Deficiency in Dietary Staffing Requirements
Penalty
Summary
The facility was found to be non-compliant with the requirement to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. During an interview conducted on January 25, 2025, the Administrator confirmed that the facility did not have a full-time dietitian employed onsite. Additionally, the facility failed to employ a qualified certified dietary manager to fulfill the role in the absence of a full-time dietitian. This deficiency was identified based on staff interviews and was previously cited on December 17, 2024. The lack of a full-time qualified dietary services manager or dietitian indicates a failure to meet the staffing requirements outlined in CFR 483.60(a), which mandates sufficient staff with appropriate competencies to carry out the functions of the food and nutrition service, considering resident assessments and individual plans of care.
Plan Of Correction
1. The facility cannot retroactively correct. 2. The facility actively advertised for a Certified Dietary Manager and one was hired and started on February 25, 2025. The facility has hired a full-time Registered Dietitian as well. 3. NHA/designee will educate HR department/recruitment of the need for a Dietary Manager in the absence of a full-time dietician. 4. When hired, the Dietary Manager will provide the NHA with the completed class courses and testing results in attaining a Certified Dietary Manager certificate. The NHA and corporate CDM will monitor that a qualified DM is in place. Results will be reported to QUAPI committee for review and analysis.