CRH Dietary Policies and Procedures.11.2014 Final PDF

Dietary Policies & Procedures

TABLE OF CONTENTS

Purpose and Organization

Dietary Department Objectives 1.M.01
Organizational Chart 1.M.02
Management/Clinical Manuals 1.M.03
Personnel Management
Job Descriptions 1.M.04

Work Schedules 1.M.05
Orientation 1.M.06
In-service Training Program 1.M.07
Health Examinations 1.M.08
Personal Hygiene 1.M.09
Hand Washing and Glove Use 1.M.10
Hand Washing Flow Chart 1.M.11
Monthly Meeting of Dietary Department 1.M.12
Personnel Allowed in the Dietary Department 1.M.13
Staffing Schedules 1.M.14
Bulletin Board Information 1.M.15
Checklists for Dietary Manager 1.M.16
Receiving, Inventory and Storage

Receiving Food and Supplies 1.M.17
Inventory 1.M.18
Food Storage 1.M.19
Tray Line Refrigerated Leftover Storage 1.M.20
Dry, Refrigerated and Freezer Storage Chart 1.M.21
Record of Refrigeration Temperatures 1.M.22
Dry Storage – Dishes and Utensils 1.M.23
Dry Storage – Paper Products 1.M.24
Dry Storage – Linen 1.M.25
Toxic Substance Storage 1.M.26
Menu Planning and Nourishments

Cycle Menus 1.M.27
Menu Planning Criteria 1.M.28
Large or Double Portions 1.M.29
Small Portions 1.M.30
Menu Posting 1.M.31
Diabetic Patterns for Crandall Menu 1.M.32
Record of Menus Served 1.M.33
Patient Food Refusal 1.M.34
Effective Date: 2002
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Menu Alternatives 1.M.35
Menu Substitutions 1.M.36
Individual Substitutions 1.M.37
Menu Evaluation 1.M.38
Nourishments 1.M.39
House Supplements 1.M.40
Nourishment Preparation 1.M.41
Snacks 1.M.42
Therapeutic Diets
Diets Available in the Facility 1.M.43
Therapeutic Diets 1.M.44
List of Diets Available in the Facility 1.M.45
Mechanically Altered Diets and Thickened Liquids 1.M.46
High Fiber Bowel Program 1.M.47
Diet Manual 1.M.48
Transmission of Diet Orders 1.M.49
Change in Diet Orders 1.M.50
Census Sheet 1.M.51
Dietary Audit 1.M.52
Tube Feeding 1.M.53
Salt Substitute 1.M.54
Consistency as Tolerated 1.M.55
Full Liquid Diet Meal Plans 1.M.56
Carbohydrate Replacement for Insulin-Dependent Diabetics 1.M.57
Food Preparation
Standardized Recipes 1.M.58
Recipes – Increasing and Decreasing 1.M.59
Standard Portions 1.M.60
Serving Utensils 1.M.61
Use Ladles and Scoops for Standard Portions 1.M.62
Standard Serving Portions 1.M.63
Food Production Sheets 1.M.64
Food Tasting 1.M.65
Food Temperatures 1.M.66
Calibrating a Probe Thermometer 1.M.67
Leftovers 1.M.68
Garnishing Ideas 1.M.69
Change of Menu Garnish 1.M.70
Milk and Cheese Cookery 1.M.71
Egg Cookery and Storage 1.M.72
Vegetable Cookery 1.M.73
Dessert Preparation 1.M.74
Fruit Preparation 1.M.75
Salad and Other Miscellaneous Food Preparation 1.M.76
Meat Cookery and Storage 1.M.77
Cooling Monitor for Hazardous Foods 1.M.78

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Cooking – General Rules 1.M.79
Cooking Temperature Chart 1.M.80
Meal Service
Meal Hours 1.M.81
Tray Sequence 1.M.82
Pre-Setting Trays 1.M.83
Tray Line Setup 1.M.84
Diet Identification Card 1.M.85
Coding On Diet Tray Cards 1.M.86
Adaptive Equipment – Feeding Devices 1.M.87
Nursing Department Responsibilities at Mealtime 1.M.88
Recording Percentage of Meals Consumed 1.M.89
Guidelines for Percentage of Meal Intake 1.M.90
Calorie Count 1.M.91
Special Meal and Holiday Diet Order 1.M.92
Unscheduled Meals 1.M.93
Guest Meals 1.M.94
Special Functions 1.M.95
Employee Meals 1.M.97
Equipment Operation, Infection Control and Sanitation

Cleaning Schedules 1.M.98
Operation and Sanitation 1.M.99
Sanitizer Use Concentrations for Food Service and Food Production 1.M.100
Blender 1.M.101
Can Opener 1.M.102
Carts 1.M.103
Coffee Urn 1.M.104
Dish Machine 1.M.105
Dish Machine Setup 1.M.106
Recording of Dish Machine Temperatures 1.M.107
Dishwashing Procedure 1.M.108
Dish and Utensil Procedure 1.M.109
Cleanup 1.M.110
De-liming the Dish Machine 1.M.111
De-staining Procedures through the Dish machine for Cup, Teapots, Pitchers & Lids 1.M.112
Discarding of Chipped, Cracked Dishes and Single Service 1.M.113
Food Processor 1.M.114
Freezer 1.M.115
Garbage and Trashcans 1.M.117
Grill – Electric 1.M.118
Grill – Gas 1.M.119
Hoods and Filters 1.M.120
Ice Machine 1.M.121
Lowerator 1.M.122
Meat Slicer 1.M.123
Microwave Oven 1.M.124

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Oven – Convection, Gas 1.M.127
Oven – Conventional, Gas 1.M.128
Portion Scales 1.M.129
Pots and Pans – Hot Water 1.M.130
Pots and Pans – Sanitizing Solution 1.M.131
Sanitation of Equipment 1.M.132
Refrigerator – Walk-In 1.M.133
Steam Table 1.M.134
Stove Top 1.M.135
Water Pitchers 1.M.136
Cabinets and Drawers 1.M.137
Floors 1.M.138
Walls and Ceilings 1.M.139
Food from Outside Sources 1.M.140
Isolation Trays 1.M.141
Safety and Emergency Procedures

Environmental Safety 1.M.143
China and Glassware Safety 1.M.144
Floor Safety 1.M.145
Knife Safety 1.M.146
Equipment Safety 1.M.147
Instructions for Implementing Menu to Be Used In the Event of
A Disaster or Emergency 1.M.148
Fire Prevention 1.M.149
Fire Extinguisher Instructions 1.M.150
Prevention of Back Injury 1.M.151
Standard Guidelines Prevention of Back injury 1.M.152
Preventing Falls 1.M.153
Accident Prevention in Food Transport 1.M.154
Accident Prevention in Cooking and Baking 1.M.155
Accident Prevention in Food Preparation 1.M.156
Accident Prevention in Serving Food 1.M.157
Can Opening Procedures 1.M.158
Cost Accounting
General Food Ordering 1.M.159
Weekly Ordering 1.M.160
Food Specifications 1.M.161
Credit Memo 1.M.162
Emergency and Special Purchases 1.M.163
Dietary Cost Control 1.M.164
Use of Budget Control Forms 1.M.165
Physical Inventory 1.M.166
Annual Raw Food and Supplies Costs Per Patient Day 1.M.167
Annual Raw Food and Supplies Costs Worksheet 1.M.168
Cost Information – Special Functions 1.M.170
Safeguarding the Dietary Department 1.M.171

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Medical Nutrition Therapy
Medical Nutrition Therapy: Nutritional Screening of High Risk Patients 1.M.172
Nutritional Assessment 1.M.173
Nutrition Plan of Care 1.M.174
Nutritional Education 1.M.175
Nutrition Monitoring 1.M.176
Nutrition Reassessment 1.M.177
Nutrition Discharge Planning 1.M.178
Medical Nutrition Therapy Practice Guidelines: Diabetic Mellitus 1.M.179
Medical Nutrition Therapy Practice Guidelines: Chronic Renal Failure
– Hemodialysis 1.M.183
Medical Nutrition Therapy Practice Guidelines: Pre-end Stage Renal 1.M.185
Medical Nutrition Therapy Practice Guidelines: Patients At Nutritional Risk 1.M.187
Medical Nutrition Therapy Practice Guidelines: Total Parenteral 1.M.188
Registered Dietitian’s Standards of Care and Responsibilities
Nutritional Parameters for Pediatric Patients in ICU/IMCU 1.M.191
Medical Nutrition Therapy Practice Guidelines: Cancer Side
Effects – Radiation or Chemotherapy 1.M.192
Medical Nutrition Therapy Practice Guidelines: Cardiac Rehab/Cardiac 1.M.193
Home Discharge Instructions 1.M.196
Diet Counseling 1.M.197
Patients Need for Palliative Care 1.M.198
Criteria for Intervention with Abnormal labs 1.M.203
Recommendation to Nursing/Fax Consultation 1.M.204
Nutrition Intervention Request Form 1.M.205
Fluid Restriction 1.M.212
Hydration Protocol 1.M.213
Quality Assurance
Dietary Member of Quality Assurance Committee 1.M.214
Quality Assurance Calendar 1.M.215
Patient Satisfaction Survey 1.M.216
Quality Assurance Report 1.M.217
Quality Assurance Manual 1.M.2187
The Ten Step Monitoring and Evaluation Process 1.M.219
Dietary Department Quality Assurance Plan 1.M.220
Quality Assurance/Performance Improvement Reporting Process 1.M.221
Performance Indicators 1.M.222
Dietary Department Quality Assurance Philosophy 1.M.223
Patient Rights and Quality of Life

Patient Rights – General Information 1.M.224
Patient Involvement in Nutritional Services 1.M.225
Information about Rights 1.M.226
Courteous Treatment 1.M.227
Appropriate Health Care 1.M.228
Physician’s Identity 1.M.229
Information about Treatments 1.M.230

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Participation in Planning Treatment 1.M.231
Freedom from Abuse 1.M.232
Confidentiality of Records 1.M.233
Responsive Service 1.M.234
Personal Privacy 1.M.235
Grievances 1.M.236
Choice of Supplies or Supplier 1.M.237
Accommodation of Needs 1.M.238
Social Services 1.M.239
Environment 1.M.240

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Dietary Department Objectives

The purpose and scope of the Dietary Department is to provide a program that meets
the nutritional needs of all patients. Standardized methods are practiced in the
preparation and presentation of therapeutic and/or modified diets in accordance with the
attending physician’s orders. Consideration is given to the patients’ physical,
psychological and social needs. Recognition is also given to the patient’s individual
eating habits, which are sometimes influenced by cultural or religious background. The
dietary program is based on a nutritional review of the needs of each individual patient
in harmony with the standards of the Food and Nutrition Board of the National Research
Council of the National Academy of Sciences. The recommended standards are
adjusted as to age, sex, and activity of the individual.
Dietary Department supervision is to be under the guidance of a full-time person

qualified by training and experience. This individual is advised by a Registered Dietitian
who renders frequent and regularly scheduled visits.
Procurement and production of food products is to be carried out to ensure the patient a
sufficient quantity of wholesome and nourishing food of acceptable variety and quality.
The individual in charge of the Dietary Department is to participate in conferences and
workshops as they may relate to patient care and is to review the progress of dietary
changes of each individual patient.
Menu planning is the responsibility of the Consulting Dietitian and Dietary Manager and
staff. Menus meet the requirements of the Food and Nutrition Board of the National
Research Council of the National Academy of Sciences. Menus are revised at least two
times a year and are implemented by the Dietary Manager in conjunction with the
Dietitian.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Organizational Chart
POLICY
The Dietary Department will function within an organizational structure. The

organizational chart will explain the departmental chain of command. Communication,
authority, and responsibility will be identified through the departmental organization
structure.
PROCEDURE
The Administrator has the overall responsibility for the management of the long-term
care facility.
Department heads are responsible to the Administrator.
Cooks and Dietary Aides are responsible to the Dietary Manager.
Dietary Aides are responsible to Cooks in the implementation of meals.
The Dietary Manager has the overall responsibility for overall operation of the Dietary
Department.
In the absence of the Dietary Manager, the Cook on duty assumes the overall
responsibility of the Dietary Department.
Department heads function in an equal working relationship with each other.
All communications and concerns with another department shall take place through the
appropriate department.
The Consultant Dietitian may make recommendations for departmental organization.

He or she will have no authority to implement change. The Consultant Dietitian
assumes the professional and ethical responsibility of the nutritional care of the patients.
All dietary staff will use the organizational chart to identify lines of communication and
authority.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Management/Clinical Manuals
POLICY
In order to organize materials and have them available for reference and surveys,
manuals shall be set up. Mandatory timeframe is stated below.
PROCEDURE
1. Quality Assurance Manual

• Patient Satisfaction Survey 10% of patients (1 year)
• Temperature – Dish machine, food, refrigeration units, test trays – 1 year
2. Other Notebooks Needed
• Policy and Procedures Manual – update annually
• Current Diet Manual – approved annually (current within last 5 years)
• Inservice/Training Manual – Yearly Plan with monthly documentation and

individual records for 1 year
• Recipe Manuals to correlate with menus and 11 x 17 menu notebook
• Dietary Reference Manual for Nursing
• Master Forms Manual
• MSDS Analysis
3. Files Needed
• Menus dated with menu substitutions – 60 to 90 days
• MSDS Employee Informed forms
• Invoices – 60 to 90 days
• Employee Files as needed

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Job Descriptions
POLICY
Job descriptions for all positions will be maintained in the department. These will be
used for screening, hiring, training and evaluating personnel.
PROCEDURE
Job descriptions will include, but not be limited to, title, duties, qualifications, person to
whom employee is responsible, and job responsibilities.
The Dietary Manager and Human Resources Department will maintain current job
descriptions.
All new employees will receive a copy of their respective job descriptions.
All job descriptions are subject to change based on the needs of the facility.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Work Schedules
POLICY
A work schedule is to be developed and written for any job description outlining set time
limits and order of routines.
PROCEDURE
The Dietary Manager shall ensure that a written work schedule is available for specific
job positions.
The employee shall receive a copy of the work schedule for his/her position at
orientation and as it is revised.
The work schedule shall identify the time and/or specific day the function is to be
performed.
Copies of the work schedules that have been established for the dietary job descriptions
in this facility are posted in the department.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Orientation
POLICY
All dietary personnel must have documentation of General Orientation. The Human
Resources Department schedule new employees for their General Orientation. A copy
of the completion is kept in their personnel file.
PROCEDURE
Using the “Competency Checklist,” * fill in employee’s name and date of employment.
As the orientation is completed, the supervisor and the employee must sign and date
the form.
Documentation of the completed competency will become part of the employee’s
permanent file.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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In-service Training Program

POLICY
An ongoing education program is planned and conducted for the development and
improvement of skills.
PROCEDURE
In-service education is the responsibility of the Dietary Manager and the Dietician. In-
service sessions for dietary employees are scheduled at least monthly. In-service
training sessions will also be held for part-time and off-duty employees. In-service
topics and pertinent guidelines will be documented and made part of the permanent
Dietary Department records.
The Dietary Manager along with the Dietitian is responsible for Department Specific
training in the Dietary Department. The Dietitian instructs staff at the monthly
department/in-service meetings. The Dietitian will present an in-service program to the
facility’s nursing staff on an annual basis
A “Schedule and Record of Dietary In-service Training”* form will be used to plan the
yearly in-service scheduled by the Dietitian and/or Dietary Manager.
In-services held will be documented on the “Summary Report of Meeting.” * Note the
type of meeting, who presented the in-service, date, time and length of presentation.
Also document subjects covered and have employees sign under “In Attendance.”
Attach materials covered to “Summary of Report of Meeting”.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Health Examinations
POLICY
Federal Conditions of Participation recommend current and annual health examinations

for all Dietary Department employees.
PROCEDURE
Newly hired employees must have a TB test prior to starting employment.
An annual TB test must be performed with results located in personnel file.
The Dietary Manager is responsible for ensuring that TB tests are kept current on all
Dietary Department employees.
The Dietary Manager is responsible for checking other state and local codes for specific
health examination requirements.
Some counties require a food handler’s permit. Where it is required, the prospective
employee has only 30 days to obtain the permit.
A current serve-safe manager’s certification for at least one employee must be posted in
the department at all times, if it is required by the county.
An employee infected with any disease in a communicable form or having a presumably

infected discharging wound, sore, or lesion may not work in the Dietary Department.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Personal Hygiene
POLICY
These are the guidelines for personal hygiene to promote a safe and sanitary
department.
PROCEDURE
1. Clean work clothing

• Work clothes must be neat, clean and washable. Refer to facility
procedure for dress code.
• Aprons are to be removed when leaving the Dietary Department and when
using the restroom.
• Hose or socks must be worn at all times.
• Shoes shall be comfortable, low-heeled, non-skid, clean, and polished.
Sandals are not permitted.
• Jewelry is limited to a wristwatch, wedding band, and post earrings.
• A name badge must be worn at all times in the facility.
2. Clean hands and fingernails
• Hands must always be washed prior to beginning work.

• Hands must always be washed after smoking using the restroom, or handling
any unsanitary items.
• Fingernails must be kept short and clean at all times.
• Nail polish is not permitted.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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• Personnel having symptoms of communicable diseases or open infected

wounds or cuts are not permitted to work in the Dietary Department, and must
report their condition immediately to the Dietary Manager.
3. Head covering worn

• If hair is long and not covered properly with a cap, a hairnet must be worn.
Hair spray is not an authorized substitute for a hairnet.
• Head covering must be clean.
• Beards or any body hair that may be exposed (i.e., arms) must be covered.
4. Conduct
• Gum chewing is not permitted in the Dietary Department
• Smoking is not permitted in the food preparation, service, or storage areas.
• Eating and drinking are not permitted in food preparation and service areas.
• Foodstuffs and supply items may not be removed from the premises without
written authorization from the Administrator.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Hand Washing and Glove Use
POLICY
Guidelines for hand washing and glove use to promote safe and sanitary conditions
throughout department.
PROCEDURE
Hand Washing Procedure –
1. Hand washing is a priority for infection control.
2. Hands must be washed prior to beginning work, after using the restroom, after
smoking, when working with different food substances i.e. raw chicken to fresh fruit,
following contact with any unsanitary surface i.e. touching hair, sneezing, opening
doors, etc.
3. Washing procedure (See Hand Washing Flow Chart)

• Wet hands
• Apply soap
• Lather, vigorously rubbing hands together for approximately 11 seconds.
• Rinse hands to remove soap and debris.
• Dry hands with a disposable paper towel.
• Discard of paper in a foot pedal trash can.
Gloves
1. Gloves may be used when working with food to avoid contact with hands. Gloves
must be worn when touching any ready-to-eat food.
2. When gloves are used, hand washing must occur per above procedure prior to
putting on gloves and whenever gloves are changed. Gloves must be changed as
often as hands need to be washed, see above. Gloves may be used for one task
only.
3. Important to remember that gloves can often give a false sense of security and
can carry germs same as our hands.
4. Gloves must be non-latex, single use, powdered or non-powdered.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Hand Washing Flow Chart

PROCEDURES
1. Get ready step 4. Brush and 6. Wash hands a

lather, second time
particularly
2. Wet Hands fingertips and
fingernails. 7. Rinse hands
again
3. Apply soap 5. Rinse hands
and fingernail 8. Dry hands
brush. using paper
towel(s)
1. Get Ready Step

Check to see that there is an adequate supply of hand soap, a fingernail brush, and
clean, disposable paper towels at the hand sink. Do not use germicidal soaps because
these preparations destroy beneficial patient skin microorganisms that are necessary to
maintain healthy skin and inhibit the growth of foreign bacteria.
2. Wet Hands
Go to the toilet microorganism wash-off hand sink in the kitchen. Turn on the water.
Let it flow at 2 gallons per minute until warm (110ºF to 120ºF). Place hands under the
flowing water to thoroughly wet the surface of the hands, fingernails and lower arms.
3. Apply Soap
Place enough hand soap or detergent (1/8 to ¼ teaspoon) to build a good lather on a
fingernail brush and palms of hands.
4. Brush and lather, particularly fingertips and fingernails.

Vigorously brush and lather the fingertips and under the fingernails of both hands,
particularly the hand that held the toilet paper. Brush the back and palms of hands.
Brushing loosens the feces and dirt and this soil is transferred to the lather.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Hand Washing Flow Chart (continued)
5. Rinse hands and fingernail brush

Rinse the lather and soap from the hands and fingernail brush in the flowing warm
water. As the soap is rinsed off, the water flushes dirt and fecal material from the
fingertips and under the fingernails down the drain. Microorganisms are reduced as
mush as 1,000 to 1. Rinse the fingernail brush to reduce bacteria on its surface to a
safe level and place the brush, bristles up, on its stand to drain and dry, stopping
microbial growth.
6. Wash your hands a second time.

