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South Carolina Association of Residential Care Homes Tuesday, October 1, 2013 2:30-4:00 pm - PowerPoint PPT Presentation

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South Carolina Association of Residential Care Homes Tuesday, October 1, 2013 2:30-4:00 pm. Double Down on Dietary Regulations & Requirements Presented by: Edna Cox Rice, RD, CSG, LD. Overview. New Dining Practice Standards Diets Regulations Strategizing Break Jeopardy Prizes !.

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Double Down on

Dietary Regulations &Requirements

Presented by:

Edna Cox Rice, RD, CSG, LD


  • New Dining Practice Standards

  • Diets

  • Regulations

  • Strategizing Break

  • Jeopardy

  • Prizes!

  • Formed in 1997, the Pioneer Network was formed by a small group of professionals in long-term care (LTC) to advocate for person-directed care.

  • Focus on changing the individual's and society’s attitudes toward aging and elders.

  • Twelve National Clinical Standard Setting Associations:

  • American Association for Long Term Care Nursing (AALTCN)

  • American Association of Nurse Assessment Coordination (AANAC)

  • Academy of Nutrition and Dietetics (AND)

  • American Medical Directors Association (AMDA)

  • American Occupational Therapy Association (AOTA)

  • American Society of Consultant Pharmacists (ASCP)

  • American Speech-Language-Hearing Association (ASHA)

  • Dietary Managers Association (DMA)

  • Gerontological Advanced Practice Nurses Association (GAPNA)

  • Hartford Institute for Geriatric Nursing (HIGN)

  • National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC)

  • National Gerontological Nursing Association (NGNA)

These nationally agreed upon new food and dining standards of practice support individualized care and self-directed living vs. traditional diagnosis-focused treatment for people living in health care facilities. The document includes the new Standards of Practice.

  • The Dining Practice Standards:

  • Reflects current thinking and consensus, which are in advance of research

  • Reflects evidence-based research available to date

  • The current thinking portions of each of the new Dining Practice Standards represent a list of recommended future research


  • Recommended Course of Practice:

  • Diet determined with the person not exclusively by diagnosis.

  • Include quality of life markers such as satisfaction with food, service received during meals, level of control and independence.

  • Recommended Course of Practice:

  • Unless a medical condition warrants a restricted diet, consider beginning with a regular diet and monitoring.

  • Empower and honor the person first, whole interdisciplinary team second, to look at concerns and create effective solutions.

  • Support self-direction and individualize the plan of care.

  • Recommended Course of Practice:

  • Ensure that the physician and consultant pharmacist are aware of resident food and dining preferences so that medication issues can be addressed and coordinated.

  • Monitor person and condition related to theirgoals regarding nutritional status, physical, mental and psychosocial well-being.

  • Although a person may have not been able to make decisions about certain aspects of their life, that does not mean they cannot make choices in dining.

  • Recommended Course of Practice:

  • When one makes “risky” decisions, plan of care will be adjusted to honor informed choice, provide support to mitigate risks.

  • Most professional codes of ethics require professional to support the person in making their own decisions.

  • All decisions default to the person.

Nutrition approaches diet liberalization

Nutrition Approaches:Diet Liberalization

Dining Practice Standard 1

  • Liberalized Diets Research:

  • Restrictive diets are a frequent cause of weight loss

  • Physicians are encouraged to liberalize diets

  • Medical needs are balanced with quality of life

  • Prevention of weight loss is viewed as a priority

  • Resident’s goals and wishes are followed

  • Diet Liberalization ADA 2010:

  • It is the position of the ADA that the quality of life and nut. status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets. 

  • Although therapeutic diets are designed to improve health, they can negatively affect the variety and flavor of the food offered. Individuals may find restrictive diets unpalatable, resulting in reducing the pleasure of eating, decreased food intake, unintended weight loss, and under-nutrition – the very maladies health care practitioners are trying to prevent.

Diet Liberalization ADA 2010:

In contrast, more liberal diets are associated with increased food and beverage intake. For many older adults residing in health care communities, the benefits of less-restrictive diets outweigh the risk.

Diabetic calorie controlled diet


Calorie-Controlled Diet

Dining Practice Standard 2

  • Research on Diabetic Diets:

  • Intensive treatment of diabetes sometimes is not appropriate for all individuals in the long-term care (LTC) setting

  • No evidence to support no-concentrated sweets, no-added-sugar diets for older adults in LTC—using medication rather than dietary changes can enhance the joy of eating

  • AMDA: Target of A1c 7–8 discourages use of sliding scale insulin

  • Diabetic/Calorie controlled Diet – AMDA:

  • AMDA: “…intensive treatment of diabetes may not be appropriate for all individuals in the LTC setting. To improve quality of life, diagnostic and therapeutic decisions should take into account the patient’s cognitive and functional status, severity of disease, expressed preferences, & life expectancy.”

  • An individualized regular diet that is well balanced and contains a variety of foods and a consistent amount of carbohydrates has been shown to be more effective than the typical treatment of diabetes.

