Breaking Down the State Survey Process

Finally!  The blog everyone has been waiting for! The interview with Rachel L., she is a Registered Dietitian and a State Surveyor!  She is here to break down all the questions you had about a state survey, and give amazing advice to ease the stress!

State surveys are a real source of stress for long term care Dietitians.  A common theme I noticed from the line of questions was, how to avoid an Ftag when a patient won’t respond to nutrition interventions?

The answer is always document-document-document!  Due to the type of patients that we have, it’s inevitable that some patients simply will not respond to nutrition interventions.  All of our patients will eventually be at the end of life, and we know nutrition interventions can’t reverse the dying process.  (If you need to know more, read this blog).

The state survey shouldn’t be an overwhelming source of stress for you.  If you know what state surveys are going to be looking at for Dietitians, you should be prepared all year.  I mean that in a very complimentary (and stress reducing) way!  

The Pocket Guide for Clinical Dietitians: What Do YOU Need to Know!

We have developed a tool that walks you step-by-step through the survey process for Dietitians.  The Pocket Guide for Dietitians Prepping for State Surveys!
This pocket guide can not only help you if you go through State Surveys, but it can also help you no matter what country you practice in!

I walk you step-by-step through:

1. Exactly what a Clinical Dietitians requirements are
2. What are your responsibilities for documenting on each patient
3. What patients are considered High Risk that you NEED to follow up on
4. How often you NEED to follow your High Risk patients
5. How to avoid being cited for improper Dietitian practice
6. Common failures of Dietitians & how to avoid them
7. Guidelines to follow daily and all year that will make your practice so much easier
& much more!

Pocket Guide for Dietitians Prepping for State Surveys
The New Pocket Guide!

We take the survey process and translate it into plain English and it is easy to understand, so you don’t have to spend weeks reading through all the guidelines! 

Buy it now in our shop by clicking here!

Okay, now it’s time to hear what Rachel has to say!

Interview with Rachel L, Nursing Home State Surveyor

  1. Can you tell me about your path to become a Dietitian (What made you want to pursue it?), and how has your career path gone?

Food has always been an important part of my life. My very first job was working as a prep cook for a local bistro. I loved being able to work with unique ingredients to put together a delicious dish. I knew that I wanted to work in the food industry, but I wanted to do more. 

My high school friends and I were watching a documentary about McDonald’s and how they create new menu items (as one does with your high school besties!), and the documentary mentioned their team of corporate chefs and dietitians working together to come up with the next big thing on the McDonald’s menu. My FAVORITE fast-food place is McDonald’s, so I was intrigued. 

I researched about how to become a dietitian, and luckily my first college pick had a dietetics program! I attended South Dakota State University and graduated with a Bachelor of Science in Dietetics with Minors in Biology and Chemistry, and thank GOD I got matched at my #1 choice for a combined Master’s program and internship! I graduated from Concordia College in 2020. 

I developed an absolute passion for geriatric nutrition and advocating for our elder’s health and wellbeing. I accepted a full-time position as the clinical RD at a psychiatric rehab hospital. I worked with each unit within the hospital – from adolescent behavioral health to their geriatric program.

I was fortunate enough to experience all aspects of dietetics – everything from clinical, to community, to foodservice management. This position provided me with the opportunity to hone-in my skills and interests in the field of nutrition, and I am grateful for the experiences that I had.

  1. How did you find out about becoming a surveyor?

My long-term goal was to move closer to my family in Sioux Falls. So, when the opportunity arose, the first link that popped up on my Indeed search was the Health Facilities Surveyor position with the South Dakota Department of Health. The DOH was specifically looking to add dietitians, social workers, and LPNs to their team. I decided to try and apply. 

Lo and behold, I made it through the interview process and was hired!

  1. What made you want to pursue being a surveyor?

Several of my family members are residents in long term care facilities, and it always pained me when they would bring up some concerns about their situation – many food complaints, feeling stranded when they needed help and had to wait a long time for someone to come assist, the works. 

I knew that if this was happening to my family members, what was happening to others? I felt the deep desire to step up and help protect my family members and their peers. 

