice.”
Each
facility
must
answer
the
questions:
How
is
the
resident
informed
about
dietary/dining
rights?
Does
the
resident
have
a
voice
or
is
it
limited?
Is
there
educating
and
informing
the
resident
about
alternatives
and
consequences
of
choices?
Is
there
a
mutually
agreed
upon
plan
recognizing
the
resident’s
choice?
Is
there
adequate
resident
support
and
monitoring
once
that
informed
refusal
is
made?
Remember
the
challenges
when
there
were
federal
mandates
of
removing
physical
and
chemical
restraints
for
a
resident’s
quality
of
life?
There
will
always
be
safety
issues
and
concerns.
We
are
facing
some
of
the
same
challenges
in
supporting
a
resident’s
informed
refusal
and
right
of
choice.116
Put
resident
choice
before
regulations
and
guidelines
such
as
Recommended
Daily
Allowances
which
are
generic
estimated
nutritional
needs
and
non‐individualized
(CHII
Recommendation).
Residents
who
have
capacity
to
decide
should
not
be
denied
the
choice
to
eat
hot
dogs
or
grapes
whole
which
many
homes
and
companies
are
imposing
to
minimize
the
potential
choking
risk
(CHII
Recommendation).
McMahon,
MM,
Hurley,
DL,
Kamath,
PS,
Mueller,
PS.
Medical
and
Ethical
Aspects
of
Long‐term
Enteral
Tube
Feeding.
Mayo
Clin
Proc
Nov.
2005;80(11):1470
mayoclinicproceedings.com/content/80/11/1461.full.pdf
116
Handy,
Linda.
Culture
Change
in
Dining
and
Regulatory
Compliance,
www.handydietaryconsulting.com
2011.
115
40
Appendix 3-A
“I’m
a
firm
believer
in
the
rights
of
elders
to
do
whatever
the
hell
they
want.
If
you
only
have
the
right
to
make
the
‘good,
wise’
decisions
that
your
grown
daughter
agrees
with,
then
you’re
not
running
your
own
life
anymore.
I’ve
taken
care
of
lots
of
people
who
didn’t
even
know
their
own
children.
Sure,
they
probably
shouldn’t
be
making
decisions
about
their
401(k)
plans,
but
they
can
decide
what
to
wear
and
what
to
eat
and
whether
to
go
outside
on
a
daily
basis.
People
think
that
if
old
people
cannot
make
the
big
decisions,
they
cannot
make
any
decisions—and
that
is
just
wrong.
They
have
the
right
to
folly.”117
Provide
education
to
the
whole
clinical
team
on
how
to
negotiate
risk
with
the
Elder
when
their
life
goals
are
contrary
to
best
medical
practices.
Health
care
professionals
need
education
in
determining
nutritional
risk,
conducting
comprehensive
nutritional
assessments,
developing
and
executing
nutritional
interventions,
and
evaluating
nutritional
outcomes.
We
need
to
make
sure
that
the
risks
and
the
benefits
are
being
discussed
with
residents
at
the
same
time
that
we’re
asking
for
their
choices
and
preferences
(CHII
Recommendation).
When
caring
for
frail
elders
there
is
often
no
clear
right
answer.
Possible
interventions
often
have
the
potential
to
both
help
and
harm
the
elder.
This
is
why
the
physician
must
…
explain
the
risks
and
benefits
to
both
the
resident
and
interdisciplinary
team.
The
information
should
be
discussed
amongst
the
team
and
resident/family
and
only
then
should
an
agreed
upon
choice
be
made.
It
is
when
the
team
makes
decisions
for
the
person
without
agreement
by
all
that
problems
arise.
The
agreed
upon
plan
of
care
should
then
be
monitored
to
make
sure
the
community
is
best
meeting
the
resident's
needs.118
Recommended
Course
of
Action
Choices
with
meaningful
options
in
accordance
with
the
person’s
preferences
are
offered
to
each
resident
numerous
times
daily,
i.e.
when
to
awaken,
when
to
eat,
what
to
eat,
where
to
eat,
what
to
do,
when
to
bathe,
when
to
retire,
what
to
wear,
etc.
A
variety
and
increased
number
of
staff
present
in
the
dining
room
enables
both
physical
and
psychosocial
needs
to
be
met.
Additionally,
staff
can
enhance
and
honor
the
individual
choices
for
all
residents
reflective
of
preferences.
There
needs
to
be
a
new
“red
flag”
or
“assumption”
for
both
surveyors
and
providers
that
a
tray
line
or
set/limited
meal
times
are
now
viewed
as
an
obvious
contradiction
of
choice
and
if
this
lack
of
choice
leads
to
failure
to
thrive
it
would
be
considered
harm
during
the
survey
process
(CHII
recommendation).
Residents’
individual
choices
are
actively
sought
after,
care
planned
and
honored,
as
Tag
F
242
requires,
based
on
life
patterns,
history
and
current
preferences.
117
Dr.
William
Thomas
as
reported
by
Brown,
Nell
Porter.
“At
Home
with
Old
Age
Reimagining
Nursing
Homes”
Harvard
Magazine
November
–
December
2008
The
Alumni,
http://harvardmagazine.com/2008/11/at‐home‐with‐old‐age.html.
Accessed
10/15/09.
118
Wayne,
Matthew.
Clinical
Standards
Task
Force
communication,
2011.
41
Appendix 3-A
Team
members
of
all
disciplines
and
MDS
Coordinators
identify
in
assessment
and
on
care
plans
a
person’s
preferences
more
so
than
problems,
distinguishing
between
true
medical
problems
and
personal
preferences
using
the
new
guidance
at
Tag
242
“actively
seeking
preferences”
to
guide
all
team
members.
Create
a
new
standard
of
practice
that
care
plans
identify
familiar
and
meaningful
foods
preferred
(CHII
Recommendation).
There
needs
to
be
another
new
“red
flag”
whereby
any
notation
in
a
resident
record
or
care
plan
of
a
resident
as
“non‐compliant”
with
physician
orders
is
viewed
as
an
obvious
contradiction
to
resident
choice
with
a
shift
to
facility
non‐compliance
with
requirements
to
offer
choice
at
Tag
242,
right
to
refuse
treatment
at
Tag
155
and
right
to
same
rights
as
any
citizen
of
the
United
States
at
Tag
151
(CHII
Recommendation).
Instead
of
labeling
one
as
“non‐compliant,”
nurses
work
with
physicians
to
eliminate
“orders”
for
restrictive
diets
residents
don’t
eat
and
instead
create
plans
with
the
person
that
work
for
the
person
(see
standards
for
various
diets
in
Diet
Liberalization
section).
When
caring
for
frail
elders
there
is
often
no
clear
right
answer.
Possible
interventions
often
have
the
potential
to
both
help
and
harm
the
elder.
This
is
why
the
physician
must
be
present
[involved]
in
order
to
explain
the
risks
and
benefits
to
both
the
resident
and
interdisciplinary
team.
The
information
should
be
discussed
amongst
the
team
and
resident/family
and
only
then
should
an
agreed
upon
choice
be
made.
It
is
when
the
team
makes
decisions
for
the
person
without
agreement
by
all
that
problems
arise.
The
agreed
upon
plan
of
care
should
then
be
monitored
to
make
sure
the
community
is
best
meeting
the
resident's
needs.119
Provide
education
and
support
to
anyone
speaking
on
behalf
of
the
resident,
including
health
care
professionals,
families,
friends,
and
legal
representative
on
their
obligation
in
advocating
for
the
resident’s/the
person’s
individual
life
patterns,
history,
current
preferences,
opinions
and
wishes
(not
necessarily
their
own).
Education
should
be
inclusive
so
that
the
representatives
clearly
see
their
role
as
an
advocate
for
the
individual’s
choice
(not
necessarily
their
own).
We
do
not
assume
that
just
because
a
resident
may
not
be
able
to
make
decisions
in
some
parts
of
their
life
they
cannot
make
choices
related
to
their
dining
preferences.
Education,
good
observational
skills,
strong
advocacy
and
consistent
relationships
with
caregivers
enables
a
person
with
impaired
decision
making
capacity
to
make
choices.
When
making
dining
decisions
that
can
be
viewed
as
a
risk
to
the
individual’s
physical
health,
the
plan
of
care
will
be
adjusted
to
honor
choice
and
provide
the
supports
available
to
mitigate
the
risks
based
upon
the
individual’s
life
goals.
119
Wayne,
Matthew.
Clinical
Standards
Task
Force
communication,
2011.
42
Appendix 3-A
Put
resident
choice
before
regulations
and
guidelines
such
as
Recommended
Daily
Allowances
which
are
generic
estimated
nutritional
needs
and
non‐individualized
(CHII
Recommendation).
Resident
preferences
in
dining
will
be
communicated
to
the
entire
interdisciplinary
team
so
that
medications
and
treatments,
schedules
and
food
offered
at
activities
are
consistent
with
choices
honoring
personal
preferences.
Resident
dining
profiles
(tray
tickets)
should
be
limited
to
adapted
equipment,
allergies,
consistency
modification
and
unique
dietary
needs.
Preferences
should
be
sought
after
as
choices
are
offered
(not
just
once
and
then
recorded
on
a
tray
ticket
indefinitely).
43
Appendix 3-A
Standard
of
Practice
for
Shifting
Traditional
Professional
Control
to
Individualized
Support
of
Self
Directed
Living
Basis
in
Current
Thinking
and
Research
AMDA:
Person‐directed
care
promotes
resident
choice
and
self‐determination
in
ways
that
are
meaningful
to
the
resident.
It
has
been
a
key
component
of
geriatric
medicine
for
decades.
The
interdisciplinary
team
and
the
medical
director
have
essential
roles
both
in
facilitating
this
process
as
well
as
in
monitoring
it
for
desired
outcomes.
Medical
directors
and
clinicians
should
help
nursing
home
administration
and
staff
understand
how
to
provide
person‐directed
care
while
maintaining
clinical
excellence.
To
ensure
success,
nursing
home
leadership
must
support
these
efforts.120
ADA:
Despite
the
growing
body
of
evidence
discouraging
the
use
of
therapeutic
diets
in
older
adults,
these
diets
are
still
regularly
prescribed.
Research
has
not
demonstrated
benefits
of
restricting
sodium,
cholesterol,
fat,
and/or
carbohydrate
in
older
adults.121
CMS:
Residents
have
the
right
to
refuse
treatment,
CMS
Tag
F151.
Residents
have
the
right
to
informed
choice,
CMS
Tag
F325.
Residents
have
the
right
to
choice,
CMS
Tag
F242.
Pioneer
Network/Hartford
Institute
for
Geriatric
Nursing:
Nurse
Competencies
for
Nursing
Home
Culture
Change
–
#2
–
Creates
systems
and
adapts
daily
routines
and
“person‐directed”
care
practices
to
accommodate
resident
preferences.
#4
–
Evaluates
the
degree
to
which
person‐directed
care
practices
exist
in
the
care
team
and
identify
and
addresses
barriers
to
person‐directed
care.
#9
–
Problem‐solves
complex
medical/psychosocial
situations
related
to
resident
choice
and
risk.
#10
–
Facilitates
team
members,
including
residents
and
families,
in
shared
problem‐
solving,
decision
making
and
planning.
Related
Research
Trends
As
we
know
that
residents
have
their
very
individual
biography
of
nutrition
and
are
experts
in
preparing
meals,
the
cook
meets
every
week
with
small
groups
of
residents
discussing
a
variety
of
food‐
and
meal‐
related
topics.
The
idea
is
the
cook
gets
to
know
each
individual
resident
and
learns
about
their
wishes,
their
expectations,
their
skills,
and
their
expertise….
What
we
observe
in
these
settings
is
that
life
becomes
normal,
livelier,
AMDA
The
Role
of
the
Medical
Director
in
Person‐Directed
Care
White
Paper,
Mar.
2010,
5.
ADA
Position
Paper
Individualized
Nutrition
Approaches
for
Older
Adults
in
Health
Care
Communities
2010.
120
121
44
Appendix 3-A
that
residents
eat
much
better
and
that
loneliness,
helplessness
and
monotony
are
reduced.
Residents
need
less
medicine
and
sleep
much
better.122
Current
Thinking
…
the
people
with
the
power
remain
the
biggest
barrier
to
meaningful
culture
change
in
long‐term
care.
They
are
too
easily
satisfied.
Even
as
they
gravitate
toward
this
new
way,
their
old
way
of
thinking
is
so
strong
it
keeps
leaders
from
truly
changing
the
organization
and
empowering
teams.
The
old
mindset
makes
us
way
too
satisfied
with
the
low‐hanging
fruit
–
those
positive
outcomes
that
inevitably
result
from
even
modest
changes.
Because
even
small
improvements
are
so
much
better
than
the
old
way,
it
is
easy
to
become
complacent
and
avoid
the
really
difficult
work
necessary
to
create
true
home
for
elders.123
Unfortunately,
these
evidence
based
guidelines
are
not
yet
widely
accepted
as
standards
of
practice,
and
even
more
unfortunately,
standards
of
traditional
best
practice
developed
for
individuals
at
earlier
stages
of
the
life
cycle
are
currently
applied
to
elders,
often
limiting
their
choices,
limiting
their
quality
of
life,
while
well‐meaning
practitioners
practice
a
medical
model
of
care
(Ibid).
Life
extension
with
medically
advanced
treatments
or
imposed
chronic
condition
management
at
an
advanced
age
negating
choice
or
satisfaction
often
leads
to
negative
outcomes
that
are
then
managed
with
more
liberal
approaches
that
should
have
been
the
approach
from
the
beginning
(Ibid).
Establish
guidelines
that
define
an
elder’s
right
to
make
an
unpopular
or
ill‐advised
decision
in
view
of
all
available
information
about
the
impact
of
the
decision
on
his/her
future
self
(“the
right
to
folly”)
versus
cognitive,
emotional
or
other
conditions
that
render
him/her
vulnerable
to
exploitation,
abuse
or
neglect.
This
should
be
based
on
imagining
future
scenarios
that
result
from
the
decision
and
how
the
elder
appreciates
and
plans
for
the
impact
on
his/her
well
being.124
We
all
need
to
shift
to
agreeing
that
care
givers
will
offer
to
do
what
is
clinically
best
for
a
person
and
if
the
person
refuses,
that’s
okay.
Along
with
liability
comes
responsibility
to
the
person
we’re
serving
–
if
an
elder
decides
to
not
eat
what
is
clinically
best
we
work
with
them
but
never
force
them
–
caring
for
someone
doesn’t
mean
you
have
to
make
the
choices
for
them
(CHII
Recommendation).
Another
level
of
education
is
needed
for
clinicians
and
care
givers
to
be
able
to
shift
traditional
professional
control
over
to
the
resident
since
it
feels
like
we’re
going
against
what
we
have
believed
to
be
our
obligation
or
even
a
nursing
license
of
what
“good
care”
is
122
Hoffmann,
AT.
Quality
of
Life,
Food
Choice
and
Meal
Patterns
–
Field
Report
of
a
Practitioner.
Ann,
Nutr
Metab
2008;
52
(suppl
1):
20‐24.
123 Bump,
Linda.
The
Deep
Seated
Issue
of
Choice
paper
for
CHII
Feb.
2010.
124
Ronch,
Judah.
Food
for
Thought:
The
Missing
Link
between
Dining
and
Positive
Outcomes,
paper
for
CHII
2010.
45
Appendix 3-A
which
we
now
realize
has
been
making
decisions
for
residents
and
not
honoring
their
decisions
(CHII
Recommendation).
Self‐directed
living
includes
honoring
the
resident's
choice
even
in
the
face
of
family
disagreement.
Power
of
Attorney
does
not
give
the
right
to
demand
restricted
diets
or
altered
consistencies.
Even
with
a
guardianship,
a
family
member
should
work
closely
with
the
physician
to
assess
all
risks
including
the
risk
of
more
restrictive
choice,
or
in
other
words,
of
not
honoring
the
resident's
choice
(CHII
Recommendation).
At
times
the
life
goals
should
supersede
medical
best
practices.
Recommendations
should
be
based
on
what
each
elder
wants,
not
what
we
would
want
for
ourselves
or
what
we
think
the
elder
wants.125
While
alcohol
is
not
a
medical
treatment
it
may
present
certain
risks.
It
is
for
some
elders
a
lifestyle
choice.
Due
to
potential
for
interactions
with
medications
and
certain
clinical
conditions
the
elder’s
physician
should
be
consulted
regarding
the
elder’s
choice
to
enjoy
an
alcoholic
beverage.
If
there
are
concerns
regarding
medications
or
effects
on
illness
there
is
a
opportunity
to
provide
information
to
the
elder
or
his/her
family
about
the
potential
risks.
The
clinician
may
choose
to
make
changes
in
the
medication
regimen
to
address
potential
concerns.
There
is
an
opportunity
to
offer
non‐alcoholic
drinks
when
the
risks
are
considered
to
be
higher
than
the
potential
benefit.
It
the
elder
and
his
or
her
family’s
right
to
make
an
informed
choice.126
If
the
patient
is
sufficiently
informed
about
the
risks
and
benefits
of
acceptance
(informed
consent)
or
refusal
(informed
refusal)
of
a
proposed
intervention
or
treatment
and
refuses,
the
clinician
should
respect
the
patient’s
decision
(Mayo
Clinic
Proceedings
2005).127
Recommended
Course
of
Action
All
decisions
default
to
the
person.
125
Hyde,
Denise.
The
Role
of
the
Pharmacist
paper
written
for
the
CHII
2010.
126
Power,
Al.
The
Physician
and
Person‐Directed
Dining,
unpublished,
April
2011.
127
McMahon,
MM,
Hurley,
DL,
Kamath,
PS,
Mueller,
PS.
Medical
and
Ethical
Aspects
of
Long‐term
Enteral
Tube
Feeding.
Mayo
Clinic
Proceedings
Nov.
2005;
80(11):
1461‐1476.
46
Appendix 3-A
New
Negative
Outcome
Basis
in
Current
Thinking
and
Research
AMDA:
“Person‐directed
care”
is
a
philosophy
that
encourages
both
older
adults
and
their
caregivers
to
express
choice
and
practice
self‐determination
in
meaningful
ways
at
every
level
of
daily
life.
Values
that
are
essential
to
this
philosophy
include
choice,
dignity,
respect,
self‐determination
and
purposeful
living.
These
values
also
are
at
the
core
of
desirable
medical
care
and
are
embraced
by
many
medical
providers.
Yet
practices
that
conflict
with
these
principles
are
common
in
the
long
term
care
setting.
Examples
include
awaking
residents
at
times
that
are
determined
by
staff
convenience,
modifying
residents’
diets
without
discussion,
and
inflexible
meal
times
and
medication
pass
times.
In
addition,
care
plans
may
be
created
without
truly
understanding
a
resident,
their
history
or
previous
occupation,
their
recreational
and
personal
preferences,
wishes
regarding
life‐sustaining
treatment,
and
other
likes
and
dislikes.
Geriatrics
is
a
discipline
that
emphasizes
medical
care
in
the
proper
context,
including
its
impact
on
function,
quality
of
life,
and
personal
preferences.128
ADA:
For
many
older
adults
residing
in
health
care
communities,
the
benefits
of
less‐restrictive
diets
outweigh
the
risks.
When
considering
a
therapeutic
diet
prescription,
a
health
care
practitioner
should
ask:
Is
a
restrictive
therapeutic
diet
necessary?
Will
it
offer
enough
benefits
to
justify
its
use?129
CMS:
Tag
F325
Nutrition,
Deficiency
Categorization
Severity
Level
4
‐
Immediate
Jeopardy:
Substantial
and
ongoing
decline
in
food
intake
resulting
in
significant
unplanned
weight
loss
due
to
dietary
restrictions
or
downgraded
diet
textures
(e.g.,
mechanic
soft,
pureed)
provided
by
the
facility
against
the
resident’s
expressed
preferences.
