QA Investigation Results

Pennsylvania Department of Health
COMMUNITIES OF DON GUANELLA AND DIVINE PROVIDENCE AT UPLAND
Health Inspection Results
COMMUNITIES OF DON GUANELLA AND DIVINE PROVIDENCE AT UPLAND
Health Inspection Results For:


There are  13 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


A focused fundamental survey visit was completed on November 28 and 29, 2022. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart I egulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was eight and the sample consisted of three individuals.













Plan of Correction:




483.480(a)(1) STANDARD
FOOD AND NUTRITION SERVICES

Name - Component - 00
Each client must receive a nourishing, well-balanced diet including modified and specially-prescribed diets.



Observations:


Based on observation, record review and interview with administrative staff, the facility failed to ensure that each client received a nourishing, well-balanced diet including modified and specially-prescribed diets for two of two sample Individuals who are over weight. This practice is specific to Individuals #2 and #3.

Findings include:

1. Observations completed on 11/29/2022 from 5:15 PM to 6:10 PM revealed the dinner meal that evening consisted of shredded chicken, egg noodles and mixed vegetables along with water and juice. For those Individuals prescribed a pureed diet, their food was placed in small individualized bowls, placed at their place setting, and their assigned staff assisted in placing the pureed food on their plate/bowl, and monitored or fed them while seated next to them at the table.

Staff were observed assisting the other Individuals by passing bowls of food around the table, prompting the Individuals to serve themselves by scooping the food from the bowl to their plate. A large serving spoon had been placed in each bowl for their use.
Individual #2 and #3 were observed taking two scoops of chicken, two scoops of egg noodles and half a scoop of vegetables and placing the food on their plate. All but one Individual, who is prescribed a pureed diet, ate all of the food that they had placed on their plates.

2. A review of the residence daily menus was completed on 11/30/2022 from 11:00 AM to 11:30 AM. This review revealed that these documents outlined the various diet textures utilized in the residence. These diet types includes the following:
-Regular
-Soft To Chew
-Dysphagia Mechanical
-Pureed
-Consistent Carbohydrate
-Consistent Carbohydrate Small Portion
-Heart Healthy
Although these menus listed portion size for each item, e.g. 2 ounces, 4 ounces,
beyond listing of diet texture, there were no caloric values stated with each type of diet menu listed.

In further review, there appeared to have minimal changes between the menus in the quantity of food to be served. An example of this would be week 1, Sunday breakfast (note the only change was 2 oz in hot or cold cereal). The rest of the day's menu was exactly the same for both menus:

CONSISTENT CARBOHYDRATE MENU
Breakfast:
4 oz. of juice
6 oz. of hot or cold cereal OR 1 slice of breakfast pizza
8 oz. of skim milk
8 oz. of hot beverage

CONSISTENT CARBOHYDRATE SMALL PORTION MENU
Breakfast:
4 oz. of juice
4 oz. of hot or cold cereal OR 1 slice of breakfast pizza
8 oz. of skim milk
8 oz. of hot beverage


3. A review of the records of Individuals # 2 and #3 revealed that these Individuals have Body Mass index values (BMI ) that place then in the overweight and obese category respectively as noted by the dietician as outlined below :

Individual #2

a. A review of Individual #2's was completed on 11/30/2022 from 8:45 AM to 11:25 PM, and revealed this individual has a diagnosis hyponatremia (a condition where sodium levels in the blood are abnormally low), hypertension (high blood pressure), hyperlipidemia unspecified (a condition that incorporates various genetic and acquired disorders that describe elevated lipid levels), dysphagia and cerebral palsy.

