Federal Nursing Home Regulation Clarifications

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Crushing of medications
Director of Food and Nutrition Services

Crushing of medications

Federal Nursing Home Regulation: F760 CFR 483.45(f)(2) The facility must ensure that residents are free of any significant medication errors.

Question:

The questions are not about crushing meds for feeding tubes – that is not new and is a clear standard of practice. The questions are about crushing medications for residents with dementia, who may otherwise refuse or be unable to take a pill/capsule. The questions are not regarding meds that should not be crushed or crushed meds that should not be combined, these issues remain important to verify for safety and effectiveness of the medications.

The issue is if a provider has determined that a medication can be crushed, and that there is no contraindication to combining crushed medications, can crushed medications given orally be combined into pudding, yogurt, or applesauce if the resident, resident’s representative, or resident’s prescriber prefers it that way and the risks vs benefits are explained and documented in the resident record?  It seems that broad prohibitions of a practice is not very resident-centered! The Alzheimer’s Association and the National Institute on Aging recommend crushing medications, after consultation with a physician or pharmacist, for dementia patients that have difficulties swallowing pills. The concerns regarding separating crushed medications for certain residents include the increased potential for medication refusal, fluid overload, and decreased meal intake. We also have a concern about the increased amount of staff time this new guidance may cause.

CMS Response:

CMS revised the language to reflect person centered care under F 760 CFR 483.45(f)(2) in the November 22, 2017 Appendix PP revision. Please see Rev. November 22, 2017 under Tag F760 CFR 483.45(f)(2) The facility must ensure that residents are free of any significant medication errors at: State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (PDF).

Director of Food and Nutrition Services

Question:

Does the MN Certified Food Manager course administered through the Minnesota Department of Health Environmental Health Division meet the federal nursing home regulatory requirement at §483.60(a)(2)(ii)?

Response:

The Minnesota Department of Health (MDH) does not recognize the Minnesota Certified Food Manager administered through the Minnesota Department of Health Environmental Health Division as meeting the federal nursing home requirement at §483.60(a) (2) (ii).

Regulatory Analysis and Rationale

After receiving questions from providers and provider groups, MDH has comprehensively reviewed the current requirements for a Director of Food and Nutrition Services noted by the Center for Medicare and Medicaid Services (CMS) at §483.60(a)(2)(ii). These requirements can be found at Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities.

As of 11/28/16, the new regulatory requirements went into effect for a Director of Food and Nutrition Services. Those changes included the new educational and training requirements for that position.

The federal regulation states:
483.60(a)(2) 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 who-

(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is:

1. A certified dietary manager; or
2. A certified food service manager; or
3. Has similar national certification for food service management and safety from a national certifying body; or
4. Has an associate’s or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and

(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and

(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

After thorough analysis, at this time MDH concludes the Minnesota Certified Food Manager (MCFM) through MDH Environmental Health Division would not be equivalence or meet qualifications to serve as the Director of Food and Nutrition Services.

MDH included in these analysis individuals and organizations actively involved in the long-term care industry and working to assure residents have their food and nutrition services met. Professionals involved in this analysis included registered dieticians, certified dietary managers and registered nurses. Organizations participating in and providing comments for the development of this analysis included the Association of Nutrition & Foodservice Professionals, Minnesota Academy of Nutrition & Dietetics, Minnesota Beef, DFK Solutions, long-term care provider organizations, CMS and MDH.

MDH has reached that conclusion based on the following rationale:

• The Director of Food and Nutrition Services is appointed in the event there is no full time dietician. The Director of Food and Nutrition Services is responsible for managing the clinical components of nutritional adequacy for facility residents in the absence of the consulting dietician.
• A certified dietary manager (CDM) has 5 tracks for training prior to taking a credentialing exam, dependent on education, training and experience. The most common track is 120 hours of classroom with 150 hours of practicum. CDMs receive education and training in the areas of nutrition, foodservice, communication and personnel, sanitation and food safety, and business operations. Additionally, CDMs are required to obtain 45 continuing education hours in their three-year recertification period; 9 of the 45 hours must pertain to sanitation and food safety.
• The federal regulation also allows for a national certification for food service management and safety from a national certifying body. CMS clarified in 3/18, the Certified Professional - Food Safety through the National Environmental Health Association (NEHA) would not meet the requirements for a Director of Food and Nutrition Services as the focus was food safety with a lack of clinical/management content. Nationally recognized certifications may be available and would be evaluated on a case-by-case basis.
• Minnesota does not have an established standard for a food service manager. There is a food manager certification through the MDH’s Environmental Health (EH) division. The food manager is trained by an organization such as ServSafe. At this time, ServSafe is the most common training used to become EH food manager. The ServSafe training is an 8-hour course, which is followed by an American National Standards Institute (ANSI) certified exam. Prior to completing the exam, the ANSI approved organization verifies satisfactory completion of the course. Once the exam is taken and passed, the student may apply for a certification card through the State of Minnesota/Environmental Health. MDH’s EH division will verify completion of the certified exam prior to providing the certification. It is not a national certification.
• The MDH EH certified food manager (CFM) training is entirely focused in food safety and food protection. The MDH EH certified food manager (CFM) requires 4 continuing education credits every 3 years. The MDH EH CFM has no education or training in the clinical or management components required by the Director of Food and Nutrition Services. For more information, go to: Minnesota Certified Food Manager.
• On a 9/7/17 CMS-sponsored Medicare Learning Network (MLN) call, CMS was asked by a provider organization representative if a state has certified food manager would meet the requirement at §483.60(a) (2) for a qualified Director of Food and Nutrition Services. CMS responded that would meet the requirement. The provider organization representative then asked the clarifying question, "Would it meet the requirement if it were a state certification not a national certification?" CMS again responded the state certification would meet the requirement. Another caller then asked CMS, "Would ServSafe or similar training with corresponding certification meet the requirement?" CMS responded that a ServSafe training and certification would not meet the federal requirement. The CMS representative then explained ServSafe provides training in only food safety. There is no corresponding dietary management training. 
• Different terminology has been used throughout the process of determining the credentials required by the federal regulations for a Director of Food and Nutrition Services. The MDH analysis was conducted with this in mind, and reviewed all credentials/requirements for the various titles considered for the Director of Food and Nutrition Services. The MDH EH CFM is trained only in food safety through an organization such as ServSafe. Therefore, CMS has confirmed the MDH CFM does not meet the federal regulatory requirements at §483.60(a)(2). MDH must enforce the requirement as directed by CMS as it is a federal requirement. Review of the MLN posted transcript and post-call-clarification verified this information to be accurate.

MDH does not recognize the Minnesota CFM as meeting the requirement at §483.60(a) (2) (ii). This concludes the MDH analysis of the federal requirements for the Director of Food and Nutrition Services.