Post on 03-Nov-2019
The CMS and Joint Commission
Dietary Standards 2018
What Hospitals Need to Know.
2
Speaker
Sue Dill Calloway RN, Esq. CPHRM, CCMSCP
AD, BA, BSN, MSN, JD
President of Patient Safety and Education Consulting
5447 Fawnbrook Lane’
Dublin, Ohio 43017
614 791-1468 (Call with Questions, No Emails)
sdill1@columbus.rr.com
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Dietary ErrorsCMS can investigate any complaints of dietary
errors
The Pa Patient Safety Authority examined dietary mistakes over a five year period and publishes a report in 2015
Found 285 errors from January 2009 through June 2014
Most frequent was meals delivered to patients who were allergic (77% or 181)
This was known and documented in the medical record prior to the event
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CMS Can Investigate if Dietary Error
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Dietary ErrorsOther types of errors:
Wrong diet (50)
Meals meant for other patients (43)
Meals delivered to patient when NPO (11)
Advice is offered to patients to help prevent dietary errors
Make sure staff know your allergies
Don’t be afraid to ask questions
Know the person taking your food order and delivering it
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The CMS Conditions of
Participation (CoPs) for Dietary
and Nutrition Services
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CMS CoPThe Centers for Medicare and Medicaid Services is
called CMS for short
CMS has a manual called the Conditions of Participation or CoPs
Every hospital that received Medicare or Medicaid reimbursement must follow this CoP manual
There is a separate manual for larger (PPS) hospitals (Appendix A) and one for critical access hospitals (CAH, Appendix W)
Must follow these for all patients and not just Medicare or Medicaid patients
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You Don’t Want One of These from CMS
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9
All Interpretative guidelines are in the state operations manual and are found at this website1
Appendix A, Tag A-0001 to A-1164
You can look up any tag number under this manual
Food and Dietetic Services starts at tag A-0618
Questions to CMS at hospitalscg@cms.hhs.gov
Manuals
Manuals are now being updated more frequently
Still need to check survey and certification and transmittals website once a month to keep up on new changes 2
1 http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
2 http://www.cms.gov/Transmittals/01_overview.asp
CMS Hospital CoPs
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Step one is publication in Federal Register
Step two is where CMS publishes the interpretive guidelines
The interpretive guidelines provide instructions to the surveyors on how to survey the CoPs
These are called survey procedure
Not all the standards have survey procedures
Questions such as “Ask patients to tell you if the hospital told them about their rights”
Survey Procedure
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Website at www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc.pdf
Email questions hospitalscg@cms.hhs.gov or CAHscg@cms.hhs.gov
Also Called the State Operation Manual
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www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/down
loads/som107_Appendixtoc.pdf
Email questions
hospitalscg@cms.hhs.gov
CMS Survey and Certification Website
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www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp#
TopOfPage
Click on Policy & Memos
CMS Survey Memos
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CMS Deficiency Reports
What are the most problematic dietary
and nutrition standards?
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Access to Hospital Complaint DataCMS issued Survey and Certification memo on
March 22, 2013 regarding access to hospital complaint data
Includes acute care and CAH hospitals
Does not include the plan of correction but can request
Questions to bettercare@cms.hhs.com
This is the CMS 2567 deficiency data and lists the tag numbers
Updating quarterly
Available under downloads on the hospital website at www.cms.gov
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Access to Hospital Complaint Data
There is a list that includes the hospital’s name and the different tag numbers that were found to be out of compliance
Many on restraints and seclusion, EMTALA, infection control, patient rights including consent, advance directives and grievances and standing orders
Two websites by private entities also publish the CMS nursing home survey data and hospitals
The ProPublica website for LTC
The Association for Health Care Journalist (AHCJ) websites for hospitals
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Updated Deficiency Data Reports
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www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html
Dietary Deficiencies
Section Tag April 17, 2018
Food & Dietetic Services 618 27
Organization 619 17
Director of Dietary Services 620 63
Qualified Director 621 49
Competent Staff 622 22
Diets 628 17 Tag number deleted
Therapeutic Diet 629 30
Diets 630 31
Diet Manual 631 15 Total 35219
CMS Final Regulations for
Food & Dietetic Services
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CMS Final Interpretive Guidelines
CMS issues survey memo dated January 30, 2015 to implement final interpretive guidelines to the federal regulation and final April 1, 2015
CMS rewrites tag number 629 and 630 and deletes tag 628
Explains process for hospitals that want to C&P their qualified dieticians or qualified nutritional specialist to order the patient’s diet
So diet can be ordered by practitioner responsible for the patient’s care or a qualified dietician or nutritional specialist who is C&P
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CMS Changes Food & Dietetic Services
Must be consistent with state law as state can determine scope of practice
State can determine the credentials and qualifications for dietitians and nutrition professionals
MS could privilege speech-language pathologist who may order diet texture modification for patients with significant swallowing problems
MS is not required to provide privileges but has the flexibility to do so if they choose
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Ordering Privileges Resources The Academy of Nutrition and Dietetics has a 13 page
resource on credentialing and privileging (C&P) so the dietician can order the patient’s diet
Also has a resource called “Practice Tip: Hospital Regulation-Ordering Privileges for the RDN”
