Changes on the Horizon for the MDS 3.0

February 22nd, 2012

By:  Cyndi Guveiyian RD, LD

Effective April 1, 2012, The Centers for Medicare and Medicaid Services (CMS) plans to implement extensive changes to the MDS  3.0.   Swallowing/Nutrition Status, Section K of the MDS 3.0 will be affected in this latest round of revisions.  Are you familiar with the upcoming changes?

Here is a brief overview of the changes:

Section K0310. Weight Gain has been added. Or should I say…. addressing weight gain is back again? For those of us that have been around long enough to remember the MDS 2.0 Section K, weight gain used to be included in Section K.  After several revisions, it was eventually removed and now weight gain is back!  In this latest version of the MDS 3.0 Section K, this item compares the resident’s weight in the current observation period with his or her weight at two snapshot periods (at a point closest to 30 days and 180 days preceding the current weight).

The individual completing this section is instructed to:

  1. Code 0, if the resident has not experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, or
    information about the prior weight is not available.
  2. Code 1, yes, on a physician-prescribed weight-gain regimen with a weight gain of 5% or more in the past 30 days or 10%
    or more in the last 180 days, and the weight gain was planned and pursuant to a physician’s order.
  3. Code 2, yes, not on physician-prescribed weight gain regimen if the weight gain was experienced in the timeframes listed above
    and the weight gain was not planned and prescribed by a physician.

Section K0510. Nutritional Approaches has been revised.  Items such as Parenteral/IV Feeding, Feeding Tube, Mechanically Altered Diet, Therapeutic Diet and None of the above remain as in the previous version of this section. However, in the April 2012 version, there are two columns adjacent to the nutritional approaches entitled “While NOT a resident” and “ While a resident”.  The individual completing the Section K will now be required to check all the nutritional approaches that were performed prior  to admission/entry or reentry to the facility and within the 7 day look-back-period.  All nutritional approaches performed after the admission/entry or reentry to the facility and within the 7 day look-back-period.  The format of distinguishing approaches administered while the resident was not a resident of the facility and while a resident was a resident of the facility in the 7 day look-back-period is consistent with other sections of the MDS 3.0 ( e.g., Section O Special Treatments, Procedures and Programs).

For more information, CMS has posted a YouTube video ( see web address below) to further explain the April 2012 changes of the MDS 3.0 Section K.  What do you think of the changes? Post a comment on the DSI blog!

 

Resources:

http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp (accessed 2.22.2012)   The download of RAI Manual and YouTube tutorial is available at the web address listed.

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Don’t Worry, Be Happy!

January 4th, 2012

By: Cyndi Guveiyian RD, LD

It’s that time of year again….time to make a New Year’s Resolution-right?  The tradition of making New Year’s Resolutions dates back to Ancient Babylon and Rome.  Nowadays, we make New Year’s Resolutions to enhance aspects of our lives for the months to come.  So what if almost a quarter of people give up on their resolutions in the first week and by the end of March over half have abandoned their resolutions?  It’s a tradition and most partake in it even if the odds are we will not carry through with our best intentions.

I have to admit that for years I have not made any proclamations of what I plan to do differently in the coming year.  Instead, I have used the day by day approach rather than global statements.  This year for the first time in many years, I have made a New Year’s Resolution and it’s quite simple.  In fact, I have only one.  Simply put, my New Year’s Resolution is:

To be happy.

After all, our degree of happiness permeates all aspects of our lives both personally and professionally. Therefore, I felt it was important to dedicate time and attention to it for the coming year and beyond.  An article I recently read helped put this into focus*. Here are the highlights:

  1. Happy people work better with others.
  2. Happy people are more creative.
  3. Happy people fix problems rather than complain.
  4. Happy people have more energy.
  5. Happy people are more optimistic.
  6. Happy people are more motivated.
  7. Happy people are sick less often.
  8. Happy people learn faster.
  9. Happy people worry less about making mistakes.
  10. Happy people make better decisions.

Have you ever heard that a happy person is one who can enjoy the scenery when on a detour?  It is true that life is full of experiences both planned and unplanned.  I hope to embrace all that is in store for me this year.  Won’t you join me?

 

 

*Source: http://EzineArticles.com/909395 accessed 12/28/2011

 

 

 

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Ready To Run

December 7th, 2011

By: Corey Perkins RD, LD

This past October I ran my first  half marathon at the Nationwide Insurance Columbus Marathon. To my surprise,  the whole experience was much more enjoyable then I expected. Running a  marathon had been on my bucket list for the past several years but I kept  putting it off, saying “I’ll sign up for the next one.” However, this past July I finally stop procrastinating and filled out my entry form. With my $60  registration fee paid and my release waiver signed, I was officially on my way  to running my first race.

