All long term care Dietitian’s will at some point go through the State Surveys process. It feels like an interrogation at certain points, but Stefanie Wilkerson, RD, who IS a state surveyor is here to ease your worries!
Stefanie Wilkerson has been a Registered Dietitian for 28 years, she has had an exciting career path from being a Clinical Dietitian in Long Term Care to running her own consulting with the State of Texas surveying!
Stefanie walks Clinical Dietitians through the State Survey process in this article and directs you to resources where you can get expert guidance to ace your state survey!
You can also check out another interview we did with State Surveyor, Rachel Landmark, RD, who had great tips as well!
Be a State Surveys Ready RDN – The Course!
First I want to take this opportunity to talk a little bit about the course that Stefanie developed to help Clinical Dietitians working in Long Term Care be prepared for State Surveys.
Stefanie developed the course called, ‘Be a State Survey Ready RDN!’, and I cannot recommend this course enough!
Stefanie has developed a comprehensive course that will help you:
1. Gain confidence that you’re ready for the state survey
2. The recorded videos will allow Stefanie to guide you through what she has seen go wrong with Dietitians in long term care
3. Teach you how to avoid getting an F-Tag in clinical nutrition
4. Teach you the terminology that you need to know for clinical nutrition
& You get 24.5 CEU’s for her course!
If you want to check out more information about her course, she has a short video that you can watch, and you can purchase the course by clicking here!
And BONUS – It’s ON SALE right now!
The second thing I want to cover just before we dive into Stefanie’s answers is the eBook that I’ve developed for being a State Surveys ready Dietitian!
Be State Surveys Ready Dietitian – The Pocket Guide
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!
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 Stefanie has to say!
State Surveys Questions From Dietitians
Personal Questions:
- How long have you been a Dietitian, and what made you get into the field?
I’ve been an RD for 28 years. When I was a teenager I went to a class at my gym that an RD was hosting and I was fascinated by her and Ive been interested in nutrition and fitness since then. - Tell me a little bit about your career path and how you ended up being a State Surveyor.
I started off in the hospital and loved it. I left there and went to work as an employee in a large nursing home as I have always loved the geriatric population and it was paying significantly more money than the hospital.
I was then offered a job as a Nutritionist Surveyor with the state of Texas and ended up accepting that position. I loved that job and I had no plans on leaving it as i loved what I did there and also the benefits of a government job.
My husband and I had toddler twins at the time and although I was very happy in my job but I longed to be home more and we were also financially not in the best position.
It was then I felt the Lord leading me to go out on my own and start doing consulting work for long term care facilities as their dietitian. With my husband’s encouragement and an RD friend who gave me some good leads I made the transition and had a full load within 1 month of leaving the state.
I started out on my own and having many contacts in the area from being a surveyor it wasn’t long before I had more facilities than I could manage myself. It was at this point I decided to expand and bring on dietitians to subcontract with the facilities and I have been doing this ever since.
If you want to be a State Surveyor keep an eye out for postings in your area. They have an in-depth hiring process and it can take some time but it is a rewarding and highly trained position where you will gain invaluable knowledge. - What advice do you have for Dietitians just starting out in their careers in long term care?
In long-term care there is a definite learning curve. It can be hard to start out in LTC as often you are by yourself and the only RD in the facilities. There are definite things that need to be done in LTC so be sure to familiarize yourself with the rules and regulations that govern LTC facilities.
Join FB groups to gain insight and knowledge from other dietitians in the same area of practice, join your area dietitian group to have support and help you from feeling alone.
State Surveys Questions:
- What specific areas related to Nutrition will be audited?
There are numerous areas related to nutrition that can be looked at:
Acceptable parameters of nutritional status
Weight losses and gains
Hydration status, wounds
Enteral feedings
Parental feedings, and
Infection control are some of the areas - How frequently are state surveys conducted and what is the typical duration of the audit?
The annual survey (otherwise called Full Book) is completed annually. They can come anywhere between 9-15 months after their last annual survey. Surveyors also can come in to investigate complaints and facility reported incidences-this can occur at any time. - Can you provide any guidance on how to ensure that a facility is in compliance with state regulations related to nutrition?
This is a very in-depth topic as there are numerous items that need to be in place to ensure compliance.
I highly recommend that RDs obtain a copy of the Federal Regulations and become familiar with them, along with the State Operations Manual (SOM). Also it’s important to be aware of your state requirements as deficiencies can be cited on failure to comply with state policies as well.
You can find the Federal Regulations by clicking here. You will need to look up your State specific regulations. - Are there any new regulations related to nutrition that we should be aware of?
CMS announces when updates or changes in regulations occur and there is usually a time delay on these to give the facility adequate time to implement any changes that need to be made.
You can find the updates and changes to CMS regulations by clicking here. This is updated when changes are made, you can check back frequently if you have concerns. - Can you provide any insight into common nutrition deficiencies that you have observed?