Privileging is optional- a hospital is not required to do but can if it wants to and must be consistent with state law
If the dietician is not C&P then cannot order the patient’s diet which include therapeutic diet, TPN, or supplemental feedings
Can’t just implement a P&P by the hospital23
Ordering Privileges Resources
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Ordering Privileges Resources Must be consistent with any state licensing laws and
any state practice acts
Add to job description if C&P and write policy to include
So if state law says only a physician or practitioner responsible for their care can order then must follow
Many states are expected to change their state law to align with the federal CoPs as many states implemented because it use to be a federal regulation
In states without dietetics licensure or no defined scope of practice that prohibits writing diet orders then Medical Staff can grant privileges when approved by the Board
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Determine Scope of Practice
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States That Allow Dietician Privileges
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www.eatrightpro.org/advocacy/legislation/all-
legislation/therapeutic-diet-orders-state-status-and-regulation
Academy Practice Tips Ordering Privileges
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Amend Your Scope of Services or PC
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CMS Hospital CoPs on Food
and Dietetic Services
Appendix A
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Sample Page from CMS Manual
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Food and Dietetic Services 618
Food and dietetic services section starts at tag 618
Hospital must have organized dietary services
Must be directed and staffed by qualified personnel
If contract with outside company need to have dietician and maintain minimum standards and provide for liaison with MS on recommendations on dietary policies
See contract management standards tag 83-86
Dietary services must be organized to ensure nutritional needs of the patient are met in accordance with physician orders and acceptable standard of practice (common problematic standard)
Acceptable Standards of Practice CMS states must follow acceptable standards of practice
These are set by professional organizations such as the Academy of Nutrition and Dietetics (Academy)
Academy has a Code of Ethics for Nutrition and Dietetic Professionals
Discusses competence and use of evidenced based practice which CMS requires
Must collaborate with others and practice within the scope of practice which are also required by CMS
Has 4 principles and standards: competence and professional development in practice, integrity in personal and organizational behaviors and practices, professionalism, and social responsibility
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www.eatrightpro.or
g
Qualified Dietician or Nutrition Specialist
CMS has changed the interpretive guidelines to match the changes in the federal register
Added after the section that says by an order of the physician
Or by an order of a qualified dietician or qualified nutrition professional as authorized by the medical staff and board and in accordance with State law governing dieticians and nutrition specialist
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Dietary Policies Required 618
Need the following 7 policies:
Availability of diet manual and therapeutic diet menus
– Sometimes called Nutrition Care Manual (NCM) or Pediatric Nutrition Care Manual (PNCM)
Frequency of meals served
System for diet ordering and patient tray delivery
Accommodation of non-routine occurrences
– Parenteral nutrition (tube feeding), TPN, peripheral parenteral nutrition, changes in diet orders, early/late trays, nutritional supplements etc.
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Seven Dietary Policies Required 618
Integration of food and dietetic services into hospital wide QAPI and infection control programs
Guidelines on acceptable hygiene practices of personnel
Guidelines for kitchen sanitation
Important to protect against germs and bacteria that cause illness
1 in 6 Americans will have food borne illness and 800 outbreaks a year,128,000 are hospitalized and 3,000 die
Compliance with state or federal laws
Remember, CMS requires compliance with SOCs such as Academy practices and positions
Policies Should Be Consistent with National Standards
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www.eatrightpro.org/practice/position-
and-practice-papers/position-papers
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www.eatrightpro.org/practice/position-and-
practice-papers/practice-papers
So What’s in Your Diet Manual?
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CDC Wants to Prevent Foodborne Illnesses
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So What’s in Your Diet Manual?
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Diet Manual
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Sanitation Guidelines
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Kitchen and Food Service Observation Tool
There is a 10 page document on kitchen and food service observation CMS Form 20055
LTC form but helpful to review for hospitals
Looks at food storage and storage temperature
Explains to the surveyor to do an initial tour of the kitchen and observe practices that might indicate a potential for food borne illness
Observe for appropriate hand washing
Make sure food items in the refrigerated are labeled and dated and temp at 41 degrees or below
Make sure food stored under sanitary conditions48
Kitchen and Food Service Observation Tool
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www.cms.gov/Medicare/
Provider-Enrollment-
and-
Certification/SurveyCerti
ficationGenInfo/Downloa
ds/CMS-20055-
Kitchen.pdf
Headlines We Don’t Want to See
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www.beckershospitalreview.com/quality/14-henry-ford-hospital-patients-sickened-from-salmonella.html
CDC Food Safety Website
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www.cdc.gov/foodsaf
ety
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FDA Center for Food Safety Website
www.fda.gov/Food/default.htm
Get FSMA Updates by Mail
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/SMA/default.htmwww.fda.gov/Food/FoodSafety/FSMA/default.htm
Every year, 1 out of 6 people in the United States—48 million people--suffers from food borne illness, more than a
hundred thousand are hospitalized, and thousands die.die.