Low sodium diet

Low-Sodium Diet

Dining Practice Standard 3

  • Research on Low-Sodium Diets:

  • May benefit some individuals, but in frail elderly more lenient blood pressure goals and more lenient diets are needed

  • A liberal approach sometimes is needed to maintain nutritional status

  • Typical 2-gram sodium diet achieved only modest effect on blood pressure and is not shown to improve cardiovascular outcomes in LTC residents

Cardiac diet

Cardiac Diet

Dining Practice Standard 4

  • Research on Cardiac Diets:

  • Diets are not shown to improve control or affect symptoms

  • Dietary Guidelines for Americans and/or DASH diet can achieve goals

  • Important to balance restrictions with adequate nutrition

  • Aggressive lipid reduction in LTC is more effectively achieved through use of medications

  • Cardiac Diet Current Thinking:

  • Limiting salt intake in individuals with congestive heart failure is felt to be of benefit by limiting fluid retention, but the clinical experience of 2 medical directors of numerous health care facilities shows that this is necessary inonly a minority of nursing home patients, usually those who are salt sensitive and often have advanced disease.

  • Drs. Leible and Wayne, The Role of the Physician Order, Creating Home II

  • Cardiac Diet Research Trends

  • The effects of the traditional low cholesterol and low fat diets typically used to treat elevated cholesterol vary greatly and, at most, will decrease lipids by only 10-15%.

  • If aggressive lipid reduction is appropriate for the nursing home resident it can be more effectively achieved through the use of medication that provides average reductions of between 30 and 40% while still allowing the individual to enjoy personal food choices (2 research studies).

  • Home II

Altered consistency diet


Consistency Diet

Dining Practice Standard 5

  • Research on Altered Consistencies:

  • Swallowing abnormalities do not necessarily require modified texture

  • Collaborate with doctor, speech pathologist, registered dietitian, and other professionals

  • Look beyond symptoms to underlying causes to avoid excessive modification of food/fluid

  • Sometimes it is necessary to evaluate tolerance of aspiration risk, compared to the slow process of wasting away

Real food first

Real Food First

Dining Practice Standard 7

  • Research on Real Food First:

  • Provide naturally soft, smooth texture before pureed foods when possible (yogurt, puddings, ice cream, and vegetable soufflés)

  • Create meals comparable to home

  • Select from approved sources from family and friends, gardens

  • Serve food before supplements

  • Choose homemade before commercial

  • Use flavor enhancers

  • Flavor Enhancement:

  • Taste and smell losses occur with aging, which can decrease food enjoyment, reduce food consumption, and negatively influence nutritional status.

  • Flavor enhancers can compensate for the diminished sensory function, which is a contributing factor to impaired appetite and decreased intake in the elderly.

  • What are flavor enhancers? They are food additives commonly added to foods, designed to enhance the existing flavors of products.

  • You can use commercially manufactured flavor enhancers, but the best flavor enhancers are those found in an ordinary spice rack or pantry.

  • You can make bland, tasteless meals a thing of the past with the improvements of culture change and dining practices.

  • Examples of Flavor Enhancers:

  • Spices and herbs: Basil, garlic, dill, rosemary, lavender, mint, pickling spices, thyme, sage, etc

  • Seasonings or flavor enhancers: Ancho powder, chili powder, Accent® (monosodium glutamate [MSG]), Spike® (hydrolyzed vegetable protein), anchovies and anchovy paste, balsamic vinegar, Bon Appetit® Seasoning Salt, capers, Chef Paul Prudomme’s® Seasoning Blends®, Chile peppers, citrus fruits (juice and zests), grapes, molasses, Old Bay® Seasoning, onions, pepper, peppermint oils and extracts, sugar, date sugar, Tabasco®, tahini, truffle oil, cooking wine, etc

  • Resource:

  • Staff Creativity Combines with Resident Choices:

  • The standard cooking techniques, recipes, and bland foods are no longer the Gold Standard

  • Staff must bring creativity to food preparation, trying new recipes, new cooking techniques and food combinations, and flavor enhancements

  • Staff and residents must form an alliance in menu choices and selections

Honoring choices

Honoring Choices

Dining Practice Standard 8

  • Research on Honoring Choices:

  • RESIDENT satisfaction with RESIDENT’S PERSONAL choice

  • Dignity & autonomy CAN increase desire to eat

  • Bulk food service and homelike environment optimize energy intake

    • It is all about choice, RESIDENT CHOICE

    • ATTITUDE ADJUSTMENT—keep an open mind

  • Current Thinking About Honoring Resident Choices:

  • Facility must provide evidence of education offered to resident and family about the risks of diet choices/behaviors

  • Physician involvement is needed in these discussions

  • Resident choice is before regulations and guidelines

  • Avoid one size–allow hot dogs and whole grapes if resident is able to eat them

“One cannot think well, sleep well, if one has not dined well.”

--Virginia Wolf

What is a Modified Diet?

A modified diet is any diet that consists of foods that are mechanically altered for the purpose of ease of chewing and swallowing.

Diet will incorporate, based on the individual needs of the person receiving it, foods that may be blended, chopped, ground, or mashed.

  • Who Needs a Modified Diet?

  • Individuals with:

    • Poor dentition, ill fitting dentures, edentulous, dysphagia

    • Medical conditions such as Alzheimer’s Disease, Cerebral Palsy, Parkinson’s Disease, history of CVA, Cancer, Trauma, MS, other muscle disorders

    • Conditions necessitating altered consistencies may be either temporary or permanent; all cases should be individually diagnosed, evaluated, and treated by a multidisciplinary medical team including physicians, nurses, registered dietitians, speech therapists, occupational therapists, and physical therapists.

