Section 144-110-18 - Dietary Services18.A.Policies and Procedures18.A.1. Dietetic services shall be described in the facility's policy and procedure manual with at least the following: a. Organization and dietetic services offered;c. Staffing and budgeting;d. orientation and in-service education;g. Resident clinical nutritional care;h. Purchasing, receiving, and storing of food and supplies;i. Food preparation and service;j. Meal and nourishment service;k. Safety, sanitation, and infection control;l. Time parameters for storage of opened or leftover foods; andm. Disaster feeding plan.18.A.2. Dietetic services will be represented in the professional policy group.18.B.Staffing18.B.1. There shall be sufficient numbers of adequately trained staff to carry out the functions of dietetic services and to meet the dietary needs of residents.18.B.2.Health and Hygienea. No person, while infected with any disease in a communicable form, or while a carrier of such disease, or while afflicted with boils, infected wounds, sores, or any acute gastrointestinal disease or other infection deemed to be transmissible through food, shall work in dietetic services in any capacity in which there is a likelihood of such person contaminating food or food-contact surfaces with pathogenic organisms, or transmitting disease to other individuals.b. Staff shall maintain a high degree of personal cleanliness and shall practice hygienic food-handling techniques.c. All staff shall thoroughly wash their hands and wrist areas with soap and warm water before starting work and after any absence from the work station, and shall wash hands during work hours as often as may be necessary to remove soil and contamination. Fingernails shall be kept clean and trimmed.d. Staff shall wear clean outer clothing and aprons. Hair shall effectively be restrained through the use of nets or other clean hair covering.18.B.3.Food Service SupervisorThere shall be a full-time employee who meets the definition of a qualified Food Service Supervisor (Dietetic Service Supervisor) assigned the overall responsibility for dietetic service.
18.B.4. A Food Service Supervisor (Dietetic Service Supervisor) is a person who:a. Is a qualified dietitian; or b. Is a graduate of a dietetic technician program, approved by the American Dietetic Association; or is a graduate of the Dietary Managers Association approved course and has passed the Certifying Board for Dietary Managers credentialing exam; orc. Is a graduate of a State-approved course in food service supervision; or d. Has training and experience in food service supervision and management in a military service, equivalent to the requirements in (b) or (c) above. Responsibilities of the Food Service Supervisor shall include performance, supervision or approval of the following:
a. Administration 1. Orientation and training for all staff on hygiene practices, with emphasis on handwashing techniques, food preparation, storage, handling and sanitation; 2. Establishing work schedules and assignments for all staff;3. Participating in development and review of dietary service policies and procedures;4. Participating in planning and conducting in-service education for dietetic, nursing and other staff, as needed; and5. Menu planning and ordering of food and supplies.b. Resident Services 1. Interviewing all new residents regarding food preferences and maintaining records of pertinent nutrition information;2. Participating in patient care planning conferences when indicated;3. Reporting to the nursing staff and/or consultant dietitian, and documenting, as necessary, significant observations and resident responses to dietary plans of care; and 4. Documenting, as necessary, in residents' medical records the nutritional care delivered, with guidance from consultant dietitian.c. Preparation, Service and Sanitation 1. Supervising preparation and service of all food including monitoring food temperatures and reviewing residents' meal trays for compliance with the prescribed diet;2. Monitoring food storage in all areas of the facility including stock rotation, inventory control, and proper packaging, labeling and dating of food; and3. Assuring that proper sanitation procedures are implemented in the kitchen and warewashing areas and all other areas in the facility where food is stored, prepared and served.18.B.5.DietitianIf the nursing facility does not employ a Registered Dietitian, there must be a written agreement with a Registered Dietitian currently licensed to practice in the State of Maine to provide consultation.
18.B.6.Responsibilities of Consultant Registered Dietitian Responsibilities shall include:
a. Preparing reports for the administrator at least monthly, reflecting all activities and recommendations;b. Evaluating the functions of the dietetic services, identifying strengths, weaknesses and priorities;c. Participating in the development and revision of policies and procedures;d. Reviewing and approving all menus, including therapeutic diets, to ensure nutritional adequacy and conformity to physician diet orders;e. Counseling residents and/or family members when appropriate;f. Documenting pertinent information regarding residents' nutritional care and status in medical record, as necessary;g. Participating in the assessment of residents and in patient care planning conferences as needed;h. Planning, with Food Service Supervisor, in-service education programs for dietetic employees at least quarterly. Providing in-service for other staff as needed and requested; andi. Participating in residents' discharge planning as indicated by residents' needs.18.C.Adequacy of DietsThe facility must provide each resident with a nourishing, well-balanced diet that meets the daily nutritional and special dietary needs of each resident and that meets the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences, adjusted for age, sex, and activity.