Severity
Level
3
‐
Actual
Harm:
Unplanned
weight
change
and
declining
food
and/or
fluid
intake
due
to
the
facility’s
failure
to
assess
the
relative
benefits
and
risks
of
restricting
or
downgrading
diet
and
food
consistency
or
to
obtain
or
accommodate
resident
preferences
in
accepting
related
risks;
AMDA
The
Role
of
the
Medical
Director
in
Person‐Directed
Care
White
Paper,
Mar.
2010,
1.
ADA
Position
Paper:
Individualized
Nutrition
Approaches
for
Older
Adults
in
Health
Care
Communities,
2010.
128
129
47
Appendix 3-A
Current
Thinking
Professional
standards
direct
nurses
to
act
to
prevent
unsafe,
illegal,
and
unethical
practices
and
protect
patients
who
may
be
at
risk.130
Nurses
are
educated
to
look
for
errors
in
medication
and
treatment
orders,
and
to
look
for
adverse
outcomes
related
to
medication
and
treatments.
When
a
resident
refuses
a
medication
or
treatment,
the
physician
is
promptly
notified.
Sometimes
this
standard
does
not
translate
into
other
aspects
of
care,
such
as
acting
on
evidence
that
nutrition
practices
are
not
achieving
intended
outcomes.
When
a
resident
refuses
a
meal
food
or
is
observed
consuming
minimal
amounts
of
food,
prompt
action
is
needed.
Using
current
practice
standards,
physician
notification
may
not
occur
until
the
resident
looses
weight.
A
proactive
approach,
which
employs
the
nursing
process,
for
all
aspects
of
care,
including
nutrition,
should
be
the
practice
standard.
The
nursing
process,
which
involves
assessment,
diagnosis
of
need,
planning
of
resident’s
care,
implementation,
and
evaluation
of
success
of
implemented
care,
supports
honoring
resident
preferences
and
implementing
dining
practices
that
support
choice.131,
132
Relevant
Research
Trends
Caregivers
often
fear
that
residents’
mealtime
choices
will
result
in
negative
outcomes.
Mealtime
dining
studies
provide
evidence
that
enabling
residents
to
choose
what
they
want
to
eat
at
mealtime
does
not
result
in
negative
nutritional
outcomes.
Enabling
choice
can
increase
nutritional
intake
and
increase
resident,
family
and
caregiver
satisfaction.133,
134,
135,
136
Moreover,
these
studies
demonstrate
that
usual
care,
which
does
not
provide
for
resident
choice,
when
compared
to
dining
practices
that
enable
choice,
can
result
in
negative
outcomes
such
as
worsening
of
nutritional
markers
and
quality
of
life
indicators.
Ongoing
discussions
of
where
residents
are
on
the
health
illness/trajectory
and
modifications
of
care
goals
are
essential
to
providing
person‐directed
care.
The
health
care
team
needs
to
recognize
when
the
goal
of
nutritional
care
is
no
longer
prevention
or
130
American
Association
of
Colleges
of
Nursing
2008.
The
Essentials
of
Baccalaureate
Education
for
Professional
Nursing
Practice.
Washington,
DC:
American
Association
of
Colleges
of
Nursing.
131
Remsburg,
Robin.
Home‐style
Dining
Interventions
in
Nursing
Homes:
Implications
for
Practice.
Paper
for
CH
II
2010.
132
Pioneer
Network/Hartford
Institute
Nurse
Competencies
for
Nursing
Home
Culture
Change
http://www.pioneernetwork.net/Data/Documents/TenCompetenciesReport0510.pdf.
133
Remsburg,
R.E.,
Luking,
A.,
Baran,
P.,
Radu,
C.,
Pineda,
D.,
Bennett,
R.G.,
Tayback,
M.
2001.
Impact
of
a
buffet‐style
dining
program
on
weight
and
biochemical
indicators
of nutritional
status
in
nursing
home
residents:
a
pilot
study.
J
Am
Diet
Assoc,
101(12),
1460‐3.
134
Nijis,
K.A.N.D.,
de
Graff,
C.,
Siebelink,
E.,
Blauw,
Y.H.,
Vanneste,
V.,
Kok,
F.J.,
van
Staveren,
W.A.
2006.
Effect
of
family‐style
meals
on
energy
intake
and
risk
of
malnutrition
in
Dutch
nursing
home
residents:
A
randomized
control
trial.
J
Gerontol
A
Biol
Sci
Med
Sci,
61(9),
935‐42.
135
Nijis,
K.A.N.D.,
de
Graff,
C.,
Kok,
F.J.,
van
Staveren,
W.A.
2006.
Effect
of
family
style
mealtimes
on
quality
of
life,
physical
performance,
and
body
weight
of
nursing
home
residents:
Cluster
randomized
controlled
trial.
BMJ,
10,
1‐5.
136
Ruigrok,
J.
&
Sheridan,
L.
2006.
Life
enrichment
programme:
Enhanced
dining
experience,
a
pilot
project.
Internat
J
of
Health
Care,
19(5),
420‐429.
48
Appendix 3-A
restoration,
but
rather
comfort
and
palliation.
Identifying
when
to
shift
practices
to
support
palliative
nutrition
will
ensure
the
resident
receives
quality
care
at
the
end
of
life.
Continuing
to
provide
active
restorative
nutritional
care
when
it
is
likely
to
have
limited,
if
any
effect
on
the
well‐being
of
the
resident,
can
create
great
distress
for
the
resident,
family
and
caregivers.137
From
researcher
psychologists
Ellen
Langer
and
Judith
Rodin:
I
had
recently
completed
research
on
the
illusion
of
control,
which
showed
me
how
important
it
was
for
people
to
control
their
own
lives.
It
was
so
important
that
even
in
chance‐determined
situations,
people
would
not
relinquish
their
control.
Therefore,
with
the
slightest
provocation,
they
engaged
in
illusory
control
behavior.
Around
this
same
time,
I
was
visiting
my
grandmother
in
a
nursing
home.
I
was
struck
by
how
little
control
she
and
the
other
residents
were
permitted.
I
thought
this
was
outrageous.
How
could
‘they’
be
so
sure
they
know
better
than
these
people?
I
thought
all
facts
were
probabilistic
statements
so
their
certainty
bothered
me.
Let
me
give
you
an
example
to
make
this
clearer.
Should
an
elderly
diabetic
be
allowed
to
have
ice
cream?
The
relationship
between
diabetes
and
sugar
is
probabilistic
even
though
it
is
treated
by
many
people
as
absolute.
Whether
or
not
that
ice
cream
will
hurt
the
person
depends
on
what
else
was
eaten
that
day,
how
much
ice
cream
is
consumed,
whether
or
not
the
person
has
exercised,
and
so
on.
Recent
evidence,
in
fact,
suggests
that
no
sugar
is
more
dangerous
than
a
small
amount
of
sugar.
Regardless
of
the
findings,
however,
I
think
nursing‐home
staff
should
make
recommendations,
but
leave
the
final
decision
up
to
the
resident.
One
cannot
know
today
what
“facts”
will
turn
up
tomorrow.
I
approached
Judy
Rodin
at
Yale,
who
was
also
working
in
the
area
of
control
at
this
time.
She
too
felt
that
this
population
was
characteristically
denied
the
opportunity
to
exercise
control.
Together
we
visited
local
nursing
homes.…
The
experiment
we
conducted
was
successful.
Psychologically,
control
proved
to
be
a
potent
variable.
The
follow‐up
showed
us
that
control
was
also
important
physiologically.
Half
as
many
people
given
our
control
intervention
had
died
18
months
later
than
those
given
a
comparison
treatment.
Because
the
longevity
findings
were
so
dramatic,
I’ve
spent
a
good
deal
of
time
trying
to
understand
how
such
a
simple
treatment
(a
pep
talk
encouraging
decision
making,
a
few
decisions,
and
a
plant
to
take
care
of)
could
have
such
a
profound
effect
on
people.
The
experimental
group
also
showed
“a
significant
improvement
over
the
control
group
in
alertness,
active
participation,
and
general
sense
of
well‐being.”138
Remsburg,
Robin.
Home‐style
Dining
Interventions
in
Nursing
Homes:
Implications
for
Practice.
Paper
for
CH
II
2010.
138 Langer,
Ellen
J.
This
Week’s
Citation
Classic:
Sept.
20,
1985.
Current
Contents/Number
44,
November
4,
1985,
14.
137
49
Appendix 3-A
Current
Thinking
The
Eden
Alternative®
recognizes
helplessness
as
one
of
the
three
plagues
of
institutionalization.
In
the
institutional
setting
staff
learn
that
if
residents
cooperate
with
their
ability
to
help
them,
it
is
a
more
efficient
use
of
their
time.
The
price
paid
is
for
the
resident
to
learn
to
wait
to
be
helped.
This
squelches
autonomy,
skills
atrophy,
residents
become
even
more
dependent
on
care
givers,
and
have
even
less
control
over
their
lives.
Staff’s
style
of
speech
encourages
learned
dependency.
Intonation
is
often
similar
to
what
is
used
with
children
which
causes
an
adult
to
feel
devalued.
Research
shows
the
person
loses
faith
in
their
ability
to
affect
outcomes
in
their
own
world.139
Not
supporting
individualized
care
and
a
person’s
choice,
not
supporting
“the
right
to
folly,”
causes
learned
helplessness,
depression,
learned
dependency,
even
bringing
death
earlier.
We
have
not
intended
harm
with
our
good
intentions,
but
we
are
creating
it.
The
Hippocratic
Oath
is
known
as
“Do
no
Harm.”140
It
is
as
difficult
as
staring
straight
at
the
sun,
but
if
we
as
a
profession
are
to
initiate
radical
change,
then
we
must
be
conscious
of
and
focus
on
the
harm
that
we
do.
Harm
–
not
just
to
the
body,
but
to
the
very
person
–
is
systematically
embedded
in
bureaucratic
institutions
that
strip
elders
of
their
personhood.141
The
harm,
the
potential
harm,
we
overly
identify
and
worry
about
is
to
the
body.
When
a
person
will
not
follow
recommended
medical
advice,
aka
the
physician’s
order,
we
worry
about
the
physical
harm
it
might
cause
their
body.
Notice
too
how
it
is
called
“against
medical
advice”
as
if
the
person
is
somehow
wrong
to
go
against
the
physician’s
advice,
again
a
bad
person,
“non‐compliant.”
We
haven’t
contemplated
much
the
harm
to
the
person
that
results
from
denying
them
this
right,
the
right
to
go
against
medical
advice,
the
right
to
their
personhood,
their
life,
their
schedule,
their
wishes.
No
one
should
have
to
fight
for,
cry
for
or
be
told
ever
again,
“You
can’t
come
in
the
dining
room
until
the
doors
are
open”
or
“You
can’t
have
this
because
it’s
not
on
your
diet.”
We
decide
for
people
they
will
only
drink
decaf
coffee.
We
decide
for
people
they
can
only
eat
this
food
and
not
eat
that
food.
If
you
were
denied
your
rights
to
this
extent,
would
it
feel
like
abuse,
neglect?
Part
of
the
culture
change
movement
is
to
call
things
as
they
are
and
not
longer
sugar
coat.142
Ronch,
Judah
2006
CMS
satellite
broadcast
Psychosocial
Severity
Outcome
Guide
www.pioneernetwork.net.
140
Bowman,
The
Food
and
Dining
Side
of
the
Culture
Change
Movement:
Identifying
Barriers
and
Potential
Solutions
to
furthering
Innovation
in
Nursing
Homes
Background
paper
for
CHII
2010.
141
Frank,
Barbara,
Sarah
Forbes‐Thompson
and
Stephen
Shields.
“The
Why
and
How
of
Radical
Change.”
Nursing
Homes/Long
Term
Care
Management,
May
2004,
44‐47.
142
Bowman,
Background
paper
for
CHII
2010.
139
50
Appendix 3-A
The
Reasonable
Person
Concept
is
defined
as
when
a
resident’s
reaction
to
a
deficient
practice
is
markedly
incongruent
with
the
level
of
reaction
the
reasonable
person
would
have
to
the
deficient
practice
(CMS).143
Even
if
a
resident’s
reaction
is
that
it
is
“fine”
for
her/his
choice
not
to
be
honored
this
is
“markedly
incongruent”
with
a
reasonable
person
like
you
and
I
living
in
the
community
at
large.
If
someone
gave
us
decaf
coffee
when
we
wanted
caffeinated
or
woke
us
up
according
to
when
they
thought
we
should
get
up,
we
would
not
be
happy
about
it
…
to
say
the
least.
I
ask
people
all
over
the
country
how
many
of
them
do
not
even
eat
breakfast.
Inevitably
half
the
crowd
raises
their
hands
whether
there
are
8
or
800.
Half
of
us
do
not
eat
breakfast.
What
is
the
number
one
driving
force
in
every
nursing
home
every
day
for
getting
people
up?
Breakfast.
Why
do
we
even
wake
people
up
at
all?
Breakfast.
I
ask
my
half
a
crowd
how
they
would
feel
about
being
awakened
from
sleep
to
eat
a
meal
they
didn’t
want.
They
say
“mad”
and
“angry.”
Someone
inevitably
says
they
would
be
“non‐
compliant”
and
administered
a
psychotropic
drug
in
order
to
be
compliant.
Unfortunately,
this
is
the
norm,
according
to
my
audiences.
This
is
Unnecessary
Drugs.
This
is
restraining
a
person
for
the
convenience
of
staff,
for
honoring
what
a
CNA
once
called
the
“almighty
schedule”
not
the
person.
This
is
non‐compliance
with
the
federal
requirements.
It
is
the
dawning
of
a
new
day
to
realize
there
are
negative
outcomes
we
are
not
considering
and
people’s
health
and
well‐being
are
in
the
balance
(Ibid).
Develop
approaches
to
dining
that
reflect
a
view
of
elders
as
capable
of
making
choices
and
deciding
what,
when,
and
with
whom
to
dine
as
a
mental
wellness
activity
because
it
“exercises”
the
decision
making
circuitry
of
the
brain,
enhances
pleasure,
and
strengthens
memory
encoding
and
retrieval.144
Residents
who
receive
good
personalized
care
and
opportunities
for
choice
have
higher
morale,
greater
life
satisfaction,
and
better
adjustment
(Institute
of
Medicine).145
143
CMS
Psychosocial
Severity
Outcome
Guide,
State
Operations
Manual,
Appendix
P,
2006.
144
Ronch,
Food
for
Thought:
The
Missing
Link
between
Dining
and
Positive
Outcomes
paper
for
CHII
2010.
145
Improving
the
Quality
of
Care
in
Nursing
Homes.
Institute
of
Medicine.
Committee
on
Nursing
Home
Regulation.
National
Academy
Press;
Washington,
D.C.,
1986.
51
Appendix 3-A
Recommended
Course
of
Practice
All
health
care
practitioners
and
care
giving
team
members
offer
choice
in
every
interaction
even
with
persons
with
cognitive
impairment
in
order
to
ensure
control
remains
with
the
person,
higher
satisfaction
with
life,
improved
brain
health
and
to
prevent
any
harm
from
not
honoring
choice
which
has
been
proven
to
bring
about
earlier
mortality.
52
Appendix 3-A
Patient
Rights
and
Informed
Consent/Refusal
across
the
Healthcare
Continuum
One
of
the
most
thorough
resources
found
on
this
subject
pertaining
to
any
person’s
rights
in
any
healthcare
setting
is
the
following
from
the
2005
Mayo
Clinic
Proceedings.
McMahon,
MM,
Hurley,
DL,
Kamath,
PS,
Mueller,
PS.
Medical
and
Ethical
Aspects
of
Long‐
term
Enteral
Tube
Feeding.
Mayo
Clinic
Proc.
Nov.
2005;
80(11):
1461‐1476
http://www.mayoclinicproceedings.com/content/80/11/1461.full.pdf.
FREQUENTLY
ENCOUNTERED
CLINICAL
AND
ETHICAL
ISSUES
The
following
case
examples
illustrate
frequently
encountered
clinical
and
ethical
questions
related
to
long‐term
tube
feeding.
Illustrative
Case
1.
A
95‐year‐old
woman
with
mild
dementia
was
hospitalized
with
progressive
neuromuscular
disease
and
dysphagia.
She
experienced
a
10%
unintentional
weight
loss
during
the
prior
3
months
and
dehydration
due
to
the
inability
to
take
food
and
water
by
mouth
for
1
week.
Videofluoroscopic
swallow
evaluation
revealed
aspiration
of
all
consistencies
of
food
and
liquid.
Tube
feeding
was
recommended
because
permanent
tube
feeding
was
anticipated.
The
patient
was
alert
and
oriented
to
person,
place,
and
time,
could
articulate
the
risks,
benefits,
and
alternatives
to
tube
feeding
discussed
with
her,
and
wished
to
proceed
with
percutaneous
endoscopic
gastrostomy
(PEG).
After
the
procedure,
she
expressed
a
desire
to
eat
small
amounts
of
food
in
addition
to
receiving
tube
feeding.
Again,
she
could
articulate
the
risks
(e.g.,
aspiration),
benefits,
and
alternatives
to
eating
small
amounts
of
food
and
remained
steadfast
in
her
desire
to
eat.
‐‐The
word
autonomy
is
derived
from
the
Greek
words
autos
(“self”)
and
nomos
(“rule”).
The
principle
of
respect
for
patient
autonomy
is
the
basis
of
informed
consent.
The
elements
of
informed
consent
include
information
(e.g.,
the
illness,
the
proposed
intervention,
and
the
risks
and
benefits
of
and
alternatives
to
the
proposed
intervention
including
doing
nothing),
understanding
of
the
information,
decision‐making
capacity,
and
voluntary
agreement
to
the
intervention.
‐‐Society
and
law
assume
that
all
adults
are
competent.
‐‐Competence
is
a
legal
term,
and
only
a
court
can
declare
a
person
incompetent.
In
contrast,
clinicians
determine
whether
a
patient
has
intact
medical
decision‐making
capacity,
which
patients
must
have
to
be
fully
autonomous
and
participate
in
the
informed
consent
process.
Although
no
universally
accepted
tool
for
determining
decision‐making
capacity
exists,
numerous
groups,
including
the
American
Psychiatric
Association,
provide
useful
guidelines.
Decision‐making
capacity
includes
the
ability
to
evidence
a
choice
(i.e.,
to
reach
a
decision
and
effectively
communicate
the
decision),
the
ability
to
understand
the
nature
of
the
decision,
the
ability
to
understand
and
appreciate
the
risks
and
consequences
of
the
decision,
and
the
ability
to
manipulate
information
rationally.
Clinicians
are
obligated
to
protect
patients
with
impaired
decision
making
capacity
from
inappropriate
53
Appendix 3-A
health
care
decisions.
The
patient
in
the
case
example
had
mild
dementia
but
had
sufficient
decision‐making
capacity
for
consenting
to
PEG
tube
placement
and
tube
feeding.
She
understood
and
could
articulate
the
indications,
risks,
and
benefits
of
the
procedure
and
voluntarily
consented
to
it.
Patients
with
impaired
cognition
may
have
sufficient
decision‐
making
capacity
for
specific
health
care
decisions.
ALGORITHM
FOR
DECISION
MAKING
Figure
1.
Decision
algorithm
for
long‐term
tube
feeding.
54
Appendix 3-A
Figure
2.
Decision
algorithm
for
long‐term
enteral
tube
feeding.
The
level
of
decision‐making
capacity
should
be
in
accordance
with
the
risks
and
benefits
of
the
decision
to
be
made.
For
example,
one
should
be
absolutely
certain
that
a
patient
who
refuses
a
low‐risk
yet
life‐saving
intervention
has
adequate
decision‐making
capacity.
The
patient
in
the
case
example
expressed
a
desire
to
eat
small
amounts
of
food
despite
the
risk
of
aspiration.