  • Dysphagia

  • Difficulty with chewing or swallowing of food or liquid

  • As many of 50% of an aging health care facility population may have some degree of dysphagia

  • Two main types

    • Esophageal

    • Oropharyngeal

  • May occur based upon a variety of diagnoses

  • Places resident at risk for variety of nutritional and medical complications

  • How Can you Tell if Someone needs a Consistency Change?

  • Signs/Symptoms

    • Choking, gasping, gurgling when eating/drinking

    • Frequent fevers or infections, particularly respiratory infections

    • Decreased appetite, weight loss, decreased involvement in meal process

  • To whom do I refer someone?

    • Physician, Speech Therapist, Registered Dietitian

  • Who decides?

    • Ultimately, the diet order is written by physician, with input from health care team.

  • Consistencies of Diets

  • Modified Regular Foods

  • Mechanical Soft Chopped

  • Mechanical Soft Ground

  • Puree

  • Advantages of Modified Diets:

  • Provide same nutritional value to residents as a resident without need for an altered consistency

  • Ability to enjoy favorite foods despite changes in medical condition

  • Potential to continue to enjoy aspects of meals that lead to optimal intake:

    • Socialization

    • Variety

    • Odors, flavors, sounds, sights

  • Disadvantages of Modified Diets:

  • Visually unattractive

  • No resemblance to original food item

  • Unpalatable

  • May not be well prepared

  • Residents miss their favorite foods

  • All of these items combine to potentially make the entire dining experience less enjoyable than it should be.

  • Disadvantages of Modified Diets:

  • These factors may combine to create an environment of less interest in foods and dining, decreased socialization at meal times, and ultimately decreased intake and its concurrent side effects:

    • Weight loss

    • Malnutrition

    • Loss of lean body mass

    • Overall decline in energy, level of activity

Does this look delicious to you?

  • Trends in Food Production & Service

  • Emphasis on fine dining experiences

  • More visually pleasing

  • Higher quality

  • More diverse variety of foods

  • More chefs in health care settings

  • Dietary managers, food service directors, Dietitians with culinary backgrounds preferred

  • Client satisfaction coupled with choice

  • Flexibility in meal schedule

    • more frequent meals, room service

  • Our Customers:

  • Aging and Living Longer

  • Well Educated

  • High Standards

  • Know what they want!

  • Goals:

  • Improve resident meal service

  • Create a wonderful experience for our residents

  • Provide a comfortable dining environment with proper meal assistance

  • Improve food quality and presentation

  • Food should look good, taste good and be offered courteously

  • What We Aim to Provide

  • Nourishing, palatable, attractive meals

  • Meet the daily nutritional and special dietary needs of each individual

  • Maintain or improve eating skills

  • Be supportive of needs

  • Enhance quality of life for each resident

  • A Resident Centered Dining Program Provides:

  • Nourishing, palatable, attractive meals

  • Meet the daily nutritional and special dietary needs of each individual

  • Maintain or improve eating skills

  • Be supportive of needs

  • Enhance quality of life for each resident

  • 2003 Becky Dorner & Associates

  • Evaluation of Dining Service:

  • If residents complain about taste, temperature, quality, quantity, or appearance of the food, be sure to satisfy their needs

  • Determine the reason for refusal of the food

  • Offer a substitute of equal nutritional value

  • Food placement, color and texture must be appropriate for needs

  • Mechanically altered foods should be prepared and served appropriately

  • 2003 Becky Dorner & Associates

Butternut Squash Pureed Soup

Beef & Gravy with Peas & Potatoes

Chicken Curry

  • Reminder: Diet Orders are Physician Orders!

  • Developed by team consisting of physicians, speech therapists, nurses, and dietitians.

  • Must be followed!!!

  • What if the Resident or Their Family Refuses?

  • All disciplines of health care team should educate resident and family members on risks of not adhering to recommended consistency

  • All disciplines should document as accurately as possible that education was provided, specifics of interaction, and the response of the parties being educated.

  • If parties continue to refuse, refer to (or develop if needed), a policy on how to document family’s refusal, with signature, time, and date of interaction.

  • What is it?

  • Follows the regular diet

  • Food is given in a form that is easily handled with fingers

  • Why is it used?

  • Allows independence in eating regardless of functional declines in cognition and/or muscle coordination.

  • Prevents spillage or loss of food

  • When might a person need this diet?

  • Decline in self-feeding ability

  • Unable to use utensils

  • Adaptive meal equipment unsuccessful

  • Previous OT interventions & dining rehabilitation have been unsuccessful

  • SECTION 1300: MEAL SERVICEGeneral: 1301-A

  • All facilities that prepare food on-site shall be approved by DHL, and shall be regulated, inspected, and graded pursuant to R.61-25.

  • Facilities preparing food on-site and licensed for 16 beds or more subsequent to the promulgation of these regulations shall have commercial kitchens.

  • Existing facilities with 16 licensed beds or more may continue to operate with equipment currently in use; however, only commercial kitchen equipment shall be used when replacements are necessary.

  • Those facilities with 15 beds or less shall be regulated pursuant to R.61-25 with certain exceptions in regard to equipment (may utilize domestic kitchen equipment.))