FDA Guidance & Regulations Documents
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www.fda.gov/food/guidanceregulation
/default.htm
CDC’s Food Safety Website & Email Updates
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www.cdc.gov/foodsafety/cdc-and-
food-safety.html
USDA Nutrient Database
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http://ndb.nal.usda.gov/
Food Safety Website
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State Public Health Departments
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State Agriculture Departments
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www.foodsafety.gov/about/state/index.html
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CDC Guidelines for Environmental IC
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www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
CDC Environmental Infection Control
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www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
Dietary 618Must comply with all state or federal laws
Most states have a specific state law on food sanitation rules
Same standard applies whether food and dietetic services are provided directly or through a contract
CMS and Joint Commission have a separate section on contracted services
Hospital needs to make sure are performed appropriately
Contracted services are evaluated through the PI process
Contract sections start at CMS tag 83 and TJC LD.04.03.09 with 10 elements of performance
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State Specific Food Sanitation Rules
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Oregon http://arcweb.sos.state.or.us/rules/OARs
_300/OAR_333/333_150.html
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Organization 620 Must have full time director of food and dietetic services
who is responsible for daily management of dietary services
Must be granted authority and delegation by the Board and MS for the operation of dietary services and this should include
Training programs for dietary staff and ensuring P&Ps are followed
Daily management of dietary
Make sure the P&Ps listed on the next slide are followed
So the job description should be position specific and clearly delineate this authority for direction of food and dietary services
66
Dietary Policies 620Safety practices for food handling
Emergency food supplies
Orientation, work assignment, supervision of work and personnel performance
Menu planning
Purchase of foods and supplies
Retention of essential records (cost, menus, training records, QAPI reports)
Service QAPI program
Dietician Qualifications 620The director must demonstrate through education,
experience, and training that he or she is qualified to manage the department
The director’s education, experience and training must be appropriate to the scope and complexity of the food service operation
Surveyor is to verify the director is a full time employee
Surveyor is to review their job description
Surveyor is to make sure he or she has the necessary education, experience, and training to manage dietary
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Dietitian 621 Qualified dietician must supervise nutritional aspects
of patient care
Responsibilities include:
Approve patient menus and nutritional supplements
Patient and family dietary counseling
Perform and document nutritional assessments
Evaluate patient tolerance to therapeutic diets when appropriate
Collaborate with other services (MS, nursing, pharmacy, social work)
Maintain data to recommend, prescribe therapeutic diets
Dietitian 621
If qualified dietician does not work full time, need to be sure there is adequate provisions for dietary consultations
Frequency of consultations depends on the total number of patients and their nutritional needs
Surveyor is to make sure that the total number of hours is appropriate to serve the needs of the patients
Must ensure adequate coverage when the dietician is not available
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Qualified Dietary Staff 622
Must have administrative and technical personnel competent in their duties
Ensure staff is competent through education, experience and specialized training
Personnel files should include documentation that the staff member is competent
Diets 628 Deleted 2015 Menus must meet the needs of the patient
Menus must be nutritional, balanced
Menus must meet the special needs of patients
Current menus should be posted in the kitchen
Screening criteria should be developed to determine what patients are at risk
Once patient is identified nutritional assessment should be done (TJC PC.01.02.01)
Patient should be re-evaluated as necessary to ensure their nutritional needs are met
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Meet Nutritional Needs 629Standard: Must meet individual patient nutritional
needs in accordance with recognized dietary practices
Includes inpatients and observation patients
Must follow recognized dietary practices
For example, the USDA Food and Nutrition Center mentions the nationally recognized source for recommended dietary intake
The IOM’s Food and Nutrition Board’s DRI or Dietary Reference Intake 4 reference values
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CMS Rewrites Tag 629
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Dietary ServicesThe IOM’s Food and Nutrition Board’s DRI or
Dietary Reference Intake 4 reference values includes:
RDA or the recommended dietary allowance is average dietary intake of a nutrition sufficient of healthy people
Adequate Intake (AI) for a nutrient is similar to the ESADDI and is only determine when an RDA cannot be determined
– Estimated Safe and Adequate Daily Intake (ESADDI)
– AI is based on observed intakes of the nutrient by a group of healthy persons
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Dietary Services 2015
IOM’s Food and Nutrition Board’s DRI or Dietary Reference Intake 4 reference values (continued)
Tolerable Upper Intake Level (UL) is highest daily intake of a nutrient that is likely to pose no risks of toxicity for most people
–As the UL increase, risk increases
Estimated Average Requirement (EAR) is the amount of the nutrient that is estimated to meet the requirement of half of the healthy people
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IOM DRI or Dietary Reference Intake
76http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes/dri-nutrient-reports
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78
www.health.gov/dietaryguidelines/2
015.asp
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80