Wash hands a second time. Place sufficient amount of soap (1/8 to ¼ teaspoon) on the
hands again and rub them together to produce a good lather, especially between the
fingers. Lather hands from the wrists to the fingertips and arms up to the tips of the
sleeves. (The fingernail brush is not used).
7. Rinse hands again.

Thoroughly rinse all the lather from the fingertips, hands and arms in flowing warm
water. Hazardous microorganisms are in the lather, and the microorganisms are
reduced as much as another 1,000 to 1 when all of the lather is removed.
↓
8. Dry hands using paper towel(s)

Use clean, disposable paper towels, turn off faucet valves and to thoroughly dry hands
and arms. Discard paper towels in waste container without touching the container.
Drying hands with paper towels removes and reduces the number of microorganisms on
hand surfaces another 100 to 1.
Remember, the goal of hand washing is to reduce the surface fecal and vomit
microorganisms on the surface of hands. Beneficial patient microorganisms on and in
skin shall not be changed because they keep the skin healthy.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Monthly Dietary Department Meetings

POLICY
Monthly departmental meetings are held by the Dietary Manager and the Dietician to
discuss problems, review job descriptions, explain policies and procedures, new
materials, and reports from professional meetings, conferences, workshops, etc.
PROCEDURE
Each employee is given a chance to discuss problems. A review is given by the Dietary
Manager at this time on the changes being made or on any specific thing that needs
discussion. Reports on professional meetings, conferences, workshops, etc., may also
be included.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Personnel Allowed in the Dietary Department

POLICY
No one is allowed in the Dietary Department without the express authorization of the
Administrator or the Dietary Manager, except for dietary employees, Consulting
Dietitian, and the Administrator.
PROCEDURE
“Dietary Employees Only” signs shall be posted on all entrances to the Dietary
Department.
All unauthorized persons are to be discouraged from entering the Dietary Department.
The Dietary Manager or designee will be responsible for enforcing this requirement.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Staffing Schedules
POLICY
Schedules are created to provide the work force necessary for accomplishment of
identified output.
PROCEDURE
“Monthly Staff Schedule” * is posted in advance.
On occasion, schedules are changed after they have been posted; each employee is
responsible for checking the schedule frequently so that changes may be noted.
Only the Dietary Manager and Administrator are authorized to change the schedule.
Meals and break-time must be taken as scheduled.
Overtime is not permitted except with approval of the Dietary Manager.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.15
Page 1 of 2
O: 2002
Bulletin Board Information
POLICY:
The following information will be posted on the Dietary Department bulletin board.
∗ Emergency Menu (See Safety and Emergency Procedures Section)
∗ Food Code
∗ Cooling Monitor Form
∗ Refrigerator/Freezer Temperature Form
∗ Dish machine Temperature Form
∗ Leftover Policy
∗ MSDS Information
∗ Cleaning schedule
∗ Laminated Dish machine Procedures from Vendor
∗ Laminated Pot and Pan Procedures
∗ Fill-line on 3rd Pot and Pan Sink
∗ Amount of sanitizer to add to 3rd Pot and Pan Sink
∗ Amount of sanitizer to add to cleaning buckets (put posted amount on buckets)
∗ Tray line checklist on tray line
∗ Therapeutic spreadsheets on tray line
∗ Temperature record on tray line (Clipboard)
∗ Large and small policies unless on therapeutic spreadsheets
∗ Diet count for production purposes

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.15
Page 2 of 2
O: 2002
Bulletin Board Information (continued)

∗ Dining Room Monitor on clipboard where appropriate.
∗ Menus – “Week at a Glance” – dated and posted in dining rooms (where

appropriate) and nursing stations. Also, post “Alternate Menu” and “Menu for the
Day”
∗ Mealtime schedule in dining rooms where appropriate. Type in nice format.
∗ Menu substitution record
∗ Work schedules (if required by our state)
∗ Nourishment list – clipboard or notebook

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.16
Page 1 of 1
O: 2002
Checklists for Dietary Manager

POLICY
Checklists are created to help Dietary Managers accomplish their necessary tasks.
PROCEDURE
Attach the “Daily Checklist” * to one clipboard and the “Weekly and Monthly Checklists”
* to another clipboard.
The Dietary Manager is to use these checklists daily to assure that they complete all
their tasks.
Use the “DM Weekly Outline” * to organize your week by pre-planning your week. Write
down in advance meetings, ordering, deliveries and charting times.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.17
Page 1 of 2
O: 2002
Receiving Food and Supplies

POLICY
Food items will be received and handled in accordance with good sanitary practice.
PROCEDURE
The Dietary Manager shall properly receive all items in agreement with the original
order.
Purveyors will be asked not to deliver food or supplies on inconvenient days or at

serving time.
Purveyors will be asked to supply duplicate invoices.
Using the original order as a guide:
1. Check invoices versus quoted prices.
2. Check for quantity, quality, weight, labels, etc. of all foods ordered.
Do not accept and return to the supplier, any item that is:
• Not what was ordered
• In dented, rusty, damaged cans
• Thawed frozen food must come in frozen, feel the product to assure
frozen state.
• Damaged produce
• Poor quality meat or incorrect weight
• Old bakery products
• Cracked eggs
• Leaking milk containers or milk not 41º or less
Only accept food of the quantity and in the quantity ordered.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
3. If an item is returned, write “returned” over item name on the invoice.
4. Date and sign invoices of accepted items. Be sure to record the temperature of
all perishable foods on the invoice when receiving them.
1.M.17
Page 2 of 2
O: 2002
Receiving Food and Supplies (continued)
Record amount(s) of purchase on budget control form.
Maintain one copy of each invoice in the Dietary Department for one year.
Keep cold food at room temperature for a minimum length of time. Do not allow cold
foods to rise above 41ºF or frozen foods to rise above 0ºF.
All foodstuffs are to be dated.
All stock must be rotated with each new order received.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.18
Page 1 of 1
O: 2002
Inventory
POLICY
The Dietary Manager will complete inventories of dry goods, perishables, and supplies
on a routine basis.
PROCEDURE
The Dietary Manager will utilize vendor order sheets in ordering needed items.
Prior to completing the food order necessary to maintain and serve the following week’s
menu, the Dietary Manager will check the current stock left in freezer, refrigerators, and
the storeroom.
At this point, it will be determined which food items required for the next week are
actually on hand and may be deleted from the purchase order.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.19
Page 1 of 6
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Food Storage
POLICY
Food items will be stored, thawed, and prepared in accordance with good sanitary
practice. During a power failure, frozen and refrigerated foods are properly handled.
PROCEDURE
All products shall be dated upon receipt or when they are prepared. Use Date shall be
marked on all food containers according to the timetable in the Dry, Refrigerated and
Freezer Storage Chart found in this section. Leftovers shall be dated according to the
Leftovers policy.
Raw Meat
1. Raw meat is to be stored separately from cooked meats and other raw foods and
at temperatures below 41ºF and on the lowest shelf in the refrigerator.
2. Wash hands before and after handling raw meat to prevent the transmission of
bacteria to food from the hands and from objects that have been touched by
hands.
3. Wash and sanitize all surfaces, equipment, and utensils that have come in
contact with raw meats before using for any other food to prevent cross-
contamination.
4. Fresh meats shall be cooked or frozen within three to four days of purchase
depending on the type of meat. Refer to Dry, Refrigerated and Freezer Storage
Chart located in 3.M.9 section.
5. All cooked meat shall be used within 3-4 days of cooking.
Frozen Meat/Poultry and Foods

• Purchasing: Specify that all frozen products purchased be held at a
temperature of 0ºF or below from the time of processing to delivery.
• Receiving: Have freezer space available upon delivery of product.
Examine all products for signs of defrosting. Return suspected items to
vendor for credit.
• Storage: Store items promptly at 0ºF or below. Foods shall be stored in
their original containers if designed for freezing. Foods to be frozen shall
be stored in airtight containers or wrapped in heavy-duty aluminum foil or
special laminated papers. Label and date all food items.
• Thawing: Thaw foods at 41ºF or below or in an airtight bag under cold
running water. Thaw prepared frozen entrees according to manufacturer’s
directions. Thaw meat by placing in deep pans and setting on lowest shelf
in refrigerator. Adhere to food specific guidelines detailing defrosting

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
procedure for different types of food. Date meat when taken out of
freezer.
• Handling: Wash hands before and after handling food. Keep work
surfaces clean and orderly.
• Cooking: It is not recommended to cook large quantities (6 to 10 pounds)
of frozen meat. Allow adequate time for thawing before cooking.
1.M.19
Page 2 of 6
O: 2002
• Refreezing: Refreezing of defrosted food is prohibited because of the

increase in growth of food bacteria and the deterioration in food quality.
Eggs, Milk and Cheese

• Eggs shall be checked for cracks and any cracked eggs shall be disposed
of. Store at temperatures below 41ºF. Pasteurized shell eggs are
preferred.
• Dairy items shall be kept under refrigeration until use. Store at
temperatures below 41ºF.
Milk, Frozen
• When freezing milk, leave ½ inch from the top of the container (this allows for
freezing expansion) and store for one month only. To thaw, refrigerate for
about four (4) hours.
Eggs, Frozen
• All frozen egg entrees and processed egg products will be stored according to
manufacturer’s instructions. These products must be pasteurized.
• Thaw in refrigerator for 8 to 10 hours.
Cheese
• Cheese can be frozen safely between -10º to 0ºF for no longer than 6
months.
• One pound or less one-inch thick or less of the following cheeses can be
frozen satisfactorily: Cheddar, Swiss, Edam, Gouda, Muenster, Brick Port de
Sault, Provolone, Mozzarella, Camembert, and cream cheese.
• Other cheeses which have been frozen shall be used for cooking instead of
slicing as it crumbles easily.
• To thaw, remove from freezer and leave in refrigerator for 24 to 48 hours.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Fresh Fruits
• Fresh fruit shall be checked and sorted for ripeness.
• Store at a temperature of 41ºF or less, except bananas, which shall be stored
at 60º to 70ºF.
• Unwashed produce shall not be placed in the refrigerator with or near
prepared foods.
• Fruit shall be left in cartons, bags or paper wrapping because the packaging
retards spoilage and prevents the loss of moisture.
• Rotate so that oldest produce is used first.
• Most fruits shall be used within 3 to 5 days. Refer to Dry, Refrigerated and
Freezer Storage Chart found in this section.
1.M.19
Page 3 of 6
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Frozen Fruits
• Frozen fruits shall be stored as purchased in a freezer with temperature of
-10º to 0ºF.
• May be thawed in refrigerator one to two days in advance
• Use within 12 months
Canned Fruits
• Canned fruit shall be stored in a dry, well-ventilated room at 50ºF to 70ºF.
• Cans shall be stacked so that labels are exposed for easy identification.
• Dented or bulging cans shall be placed on Damaged Goods Shelf and
returned for credit.
• Stock shall be rotated with oldest cans in front.
• Use within 12 months.
Fresh Vegetables
• Fresh vegetables shall be checked and sorted for ripeness.
• Store at a temperature of 41ºF or less, except potatoes, which shall be
stored in a cool and dry place at 60ºF to 70ºF.
• Unwashed produce shall not be placed in the refrigerator with or near
prepared foods.
• Shall be ordered and delivered two to three times per week to ensure
freshness. Vegetables shall be left in cartons, bags, or paper wrapping
because it retards spoilage and loss of moisture.
• Rotate so that oldest produce is used first.
• Most vegetables shall be used within 3 to 5 days. Refer to Dry,
Refrigerated and Freezer Storage Chart located in this section.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Frozen Vegetables
• Frozen vegetables shall be stored as purchased in a freezer with
temperature of -10º to 0ºF.
• May be thawed in refrigerator one to two days in advance unless
instructions state to cook in frozen state.
Canned Vegetables
• Canned vegetables shall be stored in a dry, well-ventilated room at 50º to
70ºF.
• Cans shall be stacked so that labels are exposed for easy identification.
• Dented or bulging cans shall be placed on Damaged Goods Shelf and
returned for credit.
1.M.19
Page 4 of 6
O: 2002
• Stock shall be rotated with oldest can in front.

Storage: Regular and Decaffeinated Coffee
The storage of dry products for the preparation of hot coffee will be kept in tightly
sealed, labeled, and dated containers. The containers will be kept in a cool dry
place.
Storage: Tea
The storage of dry products for the preparation of tea will be kept in tightly
sealed, labeled, and dated containers. The containers will be kept in a cool, dry
place.
Storage: Cocoa
The storage of dry products for the preparation of cocoa will be kept in tightly
sealed, labeled and dated containers. The container shall be kept in a cool, dry place.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Storage: Juices and Dry Milk
Liquid and dry bases utilized in the preparation of milk and juices shall be stored
in a tightly sealed, labeled, and date container. The container shall be kept in a cool,
dry place. These items must be pasteurized.
Storage: Fresh Milk

Fresh milk will be purchased from a reputable handler/distributor. It will be stored
and carefully rotated in refrigeration. The Dietary Manager will determine
amounts and utilization.
Storage: Frozen Juices

Frozen juices shall be stored and rotated under refrigeration.
Dry Storage:
Storage area shall be easily accessible for receiving new items. The walls,
ceiling, and floor shall be maintained in good repair and regularly cleaned. The
area should be well lit and ventilated. The temperature shall be in the range of
50º to 70ºF.
1.M.19
Page 5 of 6
O: 2002
• Shelving shall be sturdy and provided with a surface which is smooth and
easily cleaned. Shelving shall be mounted at least 6 inches from the floor
and 18 inches from the ceiling.
• All foods shall be stored away from the walls and off the floor.
• Cross-stack bags of sugar, flour, and other commodities to permit air
circulation.
• Any opened products shall be placed in seamless plastic or glass
containers with tight-fitting lids or Ziploc bags.
• Label and date all storage containers as follows:
1. The received date should already be on it.
2. Date opened.
3. Date the item expires.
• Rotate stock.
• Check for pest infestation regularly. There shall be a monthly pest control
program in place.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
• Cleaning supplies must be stored in a separate locked area away from all
food.
• Food storage area doors must be equipped with locks for security.
During a power failure, keep refrigerated and frozen foods safe: *

• Keep the Freezer door closed. Keep what cold air you have inside. Don’t
open the door any more than necessary. A full freezer will keep food
frozen for about two days; a half-full freezer about one day. If your freezer
is not full, group packages so they form an “igloo” to protect each other.
And, if you think power will be out for several days, then dry ice may be
placed in the freezer to help keep food frozen.
Some partially thawed food can be safely kept. The foods in your freezer that
partially or completely thaw before power is restored may be safely refrozen if
they still contain ice crystals or are 40ºF or below. Evaluate each item
separately. Be very careful with meat and poultry products or any food
containing milk, cream, sour cream or soft cheese. “When in doubt, throw it
out.” In general, refrigerated items shall be safe as long as power is out no
more than four hours. Keep the door closed as much as possible. Discard
any perishable foods such as meat, poultry, fish, eggs and leftovers that have
been above 40ºF for two hours or more. Dispose of any food that has an
unusual odor, color or texture, or feels warm to the touch.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.19
Page 6 of 6
O: 2002
*Reference: “September is Time for Food Safety Lessons, Top 10 Questions

Received by USDA’s Meat and Poultry Hotline,” Food Safety and
Inspection Service, United States Department of Agriculture,
September 4, 2002,
http://www.fsis.usda.gov/oa/news/2002/nfsem.htm

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.20
Page 1 of 2
O: 2002
Tray Line Refrigerated Leftover Storage

POLICY
Leftover foods will not be saved and re-used for human consumption if there is any
doubt of wholesome quality. A leftover is a product that has been on the tray line one
time. For items that have been cooked or opened but have not been on tray line, refer
to Dry, Refrigerated and Freezer Storage Chart located in Policy 1.M.21. These
timeframes are not only used to control sanitation but the quality of the food as well.
PROCEDURE
• Cover with non-absorbent lid or material.
• Date container (lids may be misplaced)
• Label unless easily identifiable without removing cover – such as sliced

peaches in glass jar.
• Total time for preparation, serving, and transportation of food shall be less
than 2 hours.
• Cool quickly in small or shallow container if in excess of 1 gallon. Must be

41º in 6 hours.
• Food that has been exposed in serving carts or at a table MUST NOT be
re-used.
• Appropriate leftovers can be used one time
• Leftovers cannot be used as alternates unless requested by residents.
• For supplements, follow manufacturer’s guidelines.
• The following guidelines are to be used for length of storage in

refrigerators once food has been on the tray line. Refer to recipe for
specific guidelines.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.20
Page 2 of 2
O: 2002
NOT TO BE SAVED 1 TO 3 DAY STORAGE

Cereal – Cooked or Super Cereal Breads – Roll, buns, sweet rolls, coffee, cake,
Commercially Frozen Entrees or Side muffins, corn bread
Dishes Breakfast meats – sausage and bacon
Cream-or Milk-based Entrees, Cakes – Frosted or plain
Gravies, Salads, Sauces, Side Casseroles without milk, cream or eggs
Dishes, Soups or Desserts Gelatin and Gelatin Desserts
Egg-based Entrees, Salads, Side Broth-based gravies (1 to 2 days) or soups
Dishes or Desserts Hot dogs
Eggs-Cooked Juice – Fruit or vegetable
Fish Lemon Wedge
French Toast, Pancakes, Waffles Luncheon and Deli Meats
Fresh Fruits – Cut (except Lemons) Meat cooked the day of service
Fresh Raw Vegetables Mousse – Made from mix
Ice Cream or Sherbet Noodles or Pasta
Mayonnaise-based Entrees, Salads, Pasta Dishes – Package
Side Dishes or Desserts Potato Dishes – Instant or Package
Meats – Precooked or the cooked day Poultry without Stuffing
before and chilled Salads – Marinated, Canned or Cooked
Mechanically Ground Foods Vegetables, cooked – Canned, Fresh, Frozen
Milk
Pies-Cream and Lemon Meringue 4 to 7 day storage
Potato dishes – Scratch Cookies, brownies and bars
Puddings or Custard Fresh fruit – uncut
Pureed Foods Fruit – canned or cooked
Rice dishes Fruit bars, cobblers, crisps, crunch, or pies
Sandwiches Pickles
Stuffing (Bread, Corn Bread or Rice)

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.21
Page 1 of 8
O: 2002
Dry, Refrigerated and Freezer Storage Chart
Following is a recommended outline of proper storage times for opened and unopened
dry, refrigerated and frozen items. Where different, follow manufacturer’s directions and
expiration dates. Expiration dates supersede these guidelines.
DRY STORAGE: (Staples; mixes and packaged foods; canned and dried foods;
spices, herbs, condiments and extracts; other)
Note: Once a product is opened, do not store longer than the total unopened time.
Food Recommended storage time at Handling Hints