Our elders deserve the best, and I wanted to make sure they were receiving the best.

Questions From Dietitians About State Surveys

  1. What is the most important thing a Dietitian can do to prepare for an upcoming survey?  (Months/weeks in advance or daily practice to make themselves prepared)

The #1 best practice is to document, document, DOCUMENT! My favorite saying is: “If it isn’t documented, it’s like it never happened!” 

Be sure to have a good tracking system in place for wounds, weight notes, and the progress of nutrition interventions. Be an advocate for your residents and your profession and demand a seat at the table!

Be sure to check out the Critical Element Pathways (CEP) that CMS has published on their website. These pathways are what surveyors use to help guide their investigations. Check out the following CEPs: Nutrition (CMS-20075), Pressure Ulcer/Injury (CMS-20078), Hydration (CMS-20092), Tube Feeding (CMS-20093), Dining (CMS-20053), and Kitchen Observation (CMS-20055). These CEPs may help you develop auditing systems to prepare for surveys.

You will never know when you will be surveyed. All surveys are random and unannounced. Best practice is to have the leadership team develop and implement their own audits.

  • Request to be involved with your facility’s QAA/QAPI committee.
  • Assist the dietary managers with developing and implementing the following:
    • Kitchen cleaning schedules.
    • Diet order audits.
    • Meal assembly audits. Make sure the correct serving sizes are being served!
    • Dining audits. Which residents may need additional assistance with eating? Do you notice anyone coughing, choking, or pocketing their food during meals? (Looking for when SLP needs to be consulted) Are some residents not eating certain food groups?
  • Make sure to gather the data, interpret the data, and implement interventions geared towards improvement. That’s essentially what a plan of correction is!

While it may seem like a huge undertaking to take charge on these quality improvement measures, the time and effort put in is worth it because you’re helping to provide your residents with the best quality of life.

  1. Regarding CDMs: If someone is not a certified CDM, are they allowed to chart (MDS, data collection tools, etc.)?  To give some context to the question, some states do not have CDM’s or they don’t have the education to call themselves a ‘CDM’, yet they are still doing all the same tasks.  Many have gone back and forth on whether this is ‘okay’ or not.  Some facilities have been told that unless someone is a CDM, they cannot do data analysis or MDS.  Which is the correct practice?

According to Appendix PP of the State Operations Manual:

“F801

(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who—

(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is:

(A) A certified dietary manager; or

(B) A certified food service manager; or

(C) Has similar national certification for food service management and safety from a national certifying body; or

D) Has an associate’s or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and

(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and

(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.”

In other words, follow your state’s statutes and regulations regarding CDM vs. CFM vs. CFSM, etc. For example, the Administrative Rule of South Dakota (ARSD) 44:73:07:11 states, “A full time dietary manager who is responsible to the administrator shall direct the dietetic services. Any dietary manager that has not completed a Dietary Manager’s course, approved by the Association of Nutrition & Foodservice Professionals, shall enroll in a course within 90 days of the hire date and complete the course within 18 months.” In other words, South Dakota requires a dietary manager to complete coursework and certification from the ANFP – which happens to be the Certified Dietary Manager, Certified Food Protection Professional credentials (CDM, CFPP).

HOWEVER! Because of the ongoing public health emergency, a blanket waiver is in place to ease up on the requirements for dietary managers in long term care settings. The current waiver states: “The specified requirements involve specialized education or training in food service management and safety resulting in an associate’s or higher degree in hospitality or food service management, a bachelor’s or higher degree granted by a regionally accredited college or university in the United States, a certified dietary manager, or a certified food service manager. These educational and training requirements range in length, at a minimum, of 18 months to four years. It has been unusually challenging for these requirements to be met due to the COVID-19 Public Health Emergency (PHE). Therefore, CMS is waiving this requirement due to the inability for individuals to enroll in, attend, or complete a certification program due to circumstances related to the COVID-19 PHE.” Essentially meaning that those in the dietary manager role currently do not need to have the formal education normally required to be in that role. The waiver will not last forever, and I suspect that as CMS is rolling back on parts of the waiver, the education requirements for dietary managers will go back into place.

