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Question for RNs and LPNs. I was told today by representatives of a private duty home care company that pureeing food for a client is considered skilled nursing and can only done by someone qualified as such. Any input on this? I asked a relative about this but was confused at the time and can't recall her answer!

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Sorry to go on, but also a lump of applesauce with pills in it, and thickened Ensure worked well for us.
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PS I am not an RN - sorry - just reread that is who you addressed the question to. In my experience - 2013 to 2016 - no Dr and no RN ever said there had to be skilled nursing for this problem.
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This was in NY State.
My father was diagnosed when he was in the hospital for something else at 88 yrs old. At 87 he had started having repeat pneumonias. He had been pretty healthy up til then. I thought it was viral and washed all bedding, etc. I had never heard of dysphasia - (swallowing problem, usually lots of coughing when eating) - or of aspiration pneumonia - (bacterial infection due to food or liquid getting into your lungs) - or of "silent" aspiration - (where you have a dead spot in your throat and you can't even feel the liquid going down the wrong pipe) .

A rather brusque nurse showed me what to do - like it's just simple, you just do this. "He can't even drink water??" (I pictured him not being able to just go and get a glass of water - he certainly would not be able to do this thickening thing. I was kind of shocked that no he couldn't get water and yes this is what I would have to do.)

The nurse never said a thing about skilled care for this. Later we saw a Speech Therapist, had a flouroscope done and watched. Thin liquid went right down into his lungs.
He had a slow swallow. It should happen in 1 second, his took 2. The "flap" didn't close fast enough. No one could figure out why. Mini stroke that doesn't show on scans? Side affect of cough drops or pain meds? (I asked). No one knew for sure.

The Speech Therapist said his food has to be something that will form a "bolus" - a ball that will slide down his throat without breaking up. And that all liquids had to be "honey thick". That's pretty thick. Later, he actually improved to "nectar thick" for a while.

We also tried electrical stimulation to his throat. Sometimes that does help. And exercises which he hated. He was too old and not well enough to really pursue these. In the end this throat problem was his worst problem and it got worse. That was the reason he passed away.

But anyway - the original question - no I don't think there is a requirement for skilled nursing. All of my father's care in this area was up to me. I had a sheet of things to avoid and a few tips that the hospital gave me.

The nursing home (he was there a few times for rehab) does note this condition and tries to create food that will work. It's very tricky. Even pureed stuff sometimes doesn't work - it gets hung up.
One thing that worked well for my father was lasagne. The cut bite sized pieces seemed to slip right down. He hated pureed stuff and really, it didn't work as well. Bananas and avocados were good - a little catalina dressing in the avocado half. Moist and slippery is good. Dense meat loaf with a lot of ketchup. Strawberry shortcake with ice cream, whipped cream, chopped strawberries with sugar to make a sauce, and those soft commercial cake things. It is a learning curve for sure.

Also we tried a lot of different thickeners. Some are cornstarch, some are a seaweed thing I think. We didn't like the cornstarch ones. The best one, to us, was Nestle's Thicken Up. They have good customer service. They have prepackaged juice, water and milk which I bought and found useful for car trips, emergency rooms, immediate needs...

You have to watch the hospitals closely as the workers make mistakes and give thin liquids when they shouldn't. I tried to be there all the time, especially at meals. Difficult. Even the nursing homes occasionally make mistakes. They actually required me to be with him if we wanted him to eat in the rehab dining room. Otherwise he would have to eat in the main room with the permanent residents. The dining room was nicer.

You just do your best and hope it works. There's only so much you can do.
I sympathize so much with you and wish you and your loved one the very best. It's not hopeless. It can sometimes improve.
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I'm the queen of take-out containers -- my adult children make fun of me. But I have saved (from various restaurants, including Chinese take-out) the type that is the same as you would get a frozen dinner in as well as others with and without lids. And that makes me think of restaurant supply stores. Here we have Gordon Food Service. You'd probably have to buy in bulk, but I definitely wash a reuse and don't see any of the effects to the plastic.
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The food gets hot and melts the plastic, I don't think any plastic container is immune from it, and they all contain chemicals just as problematic as the banned
BPA.
The thing is, you need to weigh the pros and cons of it all - the bento containers are easier to handle, can go in the freezer, and the compartments keep things separate. They are also relatively cheap, so they can be replaced fairly often.
At his age I doubt that the cumulative effects of microwaved plastic containers are ever going to cause any adverse effects, if it was for a child I would think differently.
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CM, "scuffing" is a better word than frayed. At first I thought it was food residue, but scrubbing and scrubbing couldn't remove it. Then I realized that the scuffing was around the top of where the food would have been. So something must have happened at that level, perhaps the contrast between the heated portion with food and the heated portion above it???

