“Ensuring Successful Food Service in DD Residential

Facilities”

Mary Vester-Toews, RD

Dietary Directions, Inc.

October 8, 2007

“Welcome to Our Home”

Problem Areas

• Special Diets• Texture Modifications• Food Preparation• Food Safety-Preventing Food Poisoning• Menus/Alternates• Offering Choice to Residents• Ordering/Shopping• Staff Orientation/On-going Training• Client Participation

Federal Regulations

• Revised in 1988

• Section J of States Operations Manual Interpretive Guidelines

• Food and Nutrition Services: 483.480

• W Tags: 460-480

• Federal Food Code (HACCP): Sanitation

State Regulations

• State Title Act

• Title 22 in California

• California Food Code

Local Regulations

• County Health Department

• City-Food Codes and regulations

• Require ServSafe® Certification ?

Special Diets

“Well balanced, including modified and specially-prescribed diets.” The survey will verify diet is appropriate by looking at:

• Labs-normal ranges• Medical problems-do not develop• Food allergies-followed• Diets changed-when needed• Nutritional needs are known to the facility

and are being addressed

Special Diets

• Fed Regs: prescribed by the RD or MD

• Diet Manual-outlines diets offered

• “Liberal Diet Orders: recommended by ADA and Fed Regs

• RD review diet orders to liberalize

• List of Recommended Diet Orders for facility

Liberal Diets

• Diet Order: 1750 Kcal ADA, 2 gm Na, Low Fat, Low Cholesterol, 6 small meals, Limit CHO.

• Liberal Diet Order: Consistent Carbohydrate, No Added Salt, Non-fat milk. ( CC, NAS with Non-fat milk)

RD recommended Exercise Program

Liberal Diet Orders

• Diabetic Diets: RCS or CC

• Renal: NAS, with Fluid Restriction if K+ and Po4 controlled (Po4 binders). Omit Salt Sub.

• Weight Reduction or Maintenance: Small Servings with Low Calorie Snacks, CC or RCS

• Low Sodium: NAS

Texture Modifications

• Regular: No Chewing/Swallowing problems• Mechanical Soft: Ground or Chopped • Finely Chopped• Puree: Soft Mash Potato- not runny• Fluids: Now Standardized:

Regular Nectar Honey Pudding

Textures Cont.

• Sufficient moisture for chewing and swallowing offered?

• Can texture/thickness be advanced?• Obligation to obtain highest functioning

level• Speech Therapy Reviews to document

current tolerance• Are same textures given when eating out

or in work experience? Why not?

Resident Rights

• Served according to food preferences

• Refuse meals and receive substitution

• Refuse therapeutic diets

• Served according to ethnic, cultural, religious beliefs

• Served attractive, tasty food at appropriate temps, in pleasing environment

Rights Cont.

• Prepared in safe and sanitary manor

• Participate in traditional holiday meals

• Receive information about special diet and nutritional needs

• Environment to excel to the highest functioning level. Assistive feeding devices if required

Clients Food Preferences

• Refusing items-document as a dislike

• Document/post food preferences- use during serving

• Ask families or previous care takers

• Offer substitution of similar nutrient value (list posted)

Food Preparation/ServingObligations

• Prepare in clean and safe manor

• Protect from Food Borne illness

• Conserve Nutrients

• Enhance Flavor

• Maintain attractive appearance

• Serve Diet as ordered

• Served in a reasonable time (15 min)

Food Prep Suggestions

• Follow Recipes –have all ingredients available. Cooks review day prior

• Follow Menu/preferences-visible when serving• Take Temperatures: cooking and serving: hot

>140°F and cold<41°F• Menus have all residents diet orders if possible• Portions from menu-do they have the right

serving utensils?• Puree measured: before vs. after?

Prepare Sack LunchesPicnic and BBQ’s

• Packed in insulated bag or cooler with reusable freezer pack. Keep out of sun

• Food cold or frozen prior to packing. DO NOT USE COOLER to CHILL.

• Hot food keep in thermos. Fill thermos with hot water prior to filling. Heat items> 165°F. Same with cold foods but <41°F.

• Can store foods chilled and reheat in Microwave• Check expiration dates on processed meats,

yogurt, and other items

Lunches, Picnic, and BBQ

• Discard all leftovers • Wash all fruits and vegetables • Freeze sandwiches. Pack tomato and lettuce separate• Frozen drinks can be used in place of freezer packs• Picnic

A. Wrap raw meats in plastic bags

B. Use moistened antibacterial towelettes before and after handling meat

C. Keep Mayonnaise type salads chilled at 41°F

D. Never place cooked meats on plate used for raw

Menus

• Meet Residents nutritional needs in accordance to the diet

• Meet RDI’s for age• New: Milk three 8 oz cups/day • Recommend 4 week period/seasonally changes• Commercial or facility written• Menus approved/signed by RD • Written one week in advance and posted in

facility 3 days in advance

Slide on Weekly Menu

Menus-Prepared in Advance

• Variety of foods

• Standard portions

• Kept on file for 30 days

• 3 meals a day plus snacks and HS.