It
is
ethically
and
legally
permissible
for
patients
with
decision
making
capacity
to
refuse
unwanted
medical
interventions
and
to
ignore
recommendations
of
the
clinician.
A
patient’s
choice
not
to
adhere
to
a
clinician’s
recommendations
may
be
at
odds
with
a
clinician’s
desire
to
“do
good”
or
avoid
harm.
If
the
patient
is
sufficiently
informed
about
the
risks
and
benefits
of
acceptance
(informed
consent)
or
refusal
(informed
refusal)
of
a
proposed
intervention
or
treatment
and
refuses,
the
clinician
should
respect
the
patient’s
decision.
In
the
case
example,
the
patient
placed
a
high
value
on
the
experience
of
tasting
even
small
amounts
of
food
and
on
the
social
aspects
of
eating
with
others.
The
Nutrition
Support
Services
discussed
potential
risks
of
eating
with
the
patient,
documented
the
discussion,
and
supported
her
decision
by
asking
a
dietitian
and
occupational
therapist
to
work
with
her
to
develop
the
safest
approach
to
eating
small
amounts
of
food.
Regardless
of
the
decisions
made,
clinicians
should
not
abandon
their
patients.
If
the
clinician
conscientiously
objects
to
a
patient’s
decision,
the
clinician
should
arrange
to
transfer
care
of
the
patient
to
another
clinician.
‐‐‐The
durable
power
of
attorney
for
health
care
identifies
a
surrogate
decision
maker
who
can
make
health
care
decisions
if
the
patient
no
longer
has
decision‐making
capacity.
Persons
also
may
identify
an
alternate
surrogate
in
case
the
first
person
designated
55
Appendix 3-A
is
unavailable.
Some
states
have
a
health
care
directive
that
combines
the
features
of
a
living
will
and
durable
power
of
attorney….
Surrogates
must
be
fully
informed
of
the
risks,
benefits,
and
alternatives
to
a
proposed
procedure
or
treatment.
Surrogates
should
base
their
decisions
on
the
patient’s
previously
expressed
values
and
goals
(substituted
judgment).
However,
as
with
the
case
example,
patients
often
do
not
discuss
their
health
care
values
and
goals
with
their
surrogate.
In
these
situations,
surrogates
must
make
decisions
based
on
what
they
regard
as
most
appropriate
for
the
patient’s
clinical
condition,
quality
of
life,
and
other
factors
(best
interest
of
the
patient).
Notably,
patients
may
regard
designating
a
trusted
surrogate
as
more
important
than
trying
to
predetermine
all
the
possible
future
medical
issues
and
circumstances
that
may
require
a
decision.
PREVENTING
AND
ADDRESSING
ETHICAL
DILEMMAS
The
prima
facie
principles
that
characterize
the
ethical
aspects
of
clinical
medicine
are
respect
for
patient
autonomy,
beneficence,
nonmaleficence,
and
justice.
‐‐
Respect
for
patient
autonomy
refers
to
the
duty
to
respect
persons
and
their
rights
of
self‐determination.
‐‐Beneficence
refers
to
the
clinician’s
duty
to
act
for
the
good
of
the
patient,
whereas
nonmaleficence
refers
to
the
duty
to
avoid
harming
the
patient.
‐‐Justice
refers
to
the
duty
to
treat
patients
fairly.
When
caring
for
patients
for
whom
long­term
tube
feeding
is
being
considered,
clinicians
may
find
these
ethical
principles
at
odds
with
each
other.
For
example,
respect
for
patient
autonomy
may
conflict
with
the
clinician’s
desires
to
be
beneficent
and
to
avoid
harm.
Effective
communication
among
clinicians,
patients,
and
surrogate
decision
makers
may
help
prevent
ethical
dilemmas.
Clinicians
should
take
time
to
learn
about
the
patient
and
the
patient’s
values,
goals,
and
beliefs.
The
patient
should
be
provided
ample
time
to
discuss
and
provide
his
or
her
concerns
related
to
nutrition
and
hydration.
When
conveying
medical
information
concerning
benefits
and
risks
of
long­term
tube
feeding,
clinicians
should
avoid
using
complex
medical
language
and
frequently
should
assess
the
patient’s
comprehension.
Conversely,
ineffective
communication
among
clinicians,
patients,
and
surrogate
decision
makers
may
result
in
ethical
dilemmas.
Lack
of
training,
perceived
lack
of
time,
fear
of
the
patient’s
emotional
response,
and
general
discomfort
with
these
topics
may
result
in
clinicians
avoiding
these
discussions.
In
fact,
discussions
about
life­sustaining
treatments
between
clinicians
and
patients
are
reportedly
uncommon.
Despite
good
communication,
clinicians
may
face
ethical
dilemmas
related
to
long‐term
tube
feeding
that
they
cannot
resolve.
In
these
situations,
an
ethics
consultation
may
be
valuable.
The
Ethics
Consultation
Service
at
our
institution
uses
the
4‐topic
case‐based
approach
described
by
Jonsen
et
al.
This
approach
(below)
reviews
medical
indications,
patient
preferences,
quality
of
life,
and
contextual
(e.g.,
financial,
religious,
cultural,
and
allocation
of
resources)
issues
of
a
given
case
and
facilitates
the
exposition,
organization,
and
analysis
of
the
ethically
relevant
facts
(i.e.,
the
facts
related
to
the
prima
facie
ethical
principles).
Answering
the
questions
is
a
convenient
approach
to
the
4
topics,
and,
56
Appendix 3-A
reviewed
together,
the
answers
to
the
questions
not
only
define
the
ethical
problem
but
often
suggest
a
solution.
CONCLUSIONS
The
use
of
long‐term
tube
feeding
has
increased
substantially.
Review
of
the
literature
highlights
the
need
for
improved
education
for
physicians,
patients,
and
surrogate
decision
makers
about
use
of
long‐term
tube
feeding
and
its
ethical
implications.
Clinicians
should
take
an
active
role
in
recommending
advanced
directives
to
their
patients.
Patients
should
be
encouraged
to
identify
a
surrogate
decision
maker
and
to
make
intentions
clear
to
this
person
about
use
of
long‐term
tube
feeding.
Although
outcome
data
from
prospective,
randomized,
controlled
studies
are
limited,
information
from
observational
studies
is
useful.
In
general,
PEG
or
percutaneous
endoscopic
jejunostomy
(PEJ)
feeding
tube
placement
should
not
be
considered
unless
the
anticipated
duration
of
tube
feeding
is
at
least
1
month.
The
technical
procedures
to
secure
enteral
tube
access
are
generally
safe,
but
they
are
not
risk
free.
A
simple
guideline
to
outline
the
appropriate
use
of
long‐term
tube
feeding
does
not
exist
because
each
person
has
a
unique
perspective
about
their
quality
of
life.
As
with
other
forms
of
medical
interventions
and
treatments,
the
approach
should
be
individualized.
However,
as
discussed
earlier,
a
systematic
approach
(Figures
1
and
2)
can
facilitate
the
decision‐making
process.
Physicians
[and
the
interdisciplinary
team]
should
first
determine
whether
the
patient’s
treatment
goals
are
potentially
curative,
rehabilitative,
or
palliative.
Next,
to
allow
informed
decision
making,
clinicians
should
clearly
communicate
with
patients
and
surrogate
decision
makers
about
the
patient’s
diagnosis,
prognosis,
and
potential
outcomes
from
providing
or
withholding
long‐term
tube
feeding.
For
patients
in
the
terminal
stages
of
dementia,
cancer,
or
other
illnesses,
current
studies
do
not
document
improved
outcome
from
long‐term
tube
feeding
use.
It
is
unrealistic
to
expect
artificial
nutrition
to
favorably
improve
medical
outcomes
in
these
conditions;
however,
it
is
important
to
recognize
that,
in
certain
situations,
patients
and
surrogate
decision
makers
will
choose
long‐term
tube
feeding
to
achieve
personal
goals,
independent
of
medical
outcome.
If
the
potential
medical
outcome
is
curative
or
rehabilitative,
the
decision
should
rest
on
the
patient’s
wishes.
Patients
and
surrogate
decision
makers
should
be
given
sufficient
time
and
support
for
making
informed
decisions
regarding
long‐term
tube
feeding
use,
and
their
decisions
should
be
honored.
Research
is
needed
to
improve
the
clinician’s
ability
to
estimate
the
needed
duration
of
artificial
nutrition
in
order
to
select
short‐term
vs.
long‐
term
enteral
access
for
feeding
and
to
assess
the
effect
of
long‐term
tube
feeding
on
quality
of
life
and
medical
outcome
for
differing
medical
conditions.
57
Appendix 3-A
Four‐Topic
Approach
to
Identify
Ethically
Relevant
Facts
[The
PEG/PEJ
placement
and
long‐term
tube
feeding
is
underlined
indicating
that
any
course
of
treatment
could
be
inserted
into
this
four‐topic
approach
to
decision
making.]
Medical
indications
The
principles
of
beneficence
and
nonmaleficence
1.
What
is
the
patient’s
medical
problem
that
is
prompting
consideration
of
PEG/PEJ
placement
and
long‐term
tube
feeding?
Prognosis?
2.
Is
the
problem
acute?
Chronic?
Critical?
Emergent?
Reversible?
3.
What
are
the
goals
of
PEG/PEJ
placement
and
long‐term
tube
feeding?
4.
What
are
the
probabilities
of
success?
5.
What
are
the
plans
in
case
of
therapeutic
failure?
6.
In
sum,
how
can
this
patient
benefit
from
medical
and
nursing
care,
and
how
can
harm
be
avoided?
Patient
preferences
The
principle
of
respect
for
patient
autonomy
1.
Does
the
patient
have
decision‐making
capacity?
2.
If
the
patient
has
decision‐making
capacity,
what
are
his
or
her
preferences
for
treatment?
3.
Has
the
patient
been
informed
of
the
benefits
and
risks
of
PEG/PEJ
placement
and
long‐
term
tube
feeding,
understood
this
information,
and
given
consent?
4.
If
the
patient
lacks
decision‐making
capacity,
who
is
the
appropriate
surrogate?
5.
Has
the
patient
expressed
preferences
about
PEG/PEJ
placement
and
long‐term
tube
feeding
previously
(e.g.,
advance
directive)?
6.
Is
the
patient
unwilling
or
unable
to
cooperate
with
treatment?
If
so,
why?
7.
In
sum,
is
the
patient’s
right
to
choose
being
respected
to
the
extent
possible
in
ethics
and
law?
Quality
of
life
The
principles
of
beneficence,
nonmaleficence,
and
respect
for
patient
autonomy
1.
What
are
the
prospects,
with
or
without
PEG/PEJ
placement
and
long‐term
tube
feeding,
for
a
return
to
normal
life?
2.
What
physical,
mental,
and
social
deficits
is
the
patient
likely
to
experience
if
treatment
succeeds?
3.
Are
there
biases
that
might
prejudice
the
clinician’s
evaluation
of
the
patient’s
quality
of
life?
4.
Is
the
patient’s
present
or
future
condition
such
that
his
or
her
continued
life
might
be
judged
undesirable?
5.
Is
there
any
plan
and
rationale
to
forgo
treatment?
6.
Are
there
plans
for
comfort
and
palliative
care?
58
Appendix 3-A
Contextual
features
The
principles
of
loyalty
and
fairness
(justice)
1.
Are
there
family
issues
that
may
influence
decisions
related
to
PEG/PEJ
placement
and
long‐term
tube
feeding?
2.
Are
there
clinician
issues
that
may
influence
treatment
decisions?
3.
Are
there
financial
and
economic
factors?
4.
Are
there
religious
or
cultural
factors?
5.
Are
there
limits
on
confidentiality?
6.
Are
there
problems
of
allocation
of
resources?
7.
How
does
the
law
affect
treatment
decisions
for
PEG/PEJ
placement
and
long‐term
tube
feeding?
8.
Is
clinical
research
or
teaching
involved?
9.
Is
there
any
conflict
of
interest
on
the
part
of
clinicians
or
the
institution?
Adapted
from
Jonsen
et
al,
111
with
permission
from
McGraw‐Hill.
Jonsen
AR,
Siegler
M,
Winslade
WJ.
Clinical
Ethics:
A
Practical
Approach
to
Ethical
Decisions
in
Clinical
Medicine.
5th
ed.
New
York,
NY:
McGraw
Hill;
2002.
(Permission
to
use
has
been
requested
from
Mayo
Clinic
Proceedings
as
of
1/31/11.)
59
Appendix 3-A
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–
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Contract
HHSM‐
500‐2009‐00057P.
• The
following
papers
some
of
which
address
the
dining
environment,
were
written
for
the
Creating
Home
(I)
Creating
Home
in
the
Nursing
Home:
A
National
Symposium
on
Culture
Change
and
the
Environment
Requirements
sponsored
by
CMS
and
the
Pioneer
Network,
April
2008:
Calkins,
Margaret.
Private
vs.
Shared
Bedrooms
in
Nursing
Homes.
Nelson,
Gaius.
Household
Models
for
Nursing
Home
Environment
Brawley,
Elizabeth.
Lighting:
Partner
in
Quality
Care
Environments.
Cutler,
Lois.
Nothing
is
Traditional
about
Environments
in
Traditional
Nursing
Homes.
Calkins,
Margaret.
Creating
Home
in
the
Nursing
Home:
Fantasy
or
Reality?
61
Appendix 3-A
Bowman,
Carmen.
The
Environmental
Side
of
the
Culture
Change
Movement:
Identifying
Barriers
and
Potential
Solutions
to
furthering
Innovation
in
Nursing
Homes.
Background
Paper
to
the
April
3rd,
2008
Creating
Home
in
the
Nursing
Home:
A
National
Symposium
on
Culture
Change
and
the
Environment
Requirements.
Report
of
CMS
Contract
HHSM‐500‐2005‐00076P.
Free
Water
Protocols
Panther,
K.
(2005).
The
Frazier
Free
Water
Protocol.
Perspectives
on
Swallowing
and
Swallowing
Disorders
(Dysphagia),
14
(1),
4‐9.
Planetree
Long
Term
Care
Improvement
Guide
http://www.planetree.org/LTC%20Improvement%20Guide%20For%20Download.pdf
62
Appendix 3-A
The Food and Dining Side of the Culture Change Movement:
Identifying Barriers and Potential Solutions to furthering
Innovation in Nursing Homes
Pre-symposium Paper: to the February 11, 2010 Symposium
Creating Home in the Nursing Home II: A National Symposium on Culture
Change and the Food and Dining Requirements
January 28, 2010
Prepared by
Carmen S. Bowman, MHS
This pre-symposium paper is intended to provide a context and a detailed
background for the presentations and discussions at the February 11, 2010
symposium.
Appendix 3-B
Table of Contents
Introduction
2
Chapter 1
The Importance of Food and the Dining Experience to Creating Home
5
Chapter 2
Progression of the Food and Dining Side of the Culture Change Movement 9
Chapter 3
Food and Dining Research and Outcomes Realized by Pioneering Homes
16
Chapter 4
CMS – A Partner in the Culture Change Movement
20
Chapter 5
The Issues and the Regs:
Food and Dining Issues and the CMS Food and Dining Regulations
22
Chapter 6
Current Survey Processes as they Pertain to Food and Dining
40
Chapter 7
Other Food and Dining Standards
43
Chapter 8
Tools and Resources
45
Chapter 9
Moving into New Territory
46
Bibliography
47
Appendix A:
CMS Survey & Certification letter SC 09_39 (5/29/09) re: F371 clarification
54
Appendix B:
CMS Survey & Certification letter SC 07_07 (12/21/06) re: culture change questions
56
1
Appendix 3-B
Introduction
Robinson and Gallagher have stated that the future long term care “…customer, savvy and
well educated, will re-formulate long term care by demanding fine dining, and concierge
services, and healthy fast foods from a food court with ‘brand’ named franchises open 24
hours per day” (Robinson and Gallagher, 2008).
So let’s imagine the New Nursing Home. No one wakes you up. You sleep until you
naturally rouse. You decide if you want a cup of coffee, tea or your drink of choice now or
later. Maybe you have a coffee pot in your room. If you live in a neighborhood or
household, coffee is brewing in the kitchenette or kitchen. You drink out of your own
ceramic coffee cup. There is a coffee cart available, or better yet a coffee bar that is open
early and open late. When you’re ready, someone asks you what you’re hungry for.
Whether you eat breakfast early, late or not at all, but are hungry for lunch a little earlier
than most, open dining times make it possible to eat when you are ready. You can order
room service if you don’t feel like getting up or wander down to the continental breakfast
to see what’s available today. Not only are you asked what you want every meal, you are
also involved in deciding the menus, even making up the grocery list. You are welcome to
cook what you’re famous for. Or you contribute by setting the table and washing dishes, no
one’s offer is turned away. Some of the food comes from the garden in the backyard,
presenting the opportunity to eat fresh healthy foods you yourself may have tended to and
harvested.
In the New Nursing Home, there are home-living environments called Households with a
full kitchen, living room, dining room, and, usually, all private rooms led by self-directed
work teams and a Town Center where residents gather for large events, often a coffee shop
and sometimes a general store. Nurses and other clinicians circulate among several colocated houses to provide needed care, where residents enjoy private rooms, a large dining
room table where they can dine together and a hearth, often with a cozy fireplace.
Many homes focused on providing individualized and personalized dining services are
trading in the traditional tray line meal service for a variety of dining styles such as buffet,
restaurant, family-style and others with increased choice and direct resident access to
refrigerators and the kitchen throughout the day. These alternative dining arrangements,
although common in society at large, are new to the nursing home setting and have
sometimes led to difficulties with nursing home surveyor interpretation of the federal
requirements as applied to these innovations.
In April of 2008, the Pioneer Network and the Centers for Medicare and Medicaid Services
(CMS) co-sponsored Creating Home in the Nursing Home: A National Symposium on Culture
Change and the Environment Requirements. Almost 700 people attended, experts gave
presentations, and everyone was invited to give public comment. This was followed by an
invitational workshop of culture change experts and stakeholders who were formed into
workgroups to study and further develop the options discussed. All options regarding the
nursing home environment were collected and many were acted upon. All speakers’
2
Appendix 3-B
papers and presentations, the transcript from the entire symposium, and the background
paper written for it are available at: www.pioneernetwork.net.
Due to the many questions arising around food and dining, the Pioneer Network and CMS
decided to co-sponsor a second symposium inviting another national dialogue to discuss
them. The purpose of this paper is to provide background and context for the upcoming
February 11, 2010 symposium: Creating Home in the Nursing Home II: A National
Symposium on Culture Change and the Food and Dining Requirements.
Welcome to the table. Bon appétit.
3
Appendix 3-B
Note to readers:
In this paper, italics are used for CMS regulations and interpretive guidance.
Lighting, use of color, contrasting plate and table color, music, and other environmental
factors affect the dining environment. However, because the physical environment was the
focus of the 2008 symposium, many issues of the physical setting for the dining
environment came to light then and will not be revisited in this paper. Instead, the
symposium planning team has set an agenda that focuses on some of the clinical and
quality of life issues regarding food and dining.
It should be stressed that, when referring to nursing home residents, we mean all residents
including those with dementia. The content of this paper is applicable to all residents, and
in particular each person’s right to make their own choices and to receive superb
individualized care. Persons with dementia “tell” us everyday their preferences, sometimes
with words, sometimes not. We must only observe and, as Naomi Feil, the founder of
Validation Therapy, says “exquisitely listen” (2003).
4
Appendix 3-B
Chapter One
The Importance of Food and the Dining Experience in Creating Home
Food and the experience of dining happen every day, and are so important and unique to
each of us. In fact, very often food and dining are spoken of, not separately, but together:
“We should look for someone to eat and drink with before looking for something to
eat and drink....” Epicurus
“Good food ends with good talk.” Geoffrey Neighor
“One cannot think well, love well, sleep well, if one has not dined well.”