What the company CSR asked me was how long was the container being microwaved. That's when she said 30 seconds, and maybe another 30 seconds, but definitely not more.

The containers are not designed for more than a quick warmup.

She also said not to use the containers any more, as it MIGHT BE that the plastic was deteriorating. She suggested throwing them away. Yikes.

Microscopic bits of plastic in food was my concern as well, which is why I now have over a dozen or so containers that can't be used for anything, well, maybe except storing screws, nails, sewing needles, thread, and things that aren't edible but always seem to escape open containers and wander around the house, hiding out in chair cushions or on the floor.

I too have switched to glass and some ceramics. But they do get hotter and need to be handled a bit differently. Easy for me, but not for Dad.

The only plastics I've used for freezing are ones that I bought years ago, the Ball containers for storing canned foods. When I was dreaming of living more off the produce from my garden and fantasizing that I would soon be digging out a root cellar, I bought a few dozen and have enough to last for years.

At that time I also bought other plastic ware but stopped using it when I saw a little "tail" of plastic separating from the bottom of a container. Those too are relegated for nonfood storage. I guess I'll have to stock up on nails, screws, tape, string, and whatever to make use of them.

I could recycle them, but would they be used for food storage? Who knows?

If you're not seeing any deterioration of plastic, I think they could still be used, but then that raises the issue of whether they were manufactured when BPA was still being used in plastic. I wouldn't be as concerned about the ones that are BPA free. And that raises the issue of the safety of the old Ball containers.

Sometimes I think animals have it all over us. Squirrels just have to bury their food or find a nice hole in a tree. Carnivores either consume food right on the ground, or hide it with brushes or something and come back later.

We humans have to deal with all sorts of safety issues, although at least we don't have to have bearproof containers. Well, maybe that's not so - I've seen some amusing photos of bears in a swimming pool and others not so amusing when they're getting into cars. If they're in the swimming pool, what do they do when someone barbeques?

Molecular chemistry? I literally faint at the thought of trying to understand chemistry. It's waaaaayyyy beyond me!
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GA, I bought what was supposed to be a microwave-proof vegetable dish, and when I say microwave-proof it came with instructions for cooking, not just reheating. Well. It's not fraying or cracking, but the internal base just looks a bit scummy to me - not dirt or food residue, but the plastic surface is sort of scuffed, if you see what I mean. So what's going on with that? - and does that mean that microscopic bits of plastic are skimming off the surface and getting into my broccoli?

So all in all and completely unscientifically, I regard plastic in microwaves as suspect and am now using only glass or ceramic ware. Which is a pain, I realise, if you have to decant everything; but you can get toughened glass or Pyrex containers reasonably cheaply.

I still use plastic for freezing, and I do defrost food in those containers - but then the food isn't getting hot, just up to room temperature, and there's no sign of wear. So I suppose that's all right?

It's at times like this that I wish I'd paid more attention to molecular chemistry (hangs head)...
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Quick question on the Bento plates/boxes bought from Amazon?

Are these fully microwavable for frozen meals? One set of containers I bought, which began to "fray" after being reheated, were perfectly sized, but the plastic "fraying" was a problem.


When I called the manufacturer, a customer service rep revealed that they are microwaveable, but not for more than 30 seconds. That's not much help for reheating meals.

And unfortunately, that limitation wasn't on any of the containers or the packaging, so I had no way of knowing they were for limited use.

Something that's microwaveable for multiple uses is what I want.

Those Bento containers look perfect, but I wonder if anyone has used them to reheat for several minutes, and whether or not the plastic began to deteriorate as if it was scratched.


I checked out another source, where I could probably buy or order locally, and read that the boxes can be used again, but there's also a disclaimer as to the source of the information. Users would, I think, know better from experience.


