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The Survey Process: Preventing F‐Tags in Food, Dining & Nutrition Services

PRE‐RECORDED AUDIO CONFERENCE

Release Date:

Wednesday, July 22, 2015

Presenter: Leslie Doyle

Regional Nutrition Manager, Sodexo

Packet Contents: Handout Credit Instructions CEU Affidavit Evaluation/Credit Form for NAB credit Post‐Test

.

LeadingAge New York/FLTC 13 British American Blvd. Suite 2 Latham, NY 12110 518.867.8385

The Survey Process December 16, 2014

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Confidential and proprietary to Sodexo. Do not share or post without proper consent.

The Survey ProcessPreventing F Tags in Food, Dining & Nutrition Services

June 2015

Presented by: Leslie Doyle, RD, CDPRegional Nutrition Manager; Sodexo Senior Living

AGENDA

2 –

1. Learn the common F-Tags cited for Food and Nutrition Services.

2. Learn the Survey process.

3. Learn what the Surveyors will inspect in the Food Service department and with the Clinical team (Dietitians, Diet Technicians).

4. Learn how to prepare your employees and managers for a successful survey.

The Survey Process


2

Why the survey? What’s it all about?

The Center for Medicare & Medicaid Services (CMS)

Write and enforce federal regulations that govern long term care facilities

CMS contracts with state agencies to conduct nursing home inspections or surveys

Done yearly to renew the facilities license - 9-15 month window of opportunity

Survey Team

Consist of team of nurses, dietitians and others

Prepare for visit ahead of time

Greater focus on kitchen and dining then previous years

Focus on prevention of food borne-illness

In kitchen within 10 –15 minutes of arrival

3 – The Survey Process

Federal Tags

Common Food and Nutrition F TagsF-325 Maintaining Nutritional Status

F-363 Menus and Nutritional Adequacy

F-364 Food Preparation

F-367 Prescribing Therapeutic Diets

F-371 Food Service/Storage/Preparation/Distribution

F-372 Proper Disposal of Garbage and Refuse



3

Always be ready

Educate team

Have a plan

Develop code word or phrase

Quick review

Assign employees, examples:AM cook removes any potentially hazardous food from counter tops and dispose leftover breakfast items

AM cook checks labeling and dating

AM diet aide checks dumpster door closed and area is clean

RD checks nursing pantries, activities or other food areas

5 –

Preparing Ahead and Initial Response

The Survey Process

General Manager Duties

Walk thru kitchen

hairnets/beard guards are covering ALL hair

temp logs completed and accurate,

no food storage on floor

trash cans covered, scoops are stored outside container

no personal items

no thawing in sink

clutter free and neat work stations

Check staffing

Notify any personnel required

Check menu

Stay in kitchen and await arrival of surveyor



4

Initial Walk through and Day 1

GM and possibly RD accompanies surveyor

Stay with the surveyor at all times

Take notes

Correct all concerns immediately

Continue to direct your staff

Ask if any concerns

Correct issues ASAP, act quickly


Documents Needed

Surveyors may request:

Copy of menu with therapeutic extensions including portion sizes

List of patients who receive mechanically altered diets

List of patients on adaptive devices

Meal delivery time schedule

Most recent county sanitation inspection report

Current food service contract if managed by a food service company

Credentials of GM and RD

Serve Safe Certifications



5

During the SurveyProduction

Check temperature of food

Infection control, no bare hand contact

Dishwashing procedures

Food handling techniques, proper hand washing

Trayline

Spreadsheet review

Condition of service ware, no wet nesting

Food attractive, rich in color

Glove usage

Dining

Look at time taken to deliver room trays

Dignified dining practices, serve one table at a time, proper positioning and special needs

Disposables not used, environment pleasant

Food substitutes are offered


During the Survey

Monitor all meals

Check recipes and spreadsheets

Stay on time

Make rounds in all dining location and hallways

Survey driven Resident Council MeetingWhat is the food like here?

Does the food taste good and look appealing?

Is the food served at the proper temperature?

Do you receive a bed time snack?

Do you receive the fluids you want between meals?

Review past survey results

Read past Resident Council minutes

Read Concern Logs 10 – The Survey Process


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During Survey Week

Life Safety Inspection

Kitchen equipment fire safety, hood cleaning

Usually occurs day 2 or 3

Storage shelf 18 in rule (from bottom of sprinkler head)

Temperature logs

Adequate lighting and air temperature

Fire extinguishers

No blocked exits or panels

May ask staff questions

What would you do if there was a fire?