Virginia Woolf
“Food is the most primitive form of comfort.” Sheila Graham
“When I walk into my kitchen today; I am not alone. Whether we know it or not,
none of us is. We bring fathers and mothers and kitchen tables, and every meal we
have ever eaten. Food is never just food. It’s also a way of getting at something else;
who we are, who we have been, and who we want to be.”
Molly Wizenburg, from A Home Made Life
“Food is the heart of the home and most often one of our life’s daily pleasures.”
LaVrene Norton, from Nourish the Body and Soul
Food. Dining. Eating. “What’s for dinner?” “Let’s eat.” “Let’s go out for dinner.” Favorite
foods. Comfort foods. Potlucks. Cookie exchange. Out for coffee. Over for tea. “Come on
over for a beer.” Grilled. Sauted. Steamed. Carmelized. Cookies baking. Soup simmering.
Tea steeping. Coffee brewing. Bread baking. Dishes clinking. Setting the table. Washing
the dishes. Fresh fruit. Just picked veggies. Shucking corn. Snapping peas. Appetizers.
Soup and salad. Chips and dip. Bread sticks and dipping oils. The main entree. Dessert.
“I’m full.” “That was sooo good.”
So what should food and dining look like, even in a nursing home?
“Like Mom’s chicken noodle soup, the focus on food seems to hold an answer for just
about every ailment of institutionalized living.” Keith Schaeffer, from Nourish the
Body and Soul
“Comfort foods – those familiar foods that evoke a caring, pleasant feeling even
before (emphasis added) they are tasted.” Frampton, Gilpin and Charmel, from
Putting Patients First
“Providing nourishment is more than just providing the right number of calories; it
is taking care that the appearance, presentation, aromas, flavors, delivery and
setting are optimal as well.” Ibid
5
Appendix 3-B
“We know that uneaten food provides no nourishment.” Ibid
“The feeding of persons in health is of great importance, but when (one) succumbs
to disease, then feeding becomes a question of extreme moment.” Fannie Farmer,
from Food and Cookery for the Sick and Convalescent.
“Food for the sick should be carefully prepared and attractively served at regular
intervals. The person who is ill is frequently more difficult to please than when he is
well. Individual tastes of the patient must be considered, as well as the suitability of
foods to be served.” Gorrell, McKay and Zuill, from Food and Family Living
“Let food be your medicine.” Hippocrates
There may be four different causes, any one of which will produce the same result,
viz., the patient slowly starving to death, from want of nutrition:
1. Defect in cooking;
2. Defect in choice of diet;
3. Defect in choice of hours for taking diet;
4. Defect of appetite in patient.
“Yet all these are generally comprehended in the one sweeping assertion that the
patient has 'no appetite.'” Florence Nightingale
“Our goals are always two: increase our residents’ intake and increase quality of life
through celebrations around food.” Linda Bump, from Nourish the Body and Soul
Food is the Heart of Home
Linda Bump, a leader in the culture change movement, dietitian, and licensed nursing home
administrator has written one of the only books on changing the culture of dining. It is
called Life Happens in the Kitchen…How to make the kitchen the heart of your home. She
says:
Food is the heart of our home…and most often one of our life’s daily pleasures.
When we enhance the dining experience of our elders, we nourish their souls, as
well as their bodies. As caregivers committed to maximizing the quality of life and
quality of care for the elders residing in our long term care facilities, we are called to
best serve our elders’ nutritional needs while best serving their psychological and
psychosocial needs. When we honor our elders’ preferences in dining, we honor
their past and best serve their future (Bump, 2004-2005).
Bump says so much here - home and daily pleasure, nutritional and psychological and
psychosocial needs, quality of life and quality of care. All of that is precisely our focus for
this paper, as well as Creating Home II. Moving away from institution and toward home.
Using food to nourish both body and soul. Using food to honor past and serve future. Food
is one of the main mediums to reflect and build upon our past, and as psychologist Dr.
6
Appendix 3-B
Judah Ronch teaches: when our choices and preferences are not honored we have no
“future self” (2009). Nothing to look forward to, nothing to decide, nothing to affect in our
lives. And lastly the time has come to stop viewing quality of life and quality of care as
separate.
The Institute of Medicine study and precursor to OBRA ’87 said the same thing in different
words in 1986:
For the very sick and disabled, the quality of the care and the way it is provided are
probably the most significant contributors to well-being…..Many aspects of nursing
home life that affect a resident’s perceptions of quality of life – and therefore, sense
of well-being – are intimately intertwined with quality of care (Improving the
Quality of Care in Nursing Homes, 1986).
Pioneer and culture change leader Linda Bump encourages “excellence in
individualization” and says in order to do that we must provide:
Choice – the choice of what to eat, when to eat, where to eat, who to eat with, and
how leisurely to eat. True choice, not token choice. Choice of beverages, breads,
desserts. Choice of service style, whether waited, self-selected, buffet or family
style.
Accessibility – foods of choice available when hungry, or when just longing for a
specific food. Food available 24 hours a day/7days a week, and someone available
24/7 to help prepare it. Refrigerator rights, perhaps even a refrigerator in their
own room, and perhaps a microwave too!
Individualization – the elder’s favorite foods, comfort foods, ethnic foods, foods
prepared from their own favorite recipes, foods they choose to eat in their own
home, foods that make them look forward to the day, foods that warm their heart
and soul, as well as nourish their bodies.
Liberalized diets – The elder’s right to choice in following a restrictive diet.
Food First – An expectation of OBRA since 1987, choosing food before supplements,
and food before medication is a natural decision in culture change. With choice,
accessibility and individualization, our residents eat foods of choice throughout the
day, and even during the night if need be, eliminating the need for costly, and often
refused, commercial supplements. Similarly, the need for laxatives is reduced and
often eliminated with increased fluid intake and increased opportunities for fiberrich, bowel-stimulating foods of choice. Even the need for medication for behavioral
management can be reduced when foods of choice are available at times of choice
and places of choice.
7
Appendix 3-B
Quality Service - Relationships are the key to quality care giving, and relationships
are the key to quality service in dining. Knowing the elder, their choices, their
preferences, and their daily pleasures in dining, results in service that encourages
optimal intake. Relationship-based service is caregiving from the heart. Knowing
what an elder ate, knowing what they need to eat, knowing what to tempt them
with, all can make the difference between joy in dining and failure to thrive.
Responsiveness - Relationship-based service, refrigerator rights, 24/7
accessibility…the common theme is responsiveness, and just the right amount of
attention – not hovering, just quiet attention to every need (2004-2005).
Quiet attention. Responsiveness. Quality of care and quality of life together. Individualized
care. “Excellence in individualization.” Good food. A warm and inviting dining experience.
All contribute to a person’s well-being.
8
Appendix 3-B
Chapter Two
Progression of the Food and Dining Side of the Culture Change Movement
Moving from Traditional to Transformational
Transformation begins when there is an awareness of the need for change and residentcentered care, consistent staff, engaging direct care givers and residents in decisions and
increasing choices at meal times. In the Nourish the Body and Soul DVD, Linda Bump
advises us to “Think about the opportunities to have the coffee pot on all day, smell fresh
cookies baking and enjoy a warm treat in the evenings. Even if we can’t cook the hot food
there, we can start simple hosting, offering choice of beverage, choice of white or wheat
bread, a simple salad bar cart with just a few choices or a dessert cart” (2008). It can all
start with toast:
Transformational design can be as simple as - we brought our toasters to the table.
We actually physically set the toasters in the middle of the dining room. When the
core team met, they said, “We always cook it in the kitchen, stack it up, bring it out
and by the time it gets to the dining room its cold and hard. And that’s just the way
we’ve always done it. Now a resident asks for a piece of toast, we put the bread in,
butter it and we give it to them right there. Now, it was just an experiment and the
whole building was talking about it for days afterwards, over toast. It was probably
the very best thing we did, to start with that because everybody got excited about all
the other things we could do.” (Nourish the Body and Soul DVD, 2008)
Thus, it is within the transformational model where steam tables, open dining times, buffet
style, waited table service and family style start to become possible.
Early Pioneers do Dining Differently
Sister Pauline Brecanier is considered a pioneer in the culture change movement, leading
transformation at Teresian House in Albany, New York as administrator since 1970. Sister
Pauline’s pioneering spirit began before then however. She tells of when she was at St.
Joseph’s nursing home in Connecticut in the 1960’s and sent two men to Culinary Arts
school - two brothers, who came back to serve residents as chefs. She explains that in
order to provide good cooked food for the residents, Mother Bernadette, Teresian’s
administrator from 1964 to 1970, always had a chef and “never apologized for the cost of
food as food was the most important part of a resident’s day.” She advises you’re “going to
pay a little bit more [for a chef] but you’re going to get better quality. Pre-prepared foods,
anyone can put those together.” In her matter of fact way, she says, “we’ve always had a
chef” (2009). At Teresian House there is a cocktail lounge that serves drinks and food with
hours of operation and a menu. What is most striking about it, as Sister Pauline explained,
is it gives residents the opportunity to “treat their guests,” something most nursing home
residents no longer have.
9
Appendix 3-B
Planetree is a patient-centered model of care begun in hospitals by Angelica Thieriot.
Planetree affiliates focus on providing comfort foods, creating kitchens in patient care areas
for families to prepare their relative’s favorite foods, and never turning down a request for
food any time day or night (Frampton et al, 2003). The first nursing home to adopt the
Planetree model was Wesley Village in Shelton, Connecticut under the leadership of Heidi
Gil. One of the Planetree Continuing Care Components is Recognizing the Nutritional and
Nurturing Aspects of Food (Frampton and Charmel, 2009).
Restaurant Style Dining
As reported in the book Person Centered Care: A Model for Nursing Homes, Eric Haider, as
administrator of a nursing home in Kansas in1989, implemented a restaurant style dining
service with waiters taking orders from a menu and longer/open dining times. He realized,
looking at a restaurant one day, that a nursing home has everything a restaurant has – food,
a kitchen and a dining room. In 1992 at Crestview nursing home in Missouri he added
buffet style dining, and by 1995 food was available upon request 24 hours a day (2003).
Although nursing homes have food, kitchens, and dining rooms just like a restaurant,
restaurants are able to offer a large menu, instead of only one or two choices typical of
traditional nursing homes. Restaurants are able to serve each customer what that person
wants from their menu, at the time the customer arrives. This has functioned “backwards”
in the nursing home where traditionally the “customers” are made to be ready when the
food is ready.
Buffet Style Dining
Although it began as a research study by Robin Remsburg and others, due to its success
buffet-style meal service was adopted by Johns Hopkins Geriatric Center in Baltimore for
all meals (2001). Dr. Remsburg reports that buffet style dining advantages include the
opportunity to bring tantalizing smells into the dining room to increase resident’s
appetites, and staff doesn’t get “overtaxed” when there are typically just two main items
and several side dishes (Roloff, 2006). And who doesn’t like getting to pick exactly what
they want?
Neighborhood Dining
From the Norton/Grant Stage Model, Stage III is the Neighborhood. Here is where self-led
interdepartmental teams start to make greater changes to dining practices. Dining
becomes decentralized, residents eat in smaller dining rooms on their neighborhoods, are
supported to sleep until they wake and eat when they want. Med pass, housekeeping and
activity schedules all must change, therefore it must be done as Bump says, “in team.” The
need for kitchenettes and even full kitchens with shared decentralized production kitchens
placed between two neighborhoods begins to be realized (Bump, 2008).
In 1991 Teresian House remodeled into smaller neighborhoods of 40 residents from 60
(Ronch and Weiner, 2003). Each neighborhood has its own country kitchen and pantry.
10
Appendix 3-B
Meals are made in the main kitchen and brought to the steam tables in the neighborhood,
bringing the point of service closer to the residents. A new staff position of neighborhood
coordinator was developed to administer these small settings within the larger nursing
home. Neighborhood coordinators were chosen for their leadership skills, and applicants
were not restricted to nurses.
Interestingly enough, Providence Mount St. Vincent also began its journey of
neighborhoods with food served from steam tables in each neighborhood’s kitchen in
1991, after hiring Charlene Boyd as administrator in 1990. Charlene brought experience
from the Mary Conrad Center in Anchorage, Alaska where she had been administrator from
1986- 1990. At Mary Conrad Center, the “neighborhood concept” gave residents access to a
kitchen and snacks at all times (Ronch and Weiner, 2003).
Family Style Dining
Another familiar dining style being implemented is family style, which affords one the
opportunity to serve themselves what they want and as much as they want just like at the
table at home. “From bowls and baskets on their table, residents are able to serve
themselves as much as they want of the foods they enjoy and none of the foods they dislike”
(Roloff, 2006). Apple Health Care, a small for-profit nursing home chain, implemented
family style dining in 1997 beginning at Watrous Nursing Center in Madison, Connecticut
under the leadership of dietitian Karen Morton. Sue Misiorski, former Apple nurse
consultant shares that “family style dining was very successful. Food temperatures were
great because the food came straight from the kitchen to the table and was served
immediately. Plate waste decreased dramatically because residents took what they want.
They also took lots of smaller first portions and then second helpings of things they
particularly liked” (Misiorski, personal communication, 2009).
Choice Menus, Full Service Restaurant and Room Service
The Providence Benedictine Nursing Center in Marion County, Oregon underwent major
dining transformations in the autumn of 2009 because of low resident satisfaction scores,
an overly clinical atmosphere, and an outdated dining environment. Choice Menus are
offered within the long-term care units, with staff assisting residents in choosing what they
want to order for the following day. Room Service with 19 meal options and 12 sides is
offered on the skilled unit, where there are phones in each room. A grant and donations
helped the facility to acquire the computerized menu system, which tracks preferences and
allergies for each resident. Whereas most residents used to eat on their units making the
main dining room underutilized, the full-service, updated restaurant is now filled to
capacity, residents encourage and help each other get to the restaurant, and many are
“dressing for dinner.” Through all three options residents are now “self-directing their
lives” (Havens, 2009).
11
Appendix 3-B
Household Dining
From the Stage Model, Stage IV is the Household Model, and also includes the Green
Houses®, small houses, and the Scandinavian Service Houses. Home has been established
again, living in houses with self-contained fully functioning kitchens, cross-trained staff
reporting into the house and not to departments. Elders run their lives, get up when they
want, eat what and when they want, choose snacks, have friends over for dinner or coffee,
and plan their lives (Nourish the Body and Soul, 2008). In some households there is a new
staff role, homemaker, responsible for cooking meals and other homemaking duties. Many
households designate a food budget for the household for true resident choice. On a
weekly basis, residents make their grocery list. They decide what kind of ice cream they
would like or cereal - Captain Crunch anyone?
LaVrene Norton, Executive Leader of Action Pact, often speaks of residents’ “refrigerator
rights.” When one lives where there is a kitchen, they have the same “refrigerator rights”
as any one of us has in our own home. That right to open up the fridge and ponder, “Hmm,
what do I want to eat….” We might as well take it one step further and call them “kitchen
rights.” This is something the Household Model affords. It also affords limitless
opportunities for hosting. Residents have hosted others in their homes all their lives, the
household/house also makes this possible again. According to Linda Bump, “The systems
that have held us back in the other stages are now transformed, and the entire household
team can focus on resident preferences, their rhythm of the day and their choices” (2008).
Homes that have not progressed to the Household Model yet have, nonetheless, come up
with various ways of honoring “refrigerator rights” such as pantries, snack and beverage
bars, coffee bars, the “general store” where residents can choose food items without paying
extra, ice cream parlors and loaded snack carts taken to resident living areas.
Eden Alternative® and Green House Project®
The Eden Alternative® was born in the mid 1990’s with the idea that is it better to live in a
garden than an institution. The theme of the garden describes the Eden Alternative® in
many ways. Eden has helped remind us that residents should flourish and thrive in their
home. In addition, staff members, or “care partners” as Eden refers to them, also deserve to
grow as individuals. As Nancy Fox, first Executive Director of the Eden Alternative says,
“we’ve been managing for the worst in people instead of for the best” (2007). Dr. Bill
Thomas, founder with his wife Jude of the Eden Alternative®, was one of the first to talk
about giving back to residents the opportunity to till the garden and enjoy the bounty of
fresh foods from it.
After ten years of the Eden Alternative’s existence, Dr. Thomas decided it was taking too
long to transform nursing homes. He preaches that nursing homes shouldn’t be changed,
they should be abolished - calling himself a nursing home abolitionist (Baker, 2007). This
led to the next level of creating home he called the Green House. Green House®
communities have Culinary Arts, not dietary departments. In fact, the root word “diet” of
Dietary has a negative connotation for most, and is treated by many as a four letter word.
12
Appendix 3-B
All the more reason to move away from the medical model and offer dining and culinary
services instead (McKorkell Worth, 2009). Ten to twelve elders live in a Green House®
and lead their lives in a home where they can access the kitchen, dine together at the dining
table, and enjoy “convivium.”
Convivium
Dr. Bill Thomas has resurrected the concept of “convivium,” an old Roman word that
describes the pleasure that accompanies the sharing of good food with people we know
well. Instead of fast food, instant food or, for instance, soup from large cans warmed up as
in most institutional nursing homes, soup is made from scratch and cooked slowly. It
simmers on the stovetop all day for all to experience, from the preparation if they so
choose, to the aromas, to enjoying it for the evening meal. Dr. Thomas says this about food:
At its best food nourishes us – body and soul. A meal can embody powerful symbols
of love and acceptance. The bond between comfort and food, which begins at the
breast, is fortified throughout childhood and gains renewed strength in the late
decades of life. Properly prepared, the meals we cook and serve to our elders
should be drenched in memory, ritual and culture. … Fresh, local ingredients
prepared according to authentic regional recipes are served to people eager to
share. They use smell, taste and texture as a springboard to good conversation and
vital relationships (2008).
Staff Dining with Residents – Convivium and Building Relationships
Staff dining with residents is a culture change practice that has been implemented to build
relationships between staff and residents. It opens up the opportunity for friendships to
form and grow between those living in a nursing home and those caring for them. Of
course, residents still need to receive any assistance they need, and good infection control
needs to be practiced, and staff should interact with residents and not only with each other.
Dining Together Equalizes Everyone
“The extra socialization and encouragement, plus ready offers to get an alternate or to pour
an extra cup of coffee makes all the difference between institutional food service and
enhancing the residents dining experience” (Bump, 2004-2005). An example of
“socialization in action” comes to mind. Beth Irtz, then the administrator of Clear Creek
Care Center in Colorado and now Quality of Life Lead for Sava Senior Care Colorado region
and President of the Colorado Culture Change Coalition, implemented a Wednesday Buffet
where staff were invited to eat (free of charge) with residents. The buzz of conversation
was almost deafening and thrilling to see and hear. When people dine together, they are
just people, no longer separated as “residents and staff.” All people eat. Dining together
serves as a well known experience that “equalizes everyone” a practice which serves to
soften the “us-versus-them” atmosphere that may occur in institutional living (Krugh and
Bowman, 2009).
13
Appendix 3-B
What Residents Really Hunger For
Richard Taylor, retired psychologist and outspoken person diagnosed with dementia, was
interviewed as part of a “Leaders in Eldercare” series. He said these powerful words about
dining based on an experience of his own in an institution:
The staff would come in, and they were cheery-deary and loveable and wellintended human beings who really loved what they did, and they’d come in and start
everybody eating, and then they would leave, and everybody would just sit there
silently, eating. Not saying anything, not talking to each other. Eating wasn’t an
activity, it was barely an event. It was just something that they came and got me at
five o’clock to do.
And so I started talking to people. Now, it took me five minutes to get about half the
room talking. It’s not that I got everybody to talk or everybody wanted to talk or
even could talk, but people who hadn’t talked in a long time started to talk because I
took the time to sit and listen to them. And I don’t know if they were telling me the
truth or not. They were telling me their version of it. And I found them to be very
interesting and bright people (InsideElderCare.com, 2009).