70ºF*
Unopened Opened
STAPLES
Baking Powder 18 months or Same as unopened Keep dry and covered.
expiration date on
can
Baking Soda 2 years or expiration Same as unopened Keep dry and covered.
date on package
Bouillon Cubes or Granules 2 years Same as unopened Keep dry and covered.
Cereals: Ready-to-eat 6-12 months 2-3 months Refold package liner tightly after
Cooked (before preparation) 6 months opening.
Chocolate: Pre-melted 12 months Same as unopened Keep cool.
Semi-sweet 18 months Keep cool.
Unsweetened 18 months Keep cool.
Chocolate Syrup 2 years 6 months Cover tightly. Refrigerate after
opening.
Cocoa Mixes 8 months Same as unopened Cover tightly.
Coffee: Cans 2 years 2 weeks Refrigerate after opening. Keep
Instant 1-2 years 2 months tightly closed. Use dry measuring
spoon.
Coffee Lighteners (dry) 9 months 6 months Keep lid tightly closed.
Cornmeal 12 months Same as unopened Keep tightly closed.
Cornstarch 18 months Same as unopened Keep tightly closed.
Flour: White 6-8 months Same as unopened Store in a cool, dry environment.
Whole Wheat 6-8 months Same as unopened Once opened, store in airtight
container.
Gelatin, all types 18 months Same as unopened Keep dry and covered.
Grits 12 months Same as unopened Store in an airtight container.
Honey 12 months Same as unopened Cover tightly; if crystallizes, warm
jar in pan of hot water.
Jellies and Jams 12 months Same as unopened Cover tightly. Storage life
lengthened if refrigerated after
opening.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Molasses 12 months 6 months Keep tightly closed. Refrigerate
to extend storage life. Discard if
any sign of mold.
Marshmallow Cream 2-3 months Same as unopened Cover tightly. Refrigerate after
opening to extend storage life.
Serve at room temperature.
Marshmallows 2-3 months Same as unopened Keep in airtight container.
Mayonnaise 2-3 months Same as unopened Refrigerate after opening.
Milk: Condensed or 12 months Discard Invert cans every two months.
Evaporated
Non-fat Dry 6 months 3 months Store in airtight container.
Pasta (spaghetti, macaroni, 2 years Store in a cool, dry environment.
etc.) Once opened, store in airtight
container.
Rice: White 1 year Same as unopened Store in a cool, dry environment.
Brown, Flavored or Herb 6 months Same as unopened Once opened, store in airtight
container.
Salad Dressing: Bottled 10-12 months 3 months Refrigerate after opening.
Made from Mix 2 weeks Refrigerate prepared dressing
Salad Oils 6 months 1-3 months Refrigerate after opening.
Shortenings, solid 8 months Same as unopened Refrigeration not needed
Sugar: Brown 4 months Same as unopened Store in a cool, moist area in an
airtight container.
18 months Same as unopened Store in a cool, dry environment.
Confectioners 2 years Same as unopened Once opened, store in airtight
Granulated 2 years Same as unopened container.
Sweeteners
Syrups 12 months Same as unopened Keep tightly closed. Refrigerate
to extend storage life. Discard if
any sign of mold.
Tea: Bags 18 months Same as unopened Put in airtight container.
Instant 3 years Same as unopened Cover tightly.
Loose 2 years Same as unopened Put in airtight container.
Vinegar 2 years 12 months Keep tightly closed. Slightly
cloudy appearance doesn’t affect
quality. Distilled vinegar keeps
longer than cider vinegar.
MIXES AND PACKAGED FOODS
Cakes purchased 1-2 days Same as unopened If butter-cream, whipped cream, or
custard frosting or fillings,
refrigerate.
Casseroles, complete or add own 9-12 months Same as unopened Store in a cool, dry environment.
meat Once opened, store in airtight
container.
Cookies: Homemade 2-3 weeks Put in airtight container.
Packaged 2 months Keep tightly closed.
Crackers 3 months Same as unopened Keep box tightly closed
Frostings: Canned 3 months 30 days Store leftovers in refrigerator
Mix 8 months
Hot Roll Mix 18 months Same as unopened If opened, put in airtight container.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Mixes: Angel Food Cake 12 months Same as unopened Store in cool, dry environment.
Biscuit, Brownie, Cake, Muffin 9 months Once opened, store in airtight
Pudding 12 months container.
Sauce and Gravy 6-12 months
Soup 12 months
Pancake Mix 6-9 months Same as unopened Store in a cool, dry environment.
Once opened, store in airtight
container.
Pie Crust Mix 8 months Same as unopened Store in a cool, dry environment.
container.
Pies and Pastries 2-3 days Same as unopened Refrigerate whipped cream,
custard, and chiffon fillings
Potatoes, instant 6-12 months Same as unopened Store in a cool, dry environment.
container.
Rice Mixes 6 months Same as unopened Keep cool and dry
Toaster Pastries 2-3 months Same as unopened Store in a cool, dry environment.
container.
CANNED AND DRIED FOODS
Canned Foods: Baby Food 12 months 2-3 days Keep cool. Refrigerate all opened
Meats, poultry, fish and seafood 12 months 2 days canned foods and cover tightly. To
Fruit 12 months 1 week avoid metallic taste, transfer foods
Pickles and Olives 12 months 1-2 months in cans to glass or plastic storage
Tomato Sauce 12 months 5 days container, if kept more than one
Vegetables 12 months 2-3 days day.
Canned fruit juices 9 months Up to 1 week Keep cool. Once opened, transfer
refrigerated canned juice to glass or plastic
container and keep tightly covered
and refrigerate for up to 1 week.
Fruits, dried 6 months Same as unopened Keep cool, in airtight container. If
possible, refrigerate.
Pudding, canned 12 months 1-2 days Refrigerate after opening.
Vegetables, Dried 1 year Same as unopened Keep cool, in airtight container. If
possible, refrigerate.
SPICES, HERBS, CONDIMENTS, AND EXTRACTS
Catsup/Chili sauce 12 months 1 month Refrigerate for longer storage
Mustard Prepared Yellow 2 years 6-8 months May be refrigerated. Stir before
using
Spices and Herbs: Whole Spices 1-2 years Same as unopened Store in airtight containers in dry
Dehydrated Vegetable flakes 6 months places away from sunlight and
Ground spices 6 months heat. At times listed, check aroma;
Herbs 6 months if faded, replace. Whole cloves,
Herb/Spice Blend 6 months nutmeg, and cinnamon sticks
maintain quality beyond two year
period.
Vanilla 2 years 12 months Keep tightly closed; volatile oils
escape.
Other extracts 12 months Same as unopened Keep tightly closed; volatile oils
escape.
OTHER FOODS
Cheese, Parmesan, grated 10 months 2 months Refrigerate after opening. Keep
tightly closed.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Coconut, shredded, canned or 12 months 6 months Refrigerate after opening.
packaged
Dried peas and beans 12 months Same as unopened Store in airtight container in cool
place.
Meat substitutes, textured protein 4 months Same as unopened Store in airtight container in cool
products (imitation bacon bits) place
Nuts: In Shell 4 months Refrigerate after opening. Freeze
Nutmeats packaged 1 year 2 weeks for longer storage. Unsalted and
Vacuum Can or Other Packaging 3 months blanched nuts keep longer than
salted.
Peanut butter 6-9 months 2-3 months Refrigeration not needed. Keeps
longer if refrigerated. Serve at room
temperature.
Popcorn 2 years Same as unopened Store in airtight container.
Vegetables, fresh: Onions 2 weeks Keep dry and away from sun.
Potatoes 2-4 weeks For longer storage, keep about
50ºF.
Sweet Potatoes 1-2 weeks Don’t refrigerate sweet potatoes.
Whipped Topping (dry) 12 months Same as unopened Store in a cool, dry environment.
container.
Yeast (dry) 1 year or 4 months After opening, store in airtight
expiration date container in refrigerator or freezer.
on package.
Food Recommended storage time at 35- Handling Hints
40ºF or lower*
Unopened Opened
DAIRY PRODUCTS
Butter 1-2 weeks Same as unopened Wrap or cover tightly.
Buttermilk 3-5 days Same as unopened Cover tightly. Flavor not affected if
buttermilk separates. Remix before
serving.
Cheese: Cottage, Ricotta 1-2 weeks Keep all cheese tightly packaged in
moisture resistant wrap. For longer
Cream, Neufchatel 2 weeks storage, see freezer storage chart.
Cheddar, Edam, Gouda, Swiss 2-3 months 2-3 weeks

(hard & wax-coated in large pieces)
Slices or Opened Packages
2 weeks
Parmesan, Romano (grated) Refrigerate after opening.(see dry
10 months 2 months storage chart)
Pasteurized Processed Refrigerate slices of process
3-4 weeks cheese and cheese food.
Refrigerate loaves and jars after
opened. Most squeeze packages
and aerosol cans don’t need
refrigeration (check label).
Coffee lightener (liquid) 3 weeks 1 week Cover tightly. Do not return unused
cream to original container.
Cream Light or Half-and-Half 4 weeks 1 week Cover tightly. Do not return unused
Heavy or Whipping cream to original container.
Dips, sour-cream, etc: Commercial 2 weeks Keep tightly covered.
Homemade 2 days Keep tightly covered.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Eggs: In-shell, fresh 2-3 weeks Do not keep Store covered. Keep small end
down to center yolks.
In-shell, hard cooked 1 week Do not keep Store in covered container.
Liquid pasteurized eggs 12 months 4-5 days

Or egg subs frozen
Egg containing products: 1-2 days Cover and refrigerate.
Custards, custard sauces,
puddings, custard-filled
pastries and cakes
Margarine 4-6 months Same as unopened Wrap or cover tightly.
Milk: Evaporated 3-5 days Keep covered.
Reconstituted dry nonfat 1 week Keep containers tightly closed.
Liquid Whole or Low-fat 1 week Don’t return unused milk to
original container.
Sweetened, condensed 3-5 days Keep covered.
Sour cream 2-3 weeks Keep covered.
Whipped Topping: Aerosol Can 3 months Keep covered.
Prepared from Mix 3 days
Frozen Carton (thawed) 2 weeks
Yogurt 1 month 7-10 days Keep covered.
Food Recommended storage time at 35- Handling Hints
40ºF or lower*
Unopened Opened
FRESH FRUITS
Apples 1-3 weeks** Not applicable Refrigerate
Bananas 1-2 days Not applicable Refrigerate only when fully ripe.
Unpeeled
Berries, Cherries 1-2 days** Not applicable Refrigerate
Citrus fruit 3 weeks** Not applicable Lemon wedges may be saved for 1
to 3 days refrigerated.
Grapes, peaches, pears, plums 3-5 days** Not applicable Refrigerate
Juices (bottled, reconstituted, Not applicable 1 week Keep fruit juice tightly covered.
frozen, canned) Transfer canned juice to glass or
plastic container after opening.
Melons 1 week Not applicable Wrap cut surfaces to prevent
Vitamin C loss and to control odors.
**Discard bruised or decayed fruit. Do not wash before storing; moisture encourages spoilage. Store in crisper or
moisture resistant bag or wrap.
FRESH VEGETABLES
Asparagus 2-3 days Not applicable Refrigerate
Corn with or without husks 1-2 days Not applicable Refrigerate
Beans, green or wax; celery 1 week Not applicable Keep in crisper or moisture
resistant wrap or bag.
Beets, carrots, radishes, turnips 1-2 weeks Not applicable Remove any leafy tops; keep in
crisper.
Broccoli, Brussels sprouts, cabbage, 1 weeks Not applicable Keep in crisper or moisture
cauliflower resistant wrap or bag.
Cucumbers, peppers 1 week Not applicable Refrigerate
Lettuce, head; spinach (washed and 3-4 days Not applicable Keep in crisper or moisture
thoroughly drained) resistant wrap or bags
Mushrooms 1-2 days Not applicable. Do not wash before storing.
Onions, green; okra 3-5 days Not applicable Refrigerate

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Onions, potatoes, sweet potatoes Not applicable Refrigeration not needed. (see dry
storage chart).
Peas, lima beans, unshelled 3-5 days Not applicable Store unshelled in refrigerator until
used.
Shredded cabbage, leaf and bibb 1-2 days Not applicable Refrigerate.
lettuce, salad greens
MEAT, FISH AND POULTRY – FRESH
Note: Meats may be left in distributor packaging for refrigerator storage or for very brief freezer storage.
For frozen storage beyond two weeks, rewrap in moisture-and-vapor-proof wrap or freezer bags.
Beef, lamb, pork and veal (raw): Not applicable
Chops, steaks, roasts 2-4 days
Ground meat, stew meat 1-2 days
Variety meats (liver, heart, etc.) 1-2 days
Bratwurst Fresh 1-2 days Not applicable
Precooked 5-7 days
Chicken, duck, or turkey (ready-to- 2 days Not applicable
cook)
Clams, crab, or lobster (in shell) 2 days Not applicable
Fish and Shellfish (fresh, cleaned 1 day Not applicable
fish, including steaks and fillets)
Seafood (including shucked clams, 1 day Not applicable Store in coldest part of refrigerator.
oysters, scallops, and shrimp
MEAT, FISH AND POULTRY – COOKED
Canned meat Not applicable 2-3 days Cover and refrigerate.
Cooked meat and meat dishes Not applicable 3-4 days Quickly refrigerate all cooked
meats and leftovers. Use as soon
as possible. Cut large roasts into
halves to cool in refrigerator. Fats
tend to separate I homemade
gravies, stews and sauces but
usually recombine when heated.
Gravy and meat broth Not applicable 1-2 days Under refrigeration, cool leftover
gravy and broth quickly, in shallow
containers.
CURED AND SMOKED MEATS
Bacon Refer to 5-7 days Cover and refrigerate.
package
Bologna, liverwurst Refer to 4-6 days Cover and refrigerate.
package
Corned beef Refer to 5-7 days Cover and refrigerate.
package
Dried beef Refer to 10-12 days Cover and refrigerate.
package
Dry and Semi-Dry sausages (salami, Refer to 4-5 days Cover and refrigerate.
etc.) package
Frankfurters, hot dogs 2 weeks or 7 days Cover and refrigerate.
date on
package
Hams: Whole Refer to 1 week Cover and refrigerate.
Canned package 6
months

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Luncheon meats 2 weeks of 3-5 days Cover and refrigerate.
date on
package
Sausage, fresh or smoked Refer to 1-2 days Cover and refrigerate.
package
OTHER FOODS
Casseroles Not applicable 1-2 days
Refrigerated biscuits, rolls, pastries, See expiration Same as unopened To avoid low quality, do not store in
cookie dough date on refrigerator door.
package.
FREEZER STORAGE: (Meats, fish; poultry; fruits; vegetables; commercially frozen foods – baked
goods; commercially frozen foods – main dishes; dairy)
Food Recommended storage time at 0ºF or Handling Hints

lower*
Unopened Opened
MEATS
Bacon 1 month Not applicable Frozen cured meats lose quality
rapidly.
Corned beef 1 month Not applicable Frozen cured meats lose quality
rapidly.
Frankfurters, hot dogs 1 month Not applicable Freezing not recommended.
Ground beef, lamb, veal 2-3 months Not applicable
Ground pork 1-2 months Not applicable
Ham and picnic cured Not applicable Frozen cured meats lose quality
rapidly.
Luncheon meat Not applicable Freezing not recommended.
Roasts: Beef 6-12 months Not applicable
Lamb, veal 6-9 months Not applicable
Pork 3-6 months Not applicable
Sausage, dry, smoked Not applicable Freezing alters flavor.
Sausage, fresh, unsalted 1-2 months Not applicable
Steaks and Chops: Beef 6-9 months Not applicable
Lamb, Veal 3-4 months Not applicable
Pork 2-3 months Not applicable
Venison, game birds 8-12 months Not applicable
FISH Note: Keep frozen foods in original wrapping; thaw; follow cooking directions on label.
Bluefish, perch, mackerel, salmon 2-3 months Not applicable
Cod, flounder, haddock, sole 6 months Not applicable
Breaded fish 3 months Not applicable
Clams 3 months Not applicable
Cooked fish or seafood 3 months Not applicable
King crab 10 months Not applicable
Lobster tails 3 months Not applicable
Oysters 4 months Not applicable
Scallops 3 months Not applicable
Shrimp, uncooked 12 months Not applicable
POULTRY
Chicken livers 3 months Not applicable
Chicken, whole or cut-up 10 months Not applicable
Cooked poultry 3 months Not applicable
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Duck, turkey 6 months Not applicable
FRUITS
Berries, cherries, peaches, pears, 12 months Not applicable
pineapple, etc.
Fruit juice concentrates 12 months Not applicable Keep prepared fruit juice tightly
covered. Transfer canned juice to
glass or plastic container after
opening.
VEGETABLES
Purchased frozen cartons, plastic 8 months Not applicable Cabbage, celery, salad greens and
bags, or boil-in-bags tomatoes do not freeze
successfully.
COMMERCIALLY FROZEN FOODS – BAKED GOODS (Freezing does not freshen baked goods. It can only
maintain the quality (freshness) the foot had before freezing.)
Bread, unbaked 1 month Not applicable
Cake, baked, frosted 8-12 months Not applicable
Cake, baked, unfrosted: Angel food 2 months Not applicable
Chiffon, sponge 2 months
2-3 months
Cheesecake 4 months
Chocolate 12 months
Fruit cake 6 months
Yellow or pound
Cookies, baked 8-12 months Not applicable
Fruit pie, unbaked 8 months Not applicable
Pie, baked 8 months Not applicable
Quick bread, baked 2-3 months Not applicable
Rolls, partially baked 2-3 months Not applicable
Yeast breads and rolls, baked 3-6 months Not applicable
COMMERCIALLY FROZEN FOODS – MAIN DISHES
Meat, fish, poultry pies, and 3 months Not applicable
casseroles
DAIRY FOODS
Butter 6-9 months Not applicable Store in moisture vapor-proof
container or wrap. Once opened,
store from 1-2 weeks under
refrigeration.
Margarine 12 months Not applicable Store in moisture vapor-proof
container or wrap. Once opened,
store from 4-6 weeks under
refrigeration.
Cheese: Camembert 3 months Not applicable Thaw cheeses under refrigeration
Cream cheese, ricotta 1 month Once thawed, follow recommended
Natural, aged cheeses (cheddar, 6-8 months storage time under refrigeration.
Swiss, brick, gouda, mozzarella,
etc)
Pasteurized process 6-8 months
cheese
Cream: Light, Half-and-Half 3-4 weeks Not applicable Thaw in refrigerator.
Eggs: Liquid whole, Whites 12 months Not applicable
Ice cream, ice milk, and sherbet 2 months Not applicable
Milk 1 month Not applicable Allow room for expansion in freezer
container; thaw in refrigerator.
Freezing affects flavor and
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
appearance; use in cooking and
baking.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.22
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Record of Refrigeration Temperatures

POLICY
A daily temperature record is to be kept of refrigerated items.
PROCEDURE:
• The Dietary Manager is to assign an employee to daily record all refrigerator and
freezer temperatures on “Record of Refrigeration Temperature.”* Nursing unit
refrigerators shall also be recorded.
• The freezer temperature must be 0º or below.
• The refrigerator temperatures must be 41º or below.
• Temperatures above these areas are to be reported to the Dietary Manager

immediately.
• Note on the temperature forms the plan of action taken when temperatures are
not in acceptable range.
• Have work orders in writing as proof of requested work.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.23
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Dry Storage – Dishes and Utensils

POLICY
Enclosed storage will be provided for clean and sanitized dishes and utensils.
PROCEDURE
• Spoon, knives, and forks shall be stored in containers with the handles upward.
• Storage areas will be cleaned and sanitized.
• Dish storage areas will be kept closed or covered when not in use.
• Glasses and cups shall be stored one layer high on cleanable surfaces or trays;
trays of cups or glasses may be stacked.
• Store like dishes, together, not to exceed 15 inches high.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.24
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Dry Storage – Paper Products

POLICY
Paper supplies will be stored in a safe and orderly manner.
PROCEDURE
• Storage area shall be easily, accessible for receiving and production.
• The area shall be well lit and ventilated with a temperature of 50º to 70ºF.
• The walls, ceiling, and floor shall be maintained in good repair and regularly
cleaned.
• It shall have sturdy, easy-to-clean shelves at least 6 inches from the floor and 18
inches from the ceiling. Shelving shall be sturdy and provided with a surface that
is smooth and easily cleaned.
• Heavy cases or items shall be placed on or near the bottom. Lighter cases or
items shall be placed on upper shelves.
• Opened packages or sleeves shall be stored in an enclosed area such as a

cabinet or drawer, etc.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.25
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Dry Storage – Linen

POLICY
Dietary will provide and utilize the following linens within the department:
• Aprons (cloth and disposable)

• Mops
• Rags
• Tablecloths (cloth and disposable)
PROCEDURE
1. Aprons (cloth and disposable):

• Aprons will be supplied by the Dietary Department
• Dispensing will be handled by an employee so designated by the Dietary

Manager.
• Storage will be determined by the Dietary Manager.
• Aprons will be laundered daily by the Laundry Department.
2. Mops and Rags:

• Mops and rags will be obtained and utilized by Dietary for the purpose of
sanitation of the department.
• Cleaning will be done on a daily basis as arranged through Laundry and

Dietary.
• Clean and Dirty storage will be separate and determined by the Dietary
Manager.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.26
Page 1 of 1
O: 2002
Toxic Substance Storage
POLICY
Toxic substances will be stored in a safe and orderly manner.
PROCEDURE
• Cleaning compounds, detergents, pesticides, or other toxic substances are

stored separately from food and food preparation equipment and utensils.
• Toxic substances may be stored in the janitor’s closet.
• All items will be stored off the floor.
• All containers containing toxic substances will be clearly marked as to their

contents.
• Protective gloves will be provided to use with cleaning solutions. These gloves
will not be used for any other purpose.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.27
Page 1 of 2
O: 2002
Cycle Menus
POLICY
Menu planning is the responsibility of the Dietitian. Menus meet the requirements of the
Food and Nutrition Board of the National Research Council of the National Academy, of
Sciences. Menus are implemented by the Dietary Manager in conjunction with the
Dietitian. Menus are developed taking into consideration certain budgetary allowances,
available personnel, and equipment. Seasonal availability of foods is also considered.
• The menus are three-meal plus snacks, selective and/or non-selective plans
based on week cycles.
• Menus are supplied by the Dietitian to the facility at the beginning of each
season. At least two seasonal menus are available.
• When changes in the menu are necessary, the changes must provide equal
nutritive value. Menu changes are made on the menu (posted in Dietary) for
regular and therapeutic diets before the meal is served, or on the “Substitution
List.”* Menu changes are reviewed and approved in advance by the Dietary
Manager. Substitutions will be reviewed by the Dietitian on the next visit.
• Record of dated menus, as served with documented substitutions, are filed and
maintained as required.
• Menus are flexible on holidays to allow for special food items usually served for
those holidays.
PROCEDURE
• Menus must be dated and posted in a place easily visible to patients. Post Week
at a Glance, Today’s Menus and Alternates. A “Today’s Alternates Form”* can
be used.
• Menus must be followed as written with the following exception: When ethnic,
cultural, geographic, or religious habits of the patient population require a
substitution.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
• When substitutions are made, the replacement item must be:
1. Compatible with the rest of the meal
1.M.27
Page 2 of 2
O: 2002
Cycle Menus (continued)