 

I have always been a recreational runner, but I had never run more than a couple of miles at a time. Clueless on how to properly train to  run a half marathon, I searched the Internet for a marathon training guide.   After skimming through a couple of guides, I was able to find a regimen that I  felt would work best for me. At the start of my training, things were pretty tough. My whole body was sore and I started questioning if I even wanted to run  the race anymore. But eventually the soreness wore off and the miles started to  rack up. I found that as my endurance increased and the more I ran, the more I wanted to run. Running was becoming less of something I had to do and more of  what I wanted to do.

 

As a dietitian, one of the first things I noticed was how my training regimen was forcing me to have healthier  eating habits. In order to maintain my endurance on my long runs I found myself  eating smaller, more frequent meals. I also found that I was craving less junk  food. Don’t get me wrong, I still craved some pizza and ice cream now and then, but I found that I was usually hungry for more nutritional dense foods that would help me refuel for my training regimen. Oddly enough, I found that I  wasn’t really “carbo loading” as most people say to do. Just eating a well  balanced diet of lean protein, healthy fats, and whole grains seemed to provided me with enough energy to complete my runs without sacrificing the loss of my lean body mass.

 

One of my biggest concerns as the race grew closer was what I should eat the morning of the race. I wanted to make sure that I had enough energy  to complete the race in competitive time, but I also didn’t want the uncomfortable feeling of being full while I was running. I decided my best choice was to go with a small, nutritional dense smoothie made with a scoop of protein powder, a small banana, mixed frozen berries, peanut butter, and gatorade. It was the  best way to get all the calories, protein, carbohydrates, and fat that I needed
without consuming too much volume.

 

After 10 weeks of training, race day was here before I knew it. Even though the marathon started bright and early at 7:30am, downtown Columbus was electric with the 18,000 participants getting ready for the race. I could feel the butterflies in my stomach as the announcer called everyone to the starting line and counted down to the start of the race. However, when the starting gun went off, all that anxiety went away. As the miles went by, I realized that my pre-race smoothie was a good choice. I never felt bloated and was able to make it the whole 13.1 meals without feeling too depleted.

 

Looking back on the experience now, running the half marathon around Columbus went by in a flash. Although, I don’t think I will ever forget the sense of accomplishment I got after crossing the finish line. It has been almost two months since the half marathon and I am still hitting the pavement as often as I can. Although I am not putting in as many miles as I was during my training, I am able to get in enough miles to stay in shape for my next race.

 

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It’s All In The Name

November 2nd, 2011

By: Cyndi Guveiyian RD, LD

After being in existence for almost 100 years as the American Dietetic Association, the ADA President Sylvia Escott-Stump recently made the announcement  that the organization will change its name to the Academy of Nutrition and Dietetics effective January 2012.  She went on to say, ‘The name Academy of Nutrition and Dietetics ” promotes the strong science background and academic expertise of our members, primarily registered dietitians. Nutrition science underpins wellness and treatment.”  ” An academy is a ‘society’ of learned persons organized to science.  The term describes our organization and immediately emphasizes the educational strength of our advice and expertise.”

I have had the opportunity to discuss the upcoming name change with fellow colleagues and have read comments posted on other blogs regarding this topic.  I think it is fair to say that quite a few dietary professionals are less than impressed with the name selected.  The biggest concern appears to be with the term “academy” that was chosen within the name itself.  The term “academy” brings to mind the word “school” . This implies that we are a group of learners and not experts in the field of nutrition when in fact, the opposite is in the case.  We have earned specialized education in the area of nutrition from accredited institutions, fulfilled work-related requirements to be eligible for registration examinations and participate in continuing education to maintain our credentials.

Time will tell if the name change meets the objectives that it was intended to create. After almost a  century with the same name, it is going to quite possibly be a long road to attain the desired name recognition we desire. Over time, it will ideally provide a clearer guidance to the general public, media, policy makers, and other health professionals as to who we are and what we do.   But what can be done in the meantime?

Whether we are in full agreement or not with the name selected,  the proverbal train has left the station on this one.  It is our responsibility as dietary professionals to help do what we do best…educate those around us to help make the transition as smooth as possible.  For example, it is important to begin communicating the organization’s January 2012 name change and  its ongoing vision of  ”optimizing the nation’s health through food and nutrition” with others.  We should not rely on leaders within an organization to bear the sole responsbility of communicating who we are and what we do.  With nearly 72,000 members of the organization, together, we can make a positive impact.

