1. (a) Administration.

   1. (1)

      1. (A) The food and nutrition services shall be under the daily, including weekends, onsite supervision of a qualified individual.
      2. (B) The individual shall be at a minimum a certified dietary manager and:

2. (i) Be responsible for the daily management of clinical and administrative dietetic aspects of the service by formulating, reviewing, and revising policies and procedures for all food and nutrition services practices;

   1. (ii) Ensure that all personnel in the service are oriented in their respective duties;

      1. (iii) Implement a maintenance program to ensure food service facilities, equipment, and utensils are:
3. (a) (a) Maintained in a safe, clean, sanitary manner; and

4. (b) (b) Replaced at specific intervals or as needed;

   1. (iv) Participate on hospital-wide departmental committees as required;

      1. (v)
5. (a) (a) Ensure that trained staff are maintained for daily administrative and clinical nutrition practices.

6. (b) (b) A minimum of a two-week current work schedule shall be posted and reflect all positions, including the department director; and

   1. (vi) Develop, implement, and maintain a system for recordkeeping relating to all department functions dependent on the department’s scope of services, e.g., patient assessments, counseling, diet instructions, temperatures, educational programs, etc.

      1. (vii)
7. (a) (a) A hospital within a hospital may contract with the host hospital for food and nutrition services.

8. (b) (b) Contracted services shall:

   1. (1) (1) Be under a current agreement; and
   2. (2) (2) Meet all requirements of this section.

   3. (2)

      1. (A) Policies and procedures shall have evidence of ongoing review and/or revision.

      2. (B) The first page of each manual shall have the:

         1. (i) Annual review date; and
         2. (ii) Signature of the department supervisor and/or person or persons conducting the review.

   4. (3) Policies and procedures shall include:

      1. (A) Job descriptions and performance evaluations;
      2. (B) Orientation;
      3. (C) Preventive maintenance;
      4. (D) Infection prevention and control measures;
      5. (E) Safety practices; and
      6. (F) Cleaning of equipment and applicable areas.

   5. (4)

      1. (A) Clinically relevant educational programs shall be conducted at regularly scheduled intervals with not less than twelve (12) per year.

      2. (B) There shall be evidence of:

         1. (i) Program dates;
         2. (ii) Attendance; and
         3. (iii) Subject matter.

   6. (5)

      1. (A) Nutrition services shall have an ongoing QA/PI program that addresses both clinical and administrative issues.

      2. (B) A mechanism for reporting results of audits shall be provided, to include:

         1. (i) Indicators monitored;
         2. (ii) Thresholds/standards established;
         3. (iii) Results;
         4. (iv) Corrective plan/corrective action taken; and
         5. (v) Follow-up.
   7. (6) Time and duty schedules for all hourly employees shall be maintained.

   8. (7)

      1. (A) Diet manual shall be authorized by the medical staff, reviewed and revised as needed to reflect current recognized dietary practices.
      2. (B) A cover page shall be affixed with the date of review and appropriate signatures, and a copy of the manual shall be located on each patient unit.
      3. (C) Use of electronic diet manuals is acceptable.

   9. (8) Menus shall:

      1. (A) Be planned/approved by the registered dietitian and meet the nutrition needs of the patients in accordance with the current recommended dietary guidelines of the Food and Nutrition Board of the National Research Council and the currently approved facility diet manual in accordance with the written diet order;

      2. (B)

         1. (i) Be dated at least one (1) week in advance.
         2. (ii) The current week’s menus shall be posted and available in the kitchen.
         3. (iii) The meals prepared and served shall correspond with:
9. (a) (a) The posted menu; or

10. (b) (b) Written diet orders;

    1. (C) Not be restrictive in nature (e.g., seasoning, fat, sodium, sugar content) unless required by a modified/therapeutic diet order; and

       1. (D)

          1. (i) Be of equivalent nutrition value when substitutions/changes are made.
          2. (ii) Menus/production schedules showing all changes shall be retained for at least thirty (30) days.

    2. (9)

       1. (A) Diets shall be in writing and signed by a physician or a midlevel practitioner if privileged by the medical staff and governing body.
       2. (B) Dietitians may issue orders for patient diets if authorized by the medical staff.