  • SECTION 1300: MEAL SERVICE General: 1301-B

  • When meals are catered to a facility, such meals shall be obtained from a food service establishment graded by the Department, pursuant to R.61-25, and there shall be a written executed contract with the food service establishment.

  • SECTION 1300: MEAL SERVICE General: 1301-C

  • If food is prepared at a central kitchen and delivered to separate facilities or separate buildings and/or floors of the same facility, provisions shall be made and approved by DHL for proper maintenance of food temperatures and a sanitary mode of transportation.

  • SECTION 1300: MEAL SERVICE General: 1301-D

  • Food shall be prepared by methods that conserve the nutritive value, flavor and appearance.

  • The food shall be palatable, properly prepared, and sufficient in quantity and quality to meet the daily nutritional needs of the residents in accordance with written dietary policies and procedures.

  • Efforts shall be made to accommodate the religious, cultural, and ethnic preferences of each individual resident and consider variations of eating habits, unless the orders of a physician or other authorized healthcare provider contraindicate.

  • SECTION 1300: MEAL SERVICE Food & Food Storage: 1302

  • The storage, preparation, serving, transportation of food, and the sources from which food is obtained shall be in accordance with R.61-25.

  • Home canned food usage shall be prohibited.

  • SECTION 1300 = MEAL SERVICEFood & Food Storage: 1302

  • C. All food items shall be stored at a minimum of 6” above the floor on clean surfaces, and in such a manner as to be protected from splash and other contamination.

  • D. At least a one-week supply of staple foods and a two-day supply of perishable foods shall be maintained on the premises. Supplies shall be appropriate to meet the requirements of the menu and special or therapeutic diets.

  • SECTION 1300: MEAL SERVICE Food & Food Storage: 1302-E

  • Food stored in the refrigerator/freezer shall be covered, labeled, and dated. Prepared food shall not be stored in the refrigerator for more than 72 hours.

  • SECTION 1300: MEAL SERVICE Food Equipment & Utensils: 1303

  • The equipment and utensils utilized, and the cleaning, sanitizing, and storage of such shall be in accordance with R.61-25.

SECTION 1300: MEAL SERVICE Meals & Services: 1304-A

All facilities shall provide dietary services to meet the daily nutritional needs of the residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences.

  • SECTION 1300: MEAL SERVICE Meals & Services: 1304-B

  • The dining area shall provide a congenial and relaxed environment.

  • Table service shall be planned in an attractive and colorful manner for each meal and shall include full place settings with napkins, tablecloths or place-mats, and non-disposable forks, spoons, knives, drink containers, plates, and other eating utensils/containers as needed.

  • SECTION 1300: MEAL SERVICE Meals & Services: 1304-C

  • A minimum of three nutritionally-adequate meals in each 24-hour period, shall be provided for each resident unless otherwise directed by the resident’s physician or other authorized healthcare provider.

  • Not more than 14 hours shall elapse between the serving of the evening meal and breakfast the following day.

SECTION 1300: MEAL SERVICE Meals & Services: 1304

D. Special attention shall be given to preparation and prompt serving in order to maintain correct food temperatures for serving at the table or resident room (tray service).

E. The same foods shall not be repetitively served during each seven-day period except to honor specific, individual resident requests.

SECTION 1300: MEAL SERVICE Meals & Services: 1304

F. Specific times for serving meals shall be established, documented on a posted menu, and followed.

G. Suitable food and snacks shall be available and offered between meals at no additional cost to the residents.

  • SECTION 1300: MEAL SERVICE Meals & Services: 1304-H

  • Residents shall be encouraged to eat in the dining room at mealtime.

  • Tray service shall be permitted when the resident is medically unable to access the dining area for meals, or if the facility has received written notice from the resident/responsible party of a preference to receive tray service, in which case it may be provided on an occasional basis.

  • Under no circumstances, may staff members utilize tray service for their own convenience.

SECTION 1300: MEAL SERVICEMeals Service Personnel: 1305

A. The health and cleanliness of all those engaged in food preparation and serving shall be in accordance with R.61-25.

B. Sufficient staff members/volunteers shall be available to serve food and to provide individual attention and assistance, as needed.

SECTION 1300: MEAL SERVICEMeals Service Personnel: 1305-C

Approved hair restraints (covering all loose hair) shall be worn by all individuals engaged in the preparation of foods.

  • SECTION 1300: MEAL SERVICEMeals Service Personnel: 1305-D

  • Dietary services shall be organized with established lines of accountability and clearly defined job assignments for those engaged in food preparation and serving.

  • There shall be trained staff members/volunteers to supervise the preparation and serving of the proper diet to the residents including having sufficient knowledge of food values in order to make appropriate substitutions when necessary. The facility shall not permit residents to engage in food preparation. Exceptions…

SECTION 1300: MEAL SERVICEMeals Service Personnel: 1305

EXCEPTION: A resident may engage in food preparation provided the following criteria are met:

1. Approval to engage in food preparation by a physician or other authorized medical authority;

2. The ICP of the resident has indicated food preparation as suitable/beneficial to the resident;

3. The resident is directly supervised by staff members/volunteers (must be in the kitchen with the resident);

4. Preparing food must be part of an organized program in which daily living skills are being taught;

5. The utilization of residents for preparing food is not a substitute for staff members/volunteers.

  • SECTION 1300: MEAL SERVICEDiets: 1306-A

  • If the facility accepts or retains residents in need of medically-prescribed special diets, the menus for such diets shall be planned by a professionally-qualified dietitian or shall be reviewed and approved by a physician or other authorized healthcare provider.

