Initial Comments:
A focused fundamental survey visit was completed on September 19-20, 2023. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was 10, and the sample consisted of three individuals.
Plan of Correction:
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on observation, record review and interview with administrative staff, the facility failed to ensure for employees who work with clients, receive training that focuses on skills and competencies directed toward clients' health need for one of one sample individual who has an established eating protocol for meals. This practice is specific to Individual #1.
Findings included:
1. Observations of the dinner meal completed on 09/19/2023 from 4:30 PM to 5:30 PM revealed that Individual #1 was seated at the dining table with two other Individuals.
On the table in front of Individual #1 was a plate, three cups, a napkin and a teaspoon. Under the plate was a placemat that included Individual #1's diet order, level of supervision, special instructions to include the use of a teaspoon to reduce bite size, dietary restrictions and comments. Two staff were observed assisting the three Individuals throughout the meal.
A bowl of egg noodles in a tomato meat sauce was placed next to Individual #1.
Individual #1 was asked to scoop the food onto his plate using a long black handled serving spoon. With verbal prompting from staff, Individual #1 picked up the serving spoon and scooped three spoonfuls of egg noodles, covering his entire plate. Individual #1 quickly picked up his teaspoon, scooped a large amount of pasta onto his spoon, and put the food into his mouth. He continued to rapidly consume his food with no re-direction
After the remaining individuals had been assisted in placing the food on their plate, one staff sat at the table next to Individual #1 and encouraged him to slow down eating. When Individual #1 had finished all the food on his plate, the staff who was sitting next to him encouraged him to take another serving of the egg noodles. Individual #1 scooped two large spoonfuls of food onto his plate covering two-thirds of his plate.
When the staff person was seated next to Individual #1, the staff person verbally encouraged Individual #1 to slow down. However, when the staff person attended to another Individual at the table, Individual #1 would increase his rate of ingestion. Once the staff's attention was again on Individual #1, with verbal prompting, Individual #1 would decrease his rate of ingestion.
2. A review of the record for Individual #1 was completed on 09/20/2023 from approximately 8:30 AM to 10:00 AM. This review revealed a Physician's Orders dated 09/11/2023 that included the following diagnoses: severe intellectual disability, epilepsy, autistic disorder, bipolar disorder, pure hyperglycemia (elevated triglycerides), dysphagia and constipation.
Subsequent review of a Annual Nutritional Assessment dated 03/01/2023 revealed Individual #1's diet order includes "Consistent Carbohydrate, Dysphagia Mechanical,
Thin Liquids." The Nutritionist's assessment also indicated that " [Individual #1] continues to be in the obesity range for BMI (Body Mass Index) . . . Special instructions include food needs to be moistened, close supervision at meals, aspiration precautions, encourage small bites, slow rate of intake, use teaspoon to reduce bite size."
Under the section titled Nutrition Plan of Care/Goals/Interventions the following is noted :
"Will reinforce with staff the guidelines to follow including no sugary desserts or drinks.
Limit portion size....height 65.0 inches, with an estimated IBW (Ideal Body Weight) of 115 pounds to 150 pounds." The nutritionist also notes that "obesity is related to love of food and snacks, and inability to make good food choices as evidenced by BMI over 30."
A review of the Nursing quarterly reviews of health status for the period from 11/11/2022 through 08/11/2023 revealed Individual #1's weight fluctuates between 191.8 and
198.4 pounds.
3. Interview with the Nutritionist on 09/20/2023 at 9:25 AM revealed that the facility was currently on week two of a cycle of four menus per month. A review of the dinner menu for the date of 09/19/2023 listing the following menu items for that meal :
-oven fried chicken,
- rice pilaf,
-mixed vegetables,
- lemon pudding
-skim milk.
When questioned how staff know what a Consistent Carbohydrate diet includes, the interviewee produced a binder that include a chart titled Week: Two, Day: Tuesday.
This chart listed four types of diets across the top of the document including:
Consistent Carbohydrate, Consistent Carbohydrate Small portions, Heart Healthy, and Gluten Free. There is no caloric values assigned to these diets.
On the left side of the chart listed the various meals e.g. Breakfast, Lunch, Alternate, Dinner, Alternate and Snack. Each meal listing included the food items for that meal to include
the specific serving size based on the type of diet. The Nutritionist stated that the menu and the specific details of the four types of diet are kept in a binder on a shelf in the kitchen.
The Nutritionist then subsequently removed four color-coded small handled measuring cups from a drawer in the kitchen. Each measuring cup was a different color representing a serving size including a black six ounce cup, a green four ounce cup, a white three ounce cup, and a red two ounce cup. The Nutritionist explained that these are the serving utensils staff should use to measure appropriate portion size for each Individual based on their prescribed diet. This interviewee also indicated that that all staff are trained on clients diets to include location of the binder and the use of measuring cups to serve the designated amounts listed on the menu for each diet type.
During the course of this dinner observation completed on 09/19/2023, this surveyor did not observe this binder nor the color-coded utensils being utilized by staff.
4. Subsequent interview with the Program Director conducted on 09/20/2023 at 10:30 AM, noted that when the survey staff person requested staff training documentation regarding prescribed diets and portion control, to include specialized eating protocols for individuals,
this interviewee was unable to provide this information. This interviewee acknowledged that staff had not been trained on these topics.
Plan of Correction:CE-1 The Qualified Intellectual Disabilities Professional (QIDP) conducted a meeting for individual#1 on 9/26/23. This meeting reviewed current physician orders, dietician recommendations, current menus, meal placemats, caloric intake/portion control, special mealtime instructions and development of a meal-training program.
All staff will be trained to dietary recommendations, revised placemats that will include and a color-coded portion guide as part of placemat, goal plan training program and special instructions staff should follow.
Training sheets will be kept on site and copies forwarded to training department for recording.
Target date: 10/20/23
CE-2 All facility individuals will have individual team(IDT) meetings to review current doctor orders, dietician recommendations, current menus, meal placemats, caloric intake, special mealtime instructions and development of a meal-training program. All staff will be trained to dietary recommendations, revised placemats that will include and a color-coded portion guide as part of placemat, goal plan training program and special instructions staff should follow.
Training sheets will be kept on site and copies forwarded to training department for recording.
Target date: 10/30/23
The registered dietician will provide a training to all house staff on new procedure and details of revised placemats, importance and use of menus which includes portion control, use of equipment, supervision and prompting /cueing during meals and special eating protocols.
Target date; 10/30/23
CE-3/4 The QIDP and house manager will complete weekly meal audits (varying days and times) for the next three months and then monthly for six months after. To ensure staff are performing duties effectively and competently. A meal audit form will be utilized and submitted to Administrator for review. The Administrator will direct corrective action for any non-compliance.
Target Date: 6/1/2024
The Program Director and Residential Coordinator will complete monthly audits for the next six months and forward to Administrator. Administrator will review and direct corrective action for non-compliance.
The Health Care Coordinator (HCC) will complete a quarterly review of physician orders, dietician recommendations, fluctuations in weight +/- five pounds and any related health concerns regarding diet. These findings will be brought to medical director attention . Quarterly reviews and any medical director's changes will be forwarded to Administrator who will ensure IDT is aware of changes and meets to discuss and initiate a plan.
CE-5 The Administrator will monitor all areas outlined in plan of correction and direct corrective action(s) for any areas of non-compliance.
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