Where is hood exhaust release?

RACE and PASS, do they know how to operate a fire extinguisher?


12 –

Food Service Focus

The Survey Process


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Employee Hygiene and Food Service Policies

13 –

Shower before coming to work. Wear clean uniforms, aprons, and shoes.

Remove all jewelry (except smooth surface rings) and watches. No nail polish.

Follow the rules for eating, drinking, smoking, and gum chewing only in designated areas.

Cover cuts and burns on hands and arms with clean bandage. Wear disposable glove over bandaged hand.

Inform your Manager if you are sick. If you have a fever, diarrhea, and/or vomiting, you should not work around food.

The Survey Process

Hand Washing/Personal Hygiene Key to preventing foodborne illness.

Make sure staff is educated on the proper hand washing technique (at least 20 seconds with soap and water) and when to wash hands (i.e. after using restroom, before starting work, after eating, drinking, and smoking, after coughing/sneezing, after handling chemicals).

Post sign above sinks that are designated for employees.

Good personal hygiene and clean work clothes are key to prevent FBI.



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Hairnets

Hairnets should be readily available to staff at the doorway before they enter the kitchen area.

Managers and Dietitians must set an example and comply with this same standard of practice when in kitchen area.


Hair covering

All employees working in the kitchen must have their hair covered by hair net or cap.

All mustaches and beards must have a beard covering.



9

Glove Usage

Single Use Glove Usage:

Wash hands before putting on gloves.

Wear gloves when handling ready-to-eat food without utensils, when serving food without utensils.

Change gloves when torn or soiled.

If you have cut or burn on hands, you must cover with a clean bandage and put on a disposable glove.

Gloves are for single use only. Change gloves before starting a new job (i.e. preparing food, going into a refrigerator, or handling cash).


Chemical Storage

Store chemicals away from food and preparation areas.

Be sure all chemicals (original labeled containers) are labeled.

Check to make sure your MSDS book is up to date.



10

Storage of flammable liquids

Do you have sternos stored in a fire proof safe box?

Is it locked?


Examine equipment for safety and quality

Examine cutting boards and other equipment to ensure in good shape.

Discard worn, chipped, or dented equipment (i.e. cutting boards, trays, dishes, pots/pans).



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Ice Machine

Make sure ice machine is on a regular cleaning schedule.

Audit to make sure scoop not inside machine and it is clean inside and outside.


Can Openers

Have can openers on a regular cleaning schedule.

Audit to ensure the inside shaft is clean and free of any food residue.



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Kitchen Cleaning Schedule

23 –

Have all equipment and areas of the kitchen on a cleaning schedule (i.e. daily, weekly, and/or monthly). Have schedules available for Inspectors.

Inspectors will be looking for equipment that is heavily soiled with dust & debris (F-456).

The Survey Process

Dish Machine Area and 3 Compartment Sinks

24 –

Ensure dish machine temperature logs are in place.

Ensure 3 compartment sinks have a sanitizing solution log in place to verify concentration is correct.

Train staff on the proper water temperatures, ware washing steps, how to properly sanitize, and the importance of air drying. Ask staff to explain these procedures back to you to verify their understandings.

The Survey Process


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Prevent Wet Nesting

Educate staff on the proper method of air drying pots, pans, dishes, etc.

Conduct regular audits to ensure staff is not putting wet pans and pots together.


Sanitizing Food Contact Surfaces

26 –

Any surface that comes in contact with food must be first cleaned and then sanitized to prevent contamination.

Ensure sanitizing solution is at the proper concentration and in a clearly labeled spray bottles or buckets used for sanitizing.

Test solution at least twice each day and record on sanitizer solution log.

Change solution when dirty or no longer at proper concentration. Keep wiping clothes in solution between uses. Replace cloths that have become soiled.

The Survey Process


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Cooler and Freezers

27 –

Inspect gaskets around doors of Coolers, refrigerators, and freezers to ensure they are not torn or ripped. Replace gaskets as needed.

Verify temperatures are being taken and immediately address any temperature problems.

Ensure temperature logs are in place.

