1 An Update on Current Issues in Healthcare Dietetic Services Terri Blackwell-Goetz MPH, RD Public Health Nutrition Consultant III Copyright 2012 by California Department of Public Health. All rights reserved. No part of this publication may be reproduced, scanned, or distributed in any printed or electronic form without permission of the California Department of Public Health. The commercial use of this publication is strictly prohibited.
2 Objectives Provide update regarding Dietary Services Supervisor qualifications and the link to RD Collaboration Provide overview of the requirement for patient menu nutritional adequacy and the diet manual Provide overview of current hot topics with regards to food preparation to ensure safe food handling
3 Objectives Provide a foundation for collaboration with the facility Infection Control Preventionist (ICP). Provide an update on QAPI as it relates to dietetic services and healthcare compliance
4 Dietary Service Supervisor Qualifications
5 Who is responsible for ensuring compliance? Dietary Services Supervisor Registered Dietetic Technician Registered Dietitian Infection Control Preventionist Medical Director Administrator
6 Who is responsible for ensuring compliance? Registered Dietitian Regulatory requirement Full time vs. Part time or consulting Responsibilities dietetic service and nutrition care Examples of collaboration Reporting requirements
7 Title 22, California Code of Regulations If a dietitian is not employed full time, a full time person who (meets the requirement of Health and Safety Code ) shall be employed to be responsible for the operations of the food service. Changes effective January 1, 2009
8 Health & Safety Code A Dietetic Services Supervisor must complete at least one of the following 7 educational requirements:
9 Health & Safety Code A baccalaureate degree with a major in food or nutrition, dietetics or food management and as one year of experience in the dietetic service of a licensed health facility
10 Health & Safety Code A graduate of a dietetic technician training program approved by the American Dietetic Association (ADA), accredited by the Commission on Accreditation for Dietetic Education, or currently registered by the Commission on Dietetic Registration (DTR)
11 Health & Safety Code A graduate of the dietetic assistant training program approved by the ADA. Program no longer exists Existed May still see these
12 Health & Safety Code A graduate of a dietetic services training program approved by the Dietary Managers Association (DMA) and is a certified dietary manager (CDM) credentialed by the Certifying Board of the DMA, maintains their certification and has at least six hours of in-service training on the specific California dietary service requirements contained in California Code of Regulations (CCR) Title 22 prior to taking on full-time duties as a dietetic services supervisor at the health facility.
13 Health & Safety Code A graduate of a college degree program with major studies in food/nutrition, dietetics, food management, culinary arts, or hotel and restaurant services and is a certified dietary manager (CDM) credentialed by the Certifying Board of the DMA, maintains their certification and has received at least six hours of inservice training on the specific California dietary service requirements contained in CCR Title 22 prior to taking on full-time duties as a dietetic services supervisor at the health facility.
14 Health & Safety Code A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic services supervision, or 90 hours or more of combined classroom instruction and instructor led interactive web based instruction in dietetic service.
15 Health & Safety Code Has received training experience in food service supervision and management in the military that is the equivalent to any of the above Generally requires verification of equivalency either through the DMA or one of the CA State approved programs
16 Health & Safety Code-1250 A Licensed Healthcare Facility under includes: General Acute Care Hospital Acute Psychiatric Hospital Skilled Nursing Facility (SNF) Intermediate Care Facility (see 1250 for those that apply) Special Hospital (ex. Maternity) Nursing Facility
17 Health & Safety Code Originally the code did allow for a period of time for healthcare facilities to apply for Program Flexibility requests, while current staff could pursue & complete requirements. However, the final date for this request was 12/31/2009.
18 Diet Manual, Menus and Nutritional Adequacy
19 Diet Manual Title 22: A current therapeutic diet manual, approved by the RD and the policy committee, shall be readily available to dietetic personnel and licensed healthcare practitioners Defines the diets routinely ordered Reviewed annually and revised at least every 5 years
20 Menus and Nutritional Adequacy Menus must meet the needs of the residents in accordance with the RDAs of the Food and Nutrition Board of the National Research Council To ensure this requirement is met, a nutritional analysis of the menus must be completed and include all the nutrients listed in the RDAs and DRIs
21 Menus and Nutritional Adequacy Nutrition analysis of the menu is the tool used to determine if the menus meet the nutritional needs of the resident The menus must be prepared in advance and must be followed
22 Menus and Nutritional Adequacy Title 22: The current and following week s menus for regular AND therapeutic diets must be posted in a conspicuous and prominent location, accessible to the public.