Acceptable parameters of nutritional status is a common deficiency. This is cited when the facility was deemed to have allowed a weight loss to occur that was determined to be avoidable. The RD assessments/notes can definitely come into play here.
In my course I give numerous examples of deficiencies I wrote as a surveyor and what lead to the citations. It’s often not that a weight loss necessarily occurred but the events surrounding the weight loss or what was done, or not done, once identified.
There are best practices surrounding what steps should be done when a weigh loss occurs such as obtaining a reweigh, notifying the MD, RD, and responsible party, identifying factors that could have contributed, putting appropriate interventions into place etc, all of these have time frames associated with them also.
Failure to perform these essential tasks can allow this deficiency to be cited. Also things such as did the resident receive assistance with feeding if needed, are supplements given as ordered and at the appropriate times, did the RD make timely interventions and assess the resident’s nutritional needs, was the care plan being followed, etc. - Are there any specific documentation requirements related to nutrition that we should be aware of?
Yes! I cover this extensively in my course on “Be A Survey Ready RDN”.
All high risk residents need to be documented on appropriately and in accordance with facility policy. All residents must have at least an annual assessment done and an estimation of nutritional needs included in that assessment. New admissions need to be assessed within appropriate time frames also. - Can you provide any guidance on how to ensure that staff are properly trained and educated on nutrition related regulations and best practices?
As the RD you are required to work with/provide consultation to the dietary manager, during these visits you can discuss any concerns and possible inservices that need to be conducted.
One way to ensure staff is properly trained is by doing kitchen sanitation audits and tray line audits This allows you to see any areas that need to be addressed and where education needs to be provided. I have found these audits/observations to be invaluable and it definitely helps to identify areas that need to be improved. - Can you provide any guidance on how to ensure that residents’ dietary needs and preferences are being met?
There are various ways this can be accomplished!
Making rounds during meal times is one of the best ways in my opinion. Observing residents and talking to them provides knowledge you may otherwise miss out on.
One example that I have seen is a resident may have been identified with weight loss, when reviewing their PO Intake you see that they are recorded as eating 75% at most meals. During your observation of them during meals you notice that much of the food actually ends up on the floor due to some difficulty with self-feeding.
Conducting tray line audits is another.
I find many times that when I check scoop sizes etc they are not in compliance with what is listed on the menu to be served, thereby not providing the resident with adequate nutrition. This can also go along with a tag being written as to how weight loss was determined to be avoidable.
This is common with pureed foods in my experience. I haven seen many times also where a food item such as the pureed bread is not served. I wrote weigh loss deficiencies on this by calculating the amount of calories the resident was not served and how that can attribute to a weight loss.
Conducting dining room observations is another, are residents being served in accordance to what is listed on their tray cards as preferences, are they being assisted as needed, is adaptive equipment being utilized, etc. - How are complaints related to nutrition handled during a state surveys audit?
This varies based on the exact nature of the complaint. Depending on what the complaint is they can do a kitchen inspection, dining room observations, review weights for the past 6 months, review RD notes, ask to interview the RD, etc. - Can you provide guidance on how to ensure that a facility is properly equipped to handle special dietary needs and allergies?
Be sure to have an updated copy of the diet manual that can be accessed by all staff, not one that is locked up in an office that staff cannot access. Be sure to have therapeutic diet spreadsheets available for each diet you have at the facility. - How are residents rights related to nutrition assessed during a state surveys audit?
Very in-depth! Some questions we look at are:
Are foods being taken off of the tray?
Are divided plates not being used for pureed foods unless deemed to be appropriate to assist with self-feeding?
Are proper utensils being provided?
Are food preferences being honored?
Are all residents at one table being served together and within an appropriate time frame?
Are staff sitting down when assisting residents with feeding are staff talking to one another instead of to the residents?
Are the noise levels being controlled?
Are meds not being served at meal time if at all possible?
Doing meal time audits as a Dietitian is essential, as you can catch errors being made prior to a survey being done. - Can you tell us how to ensure that food service and dining areas are in compliance with state regulations?
This is covered extensively in my course also and is an area that is looked at on every annual survey.
There are many things that are looked at during the kitchen inspection and it is important to be very familiar with this as it always a focus during full book surveys. I would definitely suggest looking at the LTC pathway for these areas.
You can find the Nutrition Critical Elements Pathway from CMS by clicking here. - How does a facility ensure that they are providing adequate hydration for all residents?
Be very familiar with the Hydration Critical Element Pathway, CMS form 20092.
This is a very important element that surveyors will look for. Again observations here are crucial.
When making rounds see if water/fluids are available at beside, are fluids being served at meal times, are there a variety of fluids offered and at least 2-3 being offered.
Do you observe any signs of dehydration in your residents such as sunken eyes, constipation, poor skin tugor, etc, be sure to review labs…are these areas being addressed and care planned appropriately?
Thanks to Stefanie Wilkerson for answering some great Dietitian questions to be State Surveys ready!
Again, if you missed it, you can find out more about Stefanie’s course for you to be a State Surveys Ready RDN by clicking here!
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.
