The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

For this tag auditors will look for:

• Ensure a resident’s Plan of Care has specific requirements for a resident’s diet
• Residents are provided alternate meals
• Alternate meals meet the nutritional requirements for the resident
• Documentation in the meal plan reflects what the resident is given at each meal
• Residents are served correct portion sizes to meet their nutritional plan
• Dietary staff are following a recipe
• Food is prepared, served, and plated in an appetizing manner
• Food is served at proper temperatures
• The facility takes into consideration resident’s concerns about food frequency, quality, variety, and timeliness.

This includes a qualified dietitian or clinically qualified nutrition professional.

Requirements for qualification include:

• Bachelor’s degree or higher from an accredited US college/university with completion of the academic requirements for a program in nutrition or dietetics
• Completion of a minimum of 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional
• Licensed or certified as a dietitian or nutrition professional in the State where services are being performed.

If the qualified person is not a full-time staff member (35+ hours/week), the facility must designate someone to serve as the Director of Food and Nutrition Services and that individual must:

• Be a certified dietary manager, certified food service manager or has a similar national certification from a national certifying body for food service management and safety
• Associate’s degree or higher in food service management or in hospitality, if the course study from an accredited institution includes food service or restaurant management
• Meets State requirements for food service managers or dietary managers in States that have such established requirements
• Receives “frequently scheduled consultations” from a qualified dietitian/ nutritional professional

“Sufficient support personnel” means having enough dietary and food and nutrition staff to safely carry out all of the functions of the food and nutrition services.

For this tag auditors will look for:

• Is there enough support personnel to safely and effectively carry out the meal preparation and other food and nutrition services
• Interview residents to determine if their needs and preferences are met
• Is the food is palatable, attractive, served at the proper temperatures and at appropriate times
• Which individual represents food and nutrition services at interdisciplinary team meetings

Menus must:

• meet the needs of residents in accordance with established national guidelines
• be prepared in advance
• be followed
• reflect, based on a facility’s reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups.
• be updated periodically
• Be reviewed by the facility’s dietitian or other clinically qualified nutrition professional for nutritional adequacy
• Nothing in this paragraph should be construed to limit the resident’s right to make personal dietary choices

For this tag auditors will look for:

• The facility has enough inventory on hand for 3+ days
• Food is the correct texture according to the resident’s diet
• Resident preferences are kept up to date
• There are a variety of food options available
• Substituted items are approved and logged

During the audit you should have the following documentation available:

• Prep & Pull sheets
• Substitution logs
• Menu change communication
• Menu posting
• Resident feedback via committee meetings or tray cards

For this tag auditors will:

• Ask residents how they feel about the food.
• Request a test tray
• Ask for recipes
• Ask how food is seasoned
• Make sure you have all ingredients available to make recipes as instructed for palatability
• Request tray delivery logs
• Ask for a temperature log and check to ensure acceptable serving temperatures are monitored and corrected
• Ask for resident feedback, comments, and compliant documentation

For this tag auditors will:

• Observe meals and food preparation to assure the food is prepared and appropriate to meet resident’s needs and according to their assessment and care plan.
• Observe residents and assess if residents are having difficulty chewing or swallowing their food
• Assess if food cut, chopped, ground, or pureed for individual resident’s needs
• Observe that modified textures are prepared in a safe and sanitary manner​
• Observe that modified textures are prepared in a way that preserves nutrient quality​
• Observe that textures prepared to a standard quality or measure

Check your compliance by:

• Performing a test tray on a modified textures
• Having diet and texture spreads posted for staff to reference, including facility-specific guidelines
• Ensuring your purees do not spread on a plate
• Making sure the food thickener is labeled and stored without utensils in it and there are directions for mixing nearby.

For this tag auditors will:

• Ask residents how the food meets their preferences, allergies and/or intolerances
• If residents refuse food or drinks, ask them if they are offered substitutes
• Interview residents or staff to determine how alternate food choices are communicated to the residents
• Assess how food textures, allergies, intolerances, and preferences are accommodated per a resident’s assessment, care plan, and choice and how is this information communicated to staff

Check your compliance by:

• Doing tray accuracy audits
• Regularly updating preference​ records
• Conducting meal rounds
• Having an Always Available menu
• Attending care plans, morning meetings, QAPIs
• Providing resident specific menus to residents and their care team

For this tag auditors will:

• Observe that drinks and other fluids provided when the resident requests that are consistent with the resident’s care plan, preferences and choices
• Observe that facility staff provide sufficient drinks that the resident prefers to maintain hydration
• Observe that other liquids, such as broth, popsicles, or ice cream, offered to the resident to encourage fluid intake
• Observe what actions facility staff take to ensure resident hydration is maintained if a resident refuses the fluid offered​

Check your compliance by:

• Doing tray accuracy audits
• Updating preference records
• Attending care plans, morning meetings, and QAPIs
• Working with the IDCT
• Having always available menus with a special request policy

A therapeutic diet is a special diet ordered by a physician to:

• Treat a disease or clinical condition
• Eliminate or decrease specific nutrients in a resident’s diet
• Increase levels of a specific nutrient in a resident’s diet
• Provide food in a form that a resident is able to eat, such as a mechanically altered diet

Mechanically altered diets are diets where the texture of the food has been altered based on the specific physician’s order.

There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served 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.

Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Definitions:

Nourishing Snack: Items from the basic food groups either singular or in combination with each other.​

The snack needs to provide a balance of nutrition, it has to have a calorific value that is consistent with their diet. It also has to have the protein, vitamins, and minerals to promote good health

Suitable and nourishing alternative meals and snacks: This means the client must have the option of a different meal or snack that is equivalent in value for their current mean care plan​

If the offered option for the day is not something the client wants to eat,  an alternative item must be provided to fit their nutritional needs, It is our responsibility to have these options available at each serving period

For this tag auditors will:

• Observe meal times and schedules and determine if they are offered at regular times comparable to normal times found in the community
• Interview residents to get their input on meal service schedules and determine if they meet their choices and gain their input regarding eating at non-traditional times and the availability of snacks throughout the day.​

Check your compliance by::

• Completing truck delivery logs to document snack & nourishment delivery
• Ensure your staff knows about time requirements
• Alert the right person if a meal is going to be late
• Understand if your meals and snacks have a buffer

For this tag auditors will:

• Determine if recommendations were made for adaptive eating equipment and utensils. If they were, determine if these utensils are available and able to be utilized by residents
• Determine if these utensils are recommended but not used if that is by the resident’s choice.
• Observe if eating equipment and utensils are not being utilized and then determine when these were recommended and how their use is being monitored by the facility and if the staff is developing alternative recommendations and monitoring ongoing assessments
• Observe whether staff competently assists residents who use assistive devices

Requirements for training of paid feeding assistants include these minimum requirements:

• A State-approved training course for paid feeding assistants must include, at a minimum, 8 hours of training in the following:

  • Feeding techniques

  • Assistance with feeding and hydration

  • Communication and interpersonal skills

  • Appropriate responses to resident behavior

  • Safety and emergency procedures, including the Heimlich maneuver

  • Infection control

  • Resident rights

  • Recognizing changes in residents that are inconsistent with their normal behavior and the importance of reporting those changes to the supervisory nurse.

• A facility must maintain a record of all individuals, used by the facility as feeding assistants, who have successfully completed the training course for paid feeding assistants.

This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.

This provision does not preclude residents from consuming foods not procured by the facility.

The facility must store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Important Definitions:

• Critical control point: This a specific point in the food production chain that should be monitored to prevent physical, biological, or chemical contamination ​
• Cross contamination: The transfer of harmful substances between two surfaces, this can be physical or biological​
• Danger zone: A temperature zone of 41F to 145F that, when food is left in, will promote rapid bacteria growth ​
• Dry storage: An area used to store non-refrigerated foods and supplies that can stay in ambient temperatures​
• Food contamination: The unintended presence of potentially harmful substances, these can be physical, chemical, or biological
• Food preparation: A series of processes to prepare foods from receiving to serving​
• Food service distribution: Process of getting the prepared plated food to the resident from the kitchen​
• Potentially hazardous foods: Food that requires time and/or temperature control to maintain the safety​
• Storage: The retention of food that is held before and after the production process

For this tag auditors will look for:

• Labeling, dating, and monitoring of refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable), or discarded​
• ​The completion of Test Tray Audits to ensure foods are being served at correct temperatures
• The separation of raw foods (e.g., beef, fish, lamb, pork, and poultry) from each other and storing raw meats on shelves below fruits, vegetables or other ready-to-eat foods so that meat juices do not drip onto these foods.
• Food is cooked to the appropriate temperature to kill pathogenic microorganisms that may cause food borne illness. Cold food is kept in a manner that prevents the growth of pathogenic microorganisms.

• • Poultry and stuffed foods, i.e., turkeys, pork chops, chickens, etc. – 165 degrees F​
  • Ground meat (e.g., ground beef, ground pork), ground fish, and eggs held for service – at least 155 degrees F​
  • Fish and other non-ground meats – 145 degrees F​
  • NOTE: Fresh, frozen, or canned fruits and vegetables that are cooked do not require the same level of microorganism destruction as raw meats/foods. Cooking to a hot holding temperature (135 degrees F) prevents the growth of pathogenic bacteria that may be present in or on these foods

• Employees utilize proper personal hygiene practices to prevent food contamination. Including include proper handwashing, use of hairnets and disposable gloves
• Use and maintain equipment and food contact surfaces (cutting boards, plates, utensils, etc) to prevent cross-contamination
  • Equipment and Utensil Cleaning and Sanitization -A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination via splash, dust, grease, etc. ​
  • Cleaning Fixed Equipment -the removable parts must be washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution. 

For this tag auditors will look for:

• The facility has a policy regarding the use and storage of foods brought in from outside sources
• Staff assists the resident in accessing and consuming the food if the resident is not able to do
  so on his or her own
• Staff uses safe food handling practices
• Food brought in by family or visitors is stored in a way that is either separate or easily distinguished from
  nursing home food
• Family and visitors are helped to understand safe food handling practices (such as safe cooling/ reheating
  process, hot/cold holding temperatures, preventing cross-contamination, hand hygiene, etc.)

For this tag auditors will look for:

• Garbage and refuse containers in good condition (no leaks) and is waste properly contained in dumpsters or compactors with lids or otherwise covered
• Areas such as loading docks, hallways, and elevators used for both garbage disposal and clean food transport kept clean, free of debris, and free of foul odors and waste fat
•  The garbage storage area is maintained in a sanitary condition to prevent the harborage and feeding of pests
• Garbage receptacles covered when being removed from the kitchen area to the dumpster