By | October 31, 2019

While awaiting final guidance from the Centers for Medicare and Medicaid Services (CMS) on Phase 3 of the Requirements of Participation (ROP), skilled nursing facilities (SNFs) can still move forward with efforts to ensure that they have qualified staff leading and working in food and nutrition services at their facilities.

Although CMS has not issued final guidance on designating a director of food and nutrition services and the qualifications required for that role as we publish this post, the intent of the Phase 3 guidance is clear. CMS wants to ensure that food service programs at SNFs are led by qualified individuals who can give nutrition and food safety appropriate attention to protect the well-being of SNF residents.

Credentials and Training

The current situation is that CMS in July proposed altering Phase 3 of the ROP in some aspects, including easing the credential requirements for food service directors. The original Phase 3 wording, issued in 2016, requires SNFs to have a designated director of food and nutrition service with appropriate credentials and ensure that food service staff have adequate training and guidance in meeting food safety and dietary needs of residents.

In the proposed Phase 3 alteration, CMS notes:

Specifically, regulations at § 483.60(a)(2)(i) state that 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. Under the existing regulations, the director of food and nutrition services must be a certified dietary manager; a certified food service manager; have similar national certification for food service management and safety from a national certifying body; or have an associate’s or higher degree in food service management or in hospitality (if the course study includes food service or restaurant management).

The original Phase 3 guidance says a person who was designated as a director of food and nutrition services before November 28, 2016, will have five years to obtain those specific credentials, and someone appointed to that role after that 2016 date and before the November 28, 2019, implementation date will have one year to obtain the credentials.

The rule change CMS proposed in July adds more flexibility on the director’s credentials, requiring that the person have a minimum of two years of experience in a director of food and nutrition services role or have “completed a minimum course of study in food safety that includes topics integral to managing dietary operations such as, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving.”

According to CMS, the proposed change recognizes that the earlier education and credential requirements “may have subjected facilities to unnecessary burden and increased costs.” CMS also noted, “We understand that facilities are concerned about a workforce shortage of certified dietary managers and the financial costs imposed on existing experienced staff to obtain specialized training.”

Person-Centered Care

Regardless of how the rule finally shakes out, it is in the best interest of SNF leaders to ensure food service teams have proper training in these areas and more.

Aligned with the ROP’s focus on person-centered care, nutrition needs and preferences vary for each resident. In general, caloric intake recommendations shift with age and physical activity levels, as noted in the 2015-2020 Dietary Guidelines for Americans.

Nutrition considerations are part of the care plan developed by the comprehensive care team, which under the ROP explicitly must include a member of the food and nutrition services staff, a nurse aide, and a social worker in addition to the attending physician and a registered nurse responsible for the resident’s care.

Aligned with person-centered care, menu plans should consider specific cultural, religious, and ethnic needs and preferences of residents, as Jayne Warwick, RN, HBScN, of PointClickCare notes in a Relias webinar on Phase 3. Food and beverage options should consider residents’ needs related to allergies and intolerances, and staff should ensure that residents have adequate hydration.

Food choices are vital to managing comorbidities such as diabetes and Parkinson’s disease, and nutritional interventions should be considered when caring for people with Alzheimer’s disease and other conditions frequently encountered with elderly patients. Researchers also note that nutritional deficits and insufficient dietary intake can increase the risk of developing pressure injuries.

Foodborne Illnesses

Beyond what is served, the way it is served also requires staff training. Food safety education is crucial, as foodborne illnesses are dangerous to older people, who may have multiple comorbidities and lowered immunities. Foodborne illnesses circulating in a nursing facility can pose risks not only to residents, but also to visitors, staff, and others in the community with whom they interact.

About 48 million people a year become ill from foodborne illnesses, according to food safety information from the CDC on foodborne illnesses and germs. Of those, about 128,000 may be hospitalized and 3,000 may die.

Older adults and people with weakened immune systems are more likely to develop foodborne illnesses, CDC notes. Medical conditions such as diabetes, liver disease, kidney disease, organ transplants, HIV/AIDS, and receiving chemotherapy or radiation treatment are factors contributing to weakened immune systems.

To prevent foodborne illnesses, the director of food and nutrition service also will need to work collaboratively with the facility’s infection preventionist to ensure that proper infection prevention and control protocols are followed by food service staff.

According to the CDC, the top five germs that cause foodborne illness in the United States are:

  • Norovirus
  • Salmonella
  • Clostridium perfringens
  • Campylobacter
  • Staphylococcus aureus

Competency Assessments

With so many aspects of food service and nutrition affecting the health of SNF residents, providing targeted education and competency assessments can protect SNF businesses, residents, staff, and visitors.

Regardless of the CMS final decision on Phase 3 requirements, it pays to prepare your staff by assessing competency and providing learning to fill any gaps in knowledge about nutrition and food safety. It reduces risk to all.

Terrey L. Hatcher

Terrey is a Content Marketing Manager at Relias. She has worked in professional development and curriculum design organizations for more than 20 years. At Relias, she has collaborated with physicians, nurses, curriculum designers, writers, and other staff members to shape healthcare content designed to improve clinical practice, staff expertise, and patient outcomes. Besides her current focus on healthcare solutions, Terrey’s experience includes sharing best practices in education, IT, and international business.

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