www.nap.edu/download/24637
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www.nap.edu/download/24883
82
www.nap.edu/download/24828
Interactive DRI Tool and Tables
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Therapeutic Diet 629Therapeutic diets may help meet the patient’s nutritional needs
Assess patients for risk of nutritional deficiencies
Therapeutic diets refer to a diet ordered as part of the patient’s treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet (e.g., sodium or potassium), or to provide mechanically altered food when indicated
84
Therapeutic Diet 629Patients must be assessed to determine if they need a therapeutic diet for other nutritional deficiencies
Include in patient’s care plan
Include the need to monitor intake
Include if need daily weights, I&O, or lab values
Nursing does an admission assessment which includes a nutritional screen
These are good things to determine the patient’s risk and if a dietary consult is needed
85
Nutritional Assessment IncludesPatient May Need Comprehensive Assessment if:
Medical or surgical conditions or physical status interferes with their ability to digest or absorb nutrients
Patient has S&S indicating risk for malnutrition
–Anorexia, bulimia, electrolyte imbalance, dysphagia, ESRD or certain medications
Patient medical condition adversely affected by intake and so need a special diet
–CHF, renal disease, diabetes, etc.86
DietaryPatient May Need Comprehensive Assessment if (continued):
Patient receiving artificial nutrition
Tube feeding, TPN, or peripheral parenteral nutrition
Need an order for diets, including therapeutic diet, from practitioner responsible for care
Dietician or qualified nutritional specialist can be C&P to order diet as consistent with state law requirement
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Nutritional Assessment Form
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Nutritional Care Process Academy of N&D
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www.eatright.org/HealthProfessionals/content.aspx?id=5902
Therapeutic Diet 629Patients who refuse food should be offered
substitutes of equal nutritional value in order to meet their basic nutritional needs
Surveyor will ask dietician how the menus and nutritional needs of patient are being met such as rely on DRIs, including RDA, in developing menus
Will ask how patients are monitored who are identified as having specialized needs
Will look for order for therapeutic diet
Will look at sample of patient records of patients identified with special nutritional needs
91
Diet Order Needed 630Standard: Need an order for all patient diets
including therapeutic diets
Must be done by a practitioner responsible for the patient’s care (doctor, PA, NP) or qualified dietician or qualified nutritional professional
Must be authorized in the medical staff bylaws
Must be consistent with state law
A few states hold it against state law for a dietician to prescribe a therapeutic diet
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Patient Diets New Tag 630
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Diet Order Needed 630Diets must be based on an assessment of the
patient’s nutritional and therapeutic needs
Must be documented in the medical record
Including patient’s tolerance to the therapeutic diet
Patient has a new diagnosis of CHF and put on a 2 gram low sodium diet and losses weight because she does not like the taste of the food without salt
Board may permit the medical staff to grant privileges to dieticians or nutritional professionals
94
Diet Order Needed 630Many states have a specific statute that determines
when someone is a qualified dietician
Registered dietician may be defined to include one who is registered with Commission on Dietetic Registration or state law
Terms such as “nutritionists,” “nutrition professionals,” “certified clinical nutritionists,” and “certified nutrition specialists” are also used to refer to individuals who are not dieticians, but who may also be qualified under State law to order patient diets.
95
Diet Order Needed 630Hospital must make sure person is qualified before
appointing them to the medical staff and C&P
If the hospital decides not to C&P, even if that state’s law allows it, the patient must have a diet ordered by the practitioner responsible for the patient’s care
If not C&P the person can still do a nutritional assessment and make recommendations
Surveyor will make sure diet is ordered and if dietician writes orders is C&P whether appointed to the medical staff or not
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Nutritional Needs Survey Procedure 630
Surveyor is suppose to ask the hospital to show them what national standard they are using
Surveyor to view patient medical records to verify diet orders are provided as prescribed by the practitioner
Surveyor is to determine if patient’s nutritional needs have been met
Will determine if dietary intake and nutritional status is being monitored
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Diet Manual 631 A current therapeutic diet manual must be readily
available to all medical, nursing, and food service personnel
The manual must be approved by the dietitian and medical staff
The diet manual can not be more than five years old
The therapeutic diet manual must be available to all medical, nursing, and food service staff
Diet manual must be in accordance with current standards and include types of diets routinely ordered
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CMS CoPs for Critical Access
Hospitals
CAH Dietary Standards
CMS issues January 16, 2015 memo that rewrites the dietary standards and final interpretive guidelines issued April 7, 2015
These are very similar to the Appendix A standard but a little shorter
Knowing the Appendix A standards will help CAH understand their interpretive guidelines which are under Appendix W
Questions at CAHscg@cms.hhs.gov
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101
CAH Manual Also Called SOM
www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downl
oads/som107_Appendixtoc.pdf
CMS Rewrite Dietary for CAHs 2015
102
Current State Operation Manual
103
www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloa
ds/som107ap_w_cah.pdf
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Dietary 279 Standard: If the CAH furnishes inpatient services,
including swing bed patients
Procedures must be in place that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practice
And the orders of a practitioner
A CAH is not required to prepare meals itself.