 

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Will You Be READY When Disaster Strikes?

October 4th, 2011

By: Kelly Rambaud RD, LD  with input from Cheryl Wymer CDM

 

Recently, I experienced first-hand a flood disaster at a long-term care facility.  As a consultant dietitian, I observed what measures were in place and also observed some surprises in dealing with the situation.  Some suggestions to help a dietary department to be prepared for a flood are as follows:

  1. Review your facility’s disaster preparedness policies with all staff.  Make sure your dietary manager has trained all new/current staff on emergency procedures and review them annually.
  2. Keep all electronic devices (e.g. modems, hard drives) off the floor, preferably on a desk, and backup all computer files on a separate device (e.g. DVD, flash drive).  Always have a hard copy printed of tray cards/tickets and important files/policies (e.g. phone numbers of all food/beverage vendors and dietary staff). Irreplaceable items (e.g. employee files) keep out of your bottom desk drawers or scan and keep on a backup device (e.g. flash drive).
  3. Have bottled water, supplies (e.g. disposable dishware and utensils) and an emergency menu for at least 3 days.  Make sure that the emergency menu items are rotated
    and not expired and are appropriate for all diet textures and therapeutic diets.  Keep these items in a separate area in your stock room on the top 2 shelves if possible.  In our case, the 12” minimum was not sufficient.
  4. Before cleanup begins, have the dietary manager make an itemized list for your insurance company of all items that came in contact with the flood waters.  Have a contract with an outside cleaning company that specializes in flood disaster cleanup before a disaster strikes.  Plus, have extra uniforms and rubber boots for the dietary staff or be prepared to reimburse staff for replacing such items.
  5. Meet with your maintenance director so you know what equipment is still safe for your staff to use after the flood.  Have an account with a local grocery store, food vendor or restaurant in the event you cannot use the kitchen and/or equipment. Find an area in your facility that was not affected by the flood and set  up a temporary kitchen with items from your kitchen that were not affected.

 

 

 

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When The Diet Is Against The Grain…..

September 6th, 2011

By: Becky O’Leary RD, LD

Recent studies have indicated that the prevalence of gluten sensitivity may be as many as 1 in 133 people (http://www.celiac.com/articles/22550).   We consulting dietitians need to not only have an increased awareness of the Gluten Free (GF) diet, but also be prepared to meet the challenges of providing a GF diet for a resident in the long term care setting.  It is essential for the dietitian and dietary manager to understand the diet limitations and to educate both the nursing and dietary staff.  In a GF diet it is necessary to avoid wheat, oat, rye and barley.  This excludes most of our standardized menu plans as there is some amount of gluten in most of the recipes.   Replacing menu items such as cereal, soups, gravy, sandwiches, casseroles and all pasta and breads requires planning and organization.  It is often beneficial to draft a gluten free cycle menu for the staff to follow.

Here are some tips:

  1.  Obtain a thorough diet history from the patient, and gear a menu plan as specific to your resident as possible,  keeping in
    mind any additional food intolerances and preferences that he/she may have.
  2. Include as many items from your usual inventory as possible.  Examples are: cream of rice
    hot cereal, yogurt, whole meats, peanut butter, rice, fruits and vegetables.
  3. Be advised that separate gluten free batch cooking with an individualized production sheet may be necessary to provide
    variety while meeting all of the requirements of the standardized diet.
  4.  Educate the administrative staff that additional cost for gluten free food items will
    be a must.  Items such as pasta, crackers, soup and dedicated entrée items will need to be purchased
    specifically for a GF diet.
  5. It will be vital to in-service dietary and nursing staff on not only the parameters for the GF diet, but on the risks of
    cross-contamination.

 

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Can We Talk?

August 1st, 2011

By: Cyndi Guveiyian RD, LD

We live in an age where things are “easier” and can be done “more efficiently” than in days gone by -right?  We have the luxury of having immediate access to people and resources anywhere in the world at our fingertips via cell phones and the internet 24/7.  But have technological advances aided in our ability to communicate with others effectively?  Face to face conversations have been substituted with text messaging, emails, and teleconferences, etc.  Granted there is value in these forms of communication in our high paced society. However, a face to face conversation can offer many rewards as a consultant working in the long-term care setting.