The Survey Process

Flour/Sugar Bins

Make sure all flour, sugar, bread crumb bins are labelled with product, and date product was added.



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Food Labeling (F371)

Train staff on the importance of covering, labeling and dating all food products.

Rotate food (FIFO).

Discard expired food items.


Thermometers

Ensure they are properly clean, sanitize, and calibrated.

Train staff how to calibrate thermometers and record on log.

Have logs available for inspectors.



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Cooking Temperatures

Staff should be aware of the required minimum internal temperatures for meat, poultry, seafood and eggs.

Taking temperatures to ensure all foods heated to the proper temperature.

ServSafe certification for all Managers and Production staff (Cooks).

Reheat foods properly and record on HACCP log.


Cooling Food

Ensure that food is cooled quickly to move it out of the danger zone by following the proper cooling methods (i.e. ice bath, pre-chilled stainless steel containers).

Have HACCP logs completed and available for Inspectors.



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Receiving and Storing Foods

Receiver should be checking temperatures of all hazardous foods received. Do not accept foods that are not at the proper temperatures.

Inspect packaging quality of all foods. Look for signs of thawing and refreezing, signs of pest infestation, dented cans. Check temperatures.

Store refrigerated and frozen foods as soon as possible (within 1 hour of delivery).

Store foods at least 6” above the floor and away from the walls.

Use the First In, First Out method for storing food.

Cover, label, and date all food in storage.

Store less hazardous foods above more hazardous foods.


Dry Storage

34 –

Use the FIFO method. Date items for proper rotation.

Store foods at least 6 inches off of the floor and walls to allow for proper cleaning.

Keep storage carts clean.

Store foods on shelf at least 18 inches from ceiling.

The Survey Process


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Food Storeroom

Does this meet the 18 inch compliance rule?


Meeting 18 inch compliance

Put a red tape line to show staff where not to store any items above.



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Dented Cans

37 –

Designate a separate area for dented cans for return.

Have Receiving staff inspect the storerooms to ensure no dented or damaged cans on shelf. Remove any dented or damaged cans from service.

The Survey Process

Conduct regular kitchen audits

Ceiling tiles in good shape and free of dust, water stains.

Examine all refrigerators and freezers to make sure the gaskets are in good shape and not torn.

Lights are covered with proper shields.

Evidence of labeling and dating all food.

Air vents are clean and free of dust.

Floor is in good shape, and clean.

No broken floor or wall tiles.

Overall kitchen is clean in appearance from floor to ceiling.

Verify cleaning schedule is being followed. Inspect all kitchen equipment for cleanliness (i.e. toaster, slicer, knife racks, ovens).



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Emergency Preparedness

Three days emergency supplies available (food, paper, and water). Stored in a separate area. Climate control.

Date all food and water with expiration date.

Have an emergency disaster plan and policy, emergency menu (includes modified diet consistency) in place.

Water supply (1 gallon of water/person X 3 days)

Ensure staff training is conducted on an annual basis.


Pest Control

Check regularly for pest infestation (i.e. fruit flies).

Have a contract with a Pest Control company with monthly inspections and any needed treatments.



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Can Your Staff Answer Confidently?

Questions frequently asked:

What should your dish machine temperatures be?

How do you test the 3 compartment sink sanitizer?

What do you do with leftovers?

How do you calibrate thermometers?

What should the temperature of the refrigerator/freezer be?

Why are you wearing gloves for this task? When do you change gloves?

How often do you wash your hands?

To what temperature do you reheat food?


Scenario

1. Surveyor watching cook take temps for lunch. You are running 10 minutes late. Puree vegetable temped at 128 degrees. First trays on line are puree diets. What should you do?

Reheat puree veg to 165 / Hold puree tickets from line / Call nursing to report delay

2. Surveyor checks the dish machine, the wash temperature is 140 degrees. What should you do?

Ask staff to stop washing dishes/ call maintenance / check recent temp recording on DM log / check booster heater / run test strip / re-run all dishes that were previously washed

3. Surveyor questions continued weight loss on resident you have been following. He/she wants to know why you have not been able to prevent the decline? How do you respond?