Can obtain meals under contract,
Infection control issues in dietary hit hard
Dietary Services 279Must be staffed to ensure that the nutritional needs of
the patients are met
Must have a qualified director
Based on education, experience, specialized training and license, certified, or registered if required by the state
If swing beds must comply with following:
Make sure resident maintains acceptable parameters of nutritional status such as body weight and proteins
Receives a therapeutic diet
105
Dietary Services 279Must follow recognized dietary practices
For example, the IOM’s Food and Nutrition Board’s DRI or Dietary Reference Intake 4 reference values
RDA or the recommended dietary allowance is average dietary intake of a nutrition sufficient of healthy people
Adequate Intake (AI) for a nutrient is similar to the ESADDI and is only determine when an RDA cannot be determined
– Estimated Safe and Adequate Daily Intake (ESADDI)
– AI is based on observed intakes of the nutrient by a group of healthy persons
106
Dietary Services 279 IOM’s Food and Nutrition Board’s DRI or Dietary
Reference Intake 4 reference values (continued)
Tolerable Upper Intake Level (UL) is highest daily intake of a nutrient that is likely to pose no risks of toxicity for most people
–As the UL increase, risk increases
Estimated Average Requirement (EAR) is the amount of the nutrient that is estimated to meet the requirement of half of the health people
107
IOM DRI or Dietary Reference Intake
108http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes/dri-nutrient-reports
109
Interactive DRI Tool and Tables
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Guiding Principles DRI Chronic Diseases
National Academy has a free book on guiding principles for developing DRIs based on chronic disease 2017
Dietary Reference Intakes (DRIs) are used to plan and assess the diets of healthy people
They developed a committee to look at food substances and specific nutrients for patients with chronic diseases
287 pages
Available at https://www.nap.edu/download/24828
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112
113
www.nap.edu/download/24637
Dietary Services 279Therapeutic diets may help meet the patient’s nutritional needs
Patients must be assessed to determine if they need a therapeutic diet for other nutritional deficiencies
Include in patient’s care plan
Include the need to monitor intake
Include if need daily weights, I&O, or lab values
114
Nutritional Assessment Includes
Patient May Need Comprehensive Assessment if:
Medical or surgical conditions or physical status interferes with their ability to digest or absorb nutrients
Patient has S&S indicating risk for malnutrition
–Anorexia, bulimia, electrolyte imbalance, dysphagia, ESRD or certain medications
Patient medical condition adversely affected by intake and so need a special diet
–CHF, renal disease, diabetes, etc.115
Dietary 279Patient May Need Comprehensive Assessment if (continued):
Patient receiving artificial nutrition
Tube feeding, TPN, or peripheral parenteral nutrition
Need an order for diets, including therapeutic diet, from practitioner responsible for care
Dietician or qualified nutritional specialist can be C&P to order diet as consistent with state law requirement
116
Survey Procedure 279
Surveyor will verify dietician is qualified
Will ask how CAH uses DRIs in its menus to meet the nutritional needs of patients
Will identify to make sure patients were screened and assessed
Will make sure all diets are ordered
Will make sure dietary intake and nutritional status are being monitored as appropriate and swing beds patients aren’t losing weight and maintaining protein level
117
Joint Commission
Provision of Care Chapter Related to Dietary
Introduction to the PC Chapter
The Provision of Care, Treatment, and Services Chapter is referred to as the PC standards
There are 48 standards
It is a very important standard and focuses on care delivered to meet patient needs and includes some dietary standards
There are four core parts of the care process: assessing patient needs, planning, providing, and coordinating care, treatment and services
Interventions can be based on the plan of care
119
Time Frames for Assessment PC.01.02.03
EP1 The time frame for the initial nursing assessment needs to be in writing
In accordance with law and regulation
References RC.01.03.01 EP1 that requires the hospital to have a written policy the requires the timely entry of information into the medical record like the initial assessment
EP2 The assessment must actually be done within this time frame specified
References RC.01.02.03 EP2 which requires this be documented in the medical record timely
120
Time Frames for Assessment PC.01.02.03
EP7 A nutritional screen is done when warranted by the patient’s need within 24 hours after admission (DELETED July 1, 2016 as routine part of care)
Nurse does initial screens for nutrition risk and consult dietician
Screening criteria might include weight loss, poor intake prior to admission, chewing or swallowing problems, skin breakdown, aspiration problems, nutrition support, NPO, certain diagnosis etc.
