Long-Term Care Survey Alert

Tune into the Centers for Medicare and Medicaid Services’ interest in the new Dining Practice Standards — or risk citations on your next survey. The standards cover the following 10 sections in detail. Below are a few highlights from each section’s “current thinking” or “recommended course of action” heading:

Individualized Nutrition Approaches/Diet Liberalization

“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.”

“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.”

Individualized Diabetic/Calorie Controlled Diet

“Diet is to be determined with the person and in accordance with his/her informed choices, goals and preferences, rather than exclusively by diagnosis.”

Individualized Low Sodium Diet

“Empower and honor the person first, and the whole interdisciplinary team second, to look at concerns and create effective solutions.”

“Monitor the person and his/her condition related to their goals regarding nutritional status and their physical, mental and psychosocial well-being.”

Individualized Cardiac Diet

“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.”

Individualized Altered Consistency Diet

“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.”

Individualized Tube Feeding

“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.”

“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 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.”

Individualized Real Food First

“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.”

Individualized Honoring Choices

“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.”

“Residents’ individual choices are actively sought after, care planned and honored, as Tag F 242 requires, based on life patterns, history and current preferences.”

Shifting Traditional Professional Control to Individualized Support of Self Directed Living

“All decisions default to the person.”

New Negative Outcome

“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.’”

“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.”