|§483.60(c) Menus and nutritional adequacy.|
§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;
§483.60(c)(2) Be prepared in advance;
§483.60(c)(3) Be followed;
§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;
§483.60(c)(5) Be updated periodically;
§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and
§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Based on observations, review of select facility documents and staff interviews it was determined that the facility failed to follow the scheduled menu as per the advance prepared menu for two out of two separate trayline observations reviewed regarding food portions.
Observation was made in the facility main kitchen on April 1, 2019, of the lunch meal tray line at 11:55 AM which revealed what appeared to be a too small portion of one slice turkey loaf being served. Additional observation were made which revealed that the portion of shepherd's pie being served was inconsistent. An observation was made that residents' receiving their meal on a plate received one overloaded scoop plus a second almost full scoop. It was observed that for some residents the shepherd's pie was served into purple bowls. Portions served into the purple bows started out with one non-overloaded scoop of shepherds' pie followed with what appeared to be one quarter of a scoop. The last several bowls were served one non-overloaded scoop and almost nothing in a second scoop attempt. It was determined that the last cart of meals on trays were for residents living in the Dementia unit.
During an interview with Dietary Server (DS) 1 at 12:10 PM following end of this lunch service, DS 1 was asked what the portion size was for the shepherds' pie. DS 1 stated that it was "four ounces." DS 1 also showed surveyor that she was using a four ounce scoop. Dietary Supervisor (DS) 2 who was on-site at the end of this tray service on April 1, 2019, was asked to weigh a portion of the turkey loaf which had appeared to be small. In consultation with Purchasing Supervisor (PS 1), DS 2 determined that they did not have a food scale on sight to weight the turkey loaf. One slice of turkey loaf was then wrapped to be weighed the following day.
Review of Dietary Services' Diet Spreadsheet for all diets revealed that the set portion for the turkey loaf to be served at lunch on April 1, 2019, was to be three ounces for all diets and the shepherd's pie portion was to be six ounces for all diets. Review of facility recipes for two items on the menu revealed matching portion sizes.
On April 2, 2019, at approximately 12:15 PM, the turkey loaf saved from lunch previous day was weighed using a digital scale by Registered Dietitian (RD) 1 and revealed a weight of 2.8 ounces.
An observation was made in the facility main kitchen on April 3, 2019, of the lunch meal tray line at 11:50 AM which revealed what appeared to be a small portion of salmon patty and potato wedges. It was observed that DS 1 was serving two small thin wedges of the potato. At 12:13 PM, RD 1 weighed one salmon patty which revealed weight of 2.5 ounces and a portion of the potato as served by DS 1 revealed a weight of 2.9 ounces. Review of facility Diet spreadsheet for all diets prior to the meal had revealed that the salmon patty was to be 3 ounces and the potato wedges 4 ounces. DS 1 was interviewed at this date/time as to how she knew what portions to serve for the items on the menu. DS 1 revealed that she was taught that when she came on board. DS 1 also revealed that she had been working for the facility for 23 years. DS 1 made no reference to menu sheets or the posting located next to the trayline which indicated portions for general categories of foods such as meat, vegetables, etc..
On April 3, 2019, at 12:16 PM surveyor met with RD 1 and PS 1 to share observations from the two lunch meals noted previously on April 1, and 3, 2019. PS 1 revealed that the extension sheet portion sizes reflected pre-cooked weights not "edible portion" (amount actually to be served). When asked what type/frequency of information/training provided to dietary staff prior to meals regarding portion sized to be served, RD 1 was unable to relate information and PS 1 revealed "often." RD 1 was unable to provide information as to why DS 1 thought portion for shepherds' pie was four ounces or for inconsistency in portion sizes. RD 1 was asked to provide information as to whether any residents were designated to receive larger/double etc. portions and rationale for what residents were to receive entrees in bowls. RD 1 revealed during this interview that residents would receive their entrees in bowls if it was their preference or if they were determined by therapy to do better with this.
No information was provided to indicate any residents were to receive large/double portions.
During an interview with Nursing Home Administrator (NHA) on April 4, 2019, at 11:40 AM, NHA revealed the expectation that food items on the menu would be served according to the menu guidelines
The facility failed to provide served food items to residents in the appropriate portion sizes determined according to the pre-planned menu (purpose of menu extension/spreadsheets is to dictate portion size to be served in order to meet dietary guidelines) for four menu items (salmon patty, potato wedges, turkey loaf, and also the shepherds' pie as amount served in the bowls was less than six ounces), failed to have a scale on sight to aid in managing appropriateness of served portions, failed to have a process in place for ensuring staff would know what portion sizes to provide.
28 Pa. Code: 211.6(a)(b) Dietary services.
| ||Plan of Correction - To be completed: 05/03/2019|
Preparation and submission of the Plan of Correction is required by state and federal law. This plan does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.