       3. (C) Notification according to facility policy shall:

          1. (i) Be made to the nutrition services department on a timely basis;
          2. (ii) Be kept current; and
          3. (iii) Include the:
11. (a) (a) Current date; and
12. (b) (b) Patient’s name, room number, and diet order.

13. (b) Food services.

    1. (1)

       1. (A) At least three (3) meal equivalents shall be served daily at regular intervals approximately five (5) hours apart.
       2. (B) No more than fifteen (15) hours shall elapse between the serving of the evening meal and the morning meal.
       3. (C) The meals shall be served at approximately the same hour each day.

    2. (2) Food shall be prepared in:

       1. (A) Accordance with approved menus and standardized recipes; and
       2. (B) A manner to conserve nutritive value, flavor, and appearance.

    3. (3) Food shall:

       1. (A) Meet patient needs; and
       2. (B) Be attractive, palatable, and served at proper temperatures.
    4. (4) An identification system shall be implemented for patient trays to ensure that each patient receives the appropriate diet as ordered.
    5. (5) Nourishing bedtime snacks appropriate to the patient’s needs shall be made available.
    6. (6) Only foods prepared and stored under the direction of nutrition services in accordance with the Rules Pertaining to Retail Food Establishments, 20 CAR pts. 190 – 197, shall be served to patients.

    7. (7)

       1. (A) All individuals who assist patients in the preparation, heating, reheating, or consumption of food or sanitation of foodware and kitchen equipment, etc., while in the facility or on the facility grounds shall be:

          1. (i) Under the direction of nutrition services; and
          2. (ii) In compliance with the Rules Pertaining to Retail Food Establishments.
       2. (B) Documentation of educational programs on food preparation, safety, and sanitation shall be performed for all applicable personnel (e.g., occupational therapy, nursing) by nutrition services at least annually.
    8. (8) Food shall not be consumed in the kitchen.

    9. (9)

       1. (A) Food shall be transported in a manner that:

          1. (i) Maintains safe food temperatures; and
          2. (ii) Prevents contamination.

       2. (B) Food carts shall not block:

          1. (i) Corridors/exits;
          2. (ii) Emergency equipment; or
          3. (iii) Patient doorways.

    10. (10) All storage containers/foodstuffs shall be stored a minimum of six inches (6”) above the floor on nonporous, easily cleaned racks, dollies, or shelving in a manner that:

        1. (A) Protects the food or food contact surfaces from splash and other contamination; and
        2. (B) Permits easy cleaning of the storage area.
    11. (11) Plastic milk crates shall not be permitted for storing of food or equipment except for the intended use for milk storage.
    12. (12) Temperature documentation of all food refrigerators/freezers in the kitchen and cafeteria shall be performed a minimum of three (3) times per day at opening, midoperation, and closing of the department.
    13. (13) Temperature documentation of all nourishment refrigerators/freezers in patient care areas shall be performed at least daily.

    14. (14)

        1. (A) Proper temperatures of vending machines containing potentially hazardous foods shall be ensured daily by the facility.
        2. (B) Vending machines shall be equipped with a thermometer easily visible to food service personnel for the purposes of monitoring the temperature of the internal environment.
        3. (C) These machines shall have the capacity to render themselves inoperable if temperatures in excess of forty degrees Fahrenheit (40°F) are maintained for more than two (2) hours.
        4. (D) Documentation of such downtime shall be maintained to include remedial action taken.
    15. (15) If, for any reason, the refrigeration equipment does not maintain the appropriate temperature, action shall be taken and a record of remedial action and downtime shall be recorded and maintained by the facility.

    16. (16)

        1. (A) Temperature documentation of the dish machine shall be recorded with each meal, and these records shall be maintained by the facility.
        2. (B) If the temperatures and, if applicable, dwell times, are not maintained properly action shall be taken and a record of remedial action, backup procedures used, and downtime shall be maintained by the facility.
    17. (17) If the facility uses a chemical method for sanitizing food preparation ware and servingware, a record of the water temperature, the chemical used, and appropriate parts per million (ppm) shall be maintained by the facility at each use.

    18. (18)

        1. (A) The temperature of the hot and cold potentially hazardous foods shall be recorded at least at the beginning and end of meal service that continues for more than fifteen (15) minutes.
        2. (B) If meal service lasts for fifteen (15) minutes or less, food temperature documentation is required only at the beginning of food service.
    19. (19) Documentation of the testing/calibration of food/refrigeration/freezer thermometers shall be performed according to manufacturer’s recommendations.