In a review of a document titled Order Summary Report/ 90 Day Physician's Orders dated 09/29/2022 the following medications are listed for this Individual ;
-Amlodipine 10 mg. daily for hypertension
-Metoprol Succ ER 150 mg. daily for hypertension
-Fish Oil 2000 mg daily for hyperlipidemia
-Simvastatin 40 mg. daily for hyperlipidemia
-Sodium Chloride 4 grams daily for hyponatremia

b. A review of the weight record for Individual #2 for the period from
11/15/2021 (169.4 pounds) through 11/14/2022 (192.0 pounds) revealed a weight gain of 22.6 pounds. In a review of Physical Therapy notes for the period from 12/15/2021 through 03/15/2022 states Individual #2 was in physical therapy for mobility and balance training. On 03/15/2022, Individual #2 was discharged from physical therapy and is no longer able to ambulate.

c. A review of the Nutritional Assessment for Individual #2, dated 09/13/2022, revealed that the reason for this assessment was due both to weight gain and an as an annual assessment. This report noted that Individual #2 had been mostly weighing "between 170-177 pounds this year and then up to 194 pounds in July and 190 pounds in August...actual weight is 193 pounds...Will assume weight gain from 177 pounds in July 2022 until now at 193 pounds." His ideal body weight is between 120 and 154 pounds."
This report noted that Indvidual #2's current LDL cholesterol level was 120.

A review of the ordered diet identified within the Nutritional Assessment noted above for was defined as:
-Prescribed diet is identified as dysphagia mechanical.
-Calories needed to maintain his current weight is 2009 and calories needed for desired weight loss is 1800 calories
-Unintended weight gain related to wheelchair dependency; good appetitie as evidenced by suspected weight gain and now obese.
-Goal at this time would be loss to at least 180 pounds. Will order 'NO SECONDS' and for him to have low calorie juices and beverages only."

d. A review of a document titled Diet Order Change notes signed by the physician on 09/14/2022 revealed that in the section titled, under new recommendations it states
"Please add to order low calorie juices and beverages only and no seconds."
This order was signed by the physician on 09/14/2022. Under the section titles previous diet order, this area was blank. There was no indication that the caloric intake as noted by the dietician in the annual report, was incorporated into the current diet order.

Individual #3
a. A review of Individual #3's record on 11/30/2022 from 8:45 AM to 11:25 PM, revealed this individual has a diagnosis of hypotension (low blood pressure), overweight, obstructive sleep apnea, and chronic systolic (congestive) heart failure, gastro-esophageal reflux disease and down syndrome.

A review of a document titled Order Summary Report (90 Day Physician's Orders) dated 09/29/2022 revealed Individual #3 takes the following medications:
-Midodrine 15 mg. for hypotension
-Wears a CPAP (continuous positive airway pressure) machine during hours of sleep for Obstructive Sleep Disorder

Individual #3's prescribed diet is soft to chew texture, thin/regular (fluid) consistency, egg whites only, reduced caloric snacks/desserts, monitor appropriate sizes for meals, snacks"
A review of Individual #3's weight record for the period from 04/05/2022 (161.0 pounds) through 11/10/2022 (172.1 pounds) revealed a weight gain of 11 pounds.

b A review of this Individual's Annual Individual Program Plan dated 07/28/2022 noted
in the assessment section "monitor appropriate portion sizes for meals and snacks."
Subsequent review of this Individual's Nutritional Assessment dated 08/04/2022 indicated that the reason for this report was an annual assessment. This report noted the following:
-"Individual #3 for 2022 has been between 160 and 168.2 pounds. For the past two months, he has been up. In 2021, he was between 158 and 170 pounds. Usual weight had been 158 to 160 pounds. He is in his higher range now. His ideal body weight is between 111 and 145 pounds." Noted also was his cholesterol level (LDL) as 117.

c. A review of the ordered diet identified within the Nutritional Assessment noted above for was defined as:
-Prescribed diet is identified as soft to chew, thin liquids.
-Special Instructions - Egg whites only for heart disease control.
-Calories Needs - 1726 calories or less to deter further gain

The dietician also notes the following ;
" [Individual #3] does not over eat, but he does not like to do physical activities. His weight is up some and he is overweight."
-Nutrition Diagnosis - Overweight related to age, history, preference to not do much physical activity is evidenced by weight up about 8 pounds from usual weight range.
-Nutrition Plan - 158 to 160 pounds is a better weight for [Individual #3] with heart disease, OSA (obstructive sleep apnea). He is unlikely to lose much with desire to sit and watch TV or color."