After all, communication skills can make the difference between being a good consultant and an exemplary one.   Communication can sometimes pose a challenge for consultants since it is not uncommon to a visit a facility once a week or even on a monthly basis.  Here are some suggestions for effective communication:

  • Make time. If your first thought when reading this is “I don’t have time to talk to people”.  This is a possible red flag.  The benefit of face to face communication helps a consultant form a rapport, establish credibility, and gain insight into areas that will assist the consultant in providing quality service.
  • Get to the point.  Prior to meeting with the leadership staff at a facility to discuss issues or concerns, think about the talking points you wish to convey.  Everyone’s time is valuable.  Be clear and concise.
  • Listen up.  Be cautious of falling into the trap of thinking about what you are going to say while the other person is still speaking.  This frequently  happens when you assume you already know what the person is trying to say, especially when it is not the first time you have discussed the topic.  Give the person the opportunity to speak.  Pause. Then respond.  An effective strategy is to then repeat back what you have heard to ensure the message was received correctly.
  • Provide valuable insight.  An important part of being a consultant involves providing the customer with information and recommendations.  It is easy to determine when something is not meeting a regulation, but that is only one part of the job of a consultant.  Customers expect and value a consultant’s ability to identify problems and insight on how to fix the problem.  Also, if you are not sure about something, a good response is…..  “That’s a really good question.  Let me look into that and get back to you.” Make a notation during the meeting, research the topic and report back your findings.
  • Be open minded.  The most rewarding part of being a member of the interdisciplinary team is collaborating with others.  Sometimes it may seem easier to  make decisions or put a plan into place without the input of others.  Our industry is ever changing so take advantage of what others bring to the table.

 

 

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Put Food Safety On The Menu For Cookouts

July 14th, 2011

By: Cyndi Guveiyian RD, LD

As a Registered Dietitian, I have to admit that the nature of the business creeps into my everyday life.  Whether it is peering behind the counter at a restaurant to see if the floor is clean, casually watching to see if a food service worker washes their hands appropriately or observing buffet line procedures at a local eatery, I just can’t help myself.  Outdoor celebrations that include food are no exception. 

Like clockwork in many facilities, summer marks the time for outdoor celebrations that include cookouts.  These functions help create a home-like environment for residents and are enjoyed by staff, residents and families alike.  Food safety plays a pivotal role in ensuring that the celebrations are memorable in all the right ways.  Here are some reminders:

  1. Assign a staff member to monitor food temperatures using an appropriately sanitized and calibrated thermometer.
  2. Keep hot foods hot – at or above 135 °F.  This may require cooking hot foods to order or keeping foods in the steam table in the main kitchen and replenishing hot foods items frequently at the outdoor location. Remember that foods are not permitted to be in the steam table for more than 4 hours.
  3. Keep cold food cold – at or below 41 °F.  Cold food items may need to be brought outdoors in batches on ice from the main kitchen and replenished as needed.
  4. Never leave food out of refrigeration for more than 2 hours. If the temperature is above 90 °F, it is recommended not to leave food out for more than 1 hour.
  5. Hot foods need to be cooked to the appropriate final cooking temperatures.*  According to the FDA Food Code 2009, the following represents the appropriate final cooking temperatures for picnic favorites:

                                        Hamburgers/Hot Dogs/Brats              155° F for a minimum of 15 seconds

                                        Poultry, stuffed foods                          165° F for a minimum of 15 seconds

                                        Steaks /Ribs                                            145° F for a minimum of 15 seconds

* Please note that the USDA recently revised the cooking temperature for all whole cuts of meat, including pork to 145° F.   Since this information was just released by the USDA in May 2011, it is probable that State food codes that nursing facilities are required to follow do not match this recommendation (e.g., Ohio).  Until State food codes are updated, whole cuts of meat are required to be cooked per existing State guidelines in nursing facilities.

  1. Potentially hazardous cooked foods should be rapidly chilled from 135° F to 70° F within two hours.  Thereafter, the food item should be chilled from 70° F to 41° F in an additional 4 hours.  The total cooling time of the cooked food item from 135° F to 41° F should not exceed 6 hours.
  2. Use the motto, “When in doubt, throw it out!”.

Sources:

http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/ucm186451.htm#part3-4 Accessed June 27, 2011.

http://www.odh.ohio.gov/ASSETS/FFB98FB7671C49B8B96A57470E5D4D5E/FR3717-1-03.3B.pdf   Accessed June 27, 2011.

http://www.fsis.usda.gov/News_&_Events/NR_052411_01/index.asp   Accessed June 27, 2011.