The staff of one nursing home reported, after deciding to dine with residents, that residents
didn’t eat. That sounds bad at first, but it turns out the residents just wanted to talk.
Residents now “fight over” which staff members they want to eat with them. They’re
showing they are hungry for companionship.
Culture change leader and administrator of Rowan Community in Denver, Colorado,
Maxine Roby eats with her residents every day, moving from table to table. Maxine often
jokingly says, “I know what’s going on in my building” - an added bonus perhaps.
Psychologist Dr. Susan Wehry on Part II of the CMS From Institutionalized to Individualized
Care DVD series, relays the power of dining together in a story about a resident that staff
were worried about. Staff identified signs of depression including not eating, although the
resident, Helen, had always seemed to enjoy meals. Helen had Alzheimer’s disease and
agnosia, meaning she didn't know what to do with her meal. When Dr. Wehry put Helen’s
fork in her hand, pointed to her potatoes and said, "This looks good- do you want to try
some?” Helen would smile, nod her head yes, but take no action. “When I demonstrated
what I wanted her to do, she mimed me very well. She wanted to eat. She had the physical
capability to eat. My intervention was then to have lunch with her. I asked staff to bring me
a tray. I would say, "That looks good," take a bite, and she would do the same. She ate the
whole meal independently by watching to see what I would do next. I suggested to the CNA
that she do the same” (2007).
Probably every staff member in a nursing home has been asked by a resident somewhere
along the way to “Sit and eat with me.” Yet staff members admit they have been
programmed to reply with something like “Oh no, I can’t” even though they say they would
love to. In a nursing home in Colorado after discussing this, the administrator said, “I’m
14
Appendix 3-B
embarrassed to say this, but I was invited by residents to eat with them the other day, and I
went and asked the dining supervisor if I could, and I still didn’t eat with my residents.”
That is a bold and brave administrator to admit what to him was embarrassing. Culture
change pioneer Eric Haider has said over the years that the culture change movement could
be called the common sense movement. Dr. Thomas and his focus on convivium and
experiences such as these are making the case that dining together makes good common
sense.
Staff Members Get to Know Residents’ Preferences
On Part II of the CMS From Institutional to Individualized Care series, staff from featured
home Salmon Family Services of Westborough and Northbridge, Massachusetts reported
that residents eat better when staff look residents in the eye to connect and get a response
directly from them. “One of the big things in my opinion is the Dietary staff. The people
who were always on the serving line, always making up trays, now get into the dining room
and actually meet people. Some of them don’t speak English very well. It’s amazing that
they can communicate. They figure out exactly what the residents want, and they have
come to know the resident” said Mike Salmon, Food Service Director (2007).
Many homes have experimented with all sorts of ways to serve residents with great results.
At Littleton Manor in Littleton, Colorado, department managers have taken turns serving
residents at mealtimes since 2003. The former director of nursing always remarked that
when it came time for quarterly re-assessment, she knew firsthand what each resident ate
or didn’t eat. Brookside Inn in Castle Rock, Colorado, had all department managers become
trained dining assistants. They rotate serving as the dining room host or hostess, and are
available to assist residents to eat if needed. Many homes have brought the kitchen staff
out of the kitchen, with many stories of relationships forming and staff members realizing
things like, “Why would we serve that to Mary? She doesn’t like it; never has.”
Other Welcomed Dining Practices
As part of a dignified dining experience, forward-thinking pioneers questioned, and then
simply stopped using bibs, serving food on trays, and got rid of what used to be called
“feeder tables” - tables designed in a horseshoe shape in order to feed four residents at a
time. What is also becoming a former long term care practice is referring to those needing
assistance or to be fed as “feeders.” Harm was not meant by these ideas, but they have
contributed to putting the task, and the goal of efficiency before the person. Many have
replaced the language “feed,” “fed,” and “feeder” with “dining,” “dine,” “assist with dining,”
and even more personal, some encourage the normal practice of using the person’s name
instead of any sort of label.
Lastly, some homes have had fun shopping with residents for real glassware and real coffee
cups, no longer serving coffee in plastic mugs. Plate, glass and silverware that came from
places like Pier 1 Imports and other dinnerware stores fits what Rose Marie Fagan,
founding executive director of the Pioneer Network, teaches wherever she goes that the
goal of the culture change movement is “rampant normalcy.”
15
Appendix 3-B
Chapter Three
Food and Dining Research and Outcomes Realized by Pioneering Homes
According to a 2005 American Dietetic Association Report of the Task Force on Aging, as
many as 65% of long term care residents experience unintended weight loss and undernutrition, and there is concern that the incidence of malnutrition is underreported. Many
causes of weight loss may be amenable to intervention. Formal research studies and
anecdotal evidence coming from homes focusing on individualizing food and dining
services show some promising results.
In a Scandinavian study, food was served family style, and residents helped themselves.
Residents experienced a 25% increase in protein and energy intake (Elmstahl et al, 1987).
In a study of thirty Veteran’s Administration homes where choice was increased, dining
environment improved and restricted diets liberalized, 50% of the residents gained weight
(Abassi and Rudman, 1994).
One family-style dining study that also focused on staff giving encouragement and praise to
persons with dementia resulted in higher participation in eating and even improvement in
appropriate communication (Altus et al, 2002). A family style dining study including
persons without cognitive impairment resulted in improvements in quality of life
measures, fine motor functioning and body weight (Nijs et al, 2006).
A study done in Canada found that “bulk” or steam table/buffet food service and a homelike
dining environment optimized energy intake in individuals at high risk for malnutrition,
particularly those with low body mass index and cognitive impairment (Desai et al, 2007).
Rolling Fields of Conneautville, Pennsylvania, an Eden registered home and winner of the
OPTIMA Long Term Living 2009 Award, offers 24 hour dining. Residents can choose food
they want to eat around the clock. As a result, pressure ulcers have healed, many residents
at risk for weight loss have gained weight, supplements have decreased and even pain and
behavioral issues have improved. Staff attributes this to being able to serve actual meals
[rather than minimal snacks] for those who are awake and hungry, especially at night.
Additionally, resident satisfaction has improved, care plan meetings and Resident Council
meetings no longer revolve around food issues but instead are filled with compliments.
During the last State surveys, not only were there no resident complaints about food, there
were instead “many glowing reviews about the food service not only from our Elders but
also from the state surveyors, who ordered lunch each day of the survey”
(Ltlmagazine.com, 2009).
After being reminded personally of the feelings that foods like soup and bread evoke for
him, Franco Diamond, administrator of Idylwood Care Center in Sunnyvale, California,
embarked on a journey focusing on foods and their aromas. A Soup of the Day contest led
his whole community into forty-plus food activities and events. Schaeffer writes, “Anyone
could participate in that experience by merely inhaling, and letting memories arise with the
aroma. For people with advanced dementia, food may be the last thing they lose interest
in” (2008). One resident, Mrs. C, was not “so easily enticed,” still complained about the
16
Appendix 3-B
“lousy” food, and her eating habits declined. Staff decided to use food as an ice-breaker
when they discovered her love for cooking Italian food with fava beans. Caregivers planted
some, but because they “didn’t know beans” about fava beans, they got her to show them
how to pick, shell and cook the gourmet bean which ultimately led to Mrs. C leading a
cooking class. Not only did she flourish socially, but nutritionally as well. “Mrs. C’s magical
transformation confirmed for Diamond that residents would become involved if offered
familiar and meaningful activities. It also fed staff’s gastronomical approach to culture
change: If Mrs. C could change so dramatically, maybe they should put more stock into how
meals were presented and the ingredients in them” (Schaeffer, 2009). Perhaps Ildylwood’s
experience makes the case for care planning “familiar and meaningful food and aromas” for
each resident.
Dietitian Sharon Leppert makes a great case for creating “a social atmosphere and culture
for resident dining” that is participatory with choice and independence as well as socially
rich “as a treatment modality” (2007). Although the term “treatment modality” sounds a
bit medical, Leppert is onto something. She invites us to consider how the dining
atmosphere contributes or takes away from an individual’s health by asking:
When residents are given the opportunity to express preferences on food selection
and portion size at the time of service, are they not also provided with an
opportunity to contribute to their sense of self-esteem by exercising control over
their environment in a small yet positive way? Adequate energy intake to prevent
weight loss is an important factor in managing the health risk in populations with
advancing age, but the value of food may impact more than nutrition when mealtime
contributes to social interaction, self-esteem, and enjoyment for the aging individual
(2007).
After Initial Increases, Budget Neutrality and Cost Savings
Linda Bump explains that initial food costs may increase with new enhancements, but as
staff learn resident preferences and plan for them, those costs “reestablish within budget”
(2004-2005). Eric Haider similarly says that staff learn what residents prefer and how
much of each item to prepare, minimizing waste. He attributed a savings of $20,000 per
year to this process (Rantz and Flesner, 2004). This is also the experience of the facility
identified in Linda Handy’s book Surveyor M.O. for Nutritional Care (F325) that there are
“budget increases at first until you figure out who is going where,” “less prep,” residents
“usually eat what they take which means we are not feeding the garbage can as much as we
used to” and budget is now “actually more efficient and more effective” (2009). Also by
avoiding the pre-plating of food, unused food may be used as leftovers following guidelines
at Tag 371 or even as “planned overs,” both of which reduce costs according to Linda Bump
(2004-2005).
There may be initial costs for a steam table and other equipment as it is added, but there
can be a coinciding decrease in main kitchen equipment replacement and repair according
to Bump. She also teaches that labor costs can be held budget-neutral following the initial
17
Appendix 3-B
confusion of transitioning to new serving styles. She encourages teams to be creative, to
tap underutilized staff minutes and to “take the plunge many homes have without
increasing staff” (2004-2005).
Real Food instead of Commercial Supplements
Margie Haider, director of nursing at Crestview in 2001, espoused that by giving people
foods they like to eat, you can minimize the use of supplements. Margie and Eric shared
that Crestview saved $1,164.00 per month by serving real foods residents wanted to eat .
In Person Centered Care it is recorded that supplements went from 72 in 1998 to only 14 by
July 2000 (2004). Bump explains that having foods of choice available 24/7 virtually
eliminates the need for supplements. She adds, “There are not many residents who will
choose a canned commercial supplement over real food or personal preference.” Bump
points out that snack and “hydration” carts can also be eliminated with the addition of
pantries and snack bars (2004-2005). Eliminating carts is also what many homes have
done to lessen the institutional feel and to create home.
In his article on malnutrition in the older individual, Webster states that “Oral supplements
are also not very beneficial and often go wasted or conflict with medications” (2008). Oral
liquid nutrition supplements have been shown to be only moderately successful in
increasing energy intake, which has also been shown to be related to the limited time staff
can devote to getting the supplements delivered and giving verbal encouragement to
consume them (Schlettwein-Gsell, 1992). Webster says that, “Improving taste is one of the
best and simplest ways of improving nutrition” (2008). The “elderly have the same taste
preferences as they have had all of their life, and thus low sodium, low fat meals are not
always as appetizing as the normal version of a food with naturally high fat and sodium
content” (Calverley, 2007).
Real Foods, Less Meds and Cost Savings
When nutrients are offered in the form of yummy foods, medication usage will decline
especially for laxatives, appetite stimulants and even multivitamins. Neighborhood and
household kitchens virtually eliminate laxatives, using food instead to support normal
bowel function (Bump, 2004-2005). Charlene Boyd of Providence Mount St. Vincent
reports that “the number of special diets is reduced to a few, as homes learn it is more
important for elders to eat appetizing food than to have meals medicalized into inedible
ordeals,” leading to less food waste and reduced use of dietary supplements, all while
residents gain weight (Baker, 2007).
18
Appendix 3-B
Common Sense Ideas and Results
Debi Majo the director of nursing at the Northwood Health Care Center in Marble Falls,
Texas shared some common sense ideas that more homes are trying in Part III of the CMS
From Insitutional to Individualized Care series:
We work diligently on reducing sugar in all of our menus because in reality, no one
needs a lot of sugar in their diet. We sweeten our cakes with applesauce and
sometimes add carrot juice or even prune puree to chocolate cupcake batter instead
of sugar. So our reduced concentrated sweet diet is actually closer to sugar free.
For all diets we do not add salt to any item that we cook. Some of the ‘pre-made’
breads contain salt so we call our reduced sodium diet ‘no added salt’ and I can tell
you that corn bread tastes a little flat without salt, but you get used to it. And
mechanically altered diets, these are just regular food that has been blended in the
blender or hand chopped (2007).
19
Appendix 3-B
Chapter Four
CMS – A Partner in the Culture Change Movement
The brochure for the upcoming Creating Home in the Nursing Home II Symposium, cosponsored by CMS and the Pioneer Network states: “CMS has become a partner in the
culture change movement, and wishes to encourage meaningful changes in food and dining
service that provide greater quality of life for residents”.
CMS has a history of support for culture change. In 2002, CMS developed a satellite
webcast for state survey agencies called “Innovations in Quality of Life: The Pioneer
Network”. Surveyors were exposed to background information on culture change, its
positive outcomes, and how facilities can make culture changes and remain compliant with
nursing home regulations.
Culture change became the basis fora pilot project that included twenty-one states during
the 8th Scope of Work for the CMS Quality Improvement Organizations (QIOs) between
August 2004 and October 2005.
CMS also took part in the St. Louis Accord in 2005. This was a gathering of long term care
stakeholders interested in culture change. The more than 400 participants included
ombudsmen, advocate groups, regulators, providers, state and national trade associations,
culture change experts, and QIO representatives. All 50 States were represented and State
teams created action plans to promote transformation of institutional culture in their
respective States (www.qualitypartnersriqio.org/cfmodules/objmgr.cfm accessed 1-1110).
In April 2006, CMS let a contract for development of the “Artifacts of Culture Change”
measurement tool. The tool is designed to capture tangible evidence of changes that come
from a changed culture and includes several dining items under the domain of Care
Practices. In 2009 the Pioneer Network developed a data base that automates the
completion of the tool. The site, which is in the test stage at this writing, will enable a
nursing home to fill out the Artifacts tool and receive a report comparing them to others in
the data base.
In December of 2006, CMS issued a Survey and Certification letter with answers to culture
change questions from the culture change community which is available at
http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCletter07-07.pdf. For
convenience, the letter is also included in Appendix B.
In April of 2008 CMS and the Pioneer Network co-sponsored Creating Home in the Nursing
Home: A National Symposium on Culture Change and the Environment. Subsequent to the
symposium, the Hulda B. and Maurice L. Rothschild Foundation funded the Pioneer
Network to convene the National Long Term Care Life Safety Task Force. The Task Force
was composed of volunteer architectural and Life Safety Code experts. They submitted five
proposals to the National Fire Protection Association regarding the Life Safety Code® in
August of 2009 for the 2012 Edition. CMS issued new interpretive guidance effective
20
Appendix 3-B
July 12, 2009 for ten regulations regarding the environment and quality of life, directly
stemming from the symposium discussions.
CMS funded the writing of the background paper for the first symposium, as well as this
background paper in preparation for the second symposium. In addition, the 2009 version
of the CMS “Guide to Choosing a Nursing Home,” contains a section describing culture
change and person-directed practices for the first time.
The Pioneer Network has asked AHFSA – the Association of Health Facility Survey Agencies
– and AHFSA in turn has invited each State survey agency, to name a culture change contact
person within their survey agency. In addition, the leadership of AHFSA has created an
Individualized Care Committee, essentially its own culture change committee.
21
Appendix 3-B
Chapter Five
Food and Dining Issues and the CMS Food and Dining Regulations
CMS has identified many culture change practices regarding food and dining in newer
interpretive guidance. However, the issues surrounding new and innovative ways of
serving food in the nursing home are not always completely addressed.
483.35(i) F325 Nutrition
Based on a resident’s comprehensive assessment, the facility must ensure that a resident –
483.35(i)(1) Maintains acceptable parameters of nutritional status such as body weight and
protein levels, unless the resident’s clinical condition demonstrates that this is not possible:
and
483.35(i)(2) Receives a therapeutic diet when there is a nutritional problem.
Receives a Therapeutic Diet
Therapeutic diet refers to two kinds of diets: restricted diets (such as no concentrated
sweets and low or no salt) and altered texture diets (such as mechanical soft or pureed). As
might be expected, residents would often prefer not to follow a restricted diet. Residents
on a modified texture diet would also sometimes prefer a regular diet, which might put
them at risk for choking.
The Intent statement in the interpretive guidance for this requirement currently states that
care and services be consistent with the resident’s comprehensive assessment and that the
therapeutic diet takes into account the resident’s clinical condition and preferences. The
resident’s personal wishes are acknowledged with the following: Goals and prognosis refer
to a resident’s projected personal and clinical outcomes. These are influenced by the
resident’s preferences (e.g., willingness to participate in weight management interventions or
desire for nutritional support at end-of-life)….
Tag F325 Nutrition guidance identifies that a person has dislikes, preferences and preferred
portion sizes.
Resident Goals
CMS Interpretive Guidance also identifies that resident goals and resident specific
interventions should be care planned. The culture change community has begun “I-format”
care planning which redirects staff to the person. I-format care planning is the resident’s
care plan in their own voice such as “I have diabetes and my goal is for my blood sugars to
be stable.” Approaches are also in the voice of the person stating to care givers what works
best for them. Providers who have committed to I-format care planning state that it is
“powerful” and helps staff see the resident as a person.
22
Appendix 3-B
Resident Choice
The Interpretive Guidance includes a section on Resident Choice at F325 Nutrition. It states
the following:
The resident or resident representative has the right to make informed choices about
accepting or declining care and treatment. The facility can help the resident exercise
those rights effectively by discussion with the resident (or the resident’s
representative) the resident’s condition, treatment options (including related risks and
benefits, and expected outcomes), personal preferences, and any potential
consequences of accepting or refusing treatment. If the resident declines specific
interventions, the facility must address the resident’s concerns and offer relevant
alternatives.
This section evidences real recognition of the right to informed choice, about the fact that
one may decline care and treatment, and that the facility can even help the resident exercise
those rights.
The Resident Choice section of Tag F325 follows:
The facility’s care reflects a resident’s choices, either as offered by the resident directly
or via a valid advance directive, or based on a decision based on a resident’s surrogate
or representative in accordance with state law. The presence of care instructions, such
as an advance directive declining some interventions does not necessarily imply that
other support and care was declined or is not pertinent. When preferences are not
specified beforehand, decisions related to the possible provision of supplemental or
artificial nutrition should be made in conjunction with the resident or resident’s
representative in accordance with State law, taking into account relevant
considerations such as condition, prognosis, and a resident’s known values and choices.
Diet Liberalization
The CMS Interpretive Guidance contains a section at F325 Nutrition on Diet Liberalization:
Research suggests that a liberalized diet can enhance the quality of life and nutritional
status of older adults in long-term care facilities. Thus, it is often beneficial to
minimize restrictions, consistent with a resident’s condition, prognosis and choices
before using supplementation. It may also be helpful to provide the residents their
food preferences, before using supplementation. This pertains to newly developed
meal plans as well as to the review of existing diets. Dietary restrictions, therapeutic
(e.g., low fat or sodium restricted) diets, and mechanically altered diets may help in
select situations. At other times, they may impair adequate nutrition and lead to
further decline in nutritional status, especially in already undernourished or at-risk
individuals. When a resident is not eating well or is losing weight, the interdisciplinary
team may temporarily abate dietary restrictions and liberalize the diet to improve the
resident’s food intake to try to stabilize their weight. Sometimes, a resident or
23
Appendix 3-B
resident’s representative decides to decline medically relevant dietary restrictions. In
such circumstances, the resident, facility and practitioner collaborate to identify
pertinent alternatives.
