Transcript DD-2 Ensuring Successful Food Service in DD Residential Facilities

“Ensuring Successful Food
Service in DD Residential
Facilities”
Mary Vester-Toews, RD
Dietary Directions, Inc.
October 8, 2007
“Welcome
to Our
Home”
Problem Areas
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Special Diets
Texture Modifications
Food Preparation
Food Safety-Preventing Food Poisoning
Menus/Alternates
Offering Choice to Residents
Ordering/Shopping
Staff Orientation/On-going Training
Client Participation
Federal Regulations
• Revised in 1988
• Section J of States Operations Manual
Interpretive Guidelines
• Food and Nutrition Services: 483.480
• W Tags: 460-480
• Federal Food Code (HACCP): Sanitation
State Regulations
• State Title Act
• Title 22 in California
• California Food Code
Local Regulations
• County Health Department
• City-Food Codes and regulations
• Require ServSafe® Certification ?
Special Diets
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“Well balanced, including modified and
specially-prescribed diets.” The survey will
verify diet is appropriate by looking at:
Labs-normal ranges
Medical problems-do not develop
Food allergies-followed
Diets changed-when needed
Nutritional needs are known to the facility
and are being addressed
Special Diets
• Fed Regs: prescribed by the RD or MD
• Diet Manual-outlines diets offered
• “Liberal Diet Orders: recommended by
ADA and Fed Regs
• RD review diet orders to liberalize
• List of Recommended Diet Orders for
facility
Liberal Diets
• Diet Order: 1750 Kcal ADA, 2 gm Na, Low
Fat, Low Cholesterol, 6 small meals, Limit
CHO.
• Liberal Diet Order: Consistent
Carbohydrate, No Added Salt, Non-fat
milk. ( CC, NAS with Non-fat milk)
RD recommended Exercise Program
Liberal Diet Orders
• Diabetic Diets: RCS or CC
• Renal: NAS, with Fluid Restriction if K+
and Po4 controlled (Po4 binders). Omit
Salt Sub.
• Weight Reduction or Maintenance: Small
Servings with Low Calorie Snacks, CC or
RCS
• Low Sodium: NAS
Texture Modifications
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Regular: No Chewing/Swallowing problems
Mechanical Soft: Ground or Chopped
Finely Chopped
Puree: Soft Mash Potato- not runny
Fluids: Now Standardized:
Regular
Nectar
Honey
Pudding
Textures Cont.
• Sufficient moisture for chewing and
swallowing offered?
• Can texture/thickness be advanced?
• Obligation to obtain highest functioning
level
• Speech Therapy Reviews to document
current tolerance
• Are same textures given when eating out
or in work experience? Why not?
Resident Rights
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Served according to food preferences
Refuse meals and receive substitution
Refuse therapeutic diets
Served according to ethnic, cultural,
religious beliefs
• Served attractive, tasty food at appropriate
temps, in pleasing environment
Rights Cont.
• Prepared in safe and sanitary manor
• Participate in traditional holiday meals
• Receive information about special diet and
nutritional needs
• Environment to excel to the highest
functioning level. Assistive feeding devices
if required
Clients Food Preferences
• Refusing items-document as a dislike
• Document/post food preferences- use
during serving
• Ask families or previous care takers
• Offer substitution of similar nutrient value
(list posted)
Food Preparation/Serving
Obligations
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Prepare in clean and safe manor
Protect from Food Borne illness
Conserve Nutrients
Enhance Flavor
Maintain attractive appearance
Serve Diet as ordered
Served in a reasonable time (15 min)
Food Prep Suggestions
• Follow Recipes –have all ingredients available.
Cooks review day prior
• Follow Menu/preferences-visible when serving
• Take Temperatures: cooking and serving: hot
>140°F and cold<41°F
• Menus have all residents diet orders if possible
• Portions from menu-do they have the right
serving utensils?
• Puree measured: before vs. after?
Prepare Sack Lunches
Picnic and BBQ’s
• Packed in insulated bag or cooler with
reusable freezer pack. Keep out of sun
• Food cold or frozen prior to packing. DO
NOT USE COOLER to CHILL.
• Hot food keep in thermos. Fill thermos with hot
water prior to filling. Heat items> 165°F. Same
with cold foods but <41°F.