  • The facility shall maintain documentation that each of these menus has been planned by a dietitian, a physician or other authorized healthcare provider…

  • SECTION 1300: MEAL SERVICEDiets: 1306-A

  • At a minimum, documentation for each resident’s special diet menu shall include the signature of the dietitian, the physician or other authorized healthcare provider, his/her title, and the date he/she signed the menu….

  • SECTION 1300: MEAL SERVICEDiets: 1306-A

  • The facility shall maintain staff capable of the preparation/serving of any special diet, e.g., low-sodium, low-fat, 1200-calorie, diabetic diet. Facility staff preparing a resident’s special diet shall be knowledgeable of the procedure to prepare each special diet.

  • The preparation of any resident’s special diet shall follow the written guidance provided by a registered dietitian, physician, or other authorized healthcare provider authorizing the resident’s special diet.

  • For each resident receiving a special diet, this written guidance shall be documented in the resident’s record.


If special diets are required, the necessary equipment for preparation of those diets shall be available and utilized.

  • SECTION 1300: MEAL SERVICEDiets: 1306-C

  • A diet manual published within the previous five years shall be available and shall address at minimum:

    • 1. Food sources and food quality;

    • 2. Food protection storage, preparation and service;

    • 3. Food worker health and cleanliness;…

  • SECTION 1300: MEAL SERVICEDiets: 1306-C

    • 4. Recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences food serving recommendations;

    • 5. General menu planning;

    • 6. Menu planning appropriate to special needs, e.g., diabetic, low-salt, low-cholesterol, or other diets appropriate for the elderly and/or infirmed.


Menus shall be planned and written at a minimum of one week in advance and dated as served. The current week’s menu, including routine and special diets and any substitutions or changes made, shall be readily available and posted in one or more conspicuous places in a public area. All substitutions made on the master menu shall be recorded in writing. Cycled menus shall be rotated so that the same weekly menu is not duplicated for at least a period of three weeks.


Records of menus as served shall be maintained for at least 30 days.

SECTION 1300: MEAL SERVICEIce & Drinking Water: 1308-A

Ice from a water system that is in accordance with R.61-58, shall be available and precautions taken to prevent contamination. The ice scoop shall be stored in a sanitary manner outside of the ice container.

SECTION 1300: MEAL SERVICEIce & Drinking Water: 1308-B

Potable drinking water shall be available and accessible to residents at all times.

SECTION 1300: MEAL SERVICEIce & Drinking Water: 1308

C. The usage of common cups shall be prohibited.

D. Ice delivered to resident areas in bulk shall be in nonporous, covered containers that shall be cleaned after each use.

  • SECTION 1300: MEAL SERVICEEquipment: 1309-A

  • Liquid or powder soap dispensers and sanitary paper towels shall be available at each food service handwash lavatory.

  • Alcohol-based waterless hand sanitizers shall not be used in lieu of liquid or powder soap.

SECTION 1300: MEAL SERVICEEquipment: 1309-B

In facilities of 16 or more licensed beds, separate handwash sinks shall be provided, convenient to serving, food preparation, and dishwashing areas.

SECTION 1300: MEAL SERVICEEquipment: 1309-C

All walk-in refrigerators and freezers shall be equipped with opening devices which will permit opening of the door from the inside at all times.


  • The disaster plan shall include…

  • A letter of agreement signed by an authorized representative of each sheltering facility which shall include…feeding….plans for the relocated residents; and provisions for accommodating relocated staff members/volunteers.

  • The letter shall be updated annually with the sheltering facility and whenever significant changes occur.

  • For those facilities located in Beaufort, Charleston, Colleton, Horry, Jasper, and Georgetown counties, at least one sheltering facility shall be located in a county other than these counties.

  • SECTION 300: ENFORCEMENT ACTIONS Violation Classifications: 302-E1

  • Specific conditions and their impact or potential impact on health, safety or well-being of the residents including…lack of food or evidence that the residents are not being fed properly.

  • SECTION 500: STAFF/TRAINING General: 501-G

  • When a facility engages a source other than the facility to provide services, normally provided by the facility, e.g….food service, professional consultant…there shall be a written agreement with the source.

  • SECTION 500: STAFF/TRAININGGeneral: 505-A

  • All staff members/direct care volunteers who have contact with residents, including food service staff members/volunteers, shall have a health assessment within 12 months prior to initial resident contact.

  • The health assessment shall include tuberculin skin testing.


  • The facility shall initiate and maintain an organized record for each resident.

  • The record shall contain… diet provided; and promote continuity of care among providers.

  • All entries shall be written legibly in ink or typed, and signed, and dated.


  • There shall be a written agreement between the resident, and/or his/her responsible party, and the facility.

  • The agreement shall include …an explanation of the specific care/services/equipment provided by the facility, e.g…. provision of special diet as necessary… assistance with…feeding.


  • Residents shall receive care, including diet…as ordered by a physician or other authorized healthcare provider.

  • Such care shall be provided and coordinated among those responsible during the process of providing such care/services and modified as warranted based upon any changing needs of the resident.


  • The provision of care/services to residents shall be guided by the recognition of and respect for cultural differences to assure reasonable accommodations shall be made for residents with regard to differences, such as, but not limited to…dietary preferences.