Stay calm review your notes first before responding / show past notes and assessments / show weekly weight trends / conversations with res or family / interventions and supplements tried and failed / care plan updates / past food preferences forms / special meal requests provided / diagnosis related decline possible reason

4. Surveyor questions how often sanitizing buckets are changed?

When water is visibly dirty / When it no longer has proper ppm concentration



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Nutrition Focus F Tags

Dietitians Focus

44 –

Registration with current documentation on file (on-line verification) for RD and DTR.

Dietitian approved and signed Menu including the diet extensions.

Approved Diet Manual available and signed by the Medical Director, Dietitian, and Speech Therapist (as needed).

High Nutrition Risk Residents- tube feeders, significant weight changes, pressure ulcers, dialysis- should have at least monthly nutrition notes.

Involved in Meal Rounds, and Tray Assessments. Be sure to taste the food and listen to what the residents are saying about the food!

Active member at all IDC team meetings (Morning report, Care plan/Family meetings, Food Committee, QAPI, Weight Committee, Wound Rounds, etc.).

The Survey Process


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Nutrition Documentation

45 –

The Clinical team (Dietitian and Diet Technician) should make sure their documentation is consistent and matches from their assessments, nutrition notes, and care plans.

Ensure nutrition documentation is up-to-date (Initial/Annual/Quarterly Assessments, Care plans).

Care plan in place for triggered CAAs. Care plan problem reflects current status with appropriate and measureable goals. Interventions appropriate and updated with recommended changes.

Appropriate calculations for needs based on practice standards.

Periodic audits to review the content and timeliness of documentation.

The Survey Process

Diet Orders and Portion Sizes (F-364)

Modified Food Consistency- ensure these foods are properly prepared. Ensure Production staff are following the recipes.

Diet orders- ensure staff is providing the correct meal and liquid consistency to the resident per the physician diet order. Verify portion sizes are correct at the meal.

Dietitian should conduct regular audits to ensure MD diet order agrees with diet served (meal ticket).



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Correct Diet Order

Must provide prescribed diet in accordance with the MD orders.

Verify you are serving the resident the correct diet ordered. Refer to the tray ticket as a guide.

The Survey Process47

Proper Thickening Training



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Menus and Choices (F-242)

49 –

Menus must be posted at wheel chair height with available alternates. Meal times should be posted.

Food Preferences honored within reason.

Request for alternate meal times honored within facility constraints.

The Survey Process

Meal Times and Evening Snacks (F-368)

50 –

System in place for offering evening snacks with evidence that it occurs.

If greater than 14 hours between dinner and breakfast meal, you must have the following:

* Resident Council approval on file.

* Substantial evening snack (including protein) offered.

* Documentation that snack was offered.

The Survey Process


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PROPER POSITIONING, MEAL TIME ASSISTANCE, AND FEEDING SAFETY

Proper positioning at meal time

Position resident to be upright at 90 degrees.

Provide a dining room chair with arm rest for support to help with the correct positioning.

Residents in wheel chairs should be at an elevated table to allow wheel chair arm supports to roll under table. The wheelchair should be locked into place.

Residents with poor sitting balance or neck control should be evaluated by a therapist for recommended strategies.

Resident should remain upright for at least 20 to 30 minutes after eating.



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Level of Assistance Needed

Know the level of assistance at meal time:

• Independent with set up and distant supervision

• Verbal cue during meal

• Set up and assist as needed

• Total feed

Staff should sit at the table with the residents that need assistance.

Staff should be alert at all times for choking.


Feeding and Swallowing Strategies

Provide training on feeding to staff. Utilize the state approved paid feeding assistant training program.

Follow the resident’s care plan that outlines their feeding and swallowing strategies.

Some examples of feeding/swallowing strategies:

*No Straws

*Eat slowly, alternating small bites with single sips

*Tongue sweep to clear residue

* Finish swallow before taking another bite

*Oral care after meals.

Staff should be familiar with signs of swallowing problems (i.e. pocketing food in cheeks, coughing, wet sounding voice).



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Feeding Safety Citations Examples

F323 – failure to provide adequate supervision (resident left unattended) for a resident on a mechanically altered diet with feeding strategies in place.

F309- failure to provide the prescribed diet in accordance with the MD orders. Visitor given permission by the nurse to give a resident who was on a ground diet marshmallows.

F323- failed to provide the level of meal assistance per resident assessment.


Probing Questions by Surveyors

The Survey Process

What type of education has been provided to staff and families regarding diets, feeding assistance, choking?