CMS has criteria to use in determining when dietician should be consulted
121
Nutrition Screen
122
Food and Nutrition PC.02.02.03Standard: The hospital makes food and nutrition
products available to its patients
Food and nutrition services is hit hard during the CMS and TJC survey
TJC has a dietary and nutrition tracer which is very detailed
Important to pay attention to make sure the patient is eating their meals
EP1 The hospital assigns responsibility for the safe and accurate provision of food and nutrition products
DELETED July 1, 2016 because duplicative of PC.02.02.03 EP 6
123
Food and Nutrition PC.02.02.03 Hospital has a dietician to run the food and nutrition
program
EP6 Prepares food and nutrition products using proper sanitation, temperature, light, moisture, ventilation, and security
Food must be cooked in hot enough temperature to kill bacteria and other food borne diseases, hand hygiene
Most states have specific regulation on this
Don’t want meat on top to drip on food below in the refrigerator, clean can openers, hair restraints
Cutting boards must be appropriate cleaned
124
Food and Nutrition PC.02.02.03EP7 Food and nutrition products are consistent with
each patient’s care
EP8 Must accommodate a patient’s special diet and altered diet unless contraindicated
Many patients have special diets such as 1500 calorie ADA or 2 gram low sodium diet
EP9 Accommodates the patient’s cultural, religious, or ethnic food and nutrition preferences
Unless contraindicated
When possible
125
Food and Nutrition PC.02.02.03 EP10 When a patient refuses food, the hospital offers substitutes of equal
nutritional value
Important to observe if patient is refusing meals
Deleted as duplicative of EP7
EP11 The hospital stores food and nutrition products, using proper sanitation, temperature, light, moisture, ventilation, and security
Including those brought in by patients or their families
Should mark refrigerators “Food No Medications”
Make sure the temperature is checked for the refrigerators
Dated things in the refrigerator to show when they should be discarded
126
Food and Nutrition PC.02.02.03EP22 A current therapeutic diet manual approved
by the dietitian and medical staff is available to all medical, nursing, and food service staff
For hospitals that use TJC for deemed status
Diet manual can provide useful information for nursing and must be in accordance with national standard
A CMS requirement under food and dietary services
Many state laws also require a current therapeutic diet manual approved by the dietician and CMS says must be approved by the MS
127
Patient Education PC.02.03.01EP1 Need to do a learning needs assessment for
each patient that includes
The patient’s cultural and religious beliefs
Emotional barriers
Desire and motivation to learn
Physical or cognitive limitations and
Barriers to communication
Considering having a patient education interdisciplinary education sheet to capture all required elements
128
Patient Education PC.02.03.01
EP5 Education and training must be coordinated by all disciplines involved in the patient’s care
New diagnosis of diabetes and pharmacist covers medication issues, dietician covers dietary issues and the diabetic nurse educator covers diabetes education
Age of patient and education level (issue of low health literacy or interpreter) will impact educational needs
129
Patient Education PC.02.03.01EP10 Education and training to patient will include
the following based on the patient’s condition and assessed needs
Explanation of the plan for care
Basic health practices and safety
Safe medication use
Nutritional interventions, diets, supplements
Pain issues such as pain management and methods
Information on oral health (much information later on this including oral bacterium (periodontal disease) as cause of cardiovascular disease, MI, VAP, stroke, CAD)
130
Patient Education PC.02.03.01
EP10 Education and training to the patient
Safe use of medical equipment
Safe use of supplies
Rehab to help the patient reach maximum independence
EP25 Must evaluate the understanding of the education and training provided
Teach back is one method to verify understanding
Ask me three program by the National Patient Safety Foundation
131
132
http://www.npsf.org/askme3/
133
Use a Patient Education Form
134
Use a Patient Education Form
135
136
http://www.docstoc.com/docs/downloaddoc.aspx/?doc_id=35987557&pt=16&ft=11
Patient Education Checklist
137
Eating Disorders Behavioral Health
TJC has eating disorder standards for behavioral health care at CTS.02.03.11
For organizations that provide eating disorders care and treatment
Discusses what must be assessed: CBC, metabolic profile, ECG, thyroid function test, measure BMI, heart rate, screen for eating disorder behaviors etc.