  • Pets shall not be allowed in the kitchen area.

  • Pets shall be permitted in resident dining areas only during times when food is not being served.

  • If the dining area is adjacent to a food preparation or storage area, those areas shall be effectively separated by walls and closed doors while pets are present.

  • SECTION 1900: DESIGN & CONSTRUCTIONConstruction/Systems: 1904-4a-d

  • Other requirements for facilities that prepare meals:

  • Separation of food service operations from living/sleeping quarters

  • Kitchen ventilation

  • Food preparation equipment approved by NSF

  • Other specifications for: Garbage cans, grease interceptor, floor drains, hand washing s inks, staff toilets & lockers, exhaust hood/duct system/extinguishing system, 3-compartment sink in addition to hand washing sink, etc.

  • (refer to for complete reg)

  • SECTION 2500: ELECTRICALLighting: 2503-D

  • All food preparation areas, equipment and utensil washing areas, hand washing areas, toilet areas for staff/volunteers, walk-in refrigeration units, dry food storage areas, and dining areas during cleaning operation shall be lighted in accordance with R.61-25.

  • R. 61-25

  • For full report go to:

  • Highlights will be reviewed today

  • Potentially Hazardous Food

  • Definition: A food that is natural

  • or synthetic and is in a form capable of supporting:

  • (1) The rapid and progressive growth of infectious or toxigenic microorganisms; or

  • (2) The growth and toxin production of

  • Clostridium botulinum.

  • Sanitization

  • Definition: “Effective bactericidal treatment by a process that provides enough cumulative heat or concentration of chemicals for enough time to reduce the bacterial count, including pathogens, to a safe level on utensils and equipment.

  • Chapter II - Food

  • Must be:

  • From sources approved or considered satisfactory by the health authority

  • Properly labeled

  • Free from spoilage, adulteration, and other contamination

  • Safe for human consumption.

  • Chapter II - Food

  • Milk/milk products meet Grade A quality standards

  • Dry milk made from pasteurized milk/milk products

  • Chapter II - Food

  • Shellfish (oysters, clams, mussels, scallops) kept in same container, andsource identification tags/labels kept on file 90 days

  • Chapter II - Food

  • Whole eggs with shells intact or pasteurized; commercially prepared hard-boiled eggs okay

  • No wild mushrooms

  • .

  • Chapter II - Food

  • Food being transported, stored, prepared, displayed, served, or sold…shall be

  • protected from dust, flies, rodents, or other vermin, toxic materials, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding by sewage, overhead leakage, and all other sources of

  • contamination.

  • Chapter II - Food

  • Raw food products shall be physically separated

  • from ready-to-eat food products during display or

  • storage by storing the raw products below ready-to-eat food products or by using other approved methods.

  • The temperature of potentially hazardous food shall be 45°F. or below, or 130°F. or above, at all times

  • Chapter II - Food

  • Different types of raw animal products (beef, fish, lamb, pork, or poultry) shall be separated during storage, processing, and display by use of different containers, partitions, shelves, or by cleaning and sanitizing the equipment between product use.

  • Chapter II - Food

  • In the event of a fire, flood, power outage, or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from

  • being held at required temperatures, the person in charge shall immediately contact the health authority.

  • Chapter II - Food

  • Containers of food shall be stored a minimum of 6” above the floor in a manner that protects the food from splash and other contamination and that permits easy cleaning of the storage area.

  • Chapter II - Food

  • Food not subject to further washing or cooking before serving shall be stored in a way that protects it against cross-contamination from food requiring

  • further preparation.

  • Chapter II - Food

  • Unless the identity is unmistakable, bulk food such as cooking oil, syrup, salt, sugar, or flour shall be stored in a container identifying the food by common name.

  • Chapter II - Food

  • Products that are held for credit, redemption, or return to the distributor, such as damaged, soiled, or recalled products, shall be held in designated areas that are separated from food, equipment, utensils, linens, and single-service and single-use articles.

  • Chapter II - Food

  • During transportation, food and food utensils shall be kept in covered containers, wrapped, or pack aged so as to be protected from contamination.

  • During transportation, including transportation to another location for service or catering operations, food shall meet the requirements of this regulation relating to food protection and food storage.

  • Chapter II - Food

  • Adequate refrigeration facilities or effectively

  • insulated facilities shall be provided in a convenient location to assure the maintenance of potentially hazardous food at 45°F. or below during display, service, and storage.

  • Chapter II - Food

  • Each mechanically refrigerated facility storing potentially hazardous food shall be provided with a numerically scaled indicating thermometer accurate to ±3°F.

  • Thermometers shall be located to measure the air temperature in the warmest part of the facility and shall be located to be easily readable.

  • Chapter II - Food

  • Potentially hazardous food requiring refrigeration

  • after preparation shall be rapidly cooled to 45°F.

  • (7.2°C.) by:

  • (1) refrigerated storage in shallow containers; or

  • (2) stirring food in a container placed in an ice bath; or

  • (3) adding ice as an ingredient; or

  • (4) using rapid cooling equipment, such as blast

  • chillers

  • Chapter II - Food

  • Potentially hazardous food to be transported shall

  • be prechilled and held at a temperature of 45°F.

  • (7.2°C.) or below unless maintained in accordance

  • with provisions of this regulation for hot food storage.