  1. If a CDM is in the building, how many hours does a Dietitian have to be there in a month?  Or is there no set number.

According to Appendix PP of the State Operations Manual:

“F801

(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.60(a) Staffing

The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e)

This includes: §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis.”

Look into your state’s rules and regulations as well. For example, ARSD 44:73:07:11 states, “If the dietary manager is not a dietitian, the facility shall schedule dietitian consultations onsite at least monthly.”

  1. Do you have any tips to aid in preventing a citation when there has been a resident complaint about the meals?  In this particular question, the Dietitian had lots of documentation about audits they perform for quality, resident council meeting minutes that they addressed the issue, residents can pick what they want for holiday meals, etc.  But they still have some residents that will nitpick on particular meals they don’t like.  How can they avoid a citation by not being able to address someone’s exact likes/dislikes at every meal?

What we look for is good faith efforts to accommodate the resident’s preferences. Is there only one menu choice, or can residents choose an alternative meal choice? Such as an always available menu? Has the resident been educated on alternative meal choices? 

Or, if the resident chose the main menu meal, finds out they do not like it, and ask for something else, what is the facility’s policy on providing alternates? Does the resident know that they have the option to choose something else? Is it documented that the resident refused the meal and then was offered something different? What was the resident’s response? 

These are the types of questions surveyors will ask when investigating food choices and quality issues. 

Good documentation is key!

  1. What are your thoughts on whether corrugated cardboard boxes being allowed in a kitchen?  Some use them for storage, as transferring to a plastic bin is a significant amount of staff time + they need to sanitize them constantly.  Is it acceptable to have corrugated cardboard boxes used for storage?

Using cardboard boxes is perfectly acceptable. 

Remember, the dietary department itself must be maintained in a clean and sanitary manner, it does not have to be sterile. If your food and produce is delivered in cardboard boxes, you must make sure that the boxes themselves are visibly clean and intact. 

For example, if you notice that a case of condiments has been stained with a condiment sachet that burst, you should discard the cardboard box and store the condiments in a different container. 

Or, if you notice that a box of produce has mold growing on the outside of the box, discard the box and check the overall temperature and humidity of your cooler. Make sure to document any maintenance requests.

  1. Situational Question: A resident continues to lose weight month after month, nutrition interventions by the RD have been exhausted and they are not working any longer to prevent weight loss.  The reason for weight loss is unspecified (it could be associated with aging/general decline).  How does the RD document and work to not get a citation/tag?

Document the weight trends, % meal intakes, % supplement intakes. Perhaps conduct a dining observation to determine if the resident requires additional assistance to eat. 

Document what interventions have been tried and the resident’s overall response – both weight response and if they like the specific intervention or not. 

Ask the resident or their representative what their goals are. Does the resident want to stop weight loss? Is the resident at the point in their life where they are accepting of their current condition? 

Look at the resident’s advanced directives – if oral intake is not meeting their caloric needs, are they open to try enteral or parenteral nutrition? 

Remember, sometimes weight loss and deconditioning are unavoidable. Just remember to always practice thorough documentation.

  1. What are some tips and areas that a Dietitian can look at when auditing the kitchen to avoid citations?  Should they be looking at specific safety issues, sanitation issues, staffing issues, etc.

Review at the Kitchen Observation Critical Element Pathway (CMS-20055). This pathway goes through probing questions about kitchen safety, sanitation, and staffing. It’s a useful tool to amp up your audit process. 

Always ask yourself – what is the resident outcome? I ask myself this question constantly when determining sufficient staffing. Sure, it may seem like a kitchen may be understaffed, but you must look at the outcomes. Are meals served late? Are you running out of food? Are there increased complaints of food quality? Such as, temperatures, textures, taste. Is there increased weight loss? 

If the answer is yes, then this could be cause for a sufficient staffing citation.

  1.  Can you tell us about the career track to become a surveyor?

The training process to become a surveyor is not for the faint of heart. 

CMS developed a rigorous training program, starting with reading the regulations, completing online learning modules, and developing on-the-job skills by going out on surveys and focusing on learning the various tasks. 