18.C.1. The minimum daily food requirements for adults shall be based on the following:a. Milk and milk products: Two or more eight ounce cups of milk or food containing the calcium equivalent of fluid milk shall be offered daily. A portion of this amount may be served in a cooked form such as milk-based chowders.b. Meat, fish, poultry, and alternatives: A minimum total of five ounces of good quality protein food shall be offered at two or more meals. The evening meal shall include a minimum of two ounces of good quality protein food.c. Fruits and vegetables: Five or more servings per day including a good food(s) source of vitamin C daily and a good food source of vitamin A at least four time weekly. Fruit flavored beverages with or without vitamins added shall not be considered a fulfillment of these requirements.d. Grain group: Six or more servings daily of breads, cereals, and other grain products made from whole grain, fortified or enriched grains.e. Other nourishing foods and beverages to meet individual diet requirements or preferences as necessary.18.C.2.Nourishments and Snacksa. Between-meal and bedtime snacks or nourishments shall be planned, scheduled, and offered routinely or upon request to all residents, except when contra indicated for medical reasons.b. When the kitchen is not open at all times, a nourishment station shall be provided and supplied.18.D.Menus18.D.1. Menus shall be planned and written in a minimum three week cycle and adjusted to include fresh foods in season.18.D.2. Menus shall be dated.18.D.3. Daily menus shall provide for a sufficient variety of foods, and no menu for a lunch or dinner shall be repeated within seven days.18.D.4. Menus shall be served as planned and substitutions shall be consistent with the Recommended Dietary Allowances. Changes shall be recorded and reviewed by the dietitian at the next visit.18.D.5. Menus shall be planned ahead and food supplies maintained so that a nutritionally adequate alternate meal can be provided at all times.18.D.6. The current menu plan shall be posted conspicuously and be readable by personnel, residents and dietetic services staff.18.E.Therapeutic Diets18.E.1. Facilities with residents in need of therapeutic diets shall provide for such diets as prescribed by the attending physician.18.E.2. Therapeutic diets and menus shall be planned, prepared, and served with consultation from a dietitian.18.E.3. Staff responsible for serving therapeutic diets shall have guidelines and knowledge of food values to make appropriate substitutions when necessary.18.E.4. A diet manual, not more than five years old, shall be approved by the professional policy group. Copies shall be readily available to attending physicians, nursing and dietetic services staff.18.F.Food Supplies18.F.1. Supplies of staple foods for a minimum of a one-week period and of perishable foods for a minimum of 48 hours to meet the requirements of the planned menu shall be kept on the premises at all times.18.F.2. Records of all food purchased shall be retained by the facility for three years.18.F.3. The facility must procure food from sources approved or considered satisfactory by Federal, State or local authorities. The use of second grade or outdated products, unlabeled canned goods, railroad salvage, and similar foods is prohibited.18.F.4. Hermetically sealed food shall be obtained from a regulated food processing establishment.18.F.5. Fluid milk and fluid milk products used or served shall be pasteurized.18.F.6. Milk served to residents for drinking shall be served in the following manner:a. In an original single serving container; orb. From the original container to the residents' glass at meal time; orc. The glass filled at meal time from a sanitary bulk milk dispenser.18.F.7. No reconstituted powdered milk or evaporated milk shall be served for drinking.18.F.8. Dry powdered or evaporated milk may be used in cooking or may be added to milk from the dairy as a high protein supplement.18.F.9. Only clean whole eggs, with shell intact and without cracks or checks; or pasteurized liquid, frozen or dry eggs or pasteurized dry egg products shall be used. Hard-boiled, peeled eggs, commercially prepared and packaged, may be used. Eggs shall be refrigerated at all times and no raw eggs shall be used in uncooked products. 18.F.10. Fresh and frozen shucked shellfish (oysters, clams or mussels) shall be obtained in non-returnable packages legibly bearing the processor's name, address and authorized certification number.18.F.11. Shell stock and shucked shellfish shall be kept in the container in which they were received until they are used.18.F.12. Sulfites may not be added to raw or cooked fruits or vegetables, nor monosodium glutamate added to any food prepared in the facility.18.G.Food Storage and Protection18.G.1. Food shall be stored, prepared, served, transported, and distributed with protection at all times from potential contamination including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage, leakage and condensation.18.G.2. Food, whether raw or prepared, if removed from the container or package in which it was obtained, shall be stored in a clean and sanitized container and be labeled and dated.18.G.3. Only containers specifically made for food storage shall be used. They shall be in good condition and maintain the safety and integrity of the contents.18.G.4. Containers of food shall be stored at least six inches above the floor, on clean racks, dollies or other clean surfaces, in such a manner as to be protected from splash and other contamination.18.G.5. Poisonous and toxic materials shall be labeled and stored in a secured