2. Comparable in nutritive value
3. Reviewed by the Dietary Manager for appropriateness
• A substitution is made by drawing a single line through the item changed and
writing in the item substituted for all diets.
• Dated menus must be filed and maintained in accordance with state and federal
requirements for days. File “Substitution List”* with menus when completed.
• If a patient choice meal is on the menu it must be filled in on the Week at a

Glance Menu and on the Therapeutic Menus. File the Therapeutic patient choice
extension in the menu file.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.28
Page 1 of 1
O: 2002
Menu Planning Criteria
POLICY
The food and nutritional needs of patients shall be planned to meet the recommended
dietary allowances as adjusted for age, sex, and activity, in order to provide menus that
include safe and adequate intake of essential nutrients.
PROCEDURE
• Make the daily menus in accordance with the recommended dietary allowances
of the Food and Nutrition Board of the National Research Council, National
Academy of Sciences, to include the following food groups and quantities or to
meet nutritional requirements for persons 51 years and over.
1. Milk: Two or more cups.
2. Meat Group: Two or more servings.
3. Vegetable Group: Three to five servings per day. Includes a source of
vitamin A daily.
4. Fruit Group: Two to four servings per day. Includes a source of vitamin C
daily.
5. Bread and Cereal Group: Six or more servings of whole grain enriched or
restored.
6. Other foods to complete meals and provide snacks.
7. At least two (2) of the following four food components is offered for the
bedtime snack:
• Fruit and/or vegetable or 100% fruit or vegetable juice.
• Whole grain or enriched cereals or breads.
• Milk or other dairy products
• Meat, fish, poultry, cheese, egg, peanut butter.
● Nutritional analysis must be available for each cycle menu and is the final basis
used to determine nutritional adequacy. The food pyramid is used as a guide and
is included with the menu program.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.29
Page 1 of 1
O: 2002
Large or Double Portions

POLICY
Large or double portions are to be physician ordered.
PROCEDURES
Food Item Large Portion Double Portion

Egg 2 2
Juice 6 oz 8 oz
Cereal 6 oz 8 oz
French Toast, Pancake, Waffle 1½ 2
Sweet Roll, Toast, Muffin, 1½ 2
Biscuit
Margarine 2 2
Jelly, Honey, Syrup 2 2
Coffee, Tea As desired As desired
Milk 1 2
Soup 6 oz 12 oz
Meat 4 oz 6 oz
Casserole #6 & #8 2 x #6
Sandwich 1½ 2
Cottage Cheese and #8 scoop #6 scoop
Fruit plate 8 pieces fruit 10 pieces fruit
Potato #6 2 x #8
Vegetable #6 2 x #8
Salad #8 2 x #8
Bread 1 2
Dessert 1 2
Approximate Calories/d 2600-2800 Cal 4000-4400 Cal

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Approximate Protein/d 100 gm Pro 160 gm Pro
1.M.30
Page 1 of 1
O: 2002
Small Portions
POLICY
Small portions are to be physician ordered.
PROCEDURES
Food Item Small Portion

Egg 1
Juice 6 oz
Cereal 3 oz
French Toast, Pancake, Waffle 1
Sweet Roll, Toast, Muffin, Biscuit 1
Margarine 1
Jelly, Honey, Syrup 1
Coffee, Tea As desired
Milk 1
Soup 4 oz
Meat 2 oz
Casserole #8
Sandwich ½
Cottage Cheese #16 scoop
Fruit Plate 4 pieces fruit
Potato #16
Vegetable #16
Bread 1
Dessert 1
Approximate Calories/d 1700-1800 Cal
Approximate Protein/d 60-70 gm Pro

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.31
Page 1 of 1
O: 2002
Menu Posting
POLICY
All menus shall be planned, dated, and posted a minimum of one week in advance in
order to inform patients of the foods to be served daily.
PROCEDURE
• Each week the menu is to be posted in an accessible location for the patients.
Post a week at a Glance, Today’s Menu and Alternates.
• Date menus with current week’s date.
• Menu substitutions will be posted as necessary.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.32
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Diabetic Patterns for Crandall Menu
POLICY
The recommended % breakdown for carbohydrates, Fat and Protein for Diabetics is
used on the Crandall Menu and in approximately 50% of calories and carbohydrates,
30% of calories from fat and 20% of calories from protein.
PROCEDURE
• Each calorie level diabetic has a diabetic meal pattern on “Diabetic Caloric Level
Meal Patterns.” Refer to Crandall Menu Program User’s Guide.
• An HS snack is included.
• A “Breakdown on Diabetic Exchange Lists” is found in the Refer to Crandall

Menu Program User’s Guide.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.33
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O: 2002
Record of Menus Served
POLICY
All master menus will be filed and retained in accordance with licensure regulations in
order to record items served for reference at a later date and to comply with state and
federal regulations.
PROCEDURE
• After menu cycle is complete, file dated menus in Dietary office. Follow state
regulations for number of days to be saved.
• Substitutions shall be noted by drawing a line through item substituted and
writing substitution above crossed-out item or by recording on the “Substitution
List.” When “Substitution List”* is full, file in menu file. Check appropriate
“Substitution List” to insure appropriate nutritional substitution.
• Fill in Supervisor/Patient Choice Meal when used and fill out blank Extended
Menu. File Extended Supervisor/Patient Choice Meal in menu file.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.34
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O: 2002
Patient Food Refusal
POLICY
Reasonable efforts shall be made to substitute nutritional equivalents for foods refused
by patients.
PROCEDURE
• Nursing is to notify the Dietary Manager or designee when patients refuse food.
• The Dietary Department will offer food or equal nutritional value. A choice of
available foods with offered (alternate for meals, cottage cheese, milk, juice, fruit,
cereal, etc.) A house supplement equal to 180 cal and 6 grams protein will be
offered when alternate foods are refused.
• In the case of insulin-dependent diabetics, available glucose will be replaced.
• If meal refusal or poor food consumption continues to be a problem, weekly

weights and the Special Nutrition Program are to be initiated. If a significant
weight loss is incurred, the physician is to be contacted. If an insulin-dependent
diabetic continues to eat poorly or refuses meals, the physician is to be contacted
by the nursing staff.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.35
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Menu Alternatives
POLICY
An alternative meat or entrée and vegetable shall be provided at every meal in the
event of personal food preferences or refusals. Alternative food must be approved by
the Dietary Manager. Alternative meat or entrée is to be posted each meal.
PROCEDURE
In addition to the menu items, an alternative meat or entrée and vegetable shall be
prepared by the cook for the meals prepared as needed.
• The following foods will always be available to the patients in the event that they
refuse the schedule alternative:
1. Soup
2. Cheese
3. Cottage cheese
4. Peanut butter or jelly
5. Juice and fruit
• Foods will always be available for patients experiencing gastric upset. They
include:
1. Ginger ale or lemon-lime soda
2. Gelatin
3. Broth/soup
4. Assorted juices
5. Sherbet
• If a food is disliked, an appropriate equivalent substitution must be made.

Alternative meals are available with therapeutic extensions and recipes that are
of equivalent nutritional value to the meals on the menu. Permanent menu
changes can be made using these alternate meals with the approval of the
Consulting Dietitian.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.36
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O: 2002
Menu Substitutions
POLICY
Substitutions in the menu actually served, being of equal nutritional value, will be
recorded directly on the menu, or on “Substitution List”* and filed in accordance with
licensure regulations.
PROCEDURE
• Substitutions of a menu item may occur when:
1. Item or ingredient is unavailable.
2. Item was prepared improperly.
3. Holiday or special occasion dictates changes.
4. Seasonal availability of an item changes.
5. Cost of item increases.
• Substitutions must be of equal nutritive value taking into consideration vitamins,

minerals, and calories. Color, texture, and flavor must also be considered.
Check menu substitution form.
• Substitutions will be recorded on the menu or on a menu “Substitution list”.
• These records will be available at Dietary Department bulletin board.
• A permanent menu change can occur with help from the Consulting Dietitian and
with his/her approval. Ethnic menus are available where meals of equivalent
value can be permanently exchanged on the menu. Therapeutic spreadsheets
and recipes are available for these ethnic changes.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.37
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O: 2002
Individual Substitutions
POLICY
Appropriate and reasonable substitutions will be offered to accommodate known food

habits, customs, and appetites of individual patients.
PROCEDURE
• Obtain and record census sheet patient information regarding serving size, likes,
dislikes, and other pertinent food habits.
• Plan and prepare substitutes of similar nutritive value. Follow “Appropriate Menu
Substitutions.”*
• If substitute is refused, another item may be prepared at the discretion of the

Dietary Manager.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.38
Page 1 of 1
O: 2002
Menu Evaluation
POLICY
Menu acceptance will be periodically checked by plate waste studies in order to control
costs by eliminating unaccepted menu items.
PROCEDURE
• The item to be studied will be determined by the Dietitian and/or Dietary

Manager.
• The minimum number of trays observed shall be one-half of the censuses.
• The Dishwashers shall be used to assist in the process of menu evaluation by

noting leftovers for meals observed.
• Evaluate findings and determine reasons for non-acceptance. Discuss with

Dietitian the possible need for a permanent menu change. The Registered
Dietitian must approve this change and help make the menu extension changes.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Nourishments
POLICY
Nourishments will be provided to offer therapeutic nutritional support. A physician’s

order will be required.
PROCEDURE
• Patients receiving nourishments may include those who are underweight, who
are on therapeutic diets, and those with poor intake, weight loss, skin problems,
low albumin and other problems addressed on care plans.
• A “Nourishment and Supplement Feeding List”* is maintained for patients
receiving physician-ordered supplements, renal diets and calorie-controlled diets.
• This list is posted in Dietary and at each nursing station.
• These nourishments are delivered by Dietary in individual portions that are
labeled with the patient’s name, date, and time.
• Percentage of consumption of these nourishments is recorded on the med
sheets by nursing services.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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House Supplements
POLICY
When an order for a house supplement is received the product may vary depending
upon availability and patient preference. At least 6 grams of protein and 180 calories
will be provided in all products used as house supplements.
PROCEDURE
• A physician’s order must be received for a house supplement to be given.
• Frequency and amounts must be specific in the physician’s order.
• House supplements will be delivered at routine snack times in this facility unless
otherwise specified in the physician’s order.
• Flavors will be routinely varied.
• The preferred house supplement is a 2 calorie/cc product with 2 oz given four

times daily at Med Pass along with the Special Nutrition Program discussed in
Medical Nutrition Therapy Section.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Nourishment Preparation
POLICY
Dietary will prepare and deliver nourishments daily to the nursing stations.
PROCEDURE
• Individual nourishments will be prepared, covered, labeled, dated, and delivered

to each nursing station. The nourishments will be on ice.
• Dietary will verbally notify Nursing that the nourishments have been delivered.
• Nursing will deliver labeled nourishments to each patient.
• Dietary shall be notified of refused nourishments so that they can be changed or

discontinued.
• The preferred nourishment is a 2 cal/cc product which nursing can store and
distribute on the med carts at the number of times and amounts ordered by the
physician. Be sure products used can be at room temperature the length of time
held on a med cart.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Snacks
POLICY
Daily snacks are provided in accordance with the prescribed diet and in accordance
with State law. Individual and/or bulk snacks are available at the nurses’station for
consumption by patients whose diet orders are not restrictive.
PROCEDURE
• At least one (1) serving or a minimum of two (2) of the following four food
components is offered for the bedtime snack:
1. Fruit and/or vegetable or full-strength fruit or vegetable juice.
2. Whole grain or enriched cereals or breads.
3. Milk or other dairy products
4. Meat, fish, poultry, cheese, eggs, peanut butter.
• Acceptance or refusal of these snacks is noted on the ADL’s where possible.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Diets Available In the Facility
POLICY
The facility will provide each patient with a regular or therapeutic diet, as ordered by the
physician, in order to ensure that each patient receives the diet prescribed by the
physician. The consistency of the diet shall also be ordered.
PROCEDURE
§ Nursing will check all diet orders received to see that they coincide with diets
available. The “Diet Order Recommendations/Preferred Wording” sheet, which
follows in this section, can help determine available diets.
§ The physician will be notified if there is any discrepancy to ensure appropriate
accommodation to facility diets offered.
§ If facility diets offered are not acceptable to attending physician, the Medical
Director may be consulted and a mutually agreeable decision made in regard to
diet order.
§ The diets provided in this facility are listed on the following pages. Liberalized
diets are recommended.
§ A liberalized diet is a Consistent Carbohydrate Diet and a No Added Salt Diet.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Therapeutic Diets
POLICY
Therapeutic diets are prepared and served as prescribed by the attending physician.
§ Therapeutic diets are planned, prepared, and served with supervision or

consultation from a Registered Dietitian.
§ Therapeutic diets are reflected on the menu extension.
§ Persons responsible for therapeutic diets have sufficient knowledge of food
values to make appropriate substitutions when necessary.
PROCEDURE
§ A therapeutic diet is defined as any deviation from the regular diet.
§ The Nursing Department is responsible for having diet orders submitted to the
Dietary Department in writing. These orders must correspond to the physician’s
diet orders in the patient’s medical record.
§ The Charge Nurse is responsible for clarifying diet orders when necessary.
§ Diet orders in patient medical records, and tray cards must coincide and are
reviewed by the Dietitian at regular intervals.
§ The Dietitian shall frequently observe preparation and serving of meals. The
Dietitian and Dietary Manager must see that:
1. The correct type and amount of food is purchased for therapeutic diet
preparation.
2. The correct type and amount of equipment is available for preparation and
serving of all diets.
3. Each food item, served separately in the regular diet, is pureed and
served separately for the pureed diet according to the puree recipes.
4. Each Dietary staff member involved with serving must refer to and follow
the appropriate therapeutic diet on the daily men. Portions of food served
must equal the written portion sizes.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
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List of Diets Available in the Facility
POLICY
Nutritionally adequate according to the Recommended Dietary Allowances

(approximately 1800 to 2300 calories, 5-6 grams sodium, 80-85 grams protein per day).
No foods are restricted.
REGULAR DIET – NO ADDED SALT PACKET (NAS) – NO ADDED SALT
Regular diet served without an additional salt packet.
REGULAR MEDHANICAL SOFT DIET AND ADVANCED DYSPHAGIA DIET (LEVEL

3)
The regular diet consists of soft fruits, vegetables, and ground meat. Fresh fruits and
vegetables are finely chopped. On the Advanced Dysphasia Diet, breads and bakery
products are slurred and corn and rice are avoided. Thickened liquids are served as
ordered: Nectar-like Consistency, Honey-like Consistency, and Spoon-thick
Consistency.
DYSPHAGIA MECHANICAL SOFT DIET (LEVEL 2)
All entrees must be ground and served with extra gravy. Fruits and vegetables shall be
pureed or chopped per menu. Fresh fruits are omitted with the exception of mashed
bananas. Soups are pureed. Bread and bakery products are slurred. Serve only soft
scrambled eggs or omelets. Thickened liquids and beverages are served as ordered:
Nectar-like Consistency, Honey-like Consistency, or Spoon-thick Consistency. Cream
of rice is used in place of rice. Corn is avoided.
DYSPHAGIA PUREE (LEVEL 1)
All foods shall be mixed in the blender to a pudding like consistency including breads
and bakery products. Cream of ricer is used in place of rice. Corn is avoided.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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List of Diets Available in the Facility (continued)

REGULAR PUREE
Regular diet with pureed meats, starches, vegetables, salads, and desserts. Products
such as bread, cake, and cookies can be blended or slurred.
2-2.5 GRAM SODIUM DIET (TRY TO OMIT)

Food is prepared without salt in cooking. A salt packet is eliminated and all highly
salted and high sodium foods are avoided. Specially prepared reduced sodium
products are substituted for foods high in sodium.
LOW FAT DIET (TRY TO OMIT)
Total amount of fat is limited to 50 grams per day. Type of fat is not specified.
LOW CHOLESTEROL DIET (TRY TO OMIT)
The cholesterol level is limited to 300 milligrams per day. Saturated fats are decreased
and polyunsaturated fats are increased. Total fat content is not limited but when
combined with the low fat diet, limit fat to 50 grams/day.
CONSISTENT CARBOHYDRATE DIET
Regular diet with three meals with consistent amounts of CHO and a bedtime snack.
Foods sweetened with sugar will be given once a day. To serve a stricter CCHO diet,
unsweetened desserts can be given at both lunch and dinner.
DIABETIC/CALORIE-RESTRICTED DIET (TRY TO OMIT)
Limitations on amounts of fat, meat, starches, and dairy products according to calorie
level. Specially prepared reduced calorie products are substituted for food high in
concentrated sugars. Calorie levels available: 2400, 2200, 2000, 1800, 1500, 1200
calories. On the menu, a nutrient analysis is used and calories are calculated within
100 calories and protein within 5 grams.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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List of Diets Available in the Facility (continued)

LIQUID DIET
Full liquid and clear liquid diets are available upon request. Refer to Menu User Guide
or Diet Manual for meal patterns.
RENAL DIET
A liberal renal diet is preferred but an 80 gm, 2-2.5 gm Na, 3 gm K diet is also available.
60 gm and 40 gm Protein modifications are also on the menu.
VEGETERIAN DIET
For patients who do not want any meat, fish or poultry. Meat or chicken base and/or
broth is even omitted. Daily menus include three meals per day. Protein at the other
two meals is provided mainly through cheese and legumes plus some additional eggs.
Only common sources of protein have been included. To increase variety, special
vegetarian products are substituted for some of the cheese dishes. A multi-vitamin with
minerals is generally recommended to replace some vitamins and minerals inadequate
in this diet.
HIGH FIBER DIET
Use the basic regular diet and add the High Fiber Bowel Program found in Section 10.

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Mechanically Altered Diets and Thickened Liquids

POLICY
Mechanically altered diets are prepared and served as prescribed by the attending
physician. One of the following mechanically altered diets may be ordered after it has
been determined which one better suits the individual:
§ Mechanical Soft (chopped)
§ Mechanical Soft (ground) – (Also used as level 3 Dysphasia Advanced except
breads and bakery items are slurred)
§ Dysphasia Mechanical Soft – (Also used as Level 2 Dysphasia Mechanically
Altered Diet)
§ Puree
§ Dysphasia Puree – (Also used as Level 1 Dysphasia Puree in blender)
PROCEDURE
§ Mechanically altered diets for Dysphasia are determined by the speech therapist
and physician. An order for the consistency determined to meet the patient’s
needs is sent to dietary signed by a Licensed Nurse.
§ Mechanically altered diets are planned, prepared, and served with supervision or
consultation from a Registered Dietitian. Pureed items shall be served
individually on a plate and not all blended together unless diet order is prescribed
that manner. When bread is blended into the meat, a recipe shall be followed so
portions are appropriate.
§ Thickened liquids and beverages shall be served as ordered:
1. Nectar-like consistency
2. Honey-like consistency
3. Spoon-thick consistency
(Follow instructions for thickness to achieve proper consistency)
§ Dietary will thicken liquids to proper consistency, i.e. juice, milk, coffee, soup, and
water. Pre-thickened juice and milk are desirable. (Send thickened water on
each tray).
§ For water at bedside, send an empty pitcher of a contrasting color on the
breakfast carts. Send pre-portioned thickeners in covered soufflé cups marked
“nectar,” “honey,” or “spoon-thick.” Another method could be thickened water or
flavored water to be sent on each tray and between meals three times daily on
nourishment cart and bedside water pitcher not to be used.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Mechanically Altered Diets and Thickened Liquids

(continued)
§ It is recommended that Nursing do I & Os x 3 days after thickened liquid are
ordered to assure proper hydration. Document consistency ordered on MAR and
care plan. Some method shall be used per facility policy, i.e. blue dot on
resident’s name outside of room with “N” for nectar, “H” for honey or “S” for
spoon on dot to indicate liquids thickness to alert family, visitors and staff of
consistency orders for liquids. The immediate family/surrogate shall be advised
of the mechanically altered diet order and order for thickened liquids. A list of
residents on thickened liquids shall be available in Dietary and for Nursing and
Activities.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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High Fiber Bowel Program

POLICY
For each patient with a diagnosis of constipation and/or a patient with bowel
medications, the Nutritional Bowel Program will be implemented. This program shall be
individualized for the patients.
PROCEDURE
§ Upon nutritional review, DM/DT or RD will identify patients who are candidates
for the High Fiber Bowel Program. Nursing can request this program also. The
patient or patient’s family shall be interviewed for preferences regarding the high
fiber foods.
§ The program can contain the following: (Different items can be used per patient’s
preference).
1. Prune Sundae – one 2 oz/day.
2. Whole Wheat Bread/Toast each meal.
3. Additional 8 oz beverage each meal – assure 8-8oz fluids/day
4. Fresh fruit or salad at lunch and dinner. Mechanically-altered diets
receive finely chopped or juice per diet order.
5. Bran type cold cereal or 2 Tbsp. unprocessed bran in 6 oz hot cereal.
6. Prune juice or prunes – ½ cup/day.
RECIPES FOR INCREASED FIBER
Cooked Cereal with Bran
Cooked Cereal 2 lb 10 oz
Unprocessed Bran 1 lb 2 oz
Procedure: Cook cereal according to package instruction. Add Bran Buds.