Diet Liberalization – A New Standard of Practice
The American Dietetic Association (ADA) in 2002 released a position paper on diet
liberalization called “Liberalized Diets for Older Adults in Long-term Care.” In it, the ADA
stated, “It is the position of the ADA that the quality of life and the nutritional status of
older residents in long-term care facilities may be enhanced by a liberalized diet.” The
paper further states that nutrition in long term care settings must meet two goals:
maintenance of health through medical care and maintenance of quality of life.
The ADA has gone beyond just looking at quality of care to consider quality of life as well:
“To meet the needs of every resident, dietetic professionals must consider each person
holistically, including personal goals, overall prognoses, benefits and risks of treatment,
and perhaps most important, quality of life” (2002).
CMS Supports Culture Change
The following is excerted from the Environmental Factors section of the F325 guidelines:
Appetite is often enhanced by the appealing aroma, flavor, form and appearance of
food. Resident-specific facility practices that may help improve intake include
providing a pleasant dining experience (e.g., flexible dining environments, styles and
schedules), providing meals that are palatable, attractive and nutritious (e.g., prepare
food with seasonings, serve food at proper temperatures, etc.), and making sure that
the environment where residents eat (e.g., dining room and/or resident’s room) is
conducive to dining.
Flexible dining environments, styles and schedules help to improve dietary intake.
Research shows that socializing with others improves appetite (Simmons et al 2001,
Simmons and Schnelle, 2004). It is accepted that certain aromas such as chocolate improve
appetite. Music, lighting, ambiance, basically a pleasant dining experience improves
everything.
Real Food over Supplements
CMS guidance states that most people prefer real food to supplements: With any nutrition
program, improving intake via wholesome foods is generally preferable to adding nutritional
supplements.
Avoidable and Unavoidable
A definition of “unavoidable” in regards to nutrition is provided at F325:
24
Appendix 3-B
“Unavoidable” means that the resident did not maintain acceptable parameters of
nutritional status even though the facility had evaluated the resident’s clinical
condition and nutritional risk factors; defined and implemented interventions that are
consistent with resident needs, goals and recognized standards of practice; monitored
and evaluated the impact of the interventions; and revised the approaches as
appropriate.
Thus, weight loss is not automatically considered a deficiency. Surveyors will investigate
whether it was avoidable in light of poor care practice or unavoidable in light of good care
practices. Only the avoidable weight loss will become a deficiency. When investigating
whether any sort of nutritional decline was unavoidable, the guidance advises that the
resident’s needs and goals be taken into account, as well as considering recognized
standards of practice. That is part of providing good care, and is now a part of the guidance
for Tag F242 Self-determination and Participation.
Investigative Protocol
Review of Facility Practices, If the interventions defined, or the care provided, appear
to be inconsistent with recognized standards of practice, interview one or more health
care practitioners as necessary (e.g., physician, hospice nurse, dietitian, charge nurse,
director of nursing or medical director).
The CMS guidance supports person-centered, self-directed living ideas by stating under
Observations in the Investigative Protocol for Tag F325 Nutrition:
During observations, surveyors may see non-traditional or alternate approaches to
dining services such as buffet, restaurant style of or family style dining. These
alternate dining approaches may include more choices in meal options, preparations,
dining areas and meal times. Such alternate dining approaches are acceptable and
encouraged.
Heavy Hitters
CMS has made a strong statement regarding the importance of resident choice and
preferences at F325 Deficiency Categorization:
The first instance is an example of Severity Level 4 - Immediate Jeopardy:
Substantial and ongoing decline in food intake resulting in significant unplanned
weight loss due to dietary restrictions or downgraded diet textures (e.g., mechanic soft,
pureed) provided by the facility against the resident’s expressed preferences.
The following are examples given at Severity Level 3 - Actual Harm:
Unplanned weight change and declining food and/or fluid intake due to the facility’s
failure to assess the relative benefits and risks of restricting or downgrading diet and
25
Appendix 3-B
food consistency or to obtain or accommodate resident preferences in accepting
related risks;
Decline in function related to poor food/fluid intake due to the facility’s failure to
accommodate documented resident food dislikes and provide appropriate substitutes.
And under the section Potential Tags for Additional Investigation, the very first tag
mentioned is Tag 150 Resident Rights and stated is, “Determine if the resident’s
preferences related to nutrition and food intake were considered.”
F360 483.35 Dietary Services
The facility must provide each resident with a nourishing, palatable, well-balanced diet that
meets the daily nutritional and special dietary needs of each resident.
F361 483.35(a) Staffing, Qualified Dietician
CMS at Tag F325 Nutrition identifies that qualified dieticians help identify nutritional risk
factors and recommend nutritional interventions, based on each resident’s medical condition,
needs, desires and goals.
Linda Roberts, RD and consultant in long term care, shares some insight into the role of the
dietitian. She says the dietitian “has been trained to treat certain diseases with food” citing
the extensive education an RD receives in chemistry, biochemistry, microbiology and
anatomy. The dietitian understands the body's workings at the cellular level and how the
components of food (carbohydrates, fats, proteins, vitamins, minerals, phytochemicals)
affect the health and wellness of the individual. And dietitians want to help people.
However, the other part of the equation, Roberts advises, is the patient's lifelong habits.
She cites the example of 80 year olds. There will be some that are very interested in
prolonging their life and others will say: “who cares if I live another 2 months or not - I'm
80 years old.”
The goal should always be to individualize according to what each person wants, needs,
will put up with, will concede to. To truly individualize means to figure out what works
best for a person, remembering that we’re all different.
Staffing to Complement the Dietitian
In order to focus on resident needs, desires and goals, some nursing homes are hiring chefs
and restaurant managers to complement the role of the required qualified dietician.
Because chefs, restaurant managers and wait staff are used to serving people what they
want when they want it, they have a real commitment to service.
Solid training in the facility’s practice of encouraging and reminding residents of any food
related recommendations is needed by all staff.
26
Appendix 3-B
“Healthcare: Chefs Needed”
Ryan Krebs is Executive Chef/Director of Dietary Services at Victoria Special Care Center in
El Cajon, California. A former executive chef from the restaurant world, Krebs is passionate
about inviting executive chefs into the meaningful business of long term care. According to
Krebs, a culinary education focus is service plus a passion and enthusiasm for food. What
many suppose is that chefs cost more. Krebs says this is true initially but to “keep in mind
that many chefs are also held to the highest of standards, especially from larger
corporations and privately owned restaurants. They manage money, large staffs, and
control costs and are held accountable to numbers in so many ways. And, their
management experience could immediately impact overhead labor and purchasing costs,
possibly allowing their salary requirements to be met. Having an executive chef is also a
great marketing tool for organizations, stating that your business has made an investment
in bringing in the best the industry has to offer….” (2009).
Johnson & Wales University, Krebs’ alma mater in Providence, Rhode Island, offers a degree
in Culinary Nutrition, the first of its kind, blending the healthcare focus of nutrition with the
culinary arts. Krebs says that as our economy suffers and restaurants and hotels are
closing or making cut-backs, there are eager chefs awaiting the chance to enter the field of
healthcare (2009).
F362 483.35(b) Sufficient Staff
This guidance points out that an assessment of whether residents are receiving sufficient
assistance for meals should be included in an assessment of the adequacy of staffing.
F363 483.35(c) Menus and Nutritional Adequacy
Menus must: Meet the nutritional needs of residents in accordance with the recommended
dietary allowances of the Food and Nutrition Board of the National Research Council,
National Academy of Sciences.
483.35 (c) (2) Be prepared in advance
483.35 (c) (3) Be followed.
The Intent section of the guidance for this regulation states: This regulation also assures
that there is a prepared menu by which nutritionally adequate meals have been planned for
the resident and followed.
In 2008 the Colorado Department of Healthcare Policy and Finance developed the Colorado
Nursing Facilities Pay for Performance (P4P) Medicaid reimbursement program which also
includes resident participation in menu planning. One of the minimum requirements is:
Menus that include numerous options, menus developed with resident input.
Menu options must be more than the entree and alternate selection. These options
should include input from a resident/family advisory group such as resident
27
Appendix 3-B
council or a dining advisory committee. The residents have input into the
appearance of the dining atmosphere.
483.35 (c) (3) Be followed
The Procedures section of the interpretive guidelines for tag, F363 states:
For sampled residents…observe if meals served are consistent with the planned menu
and care plan in the amounts, types and consistency of foods served.
If the survey team observes deviation from the planned menu, review appropriate
documentation from diet card, record review, and interviews with food service
manager or dietician to support reason(s) for deviation from the written menu.
The guidance does not state that deviation from the menu is automatically assumed to be a
deficient practice, but ratherthat surveyors should to investigate the reasons for the
deviation. CMS guides the surveyor to conduct a record review. If the facility has explained
the reasons in assessments and the plan of care, it should be taken into account.
483.35 (d) F364 Food
Each resident receives and the facility provides:
(1) Food prepared by methods that conserve nutritive value, flavor and appearance;
(2) Food that is palatable, attractive and at the proper temperature;
483.35 (d) (3) F365 Food prepared in a form and designed to meet individual needs.
483.35 (d) (4) F366 Substitutes offered of similar nutritive value to residents who refuse
food served.
F367 483.35(e) Therapeutic diets
Therapeutic diets must be prescribed by the attending physician.
In the California Dining Project, CMS Region IX encourages thinking about “partnership:”
Nursing facilities need to establish a partnership among the health care
practitioners including consistently assigned direct care staff, the long term and
short stay residents and his/her families (when appropriate) to ensure that food
and fluid decisions respect all these residents’ wants, needs and preferences and
that the capable residents, care givers and involved families are satisfied with their
care, as well as their clinical outcomes. Coordination and integration of the
nutrition and hydration services should involve and include clinical, ancillary, and
support services staff. Capable residents should be encouraged to give on-going
input about the program (2008).
28
Appendix 3-B
F368 483.35(f) Frequency of Meals – “The 14 Hour Rule”
1) Each resident receives and the facility provides at least three meals daily, at regular
times comparable to normal mealtimes in the community.
2) There must be no more than 14 hours between a substantial evening meal and
breakfast the following day, except as provided in (4) below.
3) The facility must offer snacks at bedtime daily.
4) When a nourishing snack is provided 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, and a nourishing snack is served.
CMS has given guidance in the S&C-07-07 letter (Appendix B) answering questions
including “the 14 hour rule” and the resident right to choice:
Question 1: Tag F368 (Frequency of Meals): You request a clarification that the
regulation language at this Tag that “each resident receives and the facility provides
at least three meals daily” does not require the resident to actually eat the food for
the facility to be in compliance. You also ask for clarification about the regulatory
language specifying that there must be no more than 14 hours between supper and
breakfast (or 16 hours if a resident group agrees and a nourishing snack is
provided). You state that some believe this language means all of the residents must
actually eat promptly by the 14th hour, which makes it difficult for the facility to
honor a specific resident’s request to refuse a night snack and then sleep late.
Response 1: The regulation language is in place to prevent facilities from offering
less than 3 meals per day and to prevent facilities from serving supper so early in
the afternoon that a significant period of time elapses until residents receive their
next meal. The language was not intended to diminish the right of any resident to
refuse any particular meal or snack, nor to diminish the right of a resident over their
sleeping and waking time. These rights are described at Tag F242, Selfdetermination and participation. You are correct in assuming that the regulation
language at F368 means that the facility must be offering meals and snacks as
specified, but that each resident maintains the right to refuse the food offered. If
surveyors encounter a situation in which a resident or residents are refusing snacks
routinely, they would ask the resident(s) the reason for their customary refusal and
would continue to investigate this issue only if the resident(s) complain about the
food items provided. If a resident is sleeping late and misses breakfast, surveyors
would want to know if the facility has anything for the resident to eat when they
awaken (such as continental breakfast items) if they desire any food before lunch
time begins.
F369 483.35(g) Assistive devices
Assistive devices are very helpful to certain individuals needing them, contributing greatly
to independence. This tag plays an important role in helping residents reach their highest
practicable level of well-being.
29
Appendix 3-B
F371 483.35(i) Sanitary conditions
The facility must: 1) Procure food from sources approved or considered satisfactory by
Federal, State or local authorities: and 2) Store, prepare, distribute and serve food under
sanitary conditions.
The revised guidance for this Tag F371 was issued on June 20, 2008 with an effective date
of September 1, 2008. The guidance recognizes new approaches:
Approaches to create a homelike environment or to provide accessible nourishments
may include a variety of unconventional and non-institutional food services. Meals or
snacks may be served at times other than scheduled meal times and convenience foods,
ready-to-eat foods, and pre-packaged foods may be stored and microwave heated on
the nursing units. Whatever the approach, it is important that staff follow safe food
handling practices.
Unsafe Food Sources
Unsafe food sources are not approved or considered satisfactory by Federal, State or local
authorities. Nursing homes are not permitted to use home-prepared or home preserved (e.g.,
canned, pickled) foods for service to residents.
This guidance was clarified with the following addition on May, 29 2009:
NOTE: The food procurement requirements for facilities are not intended to restrict resident
choice. All residents have the right to accept food brought to the facility by any visitor(s) for
any resident.
In a June 12, 2009 CMS Survey and Certification letter (SC 09-39 included in Appendix A)
CMS also indicated to facilities:
The facility does have a responsibility under the food and safety regulatory language
at F371 to help visitors understand safe food handling practices (such as not holding
or transporting foods containing perishable ingredients at temperatures above 41
degrees F) and to ensure that if they are assisting visitors with reheating or other
preparation activities, that facility staff use safe food handling practices and
encourage visitors and residents who are contributing to food preparation in the
facility to use these safe practices as well.
So, food can be brought in, but the facility has responsibilities to keep it safe once it’s there
and to try to have it come in as safe a condition as possible. A facility can decide on their
own policies and practices to uphold resident rights as well as keep food safe.
CMS gave guidance on this issue in the Survey and Certification S&C -07-07 December 21,
2006 answering culture change questions (Appendix B):
30
Appendix 3-B
Question 2: (370) Approved Food Sources: You ask if the regulatory language at this
Tag that the facility must procure food from approved food sources prohibits
residents from any of the following: 1) growing their own garden produce and
eating it; 2) eating fish they have caught o a fishing trip; or 3) eating food brought to
them by their own family or friends.
Response 2: The regulatory language at this Tag is in place to prohibit a facility from
procuring their food supply from questionable food sources, in order to keep
residents safe. It would be problematic if the facility is serving food to all residents
from the sources you list, since the facility would not be able to verify that the food
they are providing is safe. The regulation is not intended to diminish the rights of
specific residents to eat food in any of the circumstances you mention. In those
cases, the facility is not procuring food. The residents are making their own choices
to eat what they desire to eat. This would also be the case if a resident ordered a
pizza, attended a ball game and bought a hot dog, or any similar circumstance. The
right to make these choices is also part of the regulatory language at F242, that the
resident has the right to, “make choices about aspects of his or her life that are
important to the resident.” This is a key right that we believe is also an important
contributing factor to a resident’s quality of life.
CMS articulates in this memo the difference between the facility procuring food from
approved sources and the right of residents to make choice, an important distinction.
Gardens
In 2006, in the S&C -07-07 letter (Appendix B), CMS honored the resident’s right to choose
to eat foods they grew in a garden under the umbrella of involvement in activities, not food
procured by the facility for all residents. Since that time CMS has received many questions
as to whether food from gardens planted by the facility to serve the whole population is
acceptable. CMS is working with the FDA on this issue, and Glenda Lewis from the FDA will
address it at the Creating Home II symposium.
No bare hand contact
In the Employee Health section of this guidance it is stated: Bare hand contact with foods is
prohibited. This requirement stems from the Food and Drug Administration’s (FDA) Food
Code. The Food Code’s Intent at 1-102.10 is stated as, “The purpose of this Code is to
safeguard public health and provide to consumers food that is safe, unadulterated, and
honestly presented.”
Chapter 3 of the Food Code at 3-301.11 states: (B) “….Food employees may not contact
exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli
tissue, tongs, single use gloves or dispensing equipment.”
31
Appendix 3-B
(D) “Food employees not serving a highly susceptible population may contact exposed,
ready-to-eat food with their bare hands if…” (many points follow).
At 3-801.11 (D) Special requirements for Highly Susceptible Populations it is stated, “Food
employees may not contact ready-to-eat food” and “’Food employee’ means an individual
working with unpackaged food, food equipment or utensils, or food-contact surfaces”
according to Chapter 1 – Purpose and Definitions.
“Highly susceptible population” means persons who are more likely than other
people in the general population to experience foodborne disease because they are:
(1) Immunocompromised; preschool aged children, or older adults; and
(2) Obtaining food at a facility that provides services such as custodial care, health
care, or assisted living, such as a child or adult day care center, kidney dialysis
center, hospital or nursing home, or nutritional or socialization services such as a
senior center.
The FDA Food Code can be accessed at
http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/u
cm186464.htm (as of Dec. 2009).
Gloves
CMS has given tighter guidance regarding gloves at F371:
Gloved hands are considered a food contact surface that can get contaminated or
soiled. Failure to change gloves between tasks can contribute to crosscontamination….. NOTE: The use of disposable gloves is not a substitute for proper
hand washing with soap and water.
Resident Refrigerators
The Environment task in the QIS survey directs surveyors to look at “snack/nourishment
refrigerators on the units.” Nursing home residents sometimes have their own
refrigerators, although there is some lack of clarity as to whether the resident or the facility
has the responsibility of maintaining them.
Take-out and Delivered Foods
Based on the new CMS clarification, take-out and home delivery foods are the right of
residents. And per the 5/29/09 Survey and Certification letter (Appendix B), the facility
has the responsibility to keep foods safe.
Alcohol-based Hand Rubs
In the section Hand Washing, Gloves and Antimicrobial Gel, CMS has stated: Antimicrobial
gel cannot be used in place of proper hand washing techniques in a food service setting.
32
Appendix 3-B
Eggs
Guidance calls for any unpasteurized eggs to be cooked to a 145 degrees Fahrenheit
internal temperature, and under the section called Pooled Eggs, CMS has made the
statement: Waivers to allow undercooked unpasteurized eggs for resident preference are not
acceptable. Pasteurized shell eggs are available and allow for safe consumption of
undercooked eggs.
Hairnets
CMS only requires hair restraints of dietary staff at F371: Dietary staff must wear hair
restraints (e.g., hairnet, hat, and/or beard restraint) to prevent their hair from contacting
exposed food.
The guidance is written with the assumption of the roles and duties of staff by department.
In innovative homes with households or little houses, there is no departmental division of
labor, and there is no large, main preparation kitchen that is off limits to residents. Instead,
roles become blended. A person who is a certified nursing assistant may be cooking, a
person who is a social worker may be dishing out food from large bowls at a table, the
administrator or family member or resident may be taking cookies out of the oven, washing
dishes, etc. There is a need for clarity on what duties and situations, not what positions or
departments, need hair restraints.
Buffets and Steam Tables
There are standards of good infection control practice that are obviously required with
buffets such as sneeze guards, serving utensils, tongs, tissues and ensuring proper food
temperatures.
Food Holding Times
“Danger Zone” refers to temperatures above 41 degrees Fahrenheit (F) and below 135
degrees F that allow the rapid growth of pathogenic microorganisms that can cause
foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for
Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from
ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause foodborne
illness outbreak if consumed. CMS specifically mentions the time frame food can be on a
steam table following this 4 hour rule: The maximum length of time that foods can be held on
a steam table is a total of 4 hours.
Family Style Dining
Good infection control practice becomes especially important when foods are served in
serving bowls, as they would be in our homes. Proper food temperature is also especially
important in this instance.
33
Appendix 3-B
Staff Dining with Residents
CMS addressed this issue in 2006 in the S&C-07-07 letter (Appendix B):
Question 11 (Dining Together): Is it permissible for staff and residents to dine
together?
Answer 11: There is no federal requirement that prohibits this. We applaud efforts
of facilities to make the dining experience less institutional and more like home.
Our concern would be for the facility to make sure that residents who need
assistance receive it in a timely fashion (not making residents wait to be assisted
until staff finish their meals).