Obtain behavioral and physical health information from providers who have treated the patient
Also has a R3 report
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www.jointcommission.org/assets/1/6/R3_Eating_Dis
orders_Stds.pdf
Eating Disorders Behavioral Health
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Joint Commission Tracers
What Hospitals Need to Know about
the Dietary Tracer
Discharge Planning TracerTJC has a discharge planning-active review tracer
Will ask for a list of patients to be discharged
Will review their discharge order
During the discharge planning process surveyor is to interview the patient
Interview to make sure the patient’s understanding in the changes in diet and dietary restrictions or supplements
Will ask same in the retrospective review when calling patients at home discharged in past 48 hours
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Dietetic and Food Services TracerObjective is to assess and determine compliance
with standards and EPs related to nutrition care
Objective to increase awareness of risk in nutrition care practices and food service operations
Tracer begins where patient is located
Surveyor to look for specific diet order from doctor
Will ask what national standard the hospital is using for recommended dietary allowances
Will look at infection control issues such observe hand hygiene, hygiene practices and kitchen sanitation
Dietetic and Food Services TracerWill discuss the following;
Safe practices for handling food
– Is the hot food hot enough, is the cold food the correct temperature, how do you clean the thermometers used to check the food, wipe off can lid, clean can opener, etc
Assessment process to determine patient dietary needs
Process for prescribing and evaluating therapeutic diet orders
Process for accommodating special and altered diet schedules
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Dietetic and Food Services Tracer Discuss
Follow-up process when the patient refuses food served
Nurse contacts dietician or offers patient other courses allowed by their current diet order
Qualifications of dietitian and dietary services director
During competence assessment surveyor is instructed to review the personnel file of the director of dietary services
To verify there is a full time director
Verify availability of a current therapeutic dietary manual for reference
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Things Looked at in the PastThere are a number of things that surveyor have
also looked at in the past both from CMS and TJC
Will look for nutrition screening and dietician assessment
Look for evidence that dietician written recommendations are being followed
If physician orders consult with dietician
Be sure hospital P&P allows dieticians to accept verbal orders (see position paper)
See additional slides at the end for additional things that the surveyors have looked at in the past
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DNV Healthcare Standards
on Dietetics and Nutrition
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DNV Healthcare Dietary Standards
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DNV Dietary ServicesMust make sure technical staff are competent to
do their jobs
Qualified dietician must be available to address issues and do patient care planning
Nutritional needs of patients must be met
Must be provided in accordance with the practitioner’s orders
Director of dietary must be delegated responsibility by the medical staff and board
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DNV Dietary Services Lists many of the P&P required:
Orientation and work assignments
Safe practices for handing food
Emergency food supplies
Supervision of menu planning
Availability of diet manual & therapeutic menus
Frequency of meals served
Process for tray ordering
Accommodation of non-routine occurrences
Acceptable hand hygiene practices150
DNV Dietary ServicesAlso lists the job description of the qualified
dietician;
Approving menus
Dietary counseling
Performing nutritional assessments
Evaluating patient tolerance to diets
Maintain professional standards of practice
Keep data to recommend, prescribe or change diets
Collaborate with other hospital services such as nursing, the MS, pharmacy, social services, etc
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DNV Dietary ServicesDS.2 Services and Diets; ensure the following;
Menus meet the needs of the patient and are balanced
Therapeutic diets are prescribed by practitioner responsible for the patient’s care
Note the federal law change regarding if MS C&P dietician then dietician can order diet
Nutritional needs are met in accordance with dietary practices
Surveyor will look at screening criteria to identify patients at nutritional risk
– Patients getting artificial nutrition, like TPN, or whose medical condition interfere with ability to digest or absorb nutrients
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DNV Dietary Services If patient refuses then offered appropriate substitute
Diets should be documented in the medical record and order received
Will make sure the patient’s dietary intake and nutritional status is monitored and re-assessed
DS.3 Diet Manual requires a manual to define current therapeutic diets used by the hospital
Diet manual must be approved by dietician and MS at least every five years
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Be Aware of Organizations
Position Statements and
Guidelines
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ADA now Academy of Nutrition and Dietetics
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www.eatright.org/
Academy of Nutrition and Dietetics
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www.eatright.org/
Resources for Health Practitioners & RD
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Physical Activity Toolkit
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Position and Practice Papers ADA
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http://www.eatright.org/HealthProfessionals/content.aspx?i
d=6889
Academy of Nutrition and Dietetics
Some of the things on their website:
Nutrition care manual with 100 diseases and conditions
Pediatric nutrition care manual
Sports nutrition care manual
Practice papers
RD and hospital privileges
Evidence analysis library
Evidenced based practice guidelines160
Hospital Privileges for Dieticians 4 pages
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Society for Nutrition Education
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http://sne.org/
Writing Dietary Orders
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www.eatright.org/search.aspx?search=hospital+dietary+manual
Dietary Managers Association
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http://www.dmaonline.org/
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http://www.cdmcareer.info/
Commission on Dietetic Registration
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www.cdrnet.org/
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American Society for Nutrition or ASN
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www.nutrition.org/
AM Society for Parenteral & Enteral Nutrition
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www.nutritioncare.org/
Dietitian Central
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www.dietitiancentral.com/
ServSafe
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www.servsafe.com/home
Healthy Plate
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California Hospitals and Compliance
with the CMS Hospital CoPs
Always Be Aware of Any State Specific Laws
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California HospitalsCalifornia has Title 22 standards and surveyors are
known to be very detailed
Things they have looked at:
Pull apart every piece of lettuce to wash it
Review disaster manual and inventory and make sure patient has enough water every day
if 1500 calorie ADA diet would calculate out every calorie, fat, carb, etc.