4. A review of the facility's monthly weight policy, not signed by the administrator nor dated, revealed that the Health Care Coordinator is to notify the registered dietician of any Individual's weight fluctuations of plus or minus 5 pounds. The registered dietician is to review and communicate any recommendations with the Health Care Coordinator and Qualified Intellectual Disabilities Professional. Recommendations requiring a change to the individual's plan are to be discussed at a special team meeting.

5. Interview with the Program Director on 11/30/2022 at approximately 11:30 AM confirmed that the above policy/procedure is the process in place to communicate information to the dietician regarding weight gain evidenced by Individuals who reside in this facility.
The Program Director confirmed that there was no evidence that a meeting was held to evaluate their diet plans. This applies to both Individuals.








































Plan of Correction:

W-460
The Qualified Intellectual Disabilities Professional (QIDP) will hold individual team meeting for individuals # 2 and #3 to review each are receiving a nourished, well balance diet including any modifications and specifically prescribed by physician.
Target Date: 12/23/2022
All facility staff will be trained for individuals #2 and #3 These reviews will include but not limited to: physician orders, dietician recommendations, review of lab values related to supporting sound nutrition, review of current menus describing caloric intake and outlined in menus for all prescribed diets, review of weight policy which defines addressing weight change +/- five pounds, programmatic goals to promote weight reduction if desired and inclusion of an exercise plan.
Training sheets will be completed and recorded. Copies and content of training will be sent to training department.
Target Date: 1/6/2023
The Qualified Intellectual Disabilities Professional (QIDP) will hold individual team meeting for all other individuals to review each are receiving a nourished, well balance diet including any modifications and specifically prescribed by physician. All facility staff will be trained for all other individuals. These reviews will include but not limited to: physician orders, dietician recommendations, review of lab values related to supporting sound nutrition, review of current menus describing caloric intake and outlined in menus for all prescribed diets, review of weight policy which defines addressing weight change +/- five pounds, programmatic goals to promote weight reduction if desired and inclusion of an exercise plan. Exercise pans are desired for all individuals to promote healthy life styles.
Training sheets will be completed and recorded. Copies and content of training will be sent to training department
Target Date: 1/20/2023
The dietician will provide an on-site training for house staff, nursing and all management staff assigned to location. This training will include but not limited to; menu preparation and use of menu books, portion size, concepts of good nutrition and its importance .
Target Date: 1/31/2023
The QIDP will complete weekly audits (varying days and times) to ensure staff are performing duties effectively and competently in accordance with individuals IPP for the next 3 months and then monthly for six months after. These audits will be forwarded to Administrator for review. If areas of non-compliance are found, corrective action will be initiated.
Target Date: 9/30/2023
The Program Director will complete monthly audits to ensure staff are performing duties effectively and competently in accordance with individuals IPP for the next 3 months and then monthly for six months after. These audits will be forwarded to Administrator for review. If areas of non-compliance are found, corrective action will be initiated.
Target Date: 9/30/2023
The Director of Nursing or Assistant Director of Nursing will complete a monthly audit of each individuals current diet order, current weight, review of corresponding program plan and pertinent health changes.
Any concerns should be addressed within seven days of audit by requesting a team meeting. These audits will be also be forwarded to administrator upon completion who will initiate appropriate changes.
The Quality Management team will complete a quarterly audit of all individuals' current diet order, current weight, review of corresponding program plan and pertinent health changes. These audits will be forwarded to Administrator for review who will address areas of non-compliance immediately.
Target Date:9/30/2023