Homeland Center appreciates the efforts of the state survey team to serve the best interest of Homeland Center Residents.
Immediate re-education of the Cook occurred on 4/3/19 regarding the serving of appropriate portion sizes according to the menu, paying particular attention to the weighing of meat, as the slice of turkey loaf was 2.8 oz. versus 3.0 oz. as stated on the menu. Failure to willingly comply with the established procedures associated to the weighing of meats according to the established process, will result in immediate correction, in addition to disciplinary action.
Immediate re-education of DS (1) occurred on 4/4/19 regarding the responsibility to ensure consistency with portion sizes when using varying serving dishes and utensils (i.e. plate vs. bowl). This will ensure all residents receive consistent portions in a timely manner and would remove the need for the department to produce additional food items such as ground salmon, which occurred that day.
In addition to daily supervision, DS (1) will be visually observed, two times weekly, thru 10/31/19, by the Director of Nutritional Services, Assistant Director of Nutritional Services, Dietary Purchasing/ Production Supervisor, or Registered Dietitian during the lunch tray line to ensure compliance with serving the appropriate portion size consistently, and according to the menu. Failure to willingly comply with the established procedures associated to appropriate portion size will result in immediate correction during tray line service, in addition to disciplinary action.
With no Residents being adversely affected by identified non-compliance, further intervention will occur in that, Residents on each unit, including dementia unit, will be surveyed to ensure they remain satisfied with the past and current portion sizes. This will occur no later than 4/19/19.
Procedure associated to ensuring adherence to the scheduled menu, regarding food portions, will be strengthened to ensure compliance.
An element of the daily meal meeting, will be either the Director of Nutritional Services, Assistant Director of Nutritional Services, or Dietary Purchasing/Production Supervisor, emphasizing the importance of providing accurate portion sizes with each meal, and accountability associated, according to the revised procedure.
Director of Nutritional Services, Assistant Director of Nutritional Services, Registered Dietitian, or Dietary Purchasing/Production Supervisor, in addition to Supervisor responsible for a specific meal, will audit Server on tray line for one random breakfast meal, one random lunch meal, and one random dinner meal, on a weekly basis to ensure consistent appropriate portion sizes, according to menu/production sheets, with consistent use of appropriate serving utensils, according to revised procedure. This will occur thru 10/31/19, unless compliance is not achieved, on an on-going basis, at which time audit will continue for additional 90 day periods until compliance is achieved.
In-service education will occur for all Nutritional Service staff members associated to proper production of Resident meals to ensure an understanding is obtained relative to the importance of accuracy for portion sizes, proper serving utensils, and scale to be utilized in the creation, preparation, and serving of Resident meals. This will occur on or before 4/30/19. In-service education will occur annually.
PS (1) (Dietary Purchasing/Production Supervisor) was immediately re-educated on 4/1/19 regarding the purpose and importance of having a working scale available in kitchen, at all times, to consistently ensure appropriate portion sizes. A new scale was immediately obtained and began to be utilized for the 4/1/19 dinner meal. A back-up scale was obtained on 4/10/19. In addition, PS (1) (Dietary Purchasing/Production Supervisor) was immediately re-educated as to responsibility associated to production, compliance with procedure, regulatory requirements, job description requirements, requirements and professional knowledge associated to food production, and adherence to scheduled menu regarding food portions.
A Quality Assurance Performance Improvement (QAPI), Performance Improvement Plan (PIP), was developed on 4/3/19, and shared with Surveyor, which identified immediate measures taken to ensure compliance with the process of delivering consistently accurate portion sizes, according to scheduled menu, to Homeland Center Residents. This further includes use of a Consultant Registered Dietitian, specializing in long term care food production, being included in the revised PIP on 4/11/19, to further ensure compliance. Consultant Registered Dietitian will begin on 4/24/19. The Administrative Assistant for QAPI, or designee, will audit one random breakfast meal, one random lunch meal, and one random dinner meal, on a weekly basis, on the tray line, to ensure accuracy of scheduled menu and food portions. This will include weighing of food portions and reviewing serving sizes to ensure accuracy as determined by the scheduled production sheet/menu. This will occur thru 10/31/19, unless compliance is not achieved, on an on-going basis, at which time audit will continue for additional 90 day periods until compliance is achieved.
Results of QAPI Performance Improvement Plan will be presented at the weekly Clinical/QAPI meeting. Further interventions will occur if determined 100% timely accuracy is not being achieved. Administrator will receive results of QAPI Performance Improvement Plan at weekly Clinical/QAPI meeting.
Administrator, Administrative Assistant responsible for QAPI, Director of Nutritional Services, Assistant Director of Nutritional Services, Registered Dietitian, and Dietary Purchasing/Production Supervisor will be responsible for on-going, consistent compliance.