Yield: 28 cups Portion Size: 6 oz
Dietary Fiber: Approximately 8 grams

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
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High Fiber Bowel Program (continued)
Prune Sundae – 25 servings
Unprocessed Bran 6 ¼ Tbs

Prune juice 2 ¼ cups
Unsweetened Applesauce 4 cups
Procedure: Combine all ingredients in blender. Blend well.

Yield: 6.25 cups Portion Size: 2 oz
Dietary Fiber: Approximately 2 grams

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Diet Manual
POLICY
A current therapeutic diet manual approved by the Dietitian and Medical Director is
readily available to attending Physicians, Nursing, and Dietary Department personnel in
order to ensure that all therapeutic diets are prepared as ordered by the attending
Physician.
PROCEDURE
• The current Diet Manual is made available for the Dietary Department and all
other related disciplines.
• The name and date of the publication of the current Diet Manual in use shall be
recorded below:
Diet Manual:
Date of publication:
Approved by: Date:

Dietitian
• The form on the following page may be used for the front page of the diet
manual.
• The Diet Manual must be current and updated within the past 5 years.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
DIET MANUAL
APPROVED BY:
Registered Dietitian Date
Medical Director Date

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Transmission of Diet Orders

POLICY
The Dietary Department will be notified, of all diet orders and changes by the Nursing
Department. Dietary Staff will check the order entry program prior to each meal being
served.
PROCEDURE
Order entry system –
§ A tray card is prepared according to the prescribed diet and placed on the tray
setup.
§ The Order Entry System is also utilized to notify dietary:
1. Room Transfer
2. Expiration
3. Discharge
4. Transfer to hospital
5. Diet Change
6. Out on pass

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Change in Diet Orders

POLICY
A change in diet order is considered to be a change in dietary condition.
PROCEDURE
§ The “Order Entry System” is utilized by a Licensed Nurse when a diet change is
made.
§ Update any changes in diet order; change the tray card, production count and
nourishment list when applicable.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Census Sheet
POLICY
The Dietary department will maintain a computer printout from the order entry system in
order to record dietary information necessary to use on the patient’s tray card.
PROCEDURE
§ The Census Sheet shall contain the following information on each patient:
1. Name
2. Room number and bed location
3. Dining location, not applicable
4. Current diet order
5. Patients diet pattern, if different from the diet manual or therapeutic diet
extension shoot.
6. Prescribed supplemental feeding or extra nourishments provided to the

patient beyond those listed on the therapeutic diet extension sheet.
7. Listing of past diet orders
8. Any known allergies
9. Patients food preferences
10. Feeding ability
11. Adaptive devices
§ The census sheet shall be used to obtain the diet information for the facility.

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§ Census sheet may be copied “Dietary Interview Form”* with diet orders taped to
back.
§ Census sheets ages are maintained until patient is discharged or expires.
§ It is a good practice to retain a hard copy in case computer is down.

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Dietary Audit
POLICY
The patient’s charts must be reviewed on a regular basis to ensure that new diet orders
have not been overlooked.
PROCEDURE
§ A dietary audit is performed by the Dietary Manager at least every week.
§ The dietary audit includes the patient’s name, room number, bed number, and
diet as stated in physician orders (including supplemental feedings).
§ Physician’s diet orders are then compared to the diet orders recorded on the
dietary nourishment list and census sheet.
§ If a computer printout of patient’s diet order and nourishment order is available,

use printout for audit. If not available, do a physical audit pulling every chart
when possible.
§ One month prior to expected State Survey, use the “Clinical Chart Audit”* form to
check the following:
1. Diet order
2. Nourishment order
3. Last nutritional review
4. Care plan correct
5. Weight loss/Abnormal lab/Pressure ulcer

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Tube Feeding
POLICY
Commercial formula tube feedings will be used for those patients with prescribed
intubated feedings, unless contraindicated by the physician. The physician will
prescribe TPN orders.
PROCEDURE
§ Physician’s orders for tube feedings and TPN are diet orders and must be
reported in the usual manner to the Dietary Department, including:
1. Type of formula
2. Amount of formula and flush including med flush
3. Frequency and amount of feeding
§ It is recommended that commercial tube feedings not be less than 1500 calories
per day for females and 1800 calories per day for males unless contraindicated
by the physician.
§ The Dietitian is to review and assess tube feedings annually and monthly to
ensure nutritional adequacy. The Enteral form can be used to calculate
nutritional adequacy of the tube feeding when there is a change in the tube
feeding.
§ Dietary Managers/Dietary Technicians are to contact the consulting dietitian and

review adequacy of the TF within 48 hours. This can be noted on the appropriate
worksheet.
1. When faxed, the RD will assess and make any needed recommendations
and fax information back to the Dietary Technician within 48 hours of
identification. Upon RD’s visit, the tube feeding will be thoroughly
reviewed again with an additional note added to confirm faxed information.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Tube Feeding (cont.)

§ Always check advance directives regarding decision for nutrition via tube. If an
advance directive is needed notify appropriate discipline on recommendation
form and have them clarify ASAP. Nutrition and/or hydration shall not be held
without advance directives.
§ Oral gratification is defined as p.o. intake for the purpose of oral satisfaction for
the patient and not for nutritional support. Recommended appropriate
consistency to be determined by Physician and/or Speech Therapist. Other diet
restrictions are taken into account.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Salt Substitute
POLICY
All patients on sodium-restricted diets requesting the use of salt substitute must have a
physician order.
PROCEDURE
§ When an order for a salt substitute is received, food will be prepared according to
diet order and a salt substitute will be served as a condiment.
§ All patients with dramatic changes in overall condition will have the use of a salt
substitute reassessed.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Consistency as Tolerated
POLICY
The consistency that the patient is presently receiving will always be reflected on the
physician’s order sheet. “Diet as Tolerated” will not be allowed due to its ambiguity.
PROCEDURE
§ The physician’s order shall not include “as tolerated” in addition to the type of diet
ordered.
§ The specific consistency currently required will be stated on the physician’s order
sheet unless no consistency modification is required and, therefore, none is
stated.
§ For a period of 72 hours, the Charge Nurse and Dietary Manager may
temporarily change consistency downward not upward to determine patient’s
tolerance. After 72 hours, a physician’s order must be obtained. If the patient
has Dysphagia a speech therapist shall be used as a referral before consistency
changes are tried.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Full Liquid Diet Meal Plans

Use for Regular Diet
↓
Breakfast 1200 1500 1800 2000 2200
Instant Breakfast* 4 oz 4 oz 8 oz 8 oz 8 oz
Cereal, cooked 4 oz 4 oz 8 oz 8 oz
8 oz
Orange juice 4 oz 4 oz 4 oz 4 oz 4 oz
Milk, 2% 4 oz 4 oz 4 oz 4 oz 4 oz
Coffee, black free free free free free
Tea free free free free free
Lunch
Pineapple juice 1/3 c 2/3 c 2/3 c 2/3 c 2/3 c
Cream soup, strained 3 oz 6 oz 6 oz 6 oz
12 oz
Ice cream, plain ½c ½c ½c
Dinner
Grape juice 1/3 c 1/3 c 2/3 c 2/3 c 2/3 c
Cream soup, strained 6 oz 6 oz 6 oz 6 oz
6 oz
Ice cream, plain ½c ½c ½c
H.S.
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Full Liquid Diet Meal Plans (continued)

Totals
Carbohydrates (g) 155 203 246 263 294
Protein (g) 50 62 74 82 95
Fat (g) 42 50 60 64 76
Calories 1198 1510 1820 1956 2240
Fat (%) 32 30 31 29 31
*1 Tbsp of nondairy creamer needs to be added for each cup of low fat milk used.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Carbohydrate Replacement For Insulin-Dependent

Diabetics
POLICY
Uneaten foods for diabetics must be replaced when on insulin.
PROCEDURE
The replacements are planned by the Dietary Manager and Dietitian as follows:
§ Determine the amount of food left on the patient’s tray.

§ Using the following reference table and formula, calculate the total grams or
carbohydrates (CHO).
Food Exchange PRO (gm) FAT (gm) CHO (gm)

Bread 1 exchange 3 Trace 15
Meat 1 exchange 7 5 0
Milk, 2% 1 cup 8 5 12
Vegetable 1 exchange 2 0 5
Fruit 1 exchange 0 0 15
Fat 1 exchange 0 5 10
§ Calculations:
1. Total grams of protein, fat, and carbohydrate of uneaten foods.
2. Multiply grams of protein x 56% = (A)
Multiply grams of fat x 10% = (B)
Multiply grams of CHO x 100% = ( C )
3. Total (A) + (B) + ( C ) =
CHO that needs to be replaced
§ After the total amount of grams of CHO is figured, a replacement shall be

prepared. The following table provides examples of easily accessible sources of
CHO. Choose the quantity of replacement which approximates the total grams of
carbohydrate that need to be replaced.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Carbohydrate Replacement For Insulin-Dependent

Diabetics (continued)
Grams to be Replaced Replacements
Under 10 grams None
12-15 grams Select one item:

½ cup orange juice, or
¼ cup grape or prune juice, or 1/3 cup apple
Juice, or
1 cup of milk, or
2 graham crackers

¾ cups (6oz) orange juice, or
1/3 cup grape or prune juice, or
½ cup apple juice, or
½ cup eggnog

1 cup orange juice, or
½ cup grape or prune juice, or
2/3 cup (6 oz) apple juice, or
2 cup milk, or
4 graham crackers

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Standardized Recipes
POLICY
Standardized recipes will be used for all products prepared.
PROCEDURE
§ Use standardized recipes provided with menu cycle.
§ Standardized recipes will have adjustments for yields needed.
§ Standardized recipes will be adjusted for therapeutic and consistency

modifications.
§ The Dietary Manager will monitor and check routinely the cooks’ use of recipes.
§ If favorite recipes are added to the recipe file, they must be written, standardized
and approved by the Registered Dietitian.
§ Recipes have diet modifications noted.
§ HACCP controls are also noted on recipes.
§ Pureed recipes are found in the Puree Packet.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Recipes – Increasing and Decreasing

POLICY
Serving portion sizes and small quantity recipes may be increased or decreased.
PROCEDURE
§ Establish a working factor before increasing or decreasing every portion.
Example:
Multiply number of portions needed times portion size.
50 x ½ c. or 4 oz. = 25 c or 200 oz.
Multiply portions needed times original serving portion.

50 x 6 oz. or ¾ c. = 37.5 c. or 300 oz.
Divide:
Amount needed = Working 200 oz

Yield of new recipe Factor 300 oz
Working factor = .67 or 2/3
Multiply working factor times every ingredient.
§ Increase or decrease every ingredient in the recipe 2.5 times.
Example:
50 serv. Original 125 serv. New

1 ½ qt. milk 3 qt. 3 c. milk
8 oz. shredded cheese 1 lb. 4 oz. cheese
1 pt. chopped olives 1 qt. 1 c. olives

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Recipes – Increasing and Decreasing (continued)

§ Working factors shall be rounded to get a figure divisible by 2, 3, or 4 for ease in
converting.
Example:
35 = .70 (round to .75)

30

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Standard Portions
POLICY
Uniform food portions shall be established for each diet and served to all patients.
PROCEDURE
§ Provide proper equipment for portioning out the correct quantity of food for the
patients.
§ Instruct all Dietary employees in the procedures of standardized portions.
§ Recipes and menus will have appropriate portions noted.
§ The Dietary Manager will monitor the cooks and their use of portion control
utensils on tray line.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Serving Utensils
POLICY
Standard serving utensils will be used for serving all appropriate products.
PROCEDURE
§ Read menu and recipe to determine serving sizes needed.
§ Gather utensils needed to portion products.
§ Refer to “Use Ladles and Scoops for Standard Portions.”
1. Scoops are sized according to portions per quart, usually shown on the
ejection blade.
2. Ladle sizes are shown on the handle either by 4 oz. or by 444.
§ Have an ounce scale on tray line to weight of meat.

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Use Ladles and Scoops For Standard Portions
LADLES
Fluid Ounces Measure Use

1 oz 1/8 cups Salad dressings, dessert sauce, gravies
2 oz ¼ cup Gravies for Dysphasia Mechanical Soft Diets
3 oz 3/8 cup Cereal for Small Portions
4 oz ½ cup Cereals and Soups for Diabetics
6 oz ¾ cup Soups, stews, casseroles, cereals
SCOOPS
No.* Weight Measure Use

6 6 oz ¾ cup Luncheon salads, casseroles
8 4 oz ½ cup Vegetables, starches, salads, desserts
10 3 oz 3/8 cup Ice cream, sherbet
12 2.66 oz 1/3 cup Used often for puree portions
16 2 oz ¼ cup Scrambled eggs, 2 oz ground meat
20 1 ¾ oz 3 1/3 Tbsp Muffins, cupcakes
24 1 ½ oz 2 2/3 Tbsp Drop cookies
40 ¾ oz 1 2/3 Tbsp Seldom used
*Indicates portions per quart

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
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Standard Serving Portions

MEATS AND MAIN ENTREES
§ Portion sizes will vary to accommodate the daily portion requirements.
§ See Menu Extension for exact ounces and serving sizes for meats and main
entrees.
BREADS AND CEREALS
Item Portion Size Utensil

Bread, loaf 1 slice Hand
Coffee cake 3” x 2” square Spatula
Cereal, cooked 6 oz ladle Cereal bowl
Cereal, dry 1 pre-packaged Cereal bowl
Cornbread 3” x 2” square Hand
Dinner roll 1 Hand
Donuts/sweet rolls 1 Hand
Muffins 1 Hand
Quick bread 1 Hand
DESSERTS

Angle food cake 1 oz slice or ½” slice Spatula
Cake, homemade (cake pan) 3” x 2” square
Spatula
Cream puff 1 Hand
Gelatin, fruited 3” x 2” square Spatula
Ice cream/sherbet 1 Dixie cup, 3 oz
Pie 8-10 pieces per pie Spatula
Pudding/baked custard 3” x 2” square Spatula
Soft puddings/gelatin 4 oz #8 Scoop
Toppings/sauces 1 oz Ladle

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Standard Serving Portions (continued)

FRESH FRUITS

Apple 1 whole Hand
Apricots 2 small Hand
Banana 1 whole small or ½ large Hand
Cantaloupe 1/6 melon Hand
Cantaloupe, diced 4 oz #8 scoop
Grapefruit ½ Hand
Grapes 4 oz #8 scoop
Honeydew 1/8 melon Hand
Nectarine 1 whole Hand
Orange 1 whole Hand
Orange, slices 3-4 slices Fork/tong
Peach 1 whole Hand
Pear 1 whole Hand
Plum 1 whole Hand
Strawberries (sliced) 4 oz #8 scoop
Watermelon 4 oz #8 scoop
VEGETABLES

Creamed or mashed 4 oz #8 scoop
Pureed vegetables 4 oz #8 scoop
Whole vegetables 4 oz #8 scoop
SALADS

Coleslaw 4 oz #8 scoop
Cottage cheese ¼ - ½ cup #16 - #8 scoop
Cucumber, slices 5-6 slices Spoon
Cucumber, diced 4 oz #8 scoop
Deviled eggs 2 halves Tong/fork
Fruit salad 4 oz #8 scoop
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SALADS (continued)
Gelatin salad 3” x 2” square Spatula
Macaroni salad 2-4 oz #16-#8 scoop
Pickled beets, diced 4 oz #8 scoop
Pickled beets, slices 4-5 slices Slotted
spoon
Potato salad 2-4 oz #16-#8 scoop
Tossed salad 4 oz #8 scoop
POTATO AND POTATO SUBSTITUTES

Baked potato 1 Tong/fork
Boiled/browned potato 4 oz Spoon
Bread dressing 2-4 oz #16-#8 scoop
Creamed potatoes 4 oz #8 scoop
French fries 8-10 Tong/spoon
Hash browns 4 oz #8 scoop
Hash browns 1 patty Spatula
Macaroni 4 oz #8 scoop
Mashed potatoes 4 oz #8 scoop
Noodles 4 oz #8 scoop
Potato chips 8-10 Hand
Rice 4 oz #8 scoop
Spaghetti 4 oz #8 scoop
Sweet potato 4 oz #8 scoop
Tater tots 5 Spoon
MISCELLANEOUS
Condiments 1 Tbsp Ladle
Condiments, packet 1 individual serving packet Hand
Salad dressing 1 oz Ladle
Salad dressing, packet 1 individual serving packet Hand
Diet salad dressing 1 oz Ladle
Diet salad dressing, packet 1 individual serving packet Hand
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
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MISCELLANEOUS (continued)

Gravy 1 oz Ladle
Honey 1 individual serving packet Hand
Jelly 1 individual serving packet Hand
Soup ¾ cup 6 oz ladle
Syrup 1 oz Ladle
Tartar sauce 1 oz Ladle
(Where there are 2 sizes listed, it depends on the menu used and will be noted in the
portion column)

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Food Production Sheets

POLICY
Meals will be prepared in adequate yet not excessive amounts for all diets as
determined by the current diet census.
PROCEDURE
§ The Dietary Manager is responsible for keeping a daily “Diet/Production Count”*

and Food Preferences and Special orders record current.
§ The employees with food preparation responsibilities are trained and are able to
take information from these daily diet census records and determine the proper
amount of food required to serve the regular and therapeutic diets.
§ These two forms can be enlarged, laminated and the figures could be added on
the forms with a grease pencil so it could be erased and updated daily, or a large
white board could be used with the two forms transferred to the board.
§ Food Production Records can be prepared daily to assist in food production.