Does the education include what foods are appropriate for each level of a modified diet?

Are family members provided education when a prescribed modified diet has been ordered? Do they know what is allowed and what is not?

Has staff been trained on proper feeding and swallowing strategies?

For Agency staff, how are they made aware of the facilities policies and procedures on diets and feeding assistance?

Training provided on signs/symptoms of choking, difficulty chewing or swallowing?

56


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Dining Experience

Enforce the New Dining Standards:

*Liberalized Diets

*Focus on Food First- fortified foods

*Eliminate Medical nutrition supplements

Conduct dining room observations and audits. Verify dining standards (F-tags) are being met for:

Resident Choice (F242) Dignity (F241) Nutritional Status (F325) Food Substitutes (F366) Comfortable room temperature (F257) Space/Lighting (F257) Home-like environment (F252) Infection Control (F441) Meal times and evening snacks (F368)

Write up an action plan to address any deficient practice.


End of Each Day

Stay in the loop:

Administrator will have exit meeting

Report the day’s events

Develop plan and correct concerns

Arrive early, stay late

Correct concerns and make sure they do not reoccur

Invite them back for second look



30

Top Tags in New York

59 –

F-371 Food Service/Storage/Preparation/Distribution

- labeling, dating, outdated food or beyond “use by” date

- dirty equipment

- wet nesting pot/pans, trays, glasses

- no sanitizing buckets, cleaning towels left out

- employee drinks/food in prep area

- staff failed to wash hands after touching contaminated area.

F-325 Maintaining Nutritional Status

- significant weight loss not addressed on care plan, no goal

- res w/weight gain, supplement not discontinued

- MD order for RD recommended intervention not done on weight loss resident

- RD did not update care plan to reflect current condition.

F-372 Proper Disposal of Garbage and Refuse

- dumpster lid open

F-363 Menus and Nutritional Adequacy

- puree dessert not same as regular menu

The Survey Process

Keep our Residents healthy and happy!

60 –

Our main mission is to not only serve our residents a healthy, nutritious, and satisfying meal, but also ensure their food is safe.

The Survey Process


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Summary1. Educate and prepare your staff on an on-going basis (i.e. In-

services, competency assessments, ServSafe certification).

2. Quiz staff on the proper procedures for food handling, cleaning, equipment use, labeling, recording temperatures on a regular basis.

3. Conduct regular audits to ensure compliance to standards.

4. Managers and Supervisors must “walk the talk”. Follow the rules you have set forth in the kitchen (i.e. wear a hair net, wash your hands).

5. Have a cleaning schedule in place for the kitchen, and food pantries on the units.

6. Dietitians should have a system in place to ensure timely and appropriate documentation in place for all residents with nutrition assessments, high risk nutrition notes, and care plans.

7. Care plans should have current problems, measureable goals, and interventions.


Summary

62 –

8. Dietitians should ensure the new Dining Standard guidelines are in place (i.e. diet liberalization, food first focus).

9. Temperature logs should be in place and completed daily (HACCP, Refrigerators/Freezers, Dish machine), thermometer calibration, 3 compartment sink logs).

10.Conduct regular meal rounds and assess how meal satisfaction with the residents. Make needed changes to resident’s food preferences and menus to improve overall satisfaction.

11.All high nutrition risk residents should have at least a monthly note. Interventions should be modified if no progress (i.e. pressure ulcer healing).

12.Menus should be meet the nutritional adequacy requirements, modified seasonally, include diet extensions, and be approved/signed by Registered Dietitian.

13.Stay with Surveyors during inspection and correct any deficient practice.

The Survey Process


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You are on your way to a successful survey!


CREDIT INSTRUCTIONS

Pre‐Recorded Audio Conference: The Survey Process: Preventing F‐Tags in Food, Dining & Nutrition Services Release Date: Wed. July 22, 2015 Credit Available: 1.00 hour of Licensed Nursing Home Administrator (NAB) credit for up to four individuals from the same facility (no affiliates) Instructions for Obtaining Credit: Please complete and fax the following forms to 518.867.8386 or 518.867.8389 no later than August 5:

CEU Affidavit

Evaluation/Credit Form

Post‐Test Print the credit forms for each individual seeking credit. On each form, indicate the name of the person that your organization’s registration is under. Please note: Credit certificates will be issued approximately one month after the program if payment has been received in full. Credit Details: The FLTC is a certified sponsor of professional continuing education with the National Association of Boards of Examiners of Long Term Care Administrators (NAB). NAB has approved this program for 1.00 hours of continuing education credit. State licensure boards, however, have final authority on the acceptance of individual courses.

