1. Ensuring Successful Food Service in DD Residential Facilities Mary Vester-Toews, RD Dietary Directions, Inc. October 8, 2007

2. Welcome to Our Home

3. 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

4. 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

5. State Regulations State Title Act Title 22 in California California Food Code

6. Local Regulations County Health Department City-Food Codes and regulations Require ServSafe® Certification ?

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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?

13. 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

14. 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

15. 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)

16. Food Preparation/Serving Obligations 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)

17. 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?

18. Prepare Sack Lunches Picnic and BBQs 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

19. 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

20. Menus Meet Residents nutritional needs in accordance to the diet Meet RDIs 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

21. Slide on Weekly Menu

22. 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

23. Slide on Daily Menu

24. 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

25. Holiday Menu Slide

26. 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.

27. Menus 1.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

28. 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

29. Substitution List

30. Dining Meal Times: 10 hrs: Breakfast and Dinner 14 hrs: Substantial Dinner and Breakfast or 16 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. Orientation Check List

39. 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!

40. Monitoring Food Services RD visit at various meal times Review with QMRP or Supervisor State progress on monthly report Sanitation/Dining review

41. Sanitation Checklist

42. RD Monthly Report Form

43. Welcome Back! Mary Vester-Toews, RD President Dietary Directions, Inc. 5446 N. Palm, Suite 105 Fresno, Ca. 93704 (559) 451-0460 www.dietarydirections.com

44. Menu References Dietary Directions, Inc., Menus/Order Guides, www.dietarydirections.com,www.dietarydirections.com (559) 451-0460 Becky Dorner& Associates,Inc. www.beckydorner.com (303) 666-0116 www.beckydorner.com C L Gerwick and Associates, Inc. www.clgerwick.com (913) 383-3464 www.clgerwick.com

45. References Food Service Policy and Procedures for Intermediate Care Facilities, 2007Dietary Directions, Inc. Food Service Policy and Procedures for Intermediate Care Facilities, 2007 Dietary Directions, Inc. Diet Manual for Health Care Facilities, 2006Dietary Directions, Inc. Diet Manual for Health Care Facilities, 2006 State Operations Manual, Appendix J, Part II, 483.480 http:cmshhs.gov/manuals/downloads/som 107_intermcare.pdf.State Operations Manual, Appendix J, Part II, 483.480 http:cmshhs.gov/manuals/downloads/som 107_intermcare.pdf.