Thanks again for all the helpful posts. I'll be back for more individual expressions of appreciation.
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WoW
Mom has trouble lifting her utensils so thank goodness aides can spoon feed her if need be

Cwillie, you know you can't eat just one potato chip
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In MA we can allow the aides to prepare the food but the aides are not allowed to assist in the feeding of anyone with a swallowing problem.
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MsMadge, that is a real plus for your mom, having personal caregivers allows her some personalized care options, even if it is only occasionally!
Understandably when you are assigned a special diet in the NH they do not even attempt to stray from it, even though some people can handle forbidden items occasionally. My mom always liked her crunchy snacks and never choked on them, so last week I took some potato chips and warily fed her little nickel sized pieces... she gobbled them up!
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My private aide with mom said she's getting depressed with her purée food so I arranged for some real food for her tonight - takeout - the report was she was so happy and ate well albeit slowly
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Thanks to everyone who's posted since I last posted - lots of good advice. I just got home from a pureeing session and am ready for some Motrin and a heating pad, but wanted to thank everyone and acknowledge more posts which I'll get to tomorrow.
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I think it depends greatly on what the agency has as their rules and guidelines.
As soon as someone needs foods thickened an agency may require a "higher level" of care for a variety of reasons.
It is a way to charge you more.
If they are saying that the "regular" caregiver is not trained and they are "just" companion care then they can require that a CNA be in charge of care. This could be for legal reasons or monetary.
Anyone can puree food in most cases as long as the patient can pick up a utensil and feed themselves there is no problem with "level of care" it is when someone has to feed the patient or closely monitor the eating so as to prevent aspiration that is becomes more of a challenge.
This also go to adding a thickener to thin foods. An agency may consider a thickener as a "medication" and at that point they would require a CNA or possibly a nurse.

I would take a look at the agency guidelines and see what it specifically states about food, feeding, pureeing, thickening. If there is nothing written I would question the reason they are giving you and I would begin to interview other agencies or look into hiring a private caregiver.
Private caregivers and do anything you request of them since it is under your direction. Puree food, feed a person, even give medications, dress wounds. As long as they have been trained, taught what to do and are comfortable doing it.
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My husband was in Hospice care when he developed pneumonia. He kept coughing, and I thought it was a sign of pneumonia--but I noticed it only happened after meals. After I talked to the Hospice nurse, she advised me to not let him drink water out of a glass--feed him only a teaspoon of water at a time. When I asked why, the nurse stated that he might aspirate the fluid because he has trouble swallowing. I know how much he enjoyed drinking water--I couldn't deprive him! I discussed it with him, and we agreed it was ok to risk death from pneumonia in order to be more comfortable. The nurses advised me to purchase "ThickIt," a powder which could be added to fluids to make them easier to swallow without aspirating. I prepared solutions of thickened water for my husband to drink. I judged my success when he drank without coughing. I noticed that he couldn't tolerate solid food, so I made purees, soups, and protein drinks. The nurses didn't guide me. I figured he needed food, so I needed to find a way to prepare it so he could enjoy it and tolerate it. Now I see that he almost certainly suffered from dysphagia--maybe that is what helped cause his pneumonia. Thanks to everyone for this discussion. I used to feel guilty that I didn't do enough for him (he passed away earlier this year.) Now I'm feeling proud that I helped care for him so he could be comfortable. But I do advise all family members to persist in getting information from the nurses/doctors. And I often would ask 2 different hospice nurses, if I found the first answer wasn't working for me or I couldn't understand how to implement it.
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Care I think you are safe as long as you don't sell any. Health Inspectors have not got as far as home kitchens yet.
I do hear though that the kids are no longer allowed to bring in home made goodies. They have to be straight from the store in an unbroken package.
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Gees. So we're going to need to get a license to get a Vita Mix or Ninja? What next LOL? My guess is they were trying to make a case to stay involved and have a client, justifying their existence. Just wondering.
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I use these bento-type boxes and write what is inside on a post-it on top.
https://www.amazon.com/gp/product/B004S129AQ/ref=oh_aui_detailpage_o02_s00?ie=UTF8&psc=1
I puree enough of whatever dish and sides that I've made for several meals at a time and then freeze the extras to pull out later. The caregiver that comes at lunchtime just needs to heat it up and serve. It's still a chore to keep up with having pureed, low sodium, low vitamin K meals prepped along with full time work and everything else.
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I puree food every day for my pineapple whip. I hope I'm not breaking some law.
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Garden Artist – I think you've discovered what I was going to suggest: the particular agency may simply not want to handle dysphagia patients (or doesn't want to handle your dad specifically, for whatever combination of reasons). I've caught reps talking in a misleading way about regulations to avoid refusing a customer request. Sometimes, it's because they don't really understand what is a company practice vs a state or federal regulation. Other times, they want to avoid a discussion about it, so they give the impression that they 'can't' rather than they 'don't want to'.
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This is a great example of how the legalese we experience every day causes people to lose focus on the greater good. You might try the power of semantics — “I’m not asking you to purée her food. I just want you to make her the smoothies she likes.” (Then stock the ingredients that go into the smoothies and the recipes for them.). Sounds much less medical all around. As long as our legal system continues to support such a litigious focus, we sometimes have to just use their “letter of the law” focus against them so that the “spirit of the law” can be served.
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It might be that some elected official in your state has gotten a law passed about it. Like the "Right to Fall" law.
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$8 per meal plus shipping would get pretty expensive compared to the cost of MOW or home made, and the menu is limited, however I used to purchase similar meals to keep on hand for those times when doing it myself was just too much.