  • Chapter II - Food

  • Ice intended for human consumption shall not be

  • used as a medium for cooling stored food, food

  • containers, or food utensils, except that such ice

  • may be used for cooling tubes conveying beverages

  • or beverage ingredients to a dispenser head.

  • Chapter II - Food

  • Each enclosed hot food facility storing potentially

  • hazardous food shall be provided with a numerically

  • scaled indicating thermometer accurate to ±3°F.

  • Thermometers shall be located to measure

  • the air temperature in the coolest part of the facility

  • and shall be located to be easily readable.

  • Where it is impractical to install thermometers on equipment… a product thermometer must be available and used to check internal food temperature.

  • Chapter II – Food

  • The internal temperature of potentially hazardous food requiring hot storage during display, service, and transportation shall be 130°F. or above

  • Except that primal cuts of rare roast beef shall be held at a surface temperature of at least 130°F.

  • Chapter II - Food

  • Raw fruits and raw vegetables shall be thoroughly washed with potable water before being cooked or served.

  • Chapter II – Food

  • Potentially hazardous food requiring cooking shall be

  • cooked to heat all parts of the food to a temperature of at least 145°F. except that:

  • Pasta & stuffings containing meat: 165°F.

  • Ground beef/any food containing ground beef: 155°F.

  • Pork/any food containing pork, game animals,

  • & comminuted fish and meat: 155°F.

  • Roast beef cooked to a surface temperature of: 155°F.

  • Beef steak cooked to a surface temperature of: 155°F.

  • Chapter II - Food

  • Eggs, including liquid, frozen, and dry eggs, and any food containing egg products, shall be cooked to heat all parts of the food to 145°F.

  • Exception: Pasteurized eggs shall be used when food products are not cooked to an internal temperature of at least 145°F.

  • Chapter II – Food

  • Reheat potentially hazardous foods rapidly to 165°F.

  • The use of steam tables, warmers, and similar hot food holding facilities for reheating of potentially hazardous food is prohibited.

Chapter II – Food

Potentially Hazardous Foods should be thawed:

a. In refrigerated units not to exceed 45°F. ; or

b. Under potable running water from the cold water

supply with sufficient water velocity to agitate and

float off loose food particles into the overflow; or

c. In a microwave oven only when the food will be

immediately transferred to conventional cooking

facilities as part of a continuous cooking process or

when the entire uninterrupted cooking process takes

place in the microwave oven; or

d. As part of the conventional cooking process.

Chapter II – Food

To avoid unnecessary manual contact with food,

dispensing utensils with handles shall be used.

  • Chapter II – Food

  • Once served to a consumer, leftover food shall not be served again…

  • Except that packaged food, other than potentially hazardous food, that is still packaged and is still in sound condition, may be re-served.

Chapter II – Food

Adequate hot or cold food facilities shall be

provided to maintain potentially hazardous food on

display at 45°F. or below or 130°F. or above.

  • Chapter III – Personnel

  • No person infected with a communicable disease or who is a carrier of organisms that cause such a disease, or while afflicted with a boil, an infected wound, or a respiratory infection when accompanied by fever or diarrhea with fever shall work in a food establishment

  • Persons coughing or sneezing without fever shall

  • be restricted from food preparation activities.

Chapter III – Personnel

Cut, burns, abrasions, or other wounds shall be properly protected from contaminating food through the use of disposable gloves, finger cots, or other approved methods

Chapter III – Personnel

Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water in an approved handwashing facility before starting work, during work as often as is necessary to keep them clean, and after coughing, sneezing, handling soiled utensils or equipment, smoking, eating, drinking, or using the toilet.

Chapter III – Personnel

Employees engaged in food preparation shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are smooth and cleanable.

  • Chapter III – Personnel

  • While preparing food, employees may not wear excessive jewelry on their hands or arms.

  • Disposable gloves and hand sanitizers may be used in addition to proper handwashing.

  • Disposable gloves must be discarded after any possible contamination.

Chapter III – Personnel

Employees shall not use tobacco in any form while engaged in food preparation, processing, or service, or while in areas used for equipment or utensil washing or

for food preparation and processing. Employees shall use tobacco only in approved designated areas.

  • Chapter III – Personnel

  • Employees shall not eat or drink in food preparation, food processing, or utensil washing areas…

  • Except that, an employee may drink from a covered beverage container, provided the container is handled in a manner that prevents contamination.

  • Chapter IV – Equipment & Utensils

  • Wicker may be used only when suitably lined.

  • Galvanized metal shall not be used for utensils or

  • food-contact surfaces of equipment that are used for

  • beverages, moist food, or acidic food.

  • Copper and copper alloys, such as brass, shall not

  • be used in contact with acidic food

  • Pewter may not be used as a food-contact surface;

  • however, imitation pewter meeting the requirements

  • for multi-use utensils may be used as a food-contact surface.

  • Chapter IV – Equipment & Utensils

  • Thermometers required for immersion into

  • food shall be:

  • Metal, stem-type construction

  • Numerically scaled

  • Accurate to ±3°F

  • Capable of measuring from 45°F. to 165°F


  • Kitchenware and food-contact surfaces of

  • equipment shall be washed, rinsed, and sanitized:

  • Each time there is a change in processing

  • between types of raw animal products; or

  • Each time there is a change from raw to ready-to-

  • eat food; or

  • At any time during the operation when contamination may have occurred.