area separate from food, food preparation areas, and clean equipment and utensil storage.18.G.6. Food not subject to further washing or cooking before serving shall be protected against contamination from food requiring washing or cooking.18.G.7. Hermetically sealed cans once opened shall not be used for storage of food. Exception: Shell stock and shucked shellfish shall be kept in the original container in which they were received until they are used. Hermetically sealed packages shall be handled so as to maintain product and container integrity.18.G.8. Unserved foods from previously prepared menus must be discarded after thirty-six (36) hours. Foods that may be frozen safely, such as meat, may be frozen, retained and used according to accepted timeframes for such processes.18.G.9. Food shall not be stored with drugs or laboratory specimens. 18.G.10. All dented cans of food must be removed from the food storage area and may not be used for resident consumption.18.H.Refrigerator and Freezer18.H.1. A thermometer accurate to +3 degrees Fahrenheit shall be located inside each refrigerator, freezer, or other storage space used for potentially hazardous food(s).18.H.2. Enough conveniently located refrigeration facilities shall be provided to assure that all food is stored at required temperatures.18.H.3. The maximum temperature for the refrigerated storage of all perishable and potentially hazardous food and fluids shall be 41 degrees Fahrenheit or below.18.H.4. Potentially hazardous food shall be cooled from 140 degrees Fahrenheit to 70 degrees Fahrenheit within two hours and from 70 degrees Fahrenheit to 41 degrees Fahrenheit within an additional four hours.18.H.5. Frozen food shall be kept frozen and shall be stored at a temperature of 0 degrees Fahrenheit or below.18.I.Hot Food StorageEnough conveniently located hot food storage facilities shall be provided to assure the maintenance of food at the required temperature of 140 degrees Fahrenheit or above during storage and meal service.
18.J.Food Preparation18.J.1. Hands shall be washed prior to any food preparation, whether or not disposable gloves are used. Hands shall be washed every time they become contaminated and after gloves are removed.18.J.2. Foods shall be prepared by methods that conserve nutritive value, flavor and appearance.18.J.3. Standardized recipes that list clear descriptive procedures, portion yield and measures, shall be maintained and utilized and shall correspond to items on the posted menus.18.J.4. Foods shall be cut, chopped or ground to meet individual needs.18.J.5. Convenient and suitable serving and cooking utensils, such as forks, knives, tongs, spoons and scoops shall be provided and used to minimize direct manual contact with food at all points, where food is prepared.18.J.6. Food shall be prepared on surfaces that have been cleaned and sanitized to prevent cross-contamination.18.J.7. All raw fruits and vegetables shall be thoroughly washed to remove soil and other contaminants before being cut, combined with other ingredients, cooked or served.18.J.8. Potentially hazardous frozen foods shall be thawed as follows: a. Under refrigeration at a temperature not to exceed 41 degrees Fahrenheit; orb. Under potable running water of a temperature of 70 degrees Fahrenheit, or below, with sufficient water velocity to agitate and float off loose particles into the overflow and for a period not to exceed that needed to thaw the products; orc. As part of a continuous cooking process using a microwave oven, a conventional cooking unit or a combination of cooking equipment.18.J.9. All potentially hazardous food shall be kept at an internal temperature of 41 degrees Fahrenheit or below or at an internal temperature of 140 degrees Fahrenheit or above during service.18.J.10. Potentially hazardous food that has been cooked and then refrigerated, and which is reheated for hot holding shall be reheated rapidly to 165 degrees Fahrenheit, or higher before being served or before being placed in a hot storage food facility.18.J.11. Poultry, poultry products, pork, pork products, and stuffing containing raw poultry or pork shall be cooked to heat all parts of the food to 165 degrees Fahrenheit, or above.18.J.12. Potentially hazardous ingredients such as mayonnaise and dairy products for foods that are in a form to be consumed without further cooking such as salads, sandwiches, filled pastry products and reconstituted foods shall have been chilled to 41 degrees Fahrenheit or below prior to preparation.18.K.Food Service18.K.1. Equipment shall be provided and procedures established to maintain food at safe temperatures during tray assembly. Hot foods shall leave the kitchen above 140 degrees Fahrenheit and cold food below 41 degrees Fahrenheit. Hot foods shall be hot and cold foods cold when they reach the resident.18.K.2. During transportation, including transportation to another location for service, food and food utensils shall be protected from contamination.18.K.3. At least three meals that are nutritious and suited to special needs of residents shall be served daily, at regular times comparable to normal meal times in the community. This schedule must be modified if necessary to accommodate the individual needs of residents. If a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day, if a resident group agrees to this meal span, and a nourishing snack is served. A "nourishing snack" is defined as an offering of items, single or in combination, from the basic food groups. Adequacy of the "nourishing snack" will be determined both by resident interviews and by evaluation of the overall nutritional status of residents