GA, I think I would just buy those Bento divided meal boxes from amazon and prepare meals in bulk batches to freeze. I know that plastic containers are not the best, but at this point in his life microwaving plastic containers is the least of your worries. Even if you treated them as single use it would still be more economical than buying prepared meals, plus you would be able to provide a more personalized and varied diet.
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We saw a Mom's Meals truck one day and looked them up. They offer pureed meals. We haven't tried them out yet.
http://www.momsmeals.com/independent-at-home/pureed-menu/
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GardenArtist, check momsmeals.com --I think they were a bit more expensive, & you have to be able to store something like a week's worth in a freezer, then microwave. Not sure; it's been a couple of years. Interestingly, Dad loves his ribs too, & a couple of weeks ago I took him to an O'Charley's restaurant, bc I thought they cooked theirs tender enough for him. Annnnd ...I was right! But his taste isn't the same, so he doesn't enjoy any food like he used to, and he thinks it's bc everyone is cooking it differently. Not sure what our future holds, bc I had hoped he could stay in this place for the duration, but he's had a number of really hard days with food. Our local grocery chain here makes a peaches and creme oatmeal that he likes, tho, and so I keep a stash at the facility for the staff to make for him when he can't eat whatever they're serving. Is your dad a Parkinson's patient?
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jjariz,, I did advise all the other private duty companies that dysphagia was the top issue and that I wanted pureeing to be a top priority. They all indicated they could do it. Great!

However, in the process of speaking with different companies, I found that some of them were less than truthful on other issues. In retrospect, I think they told me what they thought I wanted to hear.

But no one raised the issue of pureeing being a skilled nursing task.

Interesting suggestion though.

Talkey, I fully understand your father's position. Eating and chewing offer such rewards that eliminating the chewing part is a significant change in the pleasure of eating.

We did discuss eating whatever Dad wants, acknowledging the risk for aspiration pneumonia. The last hospitalization and rehab were probably the worst he's experienced, so I think that factored into his decision to adapt to mushy foods.

As an aside, and a little anecdote, he loves ribs. Knowing that he couldn't eat them was what I thought would be a major sacrifice. But MOW offers a riblet dinner. With help from MOW, I contacted the supplier and found that I can get these tasty boneless riblets, about 20 in a case for around $38. They're so soft that they puree very easily.

Dad does get MOW and has gotten them for years. But the dietician advised that they can't do mechanical soft or pureed foods. I'm really interested in the fact that you're able to get that accommodation. I know there are close to 200 families that get MOW in Dad's area, so it might be that time just isn't available. The MOW staff are incredible; they're so helpful, and I have a lot of respect for them.

Thanks to both of you for your suggestions.
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GardenArtist, Dad should be on a dysphagia diet now, but he was for 2 months back in 2015 & hated it. After that, he told the speech pathologist that he just wanted to eat what he wants. (He's 10 years into Parkinson's, & he had been thru the swallow tests.) I used Meals on Wheels for his dysphagia diet for that 2 month period. When he was upgraded to mechanical soft, I bought inexpensive Oncor meat trays & meals, bc their meats were the softest. I've been looking on MOW's web-site here to verify that they still offer them, but it's unclear. Bless your heart; I know how hard it was for me until I found out they could help.
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Easiest way to find out is call another Home Health company and tell them what you need done. If you get the same answer 3 times, I'd say that's the answer in your state.
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Responding to those who posted after I addressed Shane's and DDDuck's responses...

Thanks to each of you for taking the time to respond. I really appreciate it!

Talkey, I'm sorry to learn that your father's memory care facility doesn't offer dysphagia food, and hope for his and your sake that he doesn't have to address that issue. I think perhaps a facility needs to have a speech therapist or speech pathologist on staff in order to offer dysphagia meals, and if the facility chooses not to, or can't for some reason, that option probably wouldn't be available.