So dining together is welcome as long as residents always receive assistance needed.
Does a Nurse have to be in the Dining Room for Meals?
At Tag F373, regarding paid feeding/dining assistants CMS has stated:
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, whatever the
location, the feeding assistant must be aware of and know how to access the
supervisory nurse immediately in the event that an emergency should occur. Should
an emergency arise, a paid feeding assistant must immediately call a supervisory nurse
for help on the resident call system.
F373 483.35(h) Paid Feeding Assistants – Dining Assistants
CMS published a Federal Register rule in September of 2003 creating the regulatory
language that was then placed at Tag F373, making it possible for long-term care facilities
to use Paid Feeding Assistants to help residents eat who have no complicated eating
problems.
Paid Feeding Assistant/Dining Assistant Research
Now that dining assistants (DA) have been in existence for six years, several studies, cosponsored by CMS and the Agency for Healthcare Research and Quality (AHRQ), have been
completed to investigate the impact of DA programs. The primary researchers for these
studies, Drs. Sandra Simmons of Vanderbilt University and Rosanna Bertrand of Abt
Associates will share their findings as featured speakers at the upcoming Creating Home II
symposium.
34
Appendix 3-B
A Manual for Dining Assistant Programs in Nursing Homes: Guidelines for Implementation
has been developed by Abt Associates and Vanderbilt University with funding and input
from both CMS and AHRQ. It is available at www.VanderbiltCQA.org.
Dining Assistants play a large part in the 24-hour dining that is offered by Rolling Fields of
Conneautville, Pennsylvania. Rolling Fields explains that in order to “pull off” 24 hour
dining, staff roles had to be changed, every staff member stepped out of their traditional
role and became a caregiver including, “all Staff in our home are certified feeding
assistants; therefore, anyone can sit down and assist an Elder with his/her meal”
(ltlmagazine.com 9/11/09).
Dining Assistants Enhance Quality of Care and Quality of Life
Rolling Fields says that because of their increased selection of food available and because
there is more time for one-on-one interaction with dining, partly due to the DAs, they only
have seven residents remaining on a pureed diet from the 20 to 30 they used to have. They
also state, “quality of life for our Elders has been improved greatly because they now may
choose exactly what and when they want to eat” (2009).
F240 483.15 Quality of Life
It is fitting for our discussion about food, dining, and self-directed living to think about the
requirements of this Tag that states: A facility must care for its residents in a manner and in
an environment that promotes maintenance or enhancement of each resident’s quality of life.
Quality of life is personal to each person, as are food preferences. Facilities are required by
CMS to maintain quality of life, or even better, enhance it for each resident. The facilities’
requirement to promote quality of life begins at this Tag which leads the regulatory section
of Quality of Life and continues throughout the entire section, 483.15 (a) – (h).
Depression and Weight Loss
The results of the study conducted by Simmons et al: “Prevention of Unintentional Weight
Loss in Nursing Home Residents: A Controlled Trial of Feeding Assistance” found that
residents with a diagnosis of depression lost more weight than those without the
depression diagnosis. In fact, studies by Morley and Kraenzle, Morley and Silver and
Simmons, Cadogen and Carbonnera have shown that depression is a major cause of
unintentional weight loss..
In 2006 CMS released the Psychosocial Outcome Severity Guide, which guides surveyors on
how to select the level of severity for any deficiency with a psychosocial outcome or
potential outcome to residents (State Operations Manual, Appendix P). This has helped
bring attention to the severity of psychosocial outcomes that could occur as a result of any
deficient practice.
35
Appendix 3-B
F241 483.15(a) Dignity
The facility must promote care for residents in a manner and in an environment that
maintains or enhances each resident’s dignity and respect in full recognition of his or her
individuality.
CMS issued new guidance to ten tags in July of 2009, Dignity being one of them. These
identified many institutional practices including several dining practices, and asked
facilities to now avoid them. Food served on trays has been identified as institutional, a
remnant of the old hospital-type institution. Staff standing while assisting residents to eat
has been earmarked as undignified as well. Surveyors are now guided to watch for staff
conversing with residents rather than only with each other and to provide any needed
bathroom assistance during meals. And bibs have been identified as undignfied:
Promoting dignity in dining by eliminating such practices as: bibs (also known as clothing
protectors) and instead offering cloth napkins. Bibs were addressed by CMS in the early
1990’s in the guidance to this Tag F241 Dignity. The new guidance again places emphasis
on bibs being undignified.
F242 483.15(b) Self-determination and participation
The resident has the right to:
1) Choose activities, schedules, and health care consistent with his/her interests, assessments
and plans of care;
2) Interact with members of the community both inside and outside the facility; and
3) Make choices about aspects of his or her life that are significant to the resident.
Facilities must be actively seeking preferences, choice over schedules important to the
resident, i.e., waking, eating, bathing, and retiring per CMS’ new guidance.
Even if a person can’t tell us their preferences, caregivers can still actively seek them.
Pertaining to preference, CMS has stated: If resident is unaware of the right to make such
choices determine if the home has actively sought resident preference info and if shared with
caregivers. CMS’ requirement is that the facility go deeper in finding out resident
preferences even if a resident did not tell staff, even if a resident does not realize they have
this right to choice and their preferences should be honored.
Informed Consent
A facility cannot just let people eat what they want and when they want with no oversight
or care about it. Tag F325 addresses the right to make informed choice: Sometimes, a
resident or resident’s representative decides to decline medically relevant dietary restrictions.
In such circumstances, the resident, facility and practitioner collaborate to identify pertinent
alternatives. And stated is that the resident or representative has the right to make
informed choices about accepting or declining care and treatment.
36
Appendix 3-B
F279 483.20(d) Comprehensive Care Plans including Highest Practicable Well-being
The facility must develop a comprehensive care plan for each resident that includes
measurable objectives and timetables to meet a resident’s medical, physical, mental and
psychosocial needs that are identified in the comprehensive assessment.
CMS calls for care plans to be comprehensive. This would include details of food
preferences and choice, food passions and pet peeves, what someone loves to eat and hates
to eat.
Highest Practicable Well-being
F279 continued - The care plan must describe the following:
The services that are to be furnished to attain or maintain the resident’s highest practicable
physical, mental and psychosocial well-being.
Highest practicable means innate capability, based solely on the individual’s abilities,
limitations, and potential, independent of external limitations (CMS Individualized Care
series, 2006). If someone is capable of feeding him or herself, a facility is to do all it can to
assist the person in maintaining this highest practicable level of well-being.
F280 483.10(d)(3) Participate in Planning Care and Treatment
The resident has the right to –- unless adjudged incompetent or otherwise found to be
incapacitated under the laws of the State, participate in planning care and treatment or
changes in care and treatment.
F441 483.65 Infection Control
CMS released new guidance for this requirement, effective July 17, 2009. Many infection
control guidelines having to do with food and dining are included in Tags F325, F371, and
F441:
Note: It is important that all infection prevention and control practices reflect current Centers
for Disease Control and Prevention (CDC) guidelines.
Residents can be exposed to potentially pathogenic organisms in different ways, including but
not limited to the following:
• Improper hand hygiene
• Improper glove use (e.g. utilizing a single pair of gloves for multiple tasks or multiple
residents) and
• Improper food handling.
37
Appendix 3-B
Under Hand Hygiene the following are examples relating most to food and dining:
Hand Hygiene continues to be the primary means of preventing the transmission of
infection. The following is a list of some situations that require hand hygiene:
• Before and after direct resident contact (for which hand hygiene is indicated by
acceptable professional practice);
• Before and after eating or handling food (hand washing with soap and water);
• Before and after assisting a resident with meals (hand washing with soap and
water):
• After removing gloves or aprons.
483.15(h) Environment: Safe, Clean, Comfortable and Homelike – The Short Stay
Experience and Food and Dining
In a facility in which most residents come for a short-term stay, the “good practices” listed in
this section are just as important as in a facility with a majority of long-term care residents.
CMS also states in a Note, under Procedures:
Many residents who are residing in the facility for a short-term stay may not wish to
personalize their rooms nor bring in many belongings
Persons needing a short rehab stay in a nursing home often do not want to be called
residents, they are not moving in and they do expect a medical treatment atmosphere.
However, the “good practices”/institutional features to eliminate listed in the new guidance
are still important. Additionally, all people appreciate choice and the clientele for a short
stays are quite accustomed to exerting choice. Choice in foods and meal times, choice in
whether to go to a dining area or stay and eat in the room, all are choices most people want
to make and are used to making every day.
The Role of the Consultant Pharmacist
Much could be said about medications: how they can alter taste, cause dry mouth, lethargy,
nausea, confusion, etc. which can all affect a person’s eating patterns. Pharmacists enter
into a resident’s food and dining experience in several ways besides their typical role of
reviewing medications and identifying side effects. Pharmacists can affect appetite
stimulation with medications and timing of medications, as well as identify
contraindications of foods with medications. They are charged with reducing number of
medications wherever possible. They affect whether a nutritional supplement might be
used or real food.
Tag 155 483.10 (b)(4) Refusal of treatment
The resident has the right to refuse treatment, to refuse to participate in experimental
research, and to formulate an advance directive.
38
Appendix 3-B
“Treatment” is defined as care provided for purposes of maintaining /restoring health,
improving functional level, or relieving symptoms.
From the interpretive guidelines: The facility should determine exactly what the resident is
refusing and why. To the extent the facility is able, it should address the resident’s concern.
For example, a resident requires physical therapy to learn to walk again to after sustaining a
fractured hip. The resident refuses therapy. The facility is expected to assess the reasons for
this resident’s refusal, clarify and educate the resident as to the consequences of the refusal,
offer alternative treatments, and continue to provide all other services.
If a resident’s refusal of treatment brings about significant change, the facility should reassess
the resident and institute care planning changes. A resident’s refusal of treatment does not
absolve a facility from providing a resident with care that allows him/her to attain or
maintain his/her highest practicable physical, mental and psychosocial well-being in the
context of making that refusal.
Tag 151 483.10 (a)(1) Exercise of Rights
The resident has the right to exercise his or her rights as a resident of the facility and as a
citizen or resident of the United States.
From the interpretive guidelines: The facility must not hamper, compel, treat differentially,
or retaliate against a resident for exercising his/her rights.
39
Appendix 3-B
Chapter Six
Current Survey Processes as they Pertain to Food and Dining
Traditional Survey
The nationwide implementation of the Quality Indicator Survey (QIS) will ultimately make
the traditional survey process obsolete. However, both survey processes are being used
during the transition, which will take several additional years.
New surveyor guidance issued at this time is operative for both survey processes. CMS’ has
issued new guidance at Tag 242 (Self-determination and Participation) regarding actively
seeking resident preferences. This would include resident preferences regarding what they
eat and when they eat. In addition, there is new guidance at Tags F325 (Nutrition) and
F371 (Kitchen Sanitation).
QIS
Within the new QIS process a number of the Pathways, Critical Elements and Interviews
touch on food and dining.
The QIS Dining Observation Pathway (20053 9/09), #9 asks:
9. Are resident’s desires considered when using clothing protectors?
The new revised Dining Observation Pathway (20053 revised 7/31/09) slated to be
released June 2010 does bring up the use of napkins but also still clothing protectors:
Provide napkins and non-disposable cutlery and dishware (including cups and
glasses).
Consider resident’s desires when using clothing protectors.
The Nutrition-Hydration-Tube Feeding Critical Element (20075 6/07) under the
Resident/Representative Interview on page 7 guides surveyors to ask “Whether there are
any concerns regarding…” many things. However, resident food preferences are not
inquired about, although they are under Care Planning.
The Resident Interview and Resident Observation (20050 6/07) includes this question at
B Choices:
Are you able to participate in making decisions regarding food choices/preferences?
Time to go to bed, get up and bathing schedule are reflected. There is no inquiry regarding
preferred times to eat.
The Family Interview (20049 9/08) includes these questions at B Choices:
40
Appendix 3-B
Does the facility honor [resident’s] preferences and previous life routines, such as
when to get up, and go to sleep or when to take a bath?
Does the facility honor [resident’s name] preferences on what he/she eats or
drinks?
Again, there is no question regarding preferred times to eat.
On both the current (20053 9/09) and newly revised (20053 revised 7/31/09) Dining
Observation Pathway, the following question is asked:
16. Does the facility provide meals with no greater than a 14 hour lapse between
the evening meal and breakfast (or 16 hours) with approval of a resident group and
provision of a substantial evening snack?
The new Dining Observation Pathway (20053 revised 7/13/09) slated to be issued June
2010 identifies and recognizes neighborhoods, households and expanded meal hours:
Meal times and dining room locations should be identified while the team
coordinator is conducting the entrance conference. Some nursing homes have
“households” or “neighborhoods” that contain a kitchen and dining room and
provide expanded meal service hours, such as 7-10 a.m. for breakfast, or food
services on a 24-hour basis, seven days a week. Meals may be prepared in the
household/neighborhood or catered in, such as occasionally ordering pizza or takeout food. The purpose of meal services in these settings is to provide the residents
choices for times to eat and sleep, to offer food choices/preferences, and to provide
a more home-like setting.
MDS 2.0
Within the federally required Minimum Data Set assessment in its current 2.0 version, food
and dining are mostly reflected in Section K. Oral/Nutritional Status. One item in that
section states:
K.4.c. Resident leaves 25% or More of Food Uneaten at Most Meals
Recording food intake is technically not required by regulation. Recording food intake is
mentioned by CMS in the guidance for Tag F325 Nutrition, in regards to when there is
insidious or sudden weight loss, in particular by “intensifying observation of intake and
eating patterns.” The MDS requires a 7 day look back period.
According to the MDS Active Resident Information Report: Third Quarter 2009, 34.5% of all
residents nationally leave 25% or more of their food uneaten
(http://www.cms.hhs.gov/MDSPubQIandResRep/04_activeresreport.asp?isSubmitted=res
3&var=K4c&date=28). With so many residents leaving that much food uneaten, questions
41
Appendix 3-B
about the palatability of the food arise. On the other hand, the data also support that it is
not every resident that has this problem. Facilities need to have good systems and policies
in place to ensure recording intake is completed when needed. When intake is recorded, a
good practice identified by Handy is to use printed menus first to mark resident choice and
then to record percentage intake for each item eaten (2009).
MDS 2.0 items can be tracked at MDS Active Resident Information Report at:
http://www.cms.hhs.gov/MDSPubQIandResRep/04_activeresreport.asp.
MDS 3.0
The new version of MDS (MDS 3.0) is scheduled to be implemented in October 2010. The
K.4.c. item is not included in MDS 3.0. In MDS 3.0, the only question about food posed to
the resident is: “While you are at this facility how important to you is…have snacks
available between meals?” Although bedtime preference is asked about, preferences
regarding times to eat and what to eat are not.
42
Appendix 3-B
Chapter Seven
Other Food and Dining Standards
Food and Drug Administration (FDA)
The U.S. Public Health Service (PHS) began its food protection activities at the turn of the
20th century with studies of the role of milk in the spread of disease. These studies found
that effective disease prevention called for comprehensive food sanitation measures from
production to consumption. Model codes began to be developed, the first of which was the
Grade A Pasteurized Milk Ordinance – Recommendations of the PHS/FDA published in 1924.
A new edition of the Food code is developed every 4 years by the FDA. During each 4 year
cycle the FDA may issue supplements to the code if necessary, and those supplements are
incorporated into the next edition. The FDA accepts recommendations for Food Code
modification from any individual or organization, with specific forms and time frames for
submission. The Conference for Food Protection covers retail food issues while there are
conferences specific to milk and shellfish production. The 2005 edition of the Food Code
reflects recommendations made at the 2002 and 2004 Conference for Food Protection. The
FDA has an open and democratic process of state by state delegate votes. And the FDA
“encourages interested individuals to consider raising issues and suggesting solutions
involving the federal-state cooperative programs based on FDA’s model food codes through
these organizations.”
The FDA has 75 state and territorial agencies and more than 3,000 local departments
whose primary responsibility is prevention of foodborne illness and licensure and
inspections of retail food establishments.
Information and history about the FDA were found at the following website:
http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/Food
Code2005/ucm123930.pdf.
The Food Code itself can be found at:
http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2005/d
efault.htm.
The CMS guidance at Tags F371 Kitchen Sanitation and F441 Infection Control are not in
conflict with the FDA model food code.
Centers for Disease Control and Prevention (CDC)
Originally, CDC was named the Communicable Disease Center when it was established in
1946. Descending from the wartime agency “Malaria Control in War Areas,” the CDC
initially focused on fighting malaria by killing mosquitoes. At its beginning, there were
fewer than 400 employees, with the majority being entomologists and engineers. There
were only seven medical officers on staff. The CDC, now called the Centers for Disease
Control and Prevention, celebrated its 60th anniversary in 2006.
43
Appendix 3-B
Today, the CDC is a global leader in public health and leads our nation in health promotion,
prevention, and preparedness. Its public health efforts include prevention and control of
infectious and chronic diseases, injuries, workplace hazards, disabilities, and
environmental health threats. The CDC is globally recognized for conducting research and
investigations and for an action-oriented approach. It works with states and other partners
to provide a health surveillance system to monitor and prevent disease outbreaks including
bioterrorism, implement disease prevention strategies, and maintain national health
statistics. The CDC also guards against international disease transmission with personnel
stationed in more than 25 foreign countries. CDC is one of the 13 agencies of the U.S.
Department of Health and Human Services (DHHS).
CDC guidelines are developed with the help of federal advisory committees. The Federal
Advisory Committee Act (Public Law 92-463) provides a mechanism for experts and
stakeholders to participate in the decision-making process by offering advice and
recommendations to the Federal government as members of advisory committees.
Twenty-four federal advisory committees provide advice and recommendations on a broad
range of public health issues including an advisory committee on healthcare infection
control. That federal advisory committee is called the Healthcare Infection Control
Practices Advisory Committee (HICPAC) and its function is described as follows: “The
Committee shall advise the Centers for Disease Control and Prevention on periodic
updating of existing guidelines, development of new guidelines, guideline evaluation; and
other policy statements regarding the prevention of healthcare-associated infections and
healthcare-related conditions” (www.cdc.gov/hicpac).
The Guideline for Hand Hygiene in Healthcare Settings – 2002, was developed by the CDC's
HICPAC, in collaboration with the Society for Healthcare Epidemiology of America (SHEA),
the Association of Professionals in Infection Control and Epidemiology (APIC), and the
Infectious Disease Society of America (IDSA).
Guidelines currently being developed are: Guidelines for Infection Prevention and Control
in Healthcare Personnel; Guidelines for the Prevention of Intravascular Catheter-Related
Infections; Guideline for the Prevention and Management of Norovirus Gastroenteritis
Outbreaks in Healthcare Settings; and Pediatric Infection Prevention: Gap Summary.
More information regarding the posting of guidelines in development open public comment
periods will be discussed at the HICPAC meetings and posted on the website.
And as is with the FDA Food Code, CMS’ guidance at F371 and F441 also does not conflict
with CDC guidelines.
44
Appendix 3-B
Chapter Eight
Tools and Resources
The Stage Model
The Stages Tool developed by Les Grant and LaVrene Norton is a stage model of culture
change in nursing facilities. This tool assesses the degree of culture change from an
organizational development perspective in four stages: Stage I - Institutional model, Stage
II - Transformational model, Stage III - Neighborhood model and Stage IV - Household
model. It describes the organizational status of Decision Making, Staff Roles, Physical
Environment, Organizational Design and Leadership Practices in each. The tool speaks to
the respective dining practices in each stage (also explained in Chapter Two). The tool is
available at culturechangenow.com. The Culture Change Staging Tool is a web-based
questionnaire that assesses 12 key culture change domains. It determines for a facility,
based on the facility’s responses, what its highest model stage is of the four stages
identified in the Grant and Norton Stages Tool. This tool is available at myinnerview.com.