With each survey, I was assigned a preceptor that guided me through the survey process – screening residents, identifying areas of concern, investigating the concerns by conducting interviews with residents, their family, staff members, and the facility’s leadership team, and completing other survey activities (emergency preparedness, medication pass, QAA/QAPI, sufficient staffing, kitchen observation, infection control, etc.). 

Once the new surveyor feels confident enough, they take the Surveyor Minimum Qualifications Test to survey LTC facilities without the need of a preceptor. I just passed my SMQT recently! I am still in the training process, however. For me to survey independently, I will need to show that I am competent in each survey area. 

Competency is determined through preceptor evaluations following each survey. When I started, I was told that it takes about 6 months for training, 1 year to know what you’re doing, and 2-3 years to really feel comfortable and confident in the survey process.

  1.  In relation to IDDSI diet textures being implemented: Are the surveys up to date with IDDSI standards?

There are no specific regulations currently to address IDDSI. During the survey process, we look at what the facility’s specific policies are, and if the policies are being followed. 

  1.  Is a facility allowed to buy food at a grocery store instead of order in from a supplier if the census is quite low?

Yes, facilities may buy food from an approved source. Check with your state’s laws on what food grade is acceptable.

  1.  Do you have a list of general questions that you ask Dietitian’s that can help them prepare?

Generally, when we request to interview the dietitian, the questions will be specifically geared towards a situation we are investigating. Be sure to know your residents and explain your process/reasoning for specific interventions.

  1.  For facilities with staffing issues due to COVID and hiring, is it acceptable for them to use disposable dishes without being cited?

Using disposable dishes should not be the norm. It is acceptable to use disposable dishware on rare occasions, however you should be able to provide appropriate reasoning for using disposable dishware.

  1.  How should a nutrition care plan look in MDS to be comprehensive?

In my opinion, the nutrition care plan is not accurately represented based on the MDS data. You can be more descriptive in the CAA, however. 

When writing the nutrition portion in a resident’s care plan, always bring it back to person-centered care. Don’t just write down their diet order, supplements, and textures. 

Write down their likes, dislikes, any religious accommodations. Maybe the resident likes to sleep in, so you provide a “brunch-like” mid-morning snack. Write that in the care plan! 

Maybe the resident suddenly HATES chocolate, even though they have enjoyed chocolate in the past. Write it in the care plan! The more personal the care plan, the better someone can care for that resident.

  1.  As a surveyor what specific documentation are you looking for in the resident’s medical record to ensure regulatory compliance and liability avoidance of liberalizing textured diets for quality of life?

We look for documentation from the RNs, physician, SLP, RD, as well as input from the resident and/or their representatives. If the resident can make their own healthcare decisions, then the resident must be educated on the risks of liberalizing the textured diets. 

The education must be documented in their chart. If the resident cannot make their own healthcare decisions, then their representative must be educated, and they must give consent. 

As always, document everything!

  1.  From a regulatory standpoint whose credentials/SOP are used for liberalizing texture and educating on the risks of doing so. 

The ultimate decision to liberalize diets must be up to the resident and/or their representative. The order must be signed by the physician. Education on the risks of diet liberalization does not have to come from a specific credential – although a SLP or RD may be more knowledgeable in this area.

Closing Thoughts

Thank you SO much to Rachel for being open to giving some amazing advice to us about state surveys!

I hope that you feel far more confident in going through a State Survey.  Remember, if you document all year long, you won’t need to panic when an unannounced visit happens. 

If you have any more questions, you can send an email, or ask in the Long Term Care RD Facebook group!

Lastly, don’t forget to check out our Pocket Guide to help walk you through State Surveys here!

The Pocket Guide for Dietitians Prepping for State Surveys

Michelle

Website | + posts

Michelle Saari is a Registered Dietitian based in Canada. She has a Master's Degree in Human Nutritional Sciences and is a passionate advocate for spreading easy to understand, reliable, and trustworthy nutrition information. She is currently a full time online entrepreneur with two nutrition focused websites.

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