• Can store foods chilled and reheat in Microwave
• Check expiration dates on processed meats,
yogurt, and other items
Lunches, Picnic, and BBQ
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Discard all leftovers
Wash all fruits and vegetables
Freeze sandwiches. Pack tomato and lettuce separate
Frozen drinks can be used in place of freezer packs
Picnic
A. Wrap raw meats in plastic bags
B. Use moistened antibacterial towelettes before and after
handling meat
C. Keep Mayonnaise type salads chilled at 41°F
D. Never place cooked meats on plate used for raw
Menus
• Meet Residents nutritional needs in accordance
to the diet
• Meet RDI’s for age
• New: Milk three 8 oz cups/day
• Recommend 4 week period/seasonally changes
• Commercial or facility written
• Menus approved/signed by RD
• Written one week in advance and posted in
facility 3 days in advance
Slide on Weekly Menu
Menus-Prepared in Advance
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Variety of foods
Standard portions
Kept on file for 30 days
3 meals a day plus snacks and HS.
Have separate therapeutic diet
spreadsheet-user friendly
• Posted for reading clients
Slide on Daily Menu
Holiday and Special Events
• Plan for major Holidays
• Plan for other days that reflect ethnic and
religious interests of clients
• Special Events: Summer BBQ, swimming
parties, Special Olympics, birthdays and
other important days to clients
• Promotes enthusiasm and interest in food
• Include dietary restrictions
Holiday Menu Slide
Special Events, cont.
• Can dine out or order take-out to enjoy
“typical family life”
• Refer special diets to RD for
substitutions/modifications dining-out or
take-out meals.
Menus
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Recommended Diets:
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Regular (portions stated on the menu)
Mechanical or finely chopped
Puree
Consistent Carbohydrates: Diabetic and Wt. control
No Added Salt
Small and Large Portions
Others if needed:
 Vegetarian
 Renal: NAS with fluid restrictions if K and Po4 levels
normal
 Allergies and intolerances
 High Fiber
Menu Substitutions
• Noted in writing on the posted weekly and
daily menu
• Keep “Menu Substitution Record”
• Substitute from same food groups
• List of substitutions available
Substitution List
Dining
• Meal Times:
10 hrs: Breakfast and 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
Dining- Continued
• Family style meals
• Staff provide assistance as needed and reflect
care plan
• Meals eaten outside home are nutritionally
adequate
• Staff can sit at the table and lead in
conversation. Good socialization guide
• Puree diets are not mixed up on the plate when
assisted in feeding
• Food must be positioned so client can see food
and reach if self feeding
Resident Choice in Food Service
• Food Preferences
• Special Meals: choice
of the week, month,
or weekends
• Dining in restaurants
• Family Dining
• Beverage preference
• Snacks
• Seat assignment
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Holiday menus
Seconds
Table clothes
Table decorations
Client Participation According to
Ability
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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 takeout dining
Ordering Food
• Order Guides on Commercial Menus
• Inventory to determine needs of food items
• Must purchase from approved vendors or
discount houses
• Do not use home canned or donated
prepared items
Shopping
• Use order guides
• Can shop at discount houses to save
• Milk-must be fluid to drink (do not use
powdered)
• Purchase produce 1-2 times a week
• Meats: USDA inspected
• Breads: can use day old from bakery
• Use whole grains when possible to ↑ fiber
• Do not purchase dented, bulging cans
• Rotate Stock
New Concept
• Group Purchasing company delivering food
supplies to facilities in California
• Provide Menus
• Order off order guides/prices listed
• Food delivered weekly : frozen, canned, fresh,
paper goods and cleaning supplies
Staffing Problems
• Orientation: Crucial for food service
success
• Incompetent train incompetent?
• Must appoint Dining Coordinator if a full
time RD not employed
• ServSafe® certification: local adult schools
• Establish orientation checklist
Orientation Check List
Staffing Problems Cont.
• Job descriptions a must for performance
reviews
• Ongoing inservices by facility and RD
• Establish “Annual Inservice Schedules” for
facility and RD
• RD audit sanitation, meal production, food
quality, and diet accuracy
• Monitor and educate, educate, educate!
Monitoring Food Services
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RD visit at various meal times
Review with QMRP or Supervisor
State progress on monthly report
Sanitation/Dining review
Sanitation Checklist
RD Monthly Report Form
Welcome Back!
Mary Vester-Toews, RD
President
Dietary Directions, Inc.
5446 N. Palm, Suite 105
Fresno, Ca. 93704
(559) 451-0460
www.dietarydirections.com
Menu References
• Dietary Directions, Inc., Menus/Order
Guides, www.dietarydirections.com,
(559) 451-0460
• Becky Dorner& Associates,Inc.
www.beckydorner.com (303) 666-0116
• C L Gerwick and Associates, Inc.
www.clgerwick.com (913) 383-3464
References
• Dietary Directions, Inc. Food Service
Policy and Procedures for Intermediate
Care Facilities, 2007
• Dietary 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.