23 Food Storage, Preparation & Service to Ensure Safe Food Handling
24 Why is this important? The Licensing & Certification regulations were designed to protect the vulnerable, fragile and compromised healthcare population CDC estimates that 1 in 6 persons will become sick due to food borne illness annually. Of these known cases, 128,000 are hospitalized and 3,000 die from food borne illness.
25 Regulations State vs. Federal Title 22 California Code of Regulations Federal Certification Regulations A, F, W Authoritative Guide for Safe Food Handling 2009 Food Code FoodProtection/FoodCode/FoodCode2009/ default.htm
26 Potentially Hazardous Foods- PHF Food Code authoritative reference Most recent revision 2009 One of the changes include additions to the definition of a Potentially Hazardous Food (PHF) Based on current science Annex provides rationale
27 Potentially Hazardous Foods- PHF Food that requires TCS to limit pathogenic microorganism growth or toxin formation Raw or heat treated animal food; heat treated plant food; raw seed sprouts; cut melons, leafy greens, or tomatoes unmodified Water content and ph
28 Time and Temperature Control TTC for Safety Crucial concept for surveying to food safety The facility needs to ensure foods are not in the danger zone (>41 degree F and <135 degree F) for more than four hours
29 Salad Preparation & Cooling - TTC Chicken, tuna, egg, pasta & potato salad Leftover meat or hot ingredients should have been properly cooked and cooled Consider chilling ingredients before making salad Cooled to 41 within 4 hours if prepared from ingredients at room temperature
30 Cooling Foods - TTC Two-step method: Within 2 hours from F** Within an additional 4 hours from F **Can reheat to 165 F & restart One-step method: Cooled within 4 hours to 41 F or less if prepared from ambient foods (tuna) or reconstituted foods Immediate Jeopardy potential
31 Methods for Cooling Foods Reduce the quantity and size of the food Remove from original cooking pan Loose, vented covering in shallow pan Remove any juices Ice water bath Ice paddles Blast chiller
32 Use of Leftovers - TTC Use of leftover foods is acceptable, however --- High potential for food borne illness It must have been cooked and cooled properly and must be reheated to an internal temperature of 165 F for 15 seconds.
33 Infection Control Program and Preventionist
34 Infection Control Program & Preventionist Recent update to Federal Interpretive Guidelines in the Acute Care and SNF regulations include the role of the Infection Control Practitioner ensuring a sanitary environment and ensuring an IC program for the prevention, control and investigation of infections and communicable disease.
35 Infection Control Preventionist - ICP Dietetic Service food safety and sanitation monitoring activities: food storage, preparation, serving, dish rooms, refrigerators, ice machines, pest control, waste disposal Employee health and hygiene practices Involvement of ICP in development of policies and procedures Investigating food borne illness
36 Continuous Quality Assurance & Improvement (QAPI)
37 Continuous Quality Assurance & Improvement Federal Regulations for both Acute Care and Skilled Nursing Facilities require some component of Quality Assurance and Quality Improvement This includes a dietary services component especially when there is deficient practice identified during a survey
38 QAPI - Purpose A strong QAPI program is essential to provide safe, high quality care Identification of problems BEFORE they are identified by the regulatory agency The best QAPI is data driven and show results
39 QAPI - Steps Identification of problems Data Driven QA vs. QI and Communication Priority high volume, problem prone, high risk Complexity of issue? Dependence or collaboration w/ other areas or disciplines?
40 Action Plan Analysis QAPI - Steps What are you trying to fix? What changes will be implemented? Who will you involve? How will this change be implemented? How will you measure your success?
41 QAPI - Steps Implement Change/Action Plan Planning the implementation Communication, Communication and More Communication! Systemic Changes Go ahead and JUST DO IT!
42 QAPI - Steps Evaluate the success of the change More Data Communicate the success (or failures) Develop new, more or changes to the Action Plan Repeat QAPI steps until you have met the goal Sustainability Caution - Continue to monitor