Chapter 21 Federal Regulations

the goal is not met, changes to the care plan should be developed and implemented to be more realistic and achievable. If the problem has been resolved, this should also be reflected in the care plan, along with the date of resolution. The care plan should be reflective of the resident’s status or condition at the present time. Although the facility staff develops the care plan, the resident and/or the responsible party (eg, family, guardian) are also part of this process. Care plan meet- ings are held on a quarterly basis or more frequently if needed if changes occur in the resident’s condition; the resident or responsible party should be invited to attend this meeting.

DISCHARGE PLANNING

Nursing homes do admit residents for short-term reha- bilitation. These residents, and sometimes residents with longer stays, return to their homes or former resi- dences or are transferred to another nursing facility. Education from the various disciplines and information related to services from outside agencies (eg, home health agencies, home-delivered meals) may need to be provided or put in place before discharge. Although nursing and social services coordinate the move, the RDN is an integral part of the discharge process, pro- viding simple meal preparation techniques, instructing others on diet modifications, suggesting supplemental programs under the Older Americans Act, teaching self-administration of enteral feeding, and so on. Once the resident has been discharged, the social worker is responsible for a follow-up call to see how the former resident is doing in the new setting. Discharge planning is an important activity in any health care setting. The discharge potential needs to focus on what happens to the resident before he or she can be safely discharged. This discharge potential should appear in the plan of care. Reasons for discharge planning include the following:

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Need to design written diet instructions that are required for reference and reinforcement.

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Need to contact nutrition support programs in advance and make arrangements for home- delivered meals.

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Need to have hand-off material ready that pro- vides dietary information on nutritional status and explains the degree of and the resident’s response to nutrition intervention to other health care facili- ties where the resident is to be discharged. This information can save the admitting facility time and prevent it from trying approaches that were previously unsuccessful. The nutrition discharge summary should identify any problem, such as

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weight loss, that might not be readily apparent to the admitting facility.

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Need to provide opportunity to reinforce the principles of nutrition learned while the resident was in the facility. Residents returning to the home setting have a written reminder of the nutrition services offered by the facility.

A summary of the resident’s nutritional status and problems while in one facility is valuable information for the facility that receives the resident and helps the RDN to develop an effective nutrition care plan sooner than would otherwise be possible (8). It also provides continuity of care and may, therefore, enhance the resi- dent’s quality of life.

SURVEY PROCESS

Long-term care facilities volunteer to participate in the federally funded Medicare and/or Medicaid programs. To receive payment under the Medicare and/or Medicaid programs, skilled nursing facilities (SNFs) and nursing facilities (NFs) must be in compliance with the requirements codified in 42 CFR Part 483, Subpart B. To certify a SNF or NF, an initial health survey must be completed along with a Life Safety Code Survey. The facility is then reviewed periodi- cally in a recertification survey. These are unan- nounced surveys conducted by the state survey agency, which is contracted by the federal govern- ment. The survey may occur on any day or at any time during the 24-hour period (9).

The health or standard survey (recertification survey) is a periodic, resident-centered inspection that gathers information about the quality of services fur- nished in a facility. Each SNF or NF is subjected to a standard survey no later than 15 months after the last day of the previous standard survey, and the statewide average interval between standard surveys will not exceed 12 months. A complaint survey, or an abbreviated standard

survey, focuses on a specific issue that has been identi- fied by the survey agency. These surveys gather infor- mation primarily through resident-centered techniques focused on facility compliance with the requirements for participation. They are the result of complaints received by the state agency. The complaint survey concentrates on a particular area of concern. However, the survey team can expand an abbreviated or com- plaint survey to a standard survey if they find evidence that warrants a more extensive review. In addition to the initial, recertification, or com- plaint surveys that the state agency conducts within the specified time, CMS must also conduct Federal Monitoring Surveys (FMS) to review the state agency