Use the “Diet Count”* to prepare the Daily Food Production Records.
§ If this is computerized, the data must be posted.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Food Tasting
POLICY
The Cook and/or the Dietary Manager will taste all foods prepared before serving.
PROCEDURE
§ Wash hands.
§ Obtain two teaspoons (one for serving and one for tasting).
§ With right hand, fill teaspoon from cooking container.
§ Transfer to teaspoon in left hand.
§ Taste from spoon in left hand.
§ Obtain more samples using spoon in right hand.
§ Transfer to tasting spoon in left hand.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Food Temperatures
POLICY
Foods will be served at proper temperature to insure food safety.
PROCEDURE
§ Wash, rinse and sanitize a dial face, metal probe-type thermometer with alcohol
wipe. A practical range of 0º - 220º F is recommended. Re-sanitize the
thermometer after each use.
§ Insert thermometer into center of product. Allow time for stabilization. Wait until
there is no movement for 15 seconds. Several readings may be required to
determine hot and cold spots.
§ Record reading on “Food Temperature Chart”* form at beginning of tray line and
end of tray line. If temperatures do not meet acceptable serving temperatures,
reheat the product or chill the product to the proper temperature. Take the
temperature of each pan of product before serving.
§ Acceptable serving temperatures are:
Cereal, gravy > 140º but preferably 160º - 175º

Casseroles > 140º but preferably 160º - 175º
Meat, entrees > 140º but preferably 160º - 175º
Potatoes, pasta > 140º but preferably 160º - 175º
Soup > 140º but preferably 160º - 175º
Pureed foods, hot > 140º but preferably 160º - 175º
Pureed foods, cold < 41º
Vegetables > 140º but preferably 160º - 175º
Coffee > 140º but preferably 160º - 175º
Hazardous salads and desserts < 41º
Pastries, cakes > 60º
Milk, juice < 41º
Eggs 140º - 155º
§ If temperatures are not at acceptable levels and cannot be corrected in time for
meal service, make an appropriate menu substitution and discarded out-of-
temperature range foods.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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§ Cold food needs to be put in the freezer ½ hour to ¾ hour prior to meal service.
Bring only 1 tray at a time out on tray line. Put on ice. Ice down all cold foods on
tray line. Chill dishes to be used for cold food.
§ Do not put food on tray line until ½ hour prior to meal service. Heat hot plates.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Calibrating a Probe Thermometer

PROCEDURES
§ Fill a medium size glass with ice.
§ Add water to the ice.
§ Place thermometer in glass of ice water.
§ Wait three (3 minutes)
§ Stir water occasionally.
§ After three (3) minutes, thermometer shall read 32ºF.
CORRECTIVE ACTION
§ If thermometer does not read 32ºF, leave it in the ice water.
§ Using pliers, 7/16 inch wrench, or an adjustable wrench, turn the adjustable nut
located on the back of the thermometer dial until the needle reads 32ºF.
§ Wait three minutes stir occasionally and after three minutes the thermometer
shall read 32ºF. If not, repeat procedures again.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Leftovers
POLICY
Food handling rules for leftovers will be used by Dietary employees.
PROCEDURE
§ Remove food from holding area after service is completed.
§ Chill uncovered to 41º or lower – according to Cooling Monitor for Hazardous

Foods Policy.
§ Place leftover food and/or beverage in seamless containers with tight-fitting lids
or Ziploc bags. or Ziploc bags. Label and date all containers. Note: If large
quantities are left, place no more than two quarts each into shallow pans for
quick cooling.
§ Transfer into storage containers. Place in freezer to lower temperatures quickly

to proper temperature (41ºF), then refrigerate or freeze as indicated.
§ When using leftovers to be served hot, remove from storage container, place in
appropriate size pan and heat until internal temperature reaches 165ºF.
§ Do not mix leftovers into freshly made foods; use leftovers separately.
§ Leftovers shall only be used once. Anything that is left after service (hot or cold)
shall be thrown out.
§ Leftovers shall be kept and used per leftover policy.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Garnishing Ideas
POLICY
All plates will be garnished.
PROCEDURE
§ Garnish ideas for regular textured diets:

Carrot stick Lemon wedge
Celery tops Olives
Chopped parsley Orange slice
Crabapple Parsley sprig
Crumbled bacon Peach slice
Grape royal Pickled chips
Grated cheese Pimento strips
Grated hard-cooked eggs Red apple slice
Green onion tops Shredded red cabbage
Green pepper rings Tomato slice or wedge
Creamed dished sprinkled with paprika or parsley
Dessert sprinkled with cinnamon
Dessert sprinkled with dry flavored gelatin
Fish or vegetables sprinkled with paprika
Stew sprinkled with peas
§ Garnish ideas for pureed diets:
1. Have the following items in shakers so that they’re always ready for
use:
§ Paprika
§ Crushed parsley flakes
§ Dry gelatin powders: green, red, yellow, etc.
§ Instant coffee
§ Cinnamon
2. Pureed pineapple can be used to top ham and cottage cheese while
pureed apricots and strawberries are always great for ice cream
sundaes, cakes, etc.
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Garnishing Ideas (continued)

3. In pastry bags, keep mayonnaise for salads and whipped toppings for
desserts.
4. Cheese Whiz for meats and vegetables; crumbled hard-cooked egg

yolks for salads and meats; and finely chopped hard-cooked egg
whites for salads and meats.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Change of Menu Garnish
POLICY
Dietary Managers may change garnishes on the menu if the substituted garnish
compliments the entrée.
PROCEDURE
• The garnish is not calculated into the nutritive value of the menu.
• The Dietary Manager may choose to change the garnish.
• Be sure the substitute garnish compliments the entrée.
• Notify the cooks as to the substituted garnish.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Milk and Cheese Cookery
POLICY
The Dietary Department will ensure that food is prepared in a manner to preserve
quality, maximize nutrient retention and to obtain maximum yield of the product.
PROCEDURE
Milk:
• Milk will be served from the original container. This includes service of milk from
a milk carton or pouring directly into a glass for tray line assembly.
• Milk will not be permitted to remain at room temperature for any length of time.
Milk will not be placed on tables before time of service or take out of cooling units
before tray line assembly.
• Nourishments containing milk will not remain at room temperature for any length
of time.
• All unopened cartons of milk returned with food trays will be discarded and will
not be returned to stock for reuse. If milk is routinely unopened on trays, the
Dietary Manager shall review for problems and attempt to provide appropriate
substitutions.
• Dry milk will be used for cooking purposes only. It will not be reconstituted for
general milk supply.
• Dry milk may be used for high protein milk. Local or state regulation, including
maintenance of waiver, will be met for use of milk as a food supplement.
Cheese:
• Cheese to be cooked in foods will be done at low temperatures. Temperatures

above 350ºF will cause cheese to separate and become tough and stringy.
• Cheese will be held in a sanitary manner under the same guidelines as all other
protein items.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Egg Cookery and Storage
POLICY
To serve eggs free of salmonella and acceptable to the patient.
PROCEDURE
• Store eggs in a dry, cool place (41ºF or lower).

• Thoroughly wash hands with soap and water after handling eggs.
• Do not use eggs with cracked shells.
• Do not use raw eggs as an ingredient in the preparation of uncooked, ready-
to-eat menu items unless using pasteurized eggs.
• Shell eggs must not be pooled. Pasteurized eggs shall be substituted for
shell eggs for such items as scrambled eggs, omelets, French toast, mousse,
and meringue.
• Individually prepared eggs shall be cooked to heat all parts to 145ºF or above.
The following cooking times are recommended:
1. Scrambled – 1 minute at a cooking surface of 250ºF
2. Poached – 5 minutes in boiling water
3. Sunnyside – 7 minutes at a cooking surface of 250ºF
4. Fried, over easy – 3 minutes at 250ºF on one side, turn over and fry
2 minutes on other side.
• Do not save leftover cooked eggs.
• A soft egg shall not be served unless the temperature is at least 140ºF for 3
minutes or 145ºF for 15 seconds. Generally, at these temperatures, the
whites are completely set and the yolks have congealed.
• Pasteurized eggs in the shell may be cooked and served individually per
resident’s preference.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Vegetable Cookery
POLICY
The Dietary Department will ensure that all food shall be prepared in a manner to
preserve quality, maximum nutrient retention and to obtain maximum yield of product.
PROCEDURE
• All fresh vegetables will be washed and rinsed well to remove solid pesticide
residue.
• Vegetables will be prepared as close to time of service as possible, to maintain

highest quality.
• All vegetables will be steamed or cooked in as small amount of water as

possible. When possible, the liquid from vegetables will be used in preparing
gravies or broths.
• Raw, fresh vegetables will be added to boiling water and cooked per recipe
directions.
• Frozen vegetables will be cooked or steamed from the frozen state whenever
possible.
• Canned vegetables will be heated and prepared in the following manner:
1. Can lid will be wiped. Can will be opened with bench can opener and lid
shall be completely removed.
2. Liquid from canned vegetables will be drained into a kettle and the liquid
brought to a boil.
3. The vegetables shall then be gently added to the hot liquid. The heat shall
be reduced to a simmer, allowing vegetables to reheat but not to a boil, to
maintain the highest quality possible with canned vegetables.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Dessert Preparation
POLICY
preserve quality, maximize nutrient retention and to obtain maximum yield of product.
PROCEDURE
• All desserts will be prepared the day of service, if possible. The exception to this
will be gelatin desserts.
• All desserts will be served in an attractive manner in the appropriate dish, with
the garnish as specified on the production sheet. All cooked dessert items will be
refrigerated after baking (as specified) during the cooling process. All desserts
will be refrigerated after dishing and will be covered in a refrigerator that has a
high velocity fan.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Fruit Preparation
POLICY
PROCEDURE
• All fruit will be thoroughly washed before preparation or serving.
• All fruit will be served in a form that can be tolerated by the patients.
• All canned fruit will be served chilled.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Salad and Other Miscellaneous Food Preparation
POLICY
PROCEDURE
• All salads will be attractively served on lettuce leaf or with parsley/endive garnish.
• All salads will be refrigerated until time of service.
• All salads will be covered in a refrigerator with a high velocity fan.
• All soups will be prepared from fresh ingredients, whenever possible.
• All sandwiches will be served at the appropriate temperatures. Sandwiches will

be served neatly and attractively garnished as indicated on the menu.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Meat Cookery and Storage

POLICY
To serve meat according to acceptable sanitation standards and acceptable to the

patient.
PROCEDURE
• Meat will be stored in a freezer 0ºF or less until pulled for defrosting.
• Meat which needs defrosting will be pulled three days prior to service and
defrosted in a dry, cool area 41ºF or lower. Date meat when pulled for
defrosting.
• Meat shall be cooked according to the minimum cooking food temperatures

outlined by the current FDA Food Code. To ensure that meats are completely
cooked, following are suggested guidelines for internal temperatures:
Ground Products Hamburger, beef, veal, lamb, pork 155ºF for 15

seconds
Chicken, turkey 165ºF for 15 seconds
Beef, Veal, Lamb Roast & Steak 145ºF to 165ºF for
15 secs
Fish 145ºF for 15 seconds
Pork Chops, Roast, Ribs 145ºF to 165ºF for 15
secs.
Ham, pre-cooked 155ºF for 15 seconds
Poultry Chicken, whole and pieces 165ºF for 15 seconds
Turkey (unstuffed) 165ºF for 15 seconds
Other
Stuffed Fish; Stuffed Meat; Stuffed Pasta; Stuffed Poultry 165ºF for 15
seconds
• Use a metal stem thermometer to check for proper cooking temperatures.
• Once cooked, cut large roasts and turkey into 4” pieces or less in thickness.
• Refrigerate food while hot and kept it uncovered until has reached 41ºF. It must
reach 41ºF within 6 hours.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Meat Cookery and Storage (continued)

• Check with metal stem thermometer every hour to ensure food reaching proper
cooling temperatures.
• In reheating meat, use an oven and heat to 165ºF or greater for 15 seconds. If
microwave is used, heat to 165ºF and hold for 2 minutes after removing from
microwave oven.
• Follow “Tray Line Refrigerated Leftover Storage” policy for saving leftovers.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Cooling Monitor for Hazardous Foods

POLICY
Food handling rules for cooling hazardous foods will be used by Dietary employees.
Hazardous foods will be defined as:
• Beans/Rice/Pasta
• Pies/Pastries/Eggs
• Potatoes
• Soy Protein/Meats
• Cheese/Whipped Butter
• Chicken/Shellfish
• Dairy/Non Dairy Agents
PROCEDURE
• Transfer cooked product to a container(s) with a depth no greater than two

inches.
• Label and date the container(s).
• Leave container uncovered or loosely covered during the cooling process.
• Place container(s) in the refrigerator for cooling.
• Anything that is served from the steam table may not be re-used at another meal.

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• If temperature is not dropping adequately consider using an ice bath. If it is a

roast, cut into smaller pieces, make sure you are using shallow (>2 inches in
depth) pans, etc.
• When temperature reaches 41ºF, cover tightly and store in the refrigerator or
freezer.
• If temperature doesn’t reach 70º in 2 hours, reheat to 165º and try cooling
process again.

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Cooking – General Rules

• Cook meat and poultry to the “doneness” temperature given in the chart below.
• To make sure meat or poultry over 2 inches thick is cooked all the way through,
use a meat thermometer. Insert the tip into the thickest part of the meat,
avoiding fat, bone, or gristle. For poultry, insert the tip into the thick part of the
thigh next to the body.
• For meat and poultry less than 2 inches thick, look for clear juices and lack of
pink in the center as signs of “doneness.”
• Cooking temperatures in conventional ovens shall be at least 325ºF. Do not use

recipes that call for cooking without a reliable and continuous heat source.
• Avoid interrupted cooking. Completely cook meat and poultry at one time.
Partial or interrupted cooking often produces conditions that encourage bacterial
growth.
• When cooking frozen meat or poultry that has not been defrosted, cook it about 1
½ times the length of time required for the same cut when thawed.

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Cooking Temperature Chart

Cooking food to an internal temperature of 165ºF usually protects against food-borne
illness. However, some foods are considered tastier when they are cooked to a higher
internal temperature. The higher temperature in this chart reflects a greater degree of
“doneness”.
DEGREES FAHRENHEIT
EGGS AND EGG DISHES
Eggs Cook until yolk and white are firm
Egg dishes 160ºF for 15 seconds
GROUND MEAT AND MEAT MIXTURES

Turkey, chicken 165ºF for 15 seconds
Veal, beef, lamb, pork 160ºF for 15 seconds
FRESH BEEF
Medium 165ºF for 15 seconds
Well Done 170ºF for 15 seconds
FRESH VEAL
FRESH LAMB
FRESH PORK
POULTRY
Chicken 165ºF for 15 seconds
Turkey 165ºF for 15 seconds
Turkey breasts, roasts 165ºF for 15 seconds
Thighs, wings Cook until juice runs clear
Stuffing (cooked alone or in bird) 165ºF for 15 seconds
Duck & Goose 165ºF for 15 seconds
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Cooking Temperature Chart (continued)

HAM
Fresh (raw) 160ºF for 15 seconds
Pre-cooked (to reheat) 140ºF for 15 seconds
Shaller 155ºF for 15 seconds
LEFTOVERS & CASSEROLES 165ºF for 15 seconds
FISH & SHELLFISH 145ºF for 15 seconds

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Meal Hours
POLICY
Meals are served at regularly scheduled hours. An HS snack and additional snacks are
offered and served at regularly scheduled hours and in accordance with prescribed
diets and state and federal regulations. There must not be over 14 hours between
dinner and breakfast the following morning.
PROCEDURE
• The Dietary Manager will coordinate with department heads to establish

employee meal hours that do not conflict with patient meal service.
• The Dietary Manager is responsible for seeing that the established meal hour
deadlines are met. This will assist Nursing in meeting daily patient care needs.
• PATIENT MEAL HOURS:
Breakfast
Lunch
Dinner
Bedtime Snack
• EMPLOYEE MEAL HOURS:
Breakfast
Lunch
Dinner

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Tray Sequence
POLICY
To determine an efficient sequence of trays on the tray cart, list order on Master
Serving List.
PROCEDURE
• The Director of Nursing, or whomever she/he delegates, shall meet with the
Dietary Manager to draw up the tray card lists designating the tray sequence
for eat unit. This provides an efficient sequence of trays for delivery that help
to assure each patient receives his/her tray while the food is at the correct
temperature.
• The usual routine for “Total Assist” trays is to prepare and deliver them last.
This allows nursing attendants to feed individual patients after all other trays
have been delivered.
• Use a “Master Serving List” * list the sequence of trays to the rooms. This list
shall be checked against tray cards each meal.

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Pre-Setting Trays
POLICY
To have an efficient method to pre-set trays.
PROCEDURE
• Have items needed to place on trays.

1. Stack of trays
2. Tray of sorted tray cards.
3. Tray covers
4. Four cylinders or a four-compartment container for flatware (each tray

shall contain a knife, fork, spoon, and cereal or soupspoon, if appropriate).
5. Package of napkins
6. Four-compartment container for condiments
7. Space for self-help eating devices currently being used.
• Place all pertinent items on the tray, paying close attention to correct condiments.
• After all items are placed on the tray, slide the tray into the appropriate slot on
the tray cart.
• The pre-set tray shall be arranged neatly as shown below.

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Tray Line Setup

POLICY
In facilities using tray line, trays will be set up at the beginning of each meal service
for all patient and guest meals.
PROCEDURE
• When service beings, trays are assembled completely at the tray line with diet
card, condiments, silverware, napkins, and cups.
• According to the diet called, the main plate is served from the steam table and
covered.
• Bread, salads, desserts, and any special items are placed on the tray and
sent down the tray line.
• Coffee, tea, decaffeinated coffee, milk, butter, and glasses are placed on the
tray, according to the diet order, and the tray is checked for accuracy by
Checker position on tray line.
• If tray is going to the floor all items must be covered on the tray.
• Tray is then placed in enclosed units for transport or set in window opening to
be served.

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Diet Identification Card

POLICY
A diet identification tray card will be completed for each resident by authorized Dietary
personnel to ensure residents receive the proper diet as ordered by the physician.
PROCEDURE
• Upon receipt of the written physician-prescribed diet order, complete a diet

identification tray card with the resident’s full name and diet order. When a
resident has the same first or last name as another resident, a distinct method of
“name alert” shall be put on the tray card, i.e. name in red, use of red star. This
is to insure that the correct tray is given to the correct resident.
• Include other information as appropriate, such as floor/wing designation,

table/seat number, beverage and food preferences, food allergies, hearing, vision
and feeding problems. A permanent ink is recommended for writing on the diet
tray cards.
• If a combination of diets is ordered, the tray card must identify all restrictions.
• Diet identification tray card used in this facility are displayed on the following
page.
• Diet cards shall be examined after each meal for cleanliness. Tray cards are to
be neat, legible, and free of soil, stains and smears. Soiled diet tray cards shall
be wiped clean with a sanitizing solution. Laminated tray cards shall not be sent
through the dish machine. Soiled and illegible diet ray cards shall be rewritten as
necessary.
• If a computerized tray card system is used a fresh correct tray card is used each
meal.

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Coding On Diet Tray Cards
POLICY
Each patient shall have a diet tray card. The diet tray card must identify the diet with
color coding unless a computerized system is used. Some computerized programs
provide color coding, however.
PROCEDURE
• Diet tray cards will be color coded to indicate special diets. Specific diet orders
are to be written on the card. A coding system can be used for physical
handicap also.
Diet Dot Color Code (indicate color)

Regular
Regular Mechanical Soft
Regular Puree
Sodium Restricted, 2 gm.,NAS
Diabetics & Calorie Control
Low cholesterol/Low fat
Other special diets
Total Assist trays
Vision problem
Hearing problem
• Post coding system on each unit and in the dining rooms.

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Adaptive Equipment – Feeding Devices

POLICY
Adaptive feeding equipment is used by patients who need to improve their ability to feed
themselves in order to enable patients with physically disabling conditions to improve
their eating functions.
PROCEDURE
• Upon request, verbal or written, from Dietary or Nursing, a therapist, when

possible, will assess any potential problems.
• If the assessment indicates a feeding problem can be improved with therapy

intervention (treatment and/or adapted equipment), a referral will be obtained
from the attending physician.
• Adaptive equipment will be provided by the Department. Equipment

will be labeled with patient’s name.
• Adaptive equipment will be washed in dishwasher with other dishes and stored in
a special place for easy identification.
• The therapist, when possible, will determine usefulness of adaptive equipment

and notify Nursing/Dietary when it is to be discontinued.
Types of Equipment
Built-up silverware
Built-up dish with inner lip
Special cups
Special cups and glass holders
Plate guards
• If there is no Therapy Department on site, the assessment and referrals will be

the shared responsibility of the Nursing and Dietary departments.
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Nursing Department Responsibilities At Mealtime
POLICY
• The Nursing Department is responsible for distributing food trays to all

patients in the facility that is served in their rooms. Distribution of trays in the
dining room depends on facility policy.
• The Nursing Department is responsible for documenting patient intake and

appetite by percentages.
PROCEDURE
• It is the responsibility of the Nursing Department to decide the order the room
trays will be served.
• The Nursing Department is responsible for preparing patients for meals and
for assisting patients who are unable to feed themselves. Positioning is a
responsibility of Nursing.
• The Nursing Department is responsible for distributing food trays to patients

in patient rooms.
• Nursing cuts up the meat, butters the bread and assists where needed.
• Nursing pours the beverages where needed.
• The Nursing Department is responsible for picking up food trays from patient
rooms.

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Recording Percentage of Meals Consumed

POLICY
Nursing personnel are to observe and record the food consumption of each patient.
PROCEDURE
• Nursing personnel shall be aware of the nutritional needs of each patient and
shall daily record food intake.
• A weekly Dietary Intake Sheet shall be used to document % eaten each meal.
• The chart “Guidelines for Percentage of Meal Intake” on the following page may
be posted at each nurse’s station and in the dining room for reference by the
nursing attendants.
• Percentages on the weekly dietary intake sheet must be transferred daily to the
ADL sheets.
• 50-70% intake is minimally adequate. Report to Dietary after 7 days.
• 50% or below intake is poor and below necessary requirements. Report to

Dietary after 3 days. Refusal to eat, report immediately.
• Be sure to offer a substitute if < 70% is eaten. Offer the alternate and if that is
refused, offer a house supplement.

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Guidelines for Percentage of Meal Intake

BREAKFAST
LUNCH AND DINNER
90% to 100% - Excellent

80% to 90% - Good
70% to 80% - Fair
50% to 70% - Minimally adequate. Report to Dietary after 7 days.
50% or below – Poor – Below necessary requirements. Report to Dietary after 3 days.

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Calorie Count
POLICY
When a patient is eating less than 50% for more over a 7-day period, a daily calorie
count is recommended for a 3-day period.
PROCEDURE
• Nursing is to record all food and beverages the patient consumes on the “Calorie
Count”* record form.
• Include meals, snacks, juices, supplements (Ensure, etc.), sugar, butter, and
jelly.
• Describe the amount eaten in %
• The Dietary Manager and/or Dietary Technician will contact the Dietitian to obtain
help with calculation of calories and protein. A progress note will be done to
summarize intake.
• The physician will be notified of the results of the calorie count after a 3-day
period.
• Physician, Dietitian, and Nursing shall work together to help correct low caloric
intake.
• Calorie counts can be used to justify the need of a tube feeding or to show after a
tube feeding is discontinued that intake is adequate.
• A “Calorie Count”* form is in Master Forms Manual.
• This patient shall be reviewed in the NAR meeting.