in the facility (e.g., Is the offered snack usually satisfying?).18.K.4. Food shall be palatable and attractively served in appropriate portions and in a form designed to meet individual needs.18.K.5. Substitutes of similar nutritive value shall be offered if a resident refuses food served.18.K.6. Service at a table in a dining area, other than a bedroom, shall be encouraged for all who can and will eat at a table, including wheelchair residents.18.K.7. All residents seated at the same table shall be served at the same time.18.K.8. Food shall be served on dishes and shall not be in direct contact with trays.18.K.9. Trays, when used, shall rest on firm supports such as overbed tables for bedfast residents. Sturdy tables of proper height shall be provided for residents able to be out of bed. 18.K.10. Residents needing special equipment, implements, or utensils to assist them with eating, shall have such items provided.18.K.11. Employees and guests eating meals and snacks shall do so in an area separate from the food preparation, tray service, and dishwashing areas.18.K.12. Animals shall be excluded from the food preparation area at all times and the dining room during the preparation and service of food.18.L.Cleaning, Sanitization and Storage of Equipment and Utensils18.L.1.Cleaning Frequencya. Kitchenware, tableware, utensils, and food-contact surfaces of equipment used in the storage, preparation, service, transportation or distribution of food shall be maintained in a clean and sanitary manner.b. Kitchenware, tableware, and utensils shall be allowed to drain and air-dry in racks or baskets on a nonabsorbent surface after being washed, rinsed and sanitized.c. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other accumulated soil.d. Non-food-contact surfaces of all equipment shall be cleaned at such frequency as is necessary to be free of accumulations of dust, dirt, food particles and other debris.e. Cloths used for wiping food spills on kitchenware or food-contact surfaces of equipment shall be cleaned and rinsed frequently in a sanitizing solution.f. Ice scoops shall be kept in a firm container of stainless steel, impervious plastic or fiberglass. The container and ice scoop shall be washed and sanitized daily. The handles of ice scoops shall not come in contact with the ice.18.L.2.Manual Cleaning and Sanitizinga. Prior to washing, all equipment and utensils shall be preflushed, prescraped or presoaked to remove gross food particles and soil.b. Equipment and utensils shall be thoroughly washed in a detergent solution having a temperature of at least 110 degrees Fahrenheit, and then shall be rinsed free of such solution. All eating and drinking utensils and, where required, the food-contact surfaces of all other equipment and utensils shall then be sanitized by one of the following methods: 1. Immersion for at least one-half minute in clean hot water at a temperature of at least 170 degrees Fahrenheit.2. Immersion for at least one minute in a clean solution containing at least fifty parts per million of available chlorine as a hypochlorite and at a temperature of at most 75 degrees Fahrenheit.3. All chemicals used for sanitizing shall have complete instructions for use kept in the cleaning area.c. When chemical sanitizing solutions are used for either manual or mechanical sanitization, procedures for testing shall be provided and used to measure the residual of the sanitizing chemical solution used at least daily.18.L.3.Mechanical Cleaning and Sanitizinga. Warewashing machines and their auxiliary components shall be operated in accordance with manufacturers' instructions and procedures for testing shall be provided and used.b. When chemicals are relied upon for sanitization, they shall be applied in such concentration and for such a period of time as to provide effective bactericidal treatment of the equipment and utensils:1. The temperature of the wash water shall not be less than 120 degrees Fahrenheit.2. Chemicals added for sanitization purposes shall be automatically dispensed.3. The chemical sanitizing rinse water temperature shall be the temperature specified by the machine manufacturer.c. Dishwashing racks, when not in use, shall be stored in a clean area off the floor. 18.L.4.Equipment and Utensil Handling and Storagea. Cleaned and sanitized equipment and utensils shall be handled in a way that protects them from contamination. Tableware shall be handled without contact with inside surface or surfaces that contact the user's mouth.b. Cleaned and sanitized utensils and equipment shall be stored at least six inches above the floor in an enclosed, clean, dry location and protected from contamination by splash, dust, and other means. Equipment and utensils shall not be placed under exposed or unprotected sewer lines or water lines, except for automatic fire protection sprinkler heads that may be required by law.c. Cleaned utensils shall be stored covered, inverted or appropriately stored on utensils racks.d. Facilities for the storage of knives, forks, and spoons shall be designed and used to present the handle to the employee, resident or user.e. All tableware, kitchenware, and utensils shall be in good repair and be free of stains, breaks, cracks, chipped places, corrosion and open seams.18.M.Garbage and Rubbish18.M.1.ContainersAll waste not disposed of by mechanical means shall be kept in containers constructed of durable metal or other approved types of material which do not leak and do not absorb liquids. Plastic bags and wet-strength paper bags may be used to line these containers. All containers shall be provided with tight-fitting lids or covers.