If you have any questions, please contact Donna Conroy at 518.867.8385, ext. 111 or [email protected]

PLEASE FAX TO FLTC: 518.867.8386 OR 518.867.8389

CEU Affidavit for Administrators

Pre-recorded Audio Conference: The Survey Process: Preventing F-Tags in Food, Dining & Nutrition Services Release Date: Wednesday July 22, 2015 Credit: 1.0 hour of Licensed Nursing Home Administrator (NAB) credit

Organization: ________________________________________________________________________ Name of Registrant: ___________________________________________________________________ This form attests that _________________________________________________________________,

(Full name of administrator seeking credit)

____________________________________________, was in attendance for the full 1.0 hour of the (Title)

audio conference, The Survey Process: Preventing F-Tags in Food, Dining & Nutrition Services Witness: (Print) _______________________________________________________________________

(Staff in attendance, other than the administrator)

(Signature) _______________________________________________ Date: ______________


Evaluation/Credit Form

Pre-Recorded Audio Conference: The Survey Process: Preventing F-Tags in Food, Dining & Nutrition Services Release Date: Wednesday, July 22, 2015 Credit: 1 hour of Licensed Nursing Home Administrator (NAB) credit

EVALUATION

1. How many other staff from your organization were listening to the audio conference with you?-________________

Please check the box that best describes your rating: Excellent Good Fair Poor

a. Overall rating O O O O

b. Presenter’s knowledge of material/topic O O O O

c. Learning objectives & content material O O O O

d. Usefulness of the knowledge/skill required O O O O

e. Appropriateness of topic content O O O O

3. Was participating in this seminar a wise business decision? O O

If not, why? _________________________________________________________________________________________________

_________________________________________________________________________________________________

4. Is LeadingAge New York/FLTC your first choice for educational opportunities? O O

5. What new developments in the field do you believe will have an important future impact?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

CREDIT INFORMATION - All fields MUST BE COMPLETED below in order for us to process your credit!

Name of Registrant for your Organization:______________________________________________________________

Name & Title of Person Seeking Credit:_________________________________________________________________

Organization: ____________________________________________________________________________________

Address: _________________________________________________________________________________________

City: _______________________________________________________State: ____________Zip: _________________

Telephone: ( ) ____________________________E-Mail: ______________________________________________

Place a check next to the type of credit you are seeking: ____ NAB

NYS NH Administrator License No.:____________________________________________________________________

I am also licensed in other states with license numbers as follows:___________________________________________

This program has been reviewed and approved by NAB/NCERS. NCERS strives to approve only quality programs whose

content can reasonably contribute to the professional development of long-term care administrators. If you have any confidential comments concerning this program, which you would like to make to NCERS administrators, please direct them to

[email protected].

Yes No

Yes No


Post‐Test for NAB Credit

Pre‐Recorded Audio Conference: The Survey Process: Preventing F‐Tags in Food, Dining & Nutrition Services Release Date: July 22, 2015 Credit: 1 hour of Licensed Nursing Home Administrator (NAB) credit Name of Registrant: _________________________________________________________________________ Name of Person Seeking Credit: ________________________________________________________________ PLEASE CIRCLE THE CORRECT ANSWER:

1. The key to preventing foodborne illness is:

a. To make sure staff is educated on the proper hand washing technique (at least 20 seconds with

soap and water) and when to wash hands (i.e. after using restroom, before starting work, after

eating, drinking, and smoking, after coughing/sneezing, after handling chemicals).

b. To post a sign above sinks that is designated for employees.

c. Having good personal hygiene and clean work clothes.

d. All of the above

2. Sterno must be stored in a locked fire proof safe box.

a. True

b. False

3. The ice scoop should be stored inside the ice machine.

a. True

b. False

4. Staff should ensure sanitizing solution is at the proper concentration and in clearly labeled spray

bottles or buckets used for sanitizing. Test solution once each day and record on sanitizer solution log.

a. True

b. False

5. Pureed vegetable temperatures need to be at 130 degrees.

a. True

b. False