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Special Meal and Holiday Diet Order

POLICY
If state regulations allow house orders, diet orders for holidays; and special occasions
may be relaxed in order to allow all patients to receive an unrestricted diet on special
occasions.
PROCEDURE
• On holidays and special occasions, all patients will receive a regular diet with
exception of renal diets and NPOs.
• Pureed diets will continue to be served on these occasions and ground meat will
be served as the diet order designates.
• Fluid restrictions will continue to be maintained.

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Unscheduled Meals
POLICY
Nursing will notify Dietary when a meal is necessary for a patient needing to eat at other
than the scheduled mealtime.
PROCEDURE
• Any unscheduled meals and food requests will be handled by the Dietary
Manager or designee.
• A 1-hour notice shall be given Dietary by nursing if possible.

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Guest Meals
POLICY
Patients have the option of inviting one guest per day for a free meal in order to
encourage visits and participation with patients, create a family home-like setting, and
promote good public relations.
PROCEDURE
• Meal for guest will be provided upon request during regular meal service hours.
Meal times are: Lunch 12:00 P.M., Dinner 5:00 P.M.

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Special Functions
POLICY
Special refreshments/ingredients are available from the Dietary Department upon

written, advance request.
PROCEDURE:
• Requesting department will fill out “Special Events Request Form” * seven days
in advance. It is recommended that the person requisitioning the items discuss
the request with the Dietary Manager.
• The request form is sent to the Dietary Manager so all items can be ordered.
• The Dietary Manager will fill out “Special Function Record”* and schedule
additional personnel as needed.
• Items will be delivered by the Dietary Department or picked up by the requesting

department as indicated on the request form.
• Requesting department will return all supplies and equipment to the Dietary
Department after the special function.
• The Dietary Manager will cost-out food items requested in accordance with the
Dietary Policy on Cost Control.

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Employee Meals
POLICY
Meals will be sold to employees at a facility-established cost. Cash, Check, and Credit
Card Transactions are accepted.
PROCEDURE
• Cash, Check, and Credit Card Transactions Only.

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Cleaning Schedules
POLICY
The Dietary staff shall maintain the sanitation of the Dietary Department through
compliance with written, comprehensive cleaning schedules developed for the facility by
the Dietary Manager.
PROCEDURE
• The Dietary Manager/ Dietary Technician shall record all cleaning and sanitation
tasks for the Dietary Department.
• A cleaning schedule shall be posted with tasks designated to specific positions in

the department.
• All tasks shall be addressed as to frequency of cleaning.
• The procedures to be used are listed in this Policies and Procedures Manual.
• General Daily and Weekly Cleaning schedules may be used or “Cleaning

Schedules”* by position may be used.
• On the “Position” cleaning schedules the Dietary Manager fills in the Position, the
item to be cleaned, frequency i.e. daily, day of week, or week 1, 2, 3, 4.
• Under the days of the week or the weeks the Dietary Manager or designee can
check off assignments completed or the employee can initial.

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Operation and Sanitation

POLICY
Operating instructions are made available and cleaning procedures are developed for
all Dietary Department equipment.
PROCEDURE
• The Dietary Manager assembles and organizes manufacturers’ directions for

operating and cleaning all dietary equipment.
• General operating instructions and cleaning procedures for commonly used

equipment appear on the following pages.

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Sanitizer Use Concentrations for Food Service
And Food Production Facilities
• The U.S. Public Health Service Food Code states the following guidelines for
sanitizing solutions:
1. A chlorine solution shall have a minimum temperature based on the
concentration and pH of the solution as listed in the following chart:
Minimum Minimum Temperature

Concentration
Mg/L pH 10 or less ºF pH 8 or less ºF
25 120ºF 120ºF
50 100ºF 75ºF
100 55ºF 55ºF
2. An iodine solution shall have a:

• Minimum temperature of 75ºF
• pH of 5.0 or less or a pH no higher than the level for which the
manufacturer specifies the solution is effective, and
• Concentration between 12.5 mg/L and 25 mg/L;
3. A quaternary ammonium compound solution shall:

• Have a minimum temperature of 75ºF,
• Be used only in water with 500 mg/L hardness or less or in water
having a hardness no greater than specified by the manufacturer’s
label;
4. Use chemical sanitizers in accordance with the manufacturers use

directions included in the labeling.
• Serve Safe materials recommended contact times for each for the following
sanitizers:
1. Chlorine: 7 seconds at 50 ppm at temperatures between 75ºF and 115ºF
2. Iodine: 30 seconds at 12.5-25.0 ppm at temperatures between 75ºF and

120ºF
3. Quats: 30 seconds at 200 ppm at temperatures above 75ºF
• All surfaces and equipment shall be washed with a sanitizing solution.

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Sanitizer Use Concentrations for Food Service

And Food Production Facilities (continued)
• Sanitation buckets must be established with appropriate sanitizing solution, i.e.,
generally for bleach, 50-100 ppm or Quaternary solution, 200 ppm; however
follow manufacturer’s recommended directions.
• Sanitizing cloths shall be placed in the sanitizing buckets to be used in sanitizing

all work surfaces and equipment.
• Dietary shall change these buckets at least three (3) times a day and test with
the appropriate litmus strips each time the solution is changed to assure accurate
levels of sanitizer.

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Blender
OPERATION OF EQUIPMENT
• Plug in machine
• Place ingredients in blender container.
• Place container on base. Adjust to a secure position.
• Place lid on container. Fasten lid with locks.
• Depress “on” button, beginning with low speed and advancing as needed to a
higher speed. Turn off machine when adding ingredients or inserting spatulas,
etc.
• Depress “off” button when job completed.
• Wash container after each use.
SANITATION OF EQUIPMENT - Frequency: After each meal
• Turn machine off.
• Fill container with detergent and clean water to one-third capacity.
• Blend for five seconds.
• Sanitize cover and container at the pot and pan sink.
• Rinse with clean water and air dry cover and container.
• Wash base with sanitizing solution and clean cloth.
• Move machine base and sanitize table with sanitizing solution and clean cloth.
** NOTE: Do not immerse base in water.

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Can Opener
• Place can on metal base.
• Lift shaft and slide can into position.
• Depress opener to rim of can.
• Push handle clockwise to open can.
• Remove entire lid.
• Lift up on handle and stand.
• Remove can from opener.
• Dispose of lid by placing it inside of empty can. Dispose of lid and can in an
upright position.
SANITATION OF EQUIPMENT - Frequency: After each meal; more frequently if

needed
• Remove shank to pot and pan sink, or to dish machine area.
• Scrub shank, paying special attention to blade and moving parts. Use sanitizing
solution and brush, or run through dish machine.
• Rinse with clean water or rinse cycle of dish machine.
• Air-dry on clean surface.
• Inspect blade and replace if notched.

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Can Opener (continued)

• Scrub base plate (attached to table).
• Use hot sanitizing solution and brush.
• Rinse with clean water and clean cloth.
• Replace shank.

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Carts
POLICY
TRAY CARTS, DISH CARTS, UTILITY CARTS
SANITATION OF EQUIPMENT
Frequency: After each meal
• Wash inside (side, top, bottom, tray guides, and inside of door). Use sanitizing
solution and clean cloth.
• Rinse with clean, warm water and clean cloth.
• Allow to air dry.
Frequency: Weekly
• Follow Steps 1-3 above, or take to cart wash area.
• Wash wheels and casters with brush and sanitizing solution.
• Rinse with clean water. Remove excess water with squeegee.

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Coffee Urn
• Be sure coffee urn is empty
• Water temperature shall be at bowing temperature (180º to 190º).
• Place wire basket in top of urn.
• Insert one (1) paper filter in basket. Be sure filter is smooth and upright.
• Fill with coffee (amount designated by manufacturer), and spread to form and
even bed.
• Swing water arm over center of basket.
• Press “start” or “brew” button.
• Place cover on top of urn.
• Urn will shut off automatically when the cycle is finished.
• Remove wire basket and dispose of coffee grounds in appropriate container
• Coffee is ready to serve
• Repeat procedure as needed.
SANITATION OF EQUIPMENT - Frequency: After each batch of coffee
• Rinse wire basket with hot water.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
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Coffee Urn (continued)

Frequency: End of p.m. shift
• Fill both sides ½ full with hot water fro m urn. Add one packet of cleaner per
side.
• Scrub each side thoroughly with brush.
• Clean glass gauges using small brush.
• Drain urn; rinse with clean water.
• Clean spigots; use tapered brush and damp cloth.
• Never leave urn dry; leave at least one (1) gallon of water in each urn.

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Dish Machine
• Check to see if machine is ready for use and chemical containers are full. Verify
that wash arms (top and bottom), scrap trays, rinse jets and curtains are in place.
• Close drain valve, turn on water supply fill valve, and fill machine (approximately
5 minutes). After machine is filled, turn off water supply and turn on heating
element. Preheat 15 to 20 minutes.
• Turn on machine. Electronic soap dispenser will automatically function if full.
• Check water temperature gauges. (Wash must be 140º to 160º.) To reach

proper temperatures upon startup, several empty racks shall be sent through the
machine. If machine fails to reach proper temperature, turn off machine and
report to supervisor.
• Add detergent when indicated (beeper sounds).
• Turn off heating element.
• Drain tank by opening drain valve.
• After each meal, clean machine according to cleaning procedure.
• Carefully remove top wash arms, scrap trays, and all curtains.
• Thoroughly clean and replace dish machine.
• Remove debris and rinse interior of machine.
• Wipe exertion of machine and soap dispenser. Dry and polish with cloth.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Dish Machine (continued)

• Close drain valve. Refill with 2 to 4 inches of water for overnight standing.
• Turn all equipment off.
Frequency: Weekly
Clean dish machine exterior with de-liming solution.

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Dish Machine Setup

• Check to see if machine is clean (wash arms, top and bottom; scrap trays and
rinse jets). Place all items in their proper place, including curtains.
• Close drain valve, turn on fill valve, fill machine (approximately 5 minutes). After
machine is filled, turn off water supply and turn on heating element.
• Turn on machine. Electronic soap dispenser will automatically function if full.
• Add detergent; fill drying agent if necessary.
• Check water temperature according to manufacturer’s manual.
• Add detergent when indicated (beeper sounds).

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Recording of Dish Machine Temperatures

• Before each use, prepare dish machine for use according to instructions. Allow
dish machine to run 10 minutes in order to bring water temperature up to proper
level by sending several empty racks through the machine.
• Read temperature gauges on top of machine while racks are in machine.
• Record temperatures daily on “Dish Machine Temperature Log.”*
Low Temperature High Temperature

Dish Machines Dish Machines
Wash temperature 120º - 140ºF 150º - 160ºF
Rinse temperature 120º - 150ºF > 180ºF
Or follow manufacturer’s directions, if different.
• Any inaccurate temperatures must be brought to the attention of the Dietary

Manager immediately.
• Periodically the Dietary Manager will check the accuracy of the gauges by
sending a thermometer through the dish machine. The internal thermometer will
experience a 15º temperature loss and will read 160º 165º. The 180º
temperature is measured only at the manifold and read on the temperature
gauge. Regular monitoring and maintenance is essential to maintain proper
temperature. This is on high temperature dish machines.
• The concentration of the sanitary solution during the rinse cycle is 50 ppm with
Chlorine sanitizer, 200 ppm with quaternary ammonium. This is used on low
temperature dish machines.
• A pH test kit is used daily and may be obtained from the chemical supplier for the
low temperature dish machines.
• “Dish machine Temperature Log” (See Master Forms Manual):

1. To ensure that the wash and rinse temperatures are properly monitored
and controlled, a log must be completed by those who are directly
involved in the dishwashing process. Entries must be made for each day.
2. Post the log in the immediate vicinity of the dishwashing area.
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Recording of Dish Machine Temperatures (continued)

3. Wash and rinse temperatures must be observed and logged during the
dishwashing period.
4. Actual temperatures must be entered in the log by the dish machine

operator one time daily.
5. Report temperatures that are below the required levels (see above) to the
Dietary Manager and immediately convert to paper service until the
temperature is corrected.
6. When the chemical sanitizing dispenser is broken or not working correctly

on a cold temp machine, appropriate amount of sanitizer, per
manufacturer directions, can be manually added to the dish machine at
each rinse cycle. Check for correct amount of sanitizer at each rinse cycle
with appropriate litmus paper.
7. Record ppm on low temperature machines.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Dishwashing Procedure
• Scrape food garbage from dishes into garbage disposal. This can be done with a
rubber scraper or pre-rinse sprayer. DO NOT hit china against a hard surface to
remove food. This will damage the china.
• Sort and stack dirty dishes into piles of the same kind and size.
• Place empty cups and glasses upside down in compartment-type racks to

prevent over-crowding. Metal cereal bowls and small stainless steel teapots and
plastic bowls may also be racked in a cup rack.
• Place silverware in soaking tub.
• Remove paper and plastic waste and place in garbage can.
• Carefully place dishes in soaking sink as needed.
• Rack similar dishes in peg-type racks. Soiled dishes must be loaded into the
racks so that all surfaces of each piece will be subjected to the wash and rinse
treatments. Overcrowding of pieces must be avoided if the dishwashing process
is to be effective. Dinner plates, bread and butter plates, saucers, fruit dishes,
cereal bowls, lids to metal bowls and plate covers shall be racked in a peg-type
rack. Improperly racked dishes are not cleaned effectively and increase dish
breakage.
• Place rack of dishes over disposal. Spray dishes with pre-rinse sprayer. Pre-
rinsing of all dishes and utensils is an important part of the dishwashing operation
to prevent food soil in the wash water. Operate the garbage disposal as needed.
• Remove silverware from soaking tub. Spread silverware on flat bottom rack after
each cart. Rinse silverware. Metal bowls, plastic pitchers and bowls are also
racked in flat bottom racks.
• Send all silverware through machine twice – first on a flat rack open, then on a
rack that will hold the special container for silverware. Place into container handle
side up.

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Dishwashing Procedure (continued)

• Load racks into the machine. Racks must go into the machine with the surface of
the dish facing the spray. The only exception is trays which go into the machine
sideways. The operation of the dish machine is automatic; each rack moves into
the clean dish table. This process takes about 45 seconds.
• Either two people are in the dish room, one on dirty side, one on clean side or if
one person does both they must wash and sanitize their hands between dirty and
clean areas. The sanitizer may be a sanitizing agent dispensed from the wall
area or a bucket of bleach water, which is marked “bleach water” and is 50 ppm.
• Air dry dishes by racking or putting on single trays lined with mesh (i.e., bar
matting).

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Dish and Utensil Procedure
• Spoons, knives, and forks shall be touched only by their handles.
• Cups, glasses, bowls, and plates shall be handled without contact with inside
surfaces or surfaces that contact the user’s mouth.
• Dishes and utensils shall be carried in a way as to not come in contact with
aprons or uniforms.
• Dishes and utensils shall be routinely checked for stains or spots.
• Dishes and utensils shall be handled with clean hands.
• Dishes and utensils shall be air dried before storage. Do not towel dry.
• Chipped or cracked dishes shall be discarded.
• “Single service” articles shall be discarded after one-time use.
• Any dish or utensil with debris will not be used. Send back to the dish room to be
properly washed and sanitized.

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Cleanup
• Turn off heat switch.
** NOTE: FAILURE TO TURN HEAT OFF WILL CAUSE PERMANENT DAMAGE

TO DISH MACHINE.
Before draining the machine, remove caps from the lower rinse arms. Close the
door and turn on the machine for approximately 30 seconds. Turn off machine,
open door and replace caps. Proceed to drain the machine.
• Carefully remove top wash arms, scrap trays, and all curtains. Thoroughly spray,
clean, and replace in proper place.
• Clean and sanitize counter areas, walls and all dish room work areas (sink
exterior, legs).
• Refill machine tank ¼ full with water for holding between uses, if heater is left on.
• Make certain all equipment is turned off, water drained, dish room is clean and
sanitized before leaving.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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De-liming the Dish Machine
Frequency: Monthly (or more frequently is needed)
• Inside of machine
1. Fill dish machine
2. Add de-liming solution as manufacturer recommends. Wear rubber gloves

and safety glasses.
3. Run dish machine for 10 to 15 minutes
4. Turn off machine and drain completely.
5. Fill machine with clear water and run for 5 to 10 minutes
• Outside of dish machine
1. Wear rubber gloves and safety glasses.
2. Spray all areas of dish machine’s exterior and all pipe areas with deliming
solution. Let stand for 10 minutes.
3. Scrub stainless steel. Scrub pipes with green scouring pad.
4. Rinse exterior and pipe areas thoroughly with clear water.
5. Dry surface with clean cloth and apply stainless steel polish.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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De-staining Procedures on
Cups, Teapots, Pitchers, and Lids
Frequency: Weekly
• Turn off soap dispenser.
• Fill tank (see Operation Procedure for Dish machine).
• Add liquid bleach (proportionate, according to tank size).
• Place in dish rack clean cups, teapots, pitchers, and lids using proper racking
technique.
• Run through wash and rinse cycles.
• Repeat Step #5 if necessary.
• Drain tank and refill with fresh water. Turn on soap dispenser.
• Send racks through wash and rinse cycles.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Discarding Chipped, Cracked Dishes and

Single Service Articles
POLICY
In order to prevent cross contamination, only dishes and storage containers that may be
sanitized are to be used.
PROCEDURE
• Discard chipped or cracked dishes.
• “Single service” containers such as cottage cheese containers must be discarded

after being emptied and not reused as storage containers.
• Storage containers must have been purchased specifically for that purpose, have
a tight fitting lid, and be able to be sanitized in the dish machine.

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Food Processor
See manufacturer’s instructions for operation of food processor.
Frequency: After each use (attachments only)
• Wash attachments in hot water in pot and pan sink. Use hot water and sanitizing
solution. Allow attachments to air dry.
• Wipe base clean using damp cloth.
• Store dry attachments in appropriate enclosed cabinet.
** NOTE: Do not immerse motor base in water.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Freezer
See manufacturer’s instructions for operation of freezer.
SANITATION AND DEFROSTING FREEZERS
Frequency: Monthly
• Unplug freezer or shut off circuit breaker.
• Removal all foods from freezer and place poultry in another freezer to keep from
thawing.
• Let freezer stand several hours until ice has melted.
• Drain and wipe up water with sponge or clean cloth.
• Wash inside racks and fans carefully and thoroughly. Use baking soda and
water (mix according to directions).
• Clean outside with sanitizing solution.
• When finished, plug in or turn on circuit breaker, set temperature dials, and allow
freezer to return to proper temperature.
• When freezer has returned to proper temperature (0º to -10º), replace food.
** NOTE: Do not use sharp utensils when removing ice buildup.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Garbage Disposal
• Turn on cold water. Never start disposal unless water is running and guard is in
place.
• Turn on disposal switch.
• Feed garbage into disposal using long-handled rubber spatula to push food into
disposal. Never push food down with hands.
• Turn off disposal and run water one minute.
FOOD ITEMS NOT TO BE PUT INTO DISPOSAL:

§ Bones
§ Banana peels
§ Onion skins
§ Celery
§ Rhubarb
§ Paper products
§ Grease or oil
§ Coffee grounds
§ Carrot peels
** NOTE: If disposal is malfunctioning, notify the Dietary Manager.
SANITIZING EQUIPMENT
Frequency: After each use
Allow disposal to run one minute using cold water. This is to ensure proper
flushing of the disposal and waste lines.
Frequency: Daily
Clean interior using detergent solution, stiff brush, and 180º water. Never
use chemical solvents or drain-cleaning compounds in disposal.
**NOTE: Never reach inside disposal while it is in operation.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Garbage and Trashcans
• All food waste must be placed in covered garbage and trashcans.
• Plastic can liners shall be used in clean garbage and trashcans to eliminate
spillage and reduce can-washing time.
• Garbage and trash are to be removed from the Dietary Department at least daily
and more often if needed.
• Each time the garbage and trash are emptied, the containers are to be
thoroughly inspected inside and out and cleaned, if needed, with a hot detergent
solution and then rinsed.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Grill - Electric
• Turn thermostat knobs to 350º
• Preheat grill 10 to 15 minutes.
• Adjust thermostat knobs to desired temperature.
• Prior to grilling, spread vegetable shortening on entire surface.
• Turn thermostat knobs to “off” position after each use.

• Scrape grill to loosen burned-on particles. Use pancake turner.
• Clean grill surface with grill stone and diluted degreaser.
• Rinse thoroughly with water
• Wash with mild soap and water
• Rinse thoroughly with water
• Wash back and side guards with soap and water
• Remove, empty, and wash grease tray.
• Cover grill surface with thin coat of vegetable shortening. *

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Grill – Electric (continued)

• Wipe with paper towels to remove excess shortening.
NOTE: Wear rubber gloves while cleaning grill.
*Lard or another type of shortening will cause food to stick on grill surface upon next
use. Food will also stick if degreaser is not rinsed off thoroughly.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Grill - Gas
• Turn on gas jets slowly.
• Light all pilots with assistance; burners shall light. If pilots do not light:
• Adjust flame or temperature with knobs.
• Pre-heat grill 10 to 15 minutes.
• Prior to grilling, spread all-purpose oil on entire surface.
• Shut off entire grill and pilots after use.