    20. (20) Food thermometers shall be:

        1. (A) Sanitized after each use; and
        2. (B) Stored in a manner that prevents contamination.
    21. (21) Only dietary and authorized personnel shall be allowed in the kitchen.

    22. (22) Sanitation shall be in accordance with the Rules Pertaining to Retail Food Establishments.

        1. (c) Food safety/sanitation.

    23. (1) Whole eggs and raw meat shall be stored:

        1. (A) Separately; and
        2. (B) In a way that prevents contamination of other food items in refrigerated units.

    24. (2)

        1. (A) Reheated food shall attain a temperature above one hundred sixty-five degrees Fahrenheit (165°F) prior to placement in:

           1. (i) Steam tables;
           2. (ii) Warmers; or
           3. (iii) Other hot food storage units.
        2. (B) Steam tables, warmers, or other food storage units shall not be used for the rapid heating of potentially hazardous food.

    25. (3)

        1. (A) Disposable gloves shall be worn to eliminate direct handling of food.
        2. (B) Gloves shall be properly discarded after being used, torn, or contaminated.
    26. (4) Ground beef or ground beef products shall be cooked to an internal temperature of one hundred sixty degrees Fahrenheit (160°F) or higher.

    27. (5) Potentially hazardous food shall be tempered or thawed only:

        1. (A) In designated tempering units at a temperature not to exceed forty-five degrees Fahrenheit (45°F);
        2. (B) In general refrigeration units at a temperature not to exceed forty degrees Fahrenheit (40°F);
        3. (C) As part of the conventional cooking process; or
        4. (D) In a microwave provided the food is immediately transferred to conventional cooking process.
    28. (6) Potentially hazardous food that is left over shall be labeled as such with the date and time it was removed from service.

    29. (7) Potentially hazardous food shall be:

        1. (A) Chilled to a temperature below forty degrees Fahrenheit (40°F); and
        2. (B) Retained for no longer than forty-eight (48) hours.

    30. (8)

        1. (A) Food contact surfaces, i.e., cutting boards, of all equipment and utensils shall be sanitized by:

           1. (i) Immersion for at least one-half (1/2) minute in clean, hot water at a temperature of at least one hundred eighty degrees Fahrenheit (180°F); or
           2. (ii) Any other method approved by the Division of Health Facilities Services.
        2. (B) Countertops and other huge industrial equipment shall be washed down with concentrated solutions.
    31. (9) Clean linens, mopheads, and cloths shall be stored in a manner to prevent contamination prior to use.

    32. (10)

        1. (A) Soiled linens, etc., shall be stored covered, separately from clean linen, food storage, preparation, and serving areas.
        2. (B) Containers for holding such items shall be made of nonabsorbent materials.
        3. (C) Soiled linens shall be removed from the department daily.

    33. (11)

        1. (A) Food inventory shall be handled on a first-in, first-out basis.
        2. (B) A system for labeling and dating canned, dry, and potentially hazardous foods shall be implemented.
    34. (12) Potentially hazardous frozen foods removed from freezer storage to be thawed shall be labeled with the date of pull from the freezer for thawing.
    35. (13) Supplies and perishable foods for a twenty-four-hour period and nonperishable foods for a three-day period shall be on the premises to meet the requirements of the planned menus.

    36. (14) Note. This part is referenced to the Rules Pertaining to Retail Food Establishments

        1. (d) Clinical services.

    37. (1) Clinical dietitian/nutritionist.

        1. (A) Shall be a registered dietitian or registry-eligible, and evaluate and oversee the delivery of effective nutrition care based on current, recognized nutrition practices.