  • Cloths used for wiping food spills on tableware,

  • such as plates or bowls being served to the consumer,

  • shall be clean, dry, and used for no other purpose.

  • Cloths or sponges used for cleaning surfaces of

  • equipment, counters, dining table tops, and shelves

  • shall be clean and shall be rinsed in an approved

  • sanitizing solution used for no other purpose.

  • In-use cloths and sponges shall be stored in an approved sanitizing solution.


  • Except for fixed equipment and utensils too large to be washed, rinsed, and sanitized in sink compartments, manual washing, rinsing, and sanitizing shall be conducted in the following order:

  • (1) Equipment and utensils shall be thoroughly washed in the first compartment with a hot detergent solution that is kept clean; and

  • (2) Equipment and utensils shall be rinsed free of detergent and abrasives with clean water in the second compartment; and

  • (3) Equipment and utensils shall be sanitized in the

  • third compartment.

  • After sanitization, all equipment and utensils shall be air-dried.


  • Hot Water Sanitizing:

  • (a) Immersion for at least 30 seconds in clean, hot water at a temperature of at least 170°F.; and

  • (b) The sanitizing compartment of the sink shall be capable of maintaining the water at a temperature of at least 170°F.; and

  • (c) A numerically scaled indicating thermometer, accurate to ±3°F.,

  • shall be provided as an integral part of the sink or heating device for frequent checks of water temperature; and

  • (d) Dish baskets shall be of such size and design to permit immersion of the tableware, kitchenware, and equipment in hot water.


  • Chemical Sanitizing:

  • (a) Immersion for at least 30 seconds in a clean solution containing between 50 – 100 ppm of available chlorine, or

  • (b) Immersion for at least 30 seconds in a clean solution containing 12.5 - 25 ppm available iodine, having a maximum pH of 5.0, and a minimum temp. of 75°F., or

  • (c) Immersion for at least 30 seconds in a clean solution containing between 200 - 400 ppm of quaternary ammonium at a temp. of at least 75°F., or

  • (d) Immersion in a clean solution containing any other chemical-sanitizing agent which is to the satisfaction of the health authority.

  • (e) Equipment too large to be treated by methods (a) through (d) above may be treated by spraying or swabbing with an approved sanitizing solution.

  • (f) A test kit or device that measures the ppm shall be accessible and used.


  • Mechanical Cleaning & Sanitizing:

  • The pressure of final rinse water supplied to warewashing machines shall be controlled by a pressure regulating valve and not less than 15 or more than 25 PSI in the water line immediately adjacent to the final rinse control valve.

  • Final rinse pressure shall be measured by an approved pressure gauge.

  • A gauge cock one-fourth inch Iron Pipe Size (IPS) valve shall be provided immediately upstream from the final rinse control valve to permit checking the flow pressure of the final rinse water.

  • Booster heaters for warewashing machines shall be either built-in or installed within five feet of the machine.

  • Machine or water line mounted numerically scaled indicating thermometers, accurate to ±3°F. shall be provided to indicate the temperature of the water in each tank of the machine and the temperature of the final rinse water as it enters the manifold.


  • Warewashing machines using chemicals for sanitization may be used if:

  • (1) The temperature of the wash water shall be in accordance with manufacturers data plate, but not be less than 120°F. (49°C.); and

  • (2) The wash water shall be kept clean; and

  • (3) Chemicals added for sanitization purposes are automatically dispensed; and

  • (4) Utensils & equipment shall be exposed to the final chemical sanitizing rinse in accordance with manufacturers’ specifications for time and concentration; and

  • (5) The chemical sanitizing rinse water temperature shall be no less than 75°F. or less than the temperature specified by the machine’s manufacturer; and

  • (6) Chemical sanitizers used shall be approved by the health authority; and

  • (7) A test kit or device that accurately measures the ppm is accessible and used.


  • Warewashing machines using hot water for sanitizing may be used provided that …water temperature is not less than:

  • (1) Single-tank, stationary-rack, dual-temperature machine: Wash 150°F. Rinse 180°F.

  • (2) Single-tank, stationary-rack, single-temperature machine:

  • Wash 165°F. Rinse 165°F.

  • (3) Single-tank, conveyor machine: Wash 160°F. Rinse 180°F.

  • (4) Multiple-tank, conveyor machine:

  • Wash 150°F. Pumped rinse 160°F. Final rinse 180°F.

  • (5) Single-tank, pot, pan, and utensil washer: Wash 150°F. Rinse 180°F.

  • (6) Final rinse temperature for hot water sanitation shall not exceed 195°F


  • Cleaned and sanitized utensils and equipment stored at least 6” above the floor in a clean, dry location

  • Utensils shall be air-dried before being stored, or stored in a self-draining position.

  • Utensils that have been air-dried may be polished with cloths that are maintained clean and dry.

  • Stored glasses, cups, and utensils shall be covered, inverted, or protected from contamination by other effective methods.

  • Knives, forks, and spoons that are not pre-wrapped shall be presented so that only the handles are touched by employees and by consumers.

  • Chapter VI –

  • Sanitary Facilities & Controls

  • Containers used in food preparation, food

  • processing, equipment-washing, and utensil washing

  • areas shall be kept covered when filled or stored or when not in continuous use.

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