• Have separate therapeutic diet spreadsheet-user friendly

• Posted for reading clients

Slide on Daily Menu

Holiday and Special Events

• Plan for major Holidays

• Plan for other days that reflect ethnic and religious interests of clients

• Special Events: Summer BBQ, swimming parties, Special Olympics, birthdays and other important days to clients

• Promotes enthusiasm and interest in food

• Include dietary restrictions

Holiday Menu Slide

Special Events, cont.

• Can dine out or order take-out to enjoy “typical family life”

• Refer special diets to RD for substitutions/modifications dining-out or take-out meals.

Menus1. Recommended Diets:

Regular (portions stated on the menu) Mechanical or finely chopped Puree Consistent Carbohydrates: Diabetic and Wt. control No Added Salt Small and Large Portions

2. Others if needed: Vegetarian Renal: NAS with fluid restrictions if K and Po4 levels normal Allergies and intolerances High Fiber

Menu Substitutions

• Noted in writing on the posted weekly and daily menu

• Keep “Menu Substitution Record”

• Substitute from same food groups

• List of substitutions available

Substitution List

Dining

• Meal Times: 10 hrs: Breakfast and Dinner14 hrs: Substantial Dinner and Breakfast or16 hrs: If a nourishing snack given

• Clients must dine at the table • Eating reclining-must have MD validation and plan to

increase skills• Tables at appropriate height• Dressed for meals. Hands and face washed• Eye glasses, dentures, hearing devices available

Dining- Continued

• Family style meals• Staff provide assistance as needed and reflect

care plan• Meals eaten outside home are nutritionally

adequate• Staff can sit at the table and lead in

conversation. Good socialization guide• Puree diets are not mixed up on the plate when

assisted in feeding• Food must be positioned so client can see food

and reach if self feeding

Resident Choice in Food Service

• Food Preferences• Special Meals: choice

of the week, month, or weekends

• Dining in restaurants• Family Dining• Beverage preference• Snacks• Seat assignment

• Holiday menus• Seconds• Table clothes• Table decorations

Client Participation According to Ability

• Set table• Clear off plate• Serve “Family Style”• Pour beverages• Add own

condiments/salad dressing

• Cut up food• Assist in feeding:

hand over hand

• Help with simple food preparation

• Must wash hands and be supervised

• Plan/prepare a special meal, picnic or BBQ items

• Restaurant or take-out dining

Ordering Food

• Order Guides on Commercial Menus

• Inventory to determine needs of food items

• Must purchase from approved vendors or discount houses

• Do not use home canned or donated prepared items

Shopping

• Use order guides • Can shop at discount houses to save • Milk-must be fluid to drink (do not use powdered)• Purchase produce 1-2 times a week• Meats: USDA inspected• Breads: can use day old from bakery• Use whole grains when possible to ↑ fiber• Do not purchase dented, bulging cans• Rotate Stock

New Concept

• Group Purchasing company delivering food supplies to facilities in California

• Provide Menus• Order off order guides/prices listed • Food delivered weekly : frozen, canned, fresh,

paper goods and cleaning supplies

Staffing Problems

• Orientation: Crucial for food service success

• Incompetent train incompetent?

• Must appoint Dining Coordinator if a full time RD not employed

• ServSafe® certification: local adult schools

• Establish orientation checklist

Orientation Check List

Staffing Problems Cont.

• Job descriptions a must for performance reviews

• Ongoing inservices by facility and RD

• Establish “Annual Inservice Schedules” for facility and RD

• RD audit sanitation, meal production, food quality, and diet accuracy

• Monitor and educate, educate, educate!

Monitoring Food Services

• RD visit at various meal times

• Review with QMRP or Supervisor

• State progress on monthly report

• Sanitation/Dining review

Sanitation Checklist

RD Monthly Report Form

Welcome Back!

Mary Vester-Toews, RDPresident

Dietary Directions, Inc.5446 N. Palm, Suite 105

Fresno, Ca. 93704(559) 451-0460

www.dietarydirections.com

Menu References

• Dietary Directions, Inc., Menus/Order Guides, www.dietarydirections.com,

(559) 451-0460

• Becky Dorner& Associates,Inc. www.beckydorner.com (303) 666-0116

• C L Gerwick and Associates, Inc. www.clgerwick.com (913) 383-3464

References

• Dietary Directions, Inc. Food Service Food Service Policy and Procedures for Intermediate Policy and Procedures for Intermediate Care Facilities, 2007Care Facilities, 2007

• Dietary Directions, Inc. Dietary Directions, Inc. Diet Manual for Diet Manual for Health Care Facilities, 2006Health Care Facilities, 2006

• State Operations Manual, Appendix J, Part State Operations Manual, Appendix J, Part II, 483.480 II, 483.480 http:cmshhs.gov/manuals/downloads/somhttp:cmshhs.gov/manuals/downloads/som107_intermcare.pdf.107_intermcare.pdf.