Artifacts of Culture Change
The Artifacts of Culture Change is a tool designed to capture the concrete changes homes
make that reflect a changed culture, changes in attitude, policies and practices to be more
resident-directed. A full report called Development of the Artifacts of Culture Change
Tool explains the rationale for developing the tool, the point scale, and includes a large
Source Information table. The Source Information gives background for each item, where it
exists around the country, as well as any research found which supports it. The
Development report and the Artifacts tool itself are both available at pioneernetwork.net.
NHRegsPlus
The Hulda B. and Maurice L. Rothschild Foundation provides funding for the NHRegsPlus
searchable website, which contains a repository of State nursing home regulations for each
of the 50 States. It allows the user to search through all 50 States’ requirements per
sections such as dietary services. Most States’ licensure regulations and waiver/variance
process (if there is one), can be accessed directly from the site. The website, housed at the
University of Minnesota, contains a wealth of information and can be accessed at:
http://www.hpm.umn.edu/NHRegsPlus.
45
Appendix 3-B
Chapter Nine
Moving into New Territory
The nursing home setting presents many issues in the areas of food and dining and serving
the individual. The table has now been set for the Creating Home II national symposium
February 11, 2010. We invite you to join us and share what you think. Experts have been
invited to share their experiences. Everyone is invited to come and share their own
wisdom on these subjects at this event. Together we will create a welcomed and needed
national dialogue about what needs to happen next. As Linda Roberts, registered dietitian
and long term care consultant said at her 2009 Pioneer Network session on dining, “we are
in new territory.”
We invite you to pull up a chair to the table. This is the “menu item” of most interest to all
of us: transforming our thinking and our systems to where the person and her/his
individualized preferences are in the forefront.
What will your role be in cutting the paths in this new territory? What will you stand for?
What are you willing to “take on?” Will it be volunteering to speak at a nursing course in
your community? Will it be developing a research study? Will it be taking it on personally
to educate just one physician? Will it be leading a committee in your facility? Thank you
for what you have done, for what you are doing and what you will do.
And let this be what we stand for:
“The life of a nursing home resident…should be as similar as possible
to the life he or she would choose to lead at home”
(Pearson, Hocking, Mott and Riggs, from Journal of Advanced Nursing, 1993).
46
Appendix 3-B
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Appendix 3-B
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Appendix 3-B
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53
Appendix 3-B
Appendix A
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-12-25
Baltimore, Maryland 21244-1850
Center for Medicaid and State Operations/Survey and Certification Group
DATE:
May 29, 2009
TO:
State Survey Agency Directors
FROM:
Director, Survey and Certification Group
SUBJECT:
Food Procurement at 42 CFR 483.35(i)(1)(2), Tag F 371, and Self Determination
and Participation at 42 CFR 483.15, Tag F 242
Memorandum Summary
This memorandum clarifies that:
•
•
•
The language at 42 CFR 483.35(i), Tag F 371 “Procure food from sources
approved or considered satisfactory by Federal, State or local authorities” is
intended solely for the foods procured by the facility. A revision has been made to
the interpretive guidelines at F371 to further clarify this intent;
Foods accepted by residents from visitors, family, friends, or other guests are not
subject to the regulatory requirement at F 371; and
Residents have the right to choose to accept food from visitors, family, friends, or
other guests according to their rights to make choices at §483.15, F 242, Self
Determination and Participation.
The Centers for Medicare & Medicaid Services (CMS) regulation at 42 CFR 483.35, Tag F 371,
states that foods procured by the facility must come from sources approved or considered
satisfactory by Federal, State, or local authorities. The surveyors should use the regulation and
interpretive guidelines at F 371 when determining how the facility acquired food for resident
consumption. This regulatory requirement does not expand beyond the scope of the intent to
monitor how the facility procures food for the nursing home resident population.
The surveyor(s) should not use the food procurement regulatory language at F 371 to monitor
any food(s) provided by visitors, friends, family members, or resident guests which the resident
has chosen to accept. The facility does have a responsibility under the food safety regulatory
language at F371 to help visitors to understand safe food handling practices (such as not holding
or transporting foods containing perishable ingredients at temperatures above 41 degrees F.) and
to ensure that if they are assisting visitors with reheating or other preparation activities, that
facility staff use safe food handling practices and encourage visitors and residents who are
contributing to food preparation in the facility to use these safe practices as well.
54
Appendix 3-B
Page 2 –State Survey Agency Directors
A clarification has been added to F371, which CMS has released as an advance copy along with
revisions to several quality of life and environment tags, with an issuance date of June 17, 2009.
The CMS regulation at §483.15, F242 protects the resident(s) right to choose to accept food from
visitors, family, friends, or other guests (e.g., facility-sponsored activities such as a community
pot luck). This regulation states, “the resident has the right to make choices about his or her life
in the facility that are significant to the resident.”
When the survey team determines that a facility has not allowed a resident or residents to choose
to accept food from any friends, family, visitors or other guests, the team should consult the
regulation and guidance at F 242 to determine if the resident(s) rights have been violated.
For questions regarding this memorandum, please contact Debra Swinton-Spears at (410) 7867506 or e-mail at [email protected].
Effective Date: This clarification is effective immediately. Please ensure that all appropriate staff
are fully informed within 30 days of the date of this memorandum.
Training: This information should be shared with all appropriate survey and certification staff,
surveyors, their managers, and applicable staff.
/s/
Thomas E. Hamilton
cc: Survey and Certification Regional Office Management
55
Appendix 3-B
Appendix B
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-12-25
Baltimore, Maryland 21244-1850
Center for Medicaid and State Operations/Survey and Certification Group
DATE:
December 21, 2006
TO:
State Survey Agency Directors
FROM:
Director, Survey and Certification Group
SUBJECT:
Nursing Home Culture Change Regulatory Compliance Questions and Answers
Memorandum Summary
This memorandum provides the State Survey Agencies and CMS regional offices with:
1. Responses we have made to inquiries concerning compliance with the long-term
care health and life safety code requirements in nursing homes that are changing
their cultures and adopting new practices;
2. Summarizes questions and answers from a June, 2006 CMS Pic-Tel conference with
leaders of the Green House Project (Attachment A); and
3. Provides information about an upcoming series of 4 CMS culture change satellite
webcasts (Attachment B).
Following are regulatory questions that have been sent from culture change organizations from 2004 to
date, along with our answers:
Question 1: Tag F368 (Frequency of Meals): You request a clarification that the regulation language at this
Tag that “each resident receives and the facility provides at least three meals daily” does not require the resident
to actually eat the food for the facility to be in compliance. You also ask for clarification about the regulatory
language specifying that there must be no more than 14 hours between supper and breakfast (or 16 hours if a
resident group agrees and a nourishing snack is provided). You state that some believe this language means all
of the residents must actually eat promptly by the 14th hour, which makes it difficult for the facility to honor a
specific resident’s request to refuse a night snack and then sleep late.
Response 1: The regulation language is in place to prevent facilities from offering less than 3 meals per day
and to prevent facilities from serving supper so early in the afternoon that a significant period
of time elapses until residents receive their next meal. The language was not intended to diminish the right of
any resident to refuse any particular meal or snack, nor to diminish the right of a resident over
their sleeping and waking time. These rights are described at Tag F242, Self-determination and Participation.
You are correct in assuming that the regulation language at F368 means that the facility must be offering meals
and snacks as specified, but that each resident maintains the right to refuse the
food offered. If surveyors encounter a situation in which a resident or residents are refusing snacks routinely,
they would ask the resident(s) the reason for their customary refusal and would continue to investigate this issue
only if the resident(s) complains about the food items provided. If a resident is
56
Appendix 3-B
Page 2 - State Survey Agency Directors
sleeping late and misses breakfast, surveyors would want to know if the facility has anything for the resident to
eat when they awaken (such as continental breakfast items) if they desire any food before lunch time begins.
Question 2: F370 (Approved Food Sources): You ask if the regulatory language at this Tag that the facility
must procure food from approved sources prohibits residents from any of the following: 1) growing their own
garden produce and eating it; 2) eating fish they have caught on a fishing trip; or 3) eating food brought to them
by their own family or friends.
Response 2: The regulatory language at this Tag is in place to prohibit a facility from procuring their food
supply from questionable sources, in order to keep residents safe. It would be problematic if the facility is
serving food to all residents from the sources you list, since the facility would not be able to verify that the food
they are providing is safe. The regulation is not intended to diminish the rights of specific residents to eat food
in any of the circumstances you mention. In those cases, the facility is not procuring food. The residents are
making their own choices to eat what they desire to eat. This would also be the case if a resident ordered a
pizza, attended a ball game and bought a hot dog, or any similar circumstance. The right to make these choices
is also part of the regulatory language at F242, that the resident has the right to, “make choices about aspects of
his or her life in the facility that are important to the resident.” This is a key right that we believe is also an
important contributing factor to a resident’s quality of life.
Question 3: Tag F354 (Registered Nurse): “Can the traditional DON role be shared with several registered
nurses with each nurse responsible for one or more households or clusters?”
Response 3: The interpretive guidelines (i.e., Guidance to Surveyors) already contain this language: “The
facility is required to designate an RN to serve as DON on a full time basis. This requirement can be met when
RNs share the position. If RNs share the DON position, the total hours per week must equal 40. Facility staff
must understand the shared responsibilities.” Thus, the position can be shared; however, a comprehensive set of
duties and responsibilities of a DON is not specified in the regulations or interpretive guidelines. We interpret
this role to encompass not only general supervision of nursing care for the facility, but oversight of nursing
policies and procedures, overall responsibility for hiring/firing of nursing staff, ensuring sufficient nursing staff
(F353), ensuring proficiency of nurse aides (F498), active participation in the quality assurance committee (see
Tag F520), and responsibility to receive and act on communications from the pharmacy consultant about
medication problems (Tags F429 and F430). A facility that desires to have various people share the DON
position would need to consider how these DON duties will be fulfilled in a shared position. As
long as these duties are fulfilled, we would consider the facility in compliance with F354, whether or not the
position is being shared.
Question 4: Tag F521 (Quality Assessment and Assurance): You ask whether the regulatory responsibility
for this committee to “meet” can be fulfilled if the physician member is not physically
present, but is participating through alternate means, “such as conference calls or reading minutes/issues and
giving input.”
Response 4: Yes, participation can be achieved through means of telephone conferencing, however, we do not
accept the alternative of the physician merely reading documents before or after the meeting. We believe the
purpose of these meetings is to provide a forum for discussion of issues and
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plans, which cannot be adequately fulfilled if the physician is merely reading and commenting on documents,
since this does not allow for the interchange of ideas.
Question 5: (HIPAA and Principles of Documentation): You express concern that the Statement of
Deficiencies that surveyors write, which is a publicly posted document, may violate a resident’s right to privacy,
since the details may identify a specific resident to the public.
Response 5: We have received other comments on this issue, and have provided guidance to our State Survey
Agencies and CMS regional offices on our interpretation of this issue in our Survey and Certification (S&C)
memorandum #04-18. All our S&C memoranda are stored on the CMS website for public access at
http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
Question 6 (Handrails): Could the interpretive guidelines explain that handrails are not necessary at the very
ends of the hallways on the very small sides of the door? This would allow for filling these unused areas with
live plants, for instance, without obstructing egress and handrails would still be available up to the end of each
hallway.
Answer 6: The purpose of the handrail requirements at Tag F468 is to assist residents with ambulation and/or
wheelchair navigation. They are a safety device as well as a mobility enhancer for those residents who need
assistance. The survey team onsite would need to observe the responses of residents to the placement of objects
that block the portion of the handrails that is at the end of a hallway. They would also interview residents to
gain their opinion as to whether the objects in question are interfering with their independence in navigating to
the places they wish to go.
Question 7 (Resident Call system): Could the resident call system (F463) regulation that requires calls to be
able to be received at the nurses’ station be changed to also include nurses’ work areas and direct care workers,
as well as the nurses’ stations? Many homes moving away from the institutional model are replacing nurses’
stations with normal kitchens, living room and dining room areas, and using systems whereby resident calls
connect directly to caregivers’ radio/pagers. Because it is harder to change the text of regulation, could the
phrase “at the nurses’ station” be removed from the following sentence in the Interpretive Guidelines: “The
intent of this requirement is that residents, when in their rooms and toilet and bathing areas, have a means to
directly contact staff at the nurses’ station.”
Answer 7: We agree that it is desirable for residents and/or their caregivers or visitors to be able to quickly
contact nursing staff when they need help. To meet the intent of the requirement at F463, it is acceptable to use
a modern pager/telephone system which routes resident calls to caregivers in a specified order in an organized
communication system that fulfills the intent and communication functions of a nurse’s station. We will make a
change in the Interpretive Guideline to reflect this position.
Question 8 (Posting of Survey Results): Would CMS consider adding to the posting requirements at Tag
F156 [42 CFR 483.10(b)(10)], text similar to that stated in Tag F167 about posting of survey results, “...or a
notice of their availability?” Although this may just be trading one posting for several, some homes really want
to create a homey environment without so many postings and many homes are placing postings into a photo
album or binder to minimize the institutional look of so many postings.
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Answer 8: The purpose of the posting requirements at both F156 and F167 is for residents and any other
interested parties to be able to know the information exists, and to easily locate and read the information without
needing to ask for it. What you request above, namely one posting that advises the public of what information is
available to meet requirements of both Tags, is acceptable, as long as the information itself is in public and
easily accessible, such as in a lobby area in a marked (titled) notebook or album. This includes the following
information:
•
“A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups
such as the State survey and certification agency, the State licensure office, the State ombudsman
program, the protection and advocacy network, and the Medicaid fraud control unit;.” (F156)
•
“Written information about how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments covered by such benefits;” (F156) and
•
The facility, “must make the results available for examination in a place readily accessible to residents
and must post a notice of their availability.” (F167)
Question 9 (Hallway Width): Does the 8 feet requirement (at LSC Tag K39) continue to be necessary since
evacuations are no longer done via wheeling a person out of the building in a bed? Could 6 feet meet the
requirement? If 6 feet sufficed, this would again refer back to our question regarding the requirement for
handrails when something else such as a bench might take up the other 2 feet.
Answer 9: The 8 foot corridor width is a requirement of the Life Safety Code (LSC). Corridors remain a route
to use in internal movement of residents in an emergency situation to areas of safety in different parts of the
facility. This movement may be by beds, gurney or other methods which may require the full width of the
corridor. We do not believe it would be in the best interests of the residents to reduce the level of safety in a
facility.
Question 10 (Tag K72 and Exits): In regard to LSC Tag K72 (no furnishings, decorations, or other objects are
placed to obstruct exits or visibility of exits), can secured unit doors be disguised or masked with murals, etc.?
Staff typically will be the ones to use these doors in the case of emergency and will know where they are. By
disguising exit doors, resident anxiety of wanting to go out them may decrease.
Answer 10: The life safety code allows some coverings on doors, but not concealment. The code also
specifically forbids the use of mirrors on a door. It is a judgment call by the survey team as to what would be
considered concealment of the door, but in general the door must still be recognizable
by a non-impaired person (such as a visitor). The code does not allow the removal or concealment of exit signs,
door handles, or door opening hardware.
Question 11 (Dining Together): Is it permissible for staff and residents to dine together?
Answer 11: There is no federal requirement that prohibits this. We applaud efforts of facilities to make the
dining experience less institutional and more like home. Our concern would be for the facility to make sure that
residents who need assistance receive it in a timely fashion (not making residents wait to be assisted until staff
finish their meals).
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Question 14 (Candles): Can candles be used in nursing homes under supervision, in sprinklered facilities.
Answer 14: Regarding the request to use candles in sprinklered facilities under staff supervision, National Fire
Protection Association data shows candles to be the number one cause of fires in dwellings. Candles cannot be
used in resident rooms, but may be used in other locations where they are placed in a substantial candle holder
and supervised at all times while they are lighted. Lighted candles are not to be handled by residents due to the
risk of fire and burns. If you would like to discuss this issue, you may contact James Merrill at 410-786-6998,
or via email at [email protected].
Question 15 (Tablecloths): Are cloth tablecloths and napkins permissible in nursing homes?
Answer 15: There is no regulation that prohibits it and, in fact, the use of these items is greatly preferable to the
use of bibs, as bibs can detract from the homelike attractiveness of the dining room setting.
Beginning November 3, 2006, (see attached) CMS is broadcasting a 4-part series on culture change
through fiscal year 2007. Three of the broadcasts, produced by the Quality Improvement Organizations
(QIOs), will highlight culture change principles and outcomes from the QIO scope of work. The other
broadcast, produced by CMS, will explore changes being made to medical and nursing care practices and
policies in terms of compliance and the survey process.
We are including information on the series for your convenience. We believe this broadcast series will be
of interest to providers and other stakeholders, as well as State Survey Agencies. We encourage States,
CMS regional offices, and QIOs to consider setting up joint viewing opportunities for survey personnel,
stakeholders, and nursing home staff when possible. As with all CMS broadcasts, these broadcasts may
be viewed either live via satellite or internet, or via internet for a year after each broadcast.
For questions concerning this memorandum, please contact Karen Schoeneman at
(410) 786-6855 or via e-mail at [email protected].
Effective Date: Immediately. Please ensure that all appropriate staff are fully informed within 30 days
of the date of this memorandum, and disseminate the information to affected providers.
Training: The information contained in this announcement should be shared with all nursing home
surveyors and supervisors.
/s/
Thomas E. Hamilton
Attachment
cc: Survey and Certification Regional Office Management (G-5)
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Appendix 3-B
National Long-term Care Life Safety Task Force
Summary of Proposals Approved by NFPA
Prepared by Amy Carpenter, Task Force Member
Cooking:
Kitchens will be permitted to be open to other spaces, and the corridor, as long
as they meet all of the following criteria:
May use either residential or commercial stoves or cooktops
The kitchen cannot serve more than 30 residents
The kitchen must be within a smoke compartment and must only serve
residents in that smoke compartment. However, if you have a building that has
multiple smoke compartments, each one may have an open kitchen.
The smoke compartment where the kitchen is located, whether new or
existing building, must be fully sprinkled.
A range hood must be provided with a fire suppression system, grease
clean-out capability and a 500 cfm fan. You can get all of this in a hood
manufactured by “Cooksafe”, or combine a higher end residential hood with a UL
300a fire suppression system.
Hoods may be vented to the exterior or re-circulating but do not need to
meet full commercial hood requirements.
Local smoke alarms that are not tied into the fire alarm system may be
provided in the area of the open kitchen.
Seating in corridors:
Furniture may be provided in corridors when they meet all of the following
criteria:
Appendix 3-C
Furniture must be attached to the wall or floor to prevent it from migrating
into the required hallway clearance or moving from its intended location. This
can be achieved with a simple metal bracket that is screwed to the legs of the
chair and to the floor. The bracket could be easily removed for cleaning and
maintenance purposes.
Furniture in the corridor may not reduce the clear width of the corridor to less
than 6 feet. That means if you have an 8ft corridor, you can have a maximum
chair depth of 2 ft. If you have a 12 ft corridor, you could have up to 6 ft of
furniture depth.
Furniture must be located only on one side of the corridor. This will allow
residents to navigate the hallway continuously without having to weave back and
forth across the hallway to get around seating areas. This also helps emergency
responders.
There are limits to how long a seating area can be and how far apart they
must be spaced but these are all very generous.
The building must be sprinkled and must have smoke detectors in the
corridors.
Decorations:
Combustible decorations will be permitted in resident rooms, corridors, on doors,
and in common space. There are limitations on the percentage of coverage
depending on whether the building is sprinklered and where located.
Fireplaces:
This proposal will allow gas or electric fireplaces to be used in smoke
compartments that contain sleeping rooms, but not within individual sleeping
rooms. Some of the restrictions are that the controls must be locked and a
sealed glass front must be provided to prevent anyone from throwing object into
the flames.
Appendix 3-C