Blue8385, good question on how baby feeding could be done if parents would have to hire someone to puree the food! I recall that I was taught how to manage PEG tube feeding by rehab staff, and your post reminded me that nurses do sometimes train family how to do semi-nursing tasks.

I'm going to see what I can find out from the Michigan Nursing Board, or other Michigan nursing or dysphagia guidelines. I hadn't thought of checking state organizations. Shane also mentioned the Nurse Practice Act. Maybe that would offer some insight as well.


Ms. Madge, as I understand the conversation of yesterday, the staff can prepare (i.e., microwave) meals and serve them, just not puree them. But serving wasn't what I requested as Dad can do that himself. He just can't puree the foods.

Ms. Madge and CM, I wanted someone to puree because the extra trips to Dad's house as well as the time to puree the foods, especially the MOW foods which have smaller portions that are literally too small for the food processor, are more tedious. At first it took about 1/2 hour just to fuss around with all the little portions.  And that's just for one meal.  I try to puree enough meals for at least 3 - 4 or more days, and that takes 2 - 3 hours, depending on how many little cups of food there are in the MOW trays, and how much the meat portions have to be chopped up before pureeing. 

And the working conditions are such that there's no way I can do it w/o aggravating a back condition that developed last year. So every time I puree, I go home with a backache.

As to my handling the pureeing, that's the situation now, but it's requiring additional trips, lots of extra time, and other caregiving tasks are being subordinated or not getting done. Dad's needed a higher level of care since the last hospitalization, and I'm feeling overwhelmed and unable to keep up with it, in addition to getting annoying regular backaches.

So it was my intention to hire someone to handle this so I could get back to the other tasks, including the legal work (which I started on months ago but haven't been able to finish).  I'm actually years behind on some of the work that needs to be done.

I also asked Dad's occupational therapist about Dad doing some of the pureeing; she made some observations and gave me a large "thumbs down". She felt it would be too dangerous for him, b/c of the standing while pureeing, walking back and forth to the sink to clean the utensils, danger of contact with the blade, and more. I was in agreement with her. I cut myself pretty badly once when I wasn't careful handling the blade.

In addition, his unfortunate encounter with the blade of a radial arm saw 2 decades ago left his right hand not completely functional. He has a hard time just removing lids from the containers, so I leave them partially open and hope that he doesn't spill them. Those are complicating factors.


CM, I'm sorry to read about the ordeal your mother experienced b/c of lack of someone to assess your mother's swallowing reflexes. Sometimes regulations meant to improve care actually impede it.  My mother once waited  for several hours on one of those cold slab tables until the one operating room became available to fix her broken leg.    Our tempers provided some warmth for us as we became more and more angry about the situation, but our wrath didn't help her in her discomfort.

In my experience, a speech pathologist is always brought in to do the assessment, but the nurses and other staff are expected to implement the restrictions.   And the kitchen staff was pretty strict about implementing - the restricted list of foods was always provided to them. 


CWillie, interesting comment about due diligence and legal caution. That might be an issue if the food isn't pureed to Dysphagia, level 1 standards, and that's not always possible, especially with fibrous vegetables.

This agency might be especially cautious anyway; it does seem to have higher standards than many of the agencies I've contacted, including the owner of one who claimed he could train a private duty caregiver in 4 hours. Hmmm....I don't think I'd want one of his people on my team.


Veronica, the last videoscopic swallow was in May; another would be required before I can get palliative care with speech therapy included. I want that b/c I want the exercises to be part of the therapy; the Shaker exercises are what restored his swallowing function back in 2004.

"Only a skilled professional is able to handle the treatment for a dysphagia patient who aspirates."

So then there would be a distinction between pureeing food, which might be considered treatment, but microwaving wouldn't be, so the caregiver could do that?

And I thought law was so particular and precise in analysis of issues!


Thanks to everyone for taking the time to respond. After I get another pending crisis controlled, I'm going to probe the issue in more depth with the company rep and find out what the real reason is.
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Never heard of this either. There has to be more to the reasoning.
A Speech therapist and interventional Radiologist have to do the testing for dysphagia. Maybe this testing has not been done and the agency does not want to run the risk of the patient choking. Actually come to think of it the reason is right there. Only a skilled professional is able to handle the treatment for a dysphagia patient who aspirates. So it is not actually the use of the blender that is the problem
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