 

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Sanitation: Let’s Clean Up Our Act!

June 1st, 2011

By: Cyndi Guveiyian RD, LD

According to the latest information available from The Centers for Medicare and Medicaid Services (CMS), F371 Sanitary Conditions continues to top the list of the most frequent citations for nursing homes (Source: CASPER 11/8/2010).  It ranked #6 overall in frequency for all survey types for nursing homes across the nation in the 2010 fiscal year.

Although there are many facilities that do an outstanding job of maintaining a quality operation in regards to sanitation, it is apparent that this area is still a work in progress within our industry. Storing, preparing, distributing, and serving food under sanitary conditions are critical aspects in providing quality care each and every day.

Does your facility’s kitchen meet the mark? One indicator (and I do not recommend using this as the litmus test because by the then it may be too late!) is to observe how the dietary department reacts when it is announced that the health department has just entered the facility and will tour the kitchen any minute?  Mass hysteria coupled with staff running around “cleaning” things, throwing things away and searching for paperwork or a sense of calm and confidence?

If your facility is striving to improve the current status of the dietary department or maintaining the quality that they have worked hard to achieve, here are 3 things to consider:

  • Is there a formal system in place to evaluate the sanitary conditions within the dietary department? Dietary Managers should consider completing Sanitation Audits on a weekly basis during their survey window. Monthly audits should be completed at a minimum by the dietitian/dietetic technician.  Surveyors frequently initiate surveys during evening and weekend hours.  This may be helpful when considering the timing of audits for a clear picture of areas in need of improvement.

 

  •  If an area of improvement is identified, is there a process to develop, communicate and monitor the plan for resolution? It is often easy to identify a problem, but a permanent fix is sometimes more challenging.  Depending on the scale of concerns, this may very well necessitate a team approach.  Dietary Managers should enlist the help of the registered dietitian/dietetic technician and Administrator in developing an action plan.  

 

  • Are there areas in which the dietary line staff needs additional training?  Knowledge is power!   The dietary line staff depends on the facility’s leadership to provide the training needed to complete their jobs.  Monthly inservices are required, but is the training offered of quality?  Are the topics covered generic or meet the needs of the dietary line staff?  Ongoing training is critical to the success of the dietary department.

 

It takes hard work to achieve and maintain a “clean bill of health” for your kitchen, but it is possible!  Planning, training, and follow-thru are key elements in reaching success.  To learn about our systems and training programs, visit The Learning Center.

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The Connection Between Blood Pressure and Salt

May 2nd, 2011

By: Sarah Earhart RD, LD

I was recently teaching one of The Rite Bite’s Diabetes Bootcamp sessions for a group of about 12.   The Rite Bite is a sister company of Dietary Solutions that specializes in wellness.  During this class, one gentleman innocently asked, “does the amount of salt you eat matter?” Of course he meant in regards to diabetes and blood glucose control, but I answered him in the spirit of good health for all individuals with and without diabetes. “YES, salt does matter!”

Why does salt matter? It matters because your blood pressure is affected by it. Salt and water go hand-in-hand. The salt (also referred to as sodium) in your body retains water with it. If your diet is high in sodium, the amount of water retained in your body will increase your blood volume. When your blood volume is greater, your heart has to work harder to pump the blood through your circulatory system.

Let’s look at what blood pressure is for a minute. When you go the doctor and the nurse takes your vitals, your blood pressure is one of the measurements taken. It is one number over another; might be 120 over 80, 159 over 99, or 102 over 68. The top number is called the systolic blood pressure. This is the amount of pressure your heart and arteries are under when blood is being pumped away from the heart out to the limbs. The bottom number is the diastolic blood pressure. This is the amount of pressure on your heart and arteries in between beats, when the heart is filling with more blood to pump out on its next beat. A healthy blood pressure is less than 120 over less than 80.

When your salt intake is high, you retain excess water. Ultimately this can raise your blood pressure. It affects all of us, but certain individuals are more “salt-sensitive” and will see a greater rise in blood pressure based on their dietary salt intake. To minimize the damage that sodium may have on your blood pressure, aim to meet the most recent (2010) recommendations from The Dietary Guidelines for Americans which suggest keeping intakes of this mineral below 1500 mg per day. To put this in perspective, one teaspoon of salt provides 2,300 mg of sodium. Sodium is found in almost all foods too. The food label is the best resource for identifying the quantity of sodium in the foods you eat. One idea: write down how much sodium is in all the foods you eat in a single day. How do you compare to the recommendation for health?

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