Looked at each piece of cheese from the vendor to see protein content and problem if vendor changes products
Wanted to see dates on containers in refrigerator
Wanted purpose, intent, principles of each diet in diet manual, and meal patterns
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CDPH Memo May 24, 2013Ca Dept of Public Health issues memo based on
their state law and federal law
Two pages and addresses diet manual, orders, menu planning and disaster menu planning
Diet manual needs to include the purpose and principles of each diet, the meal pattern
Diet manual and diets ordered by the physician should mirror nutritional care by the facility
To make sure meeting nutritional needs of patients in accordance with Recommended Dietary Allowances (RDA)
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California Hospitals
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www.cdph.ca.gov/certlic/facilities/Documents/LNC-AFL-13-11.pdf
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CDPH MemoDietary Reference Intake (DRIs) are most recent set
of dietary recommendations established by the Food and Nutrition Board of the Institute of Medicine
DRIs encompass the FDAs and Adequate Intakes (AIs) as the national standard of practice for menu and nutrient analysis
Nutritional adequacy related to carbs, fat, and protein content is to be evaluated
Need to develop disaster menu planning under state law
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Dietary Reference Intakes DRI
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http://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx
California Dietetic Service Requirements
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The End! Questions???
Sue Dill Calloway RN, Esq. CPHRM, CCMSCP
AD, BA, BSN, MSN, JD
President of Patient Safety and Education Consulting
5447 Fawnbrook Lane
Dublin, Ohio 43017
614 791-1468 (Call with questions, No emails)
sdill1@columbus.rr.com183183
Food Labels
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Surveyor Has Observed in the Past
Meal being served to patients; patient receives assistance with eating, when needed; staff monitoring patient food consumption
Staff practices relative to food safety such as monitoring food temperatures, transportation practices, potential food borne infections, etc.
Kitchen and food preparation areas focusing on sanitation, maintenance, and safety
Food preparation (recipes, special diet preparation, food nutrient retention considered in preparing) and serving (portion size served, system staff follows to serve correct diet)
Therapeutic diet meal preparation process (e.g., fat free, low salt, restricted/increased calorie count) or mechanical preparation (e.g., pureed, thickened)
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Topics Dietary Tracer
Assessment, care planning and instruction by qualified staff
Identification of nutrition risk
Nutrition screening criteria (CMS has also)
Timeframes for nutrition assessment and re-evaluation of nutritional risk
Measuring food consumption such as methods for doing, responsible staff, use of the data
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Topics Dietary Tracer
Specific population needs, such as patients that are NPO, receiving hyperalimentation, on vents, in isolation, suffering from burns
Process for obtaining meals for patients after food service hours
Procedures followed for patients refusing meals
Consultations and referrals
See PC.02.02.03, HR.01.04.01, HR.01.05.03
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Topics Dietary Tracer
Nutritional adequacy of patient diets
Discharge education plans and referrals
Dietetic service staff training (departmental and interdepartmental)
Communication between dietitians and food service if not considered the same department
Dietitians included and participating in care planning process
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Topics Dietary Tracer
Surveyor will speak with dietary director about day to day operations including
Qualifications of dietary director
Responsibilities of dietary and food services leadership and management
Involvement with others for P&Ps (MS, Nursing)
Scheduling of food
Safe food handling and health of dietary staff
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Topics Dietary Tracer
Contracts for services, food, and nutrition services
Emergency disaster planning for patients and staff
Hospital diets and menus (selective or nonselective, nourishment choices, foods common to community)
Sanitation and infection control (pest control, chemicals)
PI activities, PI process, standards of practice being followed and food preparation and storage procedures
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Food and Dietetic Services Tracer
Maintenance of space and equipment
Process for prescribing and evaluating therapeutic diet orders
Processes for accommodating special and altered diet schedules
Surveyor is to explore the role of dietary in the evaluation of medication
Surveyor to Discuss in Past
Process for accommodating special and altered diet schedules
Follow-up process when the patient refuses food served
Qualifications of dietitian and dietary services director
And verify availability of a current therapeutic diet manual for reference
Will also observe for hand hygiene
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Does Your Hospital Use a Tracer?
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