18.M.2.Storagea. Garbage and rubbish containing food waste while in the kitchen shall be stored so as to be inaccessible to vermin.b. Storage rooms or enclosures shall be constructed of easily cleanable, washable materials and shall be vermin proofed. c. Garbage containers and returnable/recyclable materials shall be stored outside the facility, either on a sealed and easily cleanable concrete slab, dense sealed bituminous surface, or a rack which is at least six (6) inches above the ground.d. Storage areas shall be clean, and kept free of litter.e. All storage containers shall be insect-tight, easily cleanable and adequate for the proper storage of all garbage and rubbish.f. The premises of the facility shall be kept free of litter and dirt.g. Refuse storage bins shall be maintained in a safe and sanitary condition.18.M.3.Disposala. Outside storage of unprotected plastic bags or wet-strength paper bags or baled units containing garbage or rubbish is prohibited.b. All garbage and rubbish shall be removed from the kitchen at least daily, and from the premises as frequently as necessary, but at least weekly. Where municipal or private disposal services are not available, the facility shall dispose of the refuse by transportation to a disposal site approved by the local community involved, or by the State.18.N.Dietary Areas18.N.1.Kitchen Areaa. Size and Segregation Kitchens shall be segregated from other areas and large enough to allow for adequate equipment to prepare and care for food properly.b. Floors Floors shall be waterproof and smooth with easily cleanable surfaces.
c. Walls All wall surfaces shall be smooth and non-porous.
d. Ceilings Ceilings shall be sound and heat insulated when located beneath a resident area.
e. Ventilation Ventilation must be provided to maintain food integrity and reasonable comfort of the staff. All doors, windows and fans shall be placed so that air flow is not directed at food. Outside ventilation openings shall be screened.
f. Sewer Lines Sewer lines in food storage, preparation and service areas must have anti-backflow devices and must be enclosed.
18.N.2.Equipmenta. Dietary areas shall be appropriately and adequately equipped for food storage, preparation, service, transportation and distribution.b. Installation All equipment and appliances shall be installed to permit thorough cleaning of the equipment, the floors and the walls around them.
c. Warewashing A warewashing machine shall be required in each facility. All facilities or new dietary areas for which construction is started after the effective date of these regulations shall provide a dishwashing area separated from the food preparation and serving areas by at least a four (4) foot high partition. An easily readable thermometer shall be provided in each tank of the dishwashing machine which will indicate to an accuracy of +3 degrees Fahrenheit, the temperature of the water or solution therein.
d. Sinks All new facilities or facilities proposing major renovations shall have a three compartment warewashing sink (at least 12 inches deep) and a separate handwashing sink conveniently available.
18.N.3.Storagea. Dry Storage Sufficient dry storage space that is ventilated and accessible to the kitchen shall be provided.
b. Kitchenware, Tableware, and Utensils Space that is protected from potential contamination shall be provided for the storage of kitchenware, tableware and utensils.
c. Janitor's Closet All facilities or new kitchen areas for which construction was started after July 1, 1994 shall have a separate janitor's closet for floor cleaning equipment to be used for the dietary service area. All facilities shall have designated floor cleaning equipment for the dietary service area.
10- 144 C.M.R. ch. 110, § 18