        2. (B) If not full-time, make regularly scheduled visits to accomplish the following:

           1. (i) Review, revise, and approve a current diet manual for facility use;
           2. (ii) Review, revise, approve, and implement:
14. (a) (a) Nutrition care policy and procedures, standards of nutrition care, and nutrition care protocols; and

15. (b) (b) The nutrition services QA/PI program;

    1. (iii) Coordinate nutrition care through communication with other patient care services;

       1. (iv) Provide for the:
16. (a) (a) Initiation of nutrition screening of all patients upon admission; and

17. (b) (b) Periodic screening of patients during their hospital stay;

    1. (v) Provide for the nutrition assessment of patients at nutrition risk as defined by the medical staff and collaborate with the physician on the findings of the evaluation;

       1. (vi) Ensure competency of all nutrition services personnel who:
18. (a) (a) Perform assessments;

19. (b) (b) Perform counseling;

    1. (c) (c) Develop care plans; and

       1. (d) (d) Participate in discharge planning;

          1. (vii) Provide to the facility evidence of continuing education hours;
          2. (viii) Perform orientation, preceptorship, and ongoing training/educational programs for staff;
          3. (ix) Review and revise nutrition counseling/diet education practices that are individualized to patient needs;
          4. (x) Monitor the enforcement of all policies, procedures, and practices relating to food safety and sanitation;
          5. (xi) Develop, implement, and maintain a system for recording data related to patient care;
          6. (xii) Collaborate with nursing and pharmacy to provide food/drug interaction counseling; and
          7. (xiii) If the dietitian is a consultant, submit reports to the facility administrator reflecting services performed at each regularly scheduled visit.

    2. (2) Nutrition screening and documentation.

       1. (A) Nutrition screening shall be completed within twenty-four (24) hours of admission on all patients to:

          1. (i) Determine nutrition risk; and
          2. (ii) Notify the physician and dietitian of any patients that are at nutrition risk.

       2. (B) Psychiatric, alcohol and drug, and rehabilitation patients shall be rescreened:

          1. (i) Seven (7) days from the initial screen; and
          2. (ii) At least every fourteen (14) days thereafter.

    3. (3) Nutrition care process.

       1. (A) A nutrition assessment of patients at nutrition risk, as reflected in the medical record, shall include as appropriate:

          1. (i) Anthropometric measurements, including:
20. (a) (a) Height;

21. (b) (b) Weight;

    1. (c) (c) BMI; and

       1. (d) (d) Goal weight;

          1. (ii) Abnormal pertinent laboratory values;
          2. (iii) The patient’s caloric and protein needs;
          3. (iv) Nutrient intake compared to estimated needs;
          4. (v) Determination of:
22. (a) (a) Abnormal intake; or

23. (b) (b) Recent weight loss/gain prior to admission;

    1. (vi) An objective evaluation of the patient’s compliance with a physician-ordered diet prior to admission;

       1. (vii) Pertinent food/drug interactions;

          1. (viii) An evaluation of the patient’s special feeding/nutrient/fluid needs;
          2. (ix) Patient’s food preferences, dislikes, allergies, or intolerances; and
          3. (x) Nutrition summary, including identification of nutrition problems.

       2. (B) The patient care plan on all patients found to be at nutrition risk shall include the following nutrition components, as appropriate:

          1. (i) Individualized nutrition counseling;
          2. (ii) Discharge planning;
          3. (iii) Comprehensive nutrition assessments to include further clinical, laboratory, social, or nutrition data to assist with the ongoing evaluation;
          4. (iv) Follow-up care to evaluate the effectiveness of the nutrition regimen; and
          5. (v) Any requests for alterations or modifications to the ordered diet’s nutrient content, consistency, administration route/method, or meal pattern as served in the hospital in order to meet the nutrition needs and/or special feeding needs of the patient.

    2. (4) Nutrition counseling. Documentation of nutrition counseling shall include:

       1. (A) Description of the individualized nutrition counseling;

       2. (B) Objective evaluation of the patient’s and/or caregiver’s:

          1. (i) Understanding; and
          2. (ii) Ability to carry out the diet order; and

       3. (C) Plans for continued counseling and/or recommendations for:

          1. (i) Postdischarge counseling; and
          2. (ii) Evaluation of patient diet compliance.

    3. (5) Nutrition monitoring and evaluation:

       1. (A)

          1. (i) Shall be performed when the patient is at nutrition risk and documented in the medical record.
          2. (ii) The frequency of follow-up nutritional care shall be determined by the patient’s condition;
       2. (B) Shall be documented in the patient’s medical record on all patients at nutrition risk; and
       3. (C) Shall be documented to include an evaluation of the effectiveness of the prescribed nutrition regimen, changing nutrition status/needs, nutrition counseling, and/or recommendations to improve patient nutrition care.

Codification Notes: “BMI” means body mass index.