• Scrape grill to loosen burned-on particles.
• Use heavy pancake turner.
• Clean grill surface with a grill stone and degreaser.
• Rinse thoroughly with water.
• Wipe grill clean. Rinse thoroughly with water.
• Wash back and side guards with soap and water.
• Remove empty, and wash grease tray.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Grill – Gas (continued)

• Cover grill surface with thin coat of cooking oil.
• Rinse thoroughly with clean hot water.
• Wipe dry with clean cloth.
NOTE: Wear rubber gloves while cleaning grill.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Hoods and Filters
• Wash hood with detergent solution using a brush, sponge, or cloth.
• Remove the filters and wash the retainer brackets. Wash the hood grease trench
with a detergent solution using a brush, sponge, or cloth.
• Rinse the hood with hot water. Absorb excess water with sponge or cloth.
• Polish hood with stainless steel polish using a paper towel or cloth.
• Hoods must be kept free of grease and dust at all times.
Because of a potentially high fire hazard, it is important that hood filters be part of
a strictly enforced cleaning schedule and be free of grease and dust at all times.
• Remove filters from hood.
• Soak filters in a solution of 1 cup of tri-sodium phosphate to 15 gallons water or

other approved solution.
• Remove filters from solution and rinse with hot water.
• Wash by passing each filter through the dish machine. Lay one filter flat on the
dish rack.
• Allow filters to air-dry before returning to hood.
• Hood light fixtures must be cleaned every two weeks. Hood lights must have
protective guards over them and be in good operating condition.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Ice Machine
See manufacturer’s instructions for operation of ice machine.
Frequency: Daily
• Wash exertion of machine.
Use sanitizing solution and clean cloth.
• Remove drainage grate and tray and send through dish machine.
• Replace drainage grate and tray.
Frequency: Monthly
• Remove ice
• Wash inside machine
Use sanitizing solution and clean cloth.
• Allow to air dry
• Refill with ice

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Lowerator
See manufacturer’s operating instructions.
Frequency: Daily
• Wipe down stainless steel on entire until
• Use sanitizing solution and water or stainless steel polish.
Frequency: Weekly
• Remove tubes and clean interior.
Use soap and water or stainless steel polish.
• Clean bumpers and wheels.
Use nylon brush, sanitizing solution, and water.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Meat Slicer
• Be sure plug is connected.
• Place food on tray.
• Position guard to hold food in place.
• Set gauge for desired thickness.
• Turn on machine.
• Slice food, reset gauge to “off” position.
• Turn off machine.
NOTE: Never slice with guard in place.

Never leave machine running while unattended.
Wear a steel mitt.
• Be sure machine is unplugged
• Remove all parts
• Take part to pot and pan sink
• Scrub, rinse, and sanitize parts in pot and pan sink
• Allow parts to air-dry on clean surface.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Meat Slicer (continued)

• Wash blade and machine shell. Use detergent and triple-thick cloths.
CAUTION: PROCEED WITH CARE WHILE BLADE IS EXPOSED.
• Rinse, using clean hot water and triple-thick cloths.
• Sanitize blade and machine shell.
Use clean water, sanitizing solution, and triple-thick cloths.
• Re-assemble movable parts
• Leave blade control at “off” position.
• Cover slicer after it has air-dried and is not in use.
NOTE: Proceed with care while blade is exposed. Be sure to replace guard.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
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Microwave Oven
See manufacturer’s instructions for operation of microwave oven.
SANITITATION OF EQUIPMENT
Frequency: Daily
Wipe down inside with special attention to inside of oven door to provide adequate seal
to prevent microwave leakage.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
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Oven – Convection, Gas

• Select and place oven racks in appropriate positions.
• Turn on oven, check thermostat setting, check position of damper, and turn fan
switch and dial to “on” position.
• Pre-heat oven according to manufacturer’s recommendations.
• Load oven according to manufacturer’s recommendations.
• Set timer.
• Reverse procedure to turn off oven after food is finished cooking.
Frequency: Immediate
Remove spills, spillovers, and burned food deposits.
Frequency: Daily
• Wipe cool over exterior and interior with wet cloth.
• Remove and scrape drip pans, send through dishwasher cycle, and allow to air
dry.
Frequency: Weekly
• Wipe oven exterior. Use damp cloth.
• Remove oven racks; take to designated area for spraying. Use oven cleaner and
allow racks to stand according to manufacturer’s directions.
• Spray sides, interiors, and over doors. Use oven cleaner according to
manufacturer’s directions.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Oven – Convection, Gas (continued)

• Wash and rinse racks. Use detergent and hot water. Allow to air dry.
• Wash oven interior. Use wet cloth, sanitizing solution, and hot water.
• Rinse and allow to air dry.
• Replace oven racks in appropriate positions.
NOTE: For convection ovens, be careful not to spray the fan area with oven cleaner.
While using oven cleaner, rubber gloves and safety glasses shall be worn.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Oven – Conventional, Gas

• Turn on oven. Oven shall light automatically. If not, turn oven knobs to “off”
position and see procedure on Pilot Lights – Gas Ovens.
• Select desired temperature setting.
• Pre-heat oven according to manufacturer’s recommendations.
• Load oven according to manufacturer’s recommendations.
• Set timer.
• Reverse procedure to turn off oven after food is finished cooking.
Frequency: Immediate
• Remove spills, spillovers, and burned food deposits.
Frequency: Daily
• Wipe cool over exterior and interior with wet cloth.
• Remove and scrape drip pans; send through dishwasher cycle and allow to air
dry.
Frequency: Weekly
• Wipe oven exterior. Use damp cloth.
• Remove oven cleaner according to manufacturer’s directions.
• Spray sides, interior and over doors.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Oven – Conventional, Gas (continued)

• Use oven cleaner according to manufacturer’s directions.
• Wash and rinse racks. Use sanitizing solution and hot water. Allow to airy dry.
• Wash oven interior. Use wet cloth, sanitizing solution, and hot water.
• Rinse and allow to air dry.
• Replace oven racks in appropriate positions.
NOTE: While using oven cleaner, rubber gloves and safety glasses shall be worn.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Portion Scales
• Wipe off any food particles on platform and frame with clean damp cloth.
• Sanitize with chemical sanitizer in clean water.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Pots and Pans – Hot Water

• Clean 3-compartment sink prior to use.
• Fill all tanks 2/3 full.

1. Fill first tank with water (110º to 120º) and an effective concentration of
detergent.
2. Fill second tank with clean rinse water (110º to 120º).
3. Fill third tank with water (180º) for sanitizing. Check water temperature
with thermometer provided.
• Turn on tank-heater.
• Scrape food particles from pots and pans into garbage disposal. Do not scrape
food into washing sink.
• Scrub pot and pans in first tank using scouring pad or appropriate cleaning tool.
• Rinse pots and pans free of detergent in second tank.
• Sanitize pots and pans in third tank by immersing in 180º water for at least two
minutes.
• Remove items with long-handled tongs or wear rubber gloves.
CAUTION: Water, pots, pans, and utensils are very hot!
• Invert items on drying rack. Place small items in a flat bottom dish rack to dry.
NOTE: Allow all items to air dry. Towels shall never be used for drying.
• When items are dry, store in proper storage area.
NOTE: All three tanks must be maintained in a clean condition by changing the water at
frequent intervals.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Pots and Pans – Sanitizing Solution

• Clean 3-compartment sink prior to use.
• Fill all tanks 2/3 full.
1. Fill first tank with water and an effective concentration of detergent.
2. Fill second tank with clean rinse water.
3. Fill third tank with tepid water for sanitizing to fill line.*
• Add sanitizing agent to third tank according to manufacturer’s directions. Post

amount.*
1. To test concentration of sanitize, a test kit is required.
2. 50 ppm is required concentration of sanitizer to water using chlorine-based

sanitizer or 200 ppm using ammonia-based sanitizer.
• Scrape food particles from pots and pans into garbage disposal. Do not scrape
food into washing sink.
• Scrub pots and pans in first tank using scouring pad or appropriate cleaning tool.
• Rinse pots and pans free of detergent in second tank.
• Sanitize pots and pans in third tank by immersing in water with sanitizing agent
@ two minutes. *
• Remove items.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Pots and Pans – Sanitizing Solution (continued)

• Invert items on counter.
NOTE: Allow all items to air dry. Towels shall never be used for drying.
• When items are dry, store in proper storage area.
NOTE: Test kits are available through dishwashing chemical sales representatives.
• If a third sink isn’t available or isn’t used pots and pans are run through the dish
machine to sanitize as an alternate method.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Sanitation of Equipment
Frequency: Daily
• Wipe up spills on shelves, sides, and floor of refrigerator.
Use clean sanitizing solution and clean cloth.
• Wash doors, inside and out doorframe and front, and gaskets. Use sanitizing
solution and clean cloth.
• Dry outside with clean cloth.
• Polish outside (if stainless steel).
Use stainless steel polish and soft dry cloth.
Frequency: Weekly
• Transfer all items to another refrigerator, use cart for transfer.
• Remove shelves and take to pot and pan sink.
• Scrub shelves, top and bottom; use soft brush.
• Rinse and sanitize.
• Air dry.
• Scrub interior and exterior, especially shelf guides, gaskets, doorframe, and
hinge areas. Use hot detergent solution and brush or clean cloth.
• Rinse and air-dry.
• Replace shelves.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Sanitation of Equipment (continued)

• Dry outside of refrigerator using clean dry cloth.
• Polish stainless steel, using stainless steel polish and soft dry cloth.
• Replace food items as soon as temperature reaches 40º

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Refrigerator – Walk-In
Shelving
Frequency: Weekly
• Remove all food from shelves.
• Scrub shelves with sanitizing solution and clean cloth. DO NOT USE
ABRASIVES.
• Wash walls with sanitizing solution and clean cloth.
• Return food to shelves.
Floor
Frequency: Weekly
• Remove all carts from refrigerator.
• Thoroughly sweep all floor areas and corners.
• Mop floor and drain area. Scrub any hard-to-clean areas using a sanitizing
solution and scouring pad.
• Be sure to clean fans.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Steam Table
• Fill stream wells to water level line.
• Turn control knob to “on” position.
• Select proper temperature setting by turning knob to appropriate setting. Cover

steam wells with appropriate covers to allow water to pre-heat.
• Place covered pans in wells as close to serving time as possible.
• Turn knob to “off” position when finished serving.
• Turn off steam table
• Remove food from steam wells.
• Wash shelf above steam table.
Use hot water, sanitizing solution, and clean cloth.
• Rinse thoroughly and dry with clean dry cloth.
• Wash shelf above steam table, the inside of the wells after they have cooled, and
all exterior surfaces. Use clean hot water, sanitizing solution, and clean cloth.
• Rinse thoroughly and dry with clean dry cloth.
• Polish stainless steel as needed.
Use stainless steel polish and soft dry cloth.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Stove Top
Wipe off burner grids using clean cloth and detergent.
Frequency: After p.m. shift
• Allow range to cool.
• Remove stovetop sections.
• Take to pot and pan sink and scrub or send through dish machine.
• Use hot water, detergent, and brush or scouring pad.
• Rinse with clean hot water.
• Air dry.
• Clean back and side splashguard using hot water, detergent, and clean cloth.
• Remove drip pans
• Take to pot and pan sink and scrub.
• Use hot water detergent, and clean cloth.
• Rinse and sanitize.
• Replace stovetop and drip pans.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Water Pitchers
• Water pitchers are sanitized in the Dietary Department at least daily. They must
air dry.
• After water pitchers are sanitized, they are to be filled by sanitary methods with
ice water by Nursing.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Cabinets and Drawers

SANITATION
Frequency: Weekly
• Use a mild detergent and water. Removable drawers shall be removed and
washed. Rinse shelves and drawers with a clean sponge and dry.
• Do not use contact paper or other materials to line drawers.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Floors
SANITATION
• Dust mop or sweep the area.
• Fill one mop bucket 2/3 full of clean warm water.
• Add cleaning agent to water according to directions on the label of the container.
• Fill a second mop bucket 2/3 full of clean warm water.
• Place “wet floor” signs around the area to be mopped.
• Dip the mop into the bucket with the cleaning agent.
• Wring out the excess solution from the mop, but do not wring fully dry.
• Start the mopping stroke approximately 2 feet straight out from the baseboard.
• Make a long mopping stroke close to the baseboard.
• Continue mopping in a figure-eight pattern.
• After turning the mop over two or three times, dip into the bucket with the
cleaning agent.
• Mop an area 9 by 12 feet at a time.
• Dip the second mop in the clean water.
• Wring the mop out and rinse the floor previously mopped with the cleaning
solution.
• Allow the floor to dry. Then mop and rinse the other half or other areas that have
not been mopped.
• Change the cleaning solution water and rinse water as the water color turns
brown.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Floors (continued)
• Empty the mop buckets and rinse the buckets with clean warm water.
• Rinse the mops in clean warm water and wring out as much water as possible.
• Hang the mops on the mop hooks over the floor drain to allow mop heads to air
dry.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Walls and Ceilings

SANITATION
• Walls and ceilings must be free of chipped and/or peeling paint.
• Walls and ceilings must be washed thoroughly at least twice a year. Heavily
soiled surfaces must be cleaned more frequently and as required. It is important
to repair peeling paint areas as soon as they appear.
• The type of surface will determine the type of detergent and cleaning method.
1. Painted walls and ceilings shall be washed with a mild detergent solution,
rinsed using a clean cloth, and dried to eliminate streaking.
2. Ceramic tile, stainless steel, and other surfaces must be cleaned

according to product manufacturer’s instructions.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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O: 2002
Food from Outside Sources

POLICY
Food brought in by visitors for patients is discouraged due to problems of infection

control.
PROCEDURE
• Food brought in for patients will not be served by the Dietary Department.
• If food is brought in, it must be approved by the Charge Nurse before it is given
to the patient.
• Visitors are discouraged from bringing in potentially hazardous foods, i.e., meats,
fish, eggs, custards, etc. If such foods are brought to the patient, they shall be
consumed immediately, but not stored in the facility and not shared with other
patients with the facility.
• Non-perishable foods left in patient’s room shall be tightly sealed to prevent

infestation of vermin and rodents.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Isolation Trays
POLICY
The Dietary Department is responsible for instituting dietary infection control techniques
when a patient is placed in infection control isolation.
PROCEDURE
• The Charge Nurse shall notify the Dietary Department in writing of any infection
control isolation condition.
• The Dietary Manager is to institute the following infection control isolation

techniques:
1. Dietary Department employees are to be informed of the infection-control

condition.
2. Dishes, flatware, trays, and diet tray cards used for an infection control
isolation patient may need to be disposable.
3. Do not use reusable diet cards. Use copies of the original card.
• Nursing personnel shall be responsible for disposing of disposable dishes and/or

food that has been in an infection control isolation room.
1. At the end of each meal, disposable dishes shall be placed in a double

plastic bag and secured with an appropriate tie to seal the bag.
2. The bag and contents shall be disposed of in the designated approved

area according to facility policy.
• Disposable dishes for infection control use shall be available at all times in the
Dietary Department.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Environmental Safety
POLICY
All work areas shall be provided with adequate lighting, ventilation, and humidity control.
PROCEDURE
• Dietary personnel will report safety problems immediately to the Dietary

Manager.
• The Dietary Manager is responsible for communicating any safety problems

immediately to the Administrator and maintenance.
• The Dietary Manager is a member of the Quality/Risk Committee.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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China and Glassware Safety
POLICY
Chipped, cracked, or unsanitizable surfaces on china and glassware will not be used.
PROCEDURE
• The dish room personnel will visually inspect all china and glassware. Any found
with chips, cracks, and non-sanitizable surfaces will be disposed of by wrapping
individually and then disposing immediately in the same manner as trash.
• Use a pan and broom to sweep pieces of broken glass. Use a dampened towel
for cleaning up slivers of glass.
• In order to reduce the amount of chipped, cracked, or unsanitizable surfaces on

china and glassware, the following procedures are to be used:
1. Use care in handling glasses and dishes.
2. Do not place china and glassware in the pot and pan sink.
3. Do not use glassware in forming or preparing food, such as for cutting
biscuits or liquids.
4. Do not force a towel inside a glass to dry it.
5. When china and glassware are carried from one location to another,
employees shall be alert and move cautiously. Maintain complete control
of the load at all times.
6. Stack like dishes together.
7. Use a rubber scraper or a spray to remove food from plates, not another
plate.
8. Do not use abrasive cleaning pads since they can leave a pattern of
scratches that become embedded with food, making them unsanitary.
9. Eliminate excessive pre-soaking since dishes may be damaged by piece-
against-piece impact.
10. Use carts or lowerators to transport dishes as much as possible.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Floor Safety
POLICY
Floors shall be maintained in a safe manner.
PROCEDURE
• Floors shall be kept clean and dry.
• When floors are cleaned, one area shall be mopped at a time.
Keep mops and cleaning equipment out of the line of traffic.
• Employees shall walk across floors, never run, and always look where they
are going.
• Clear traffic lanes shall be maintained. Objects shall be kept off the floor and
out of the aisles and doorways.
• Floors are to be rinsed well to prevent slipping.
• When operating electrical equipment, do not stand on a wet floor.
• Any spills occurring shall be cleaned immediately.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Knife Safety
POLICY
Knives shall be handled in a safe manner.
PROCEDURE
• Employees shall pay special attention to their work when using knives.
• Knives are to be utilized only for the operation for which they are intended.
• When knives are in use, they shall be pointed away from the employee’s body
and away from other employees.
• When employees are drying, cleaning, or wiping knives, the sharp edge shall be
pointed away from their bodies.
• All knives shall be placed in their proper location when not in use.
• Remove steel particles from knives after they are sharpened.
• Do not place knives in the sink or in locations where they are not visible.
• If a knife falls, do not reach for it but let the knife touch the floor.
• Never place knives in dishwater since someone may reach into soapy water.
Wash each knife separately.
• A cutting board shall be used at all times. Never cut on metal.
• Pick up knives by the handle only.
• Always use a sharp knife since it is safer than a dull one. The chances of
slipping are not as great and less pressure needs to be applied.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Equipment Safety
POLICY
Safety precautions shall be followed when electric equipment is utilized.
PROCEDURE
• Machines shall not be used by employees who are not trained in their use.
• Be certain that all safety devices are in place.
• Turn the switch to “off” and unplug the machine before cleaning or adjusting any
machine.
• Keep fingers, hands, spoons, knives, etc. away from moving parts. Do not
remove food until the machine has stopped.
• All electrical appliances shall be in the “off” position before being plugged into the
outlet.
• Particular care shall be taken when cleaning the slicing machine.
• Mixing machines shall not be started until the bowl is properly placed and the
“beater” is securely fastened.
• Always use a spatula to push food into the grinder, not hands.
• Equipment shall not be left “on” unattended.
• Employees will not be permitted to operate or clean a meat slicer and/or meat
grinder unless trained, and no minors shall operate that type of equipment.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Instructions for Implementing Menu To be Used

In the Event of a Disaster or Emergency
POLICY
To provide a planned menu that is simplified and nutritious to be used during an

emergency or disaster event.
PROCEDURE
• The 3-day menu, or 7-day menu, per state* regulations, to be used in the event
of a disaster or emergency has been planned to provide basic nutrients. It has
the following limitations:
1. Each meal provides one hot item in the expectation that (1) only an
electric burner running off emergency power is supplied, or (2) a gas camp
stove is available for cooking.
2. All patients shall be served the regular menu except:

• Patients with allergies to the regular food.
• Patients with severe dietary limitations, i.e., brittle diabetics.
• Patients who cannot chew or swallow regular food.
• Instructions for using the emergency menu:

1. Food items designated in the emergency menu must be available at all
times.
2. Food items not normally used shall be stored in a separate, marked area.
These items must be dated and rotated back into the regular stock
according to shelf life; approximately 6 months.
3. Disposable items, adequate for three meals a day for three days, must be
stocked at all times. Disposable items may be plastic, Styrofoam, or
paper.
4. Every three months the Dietary Manager, utilizing the supply checklist
(adjusted for number of beds in the facility), shall inventory the storeroom
to verify all food and supply items are present in the quantities specified.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Instructions for Implementing Menu to be used

In the Event of a Disaster or Emergency (continued)
• In the event of an emergency, the following suggestions are made:
1. Notify the Dietitian.
2. Immediately turn off all faucets if water supply is affected. Conserve water
from hot water heater and toilet tanks.
3. Inventory freezer and refrigerator for items that can be used. Inspect for
wholesomeness. Use these items first. Do not use frozen foods that appear
to have thawed or refrigerated items greater than 41º.
4. Keep freezer(s) and refrigerator(s) doors closed to prevent unnecessary

temperature increases.
5. Save liquids from canned vegetables and fruits, and water from cooking
pasta products. Recycle liquid into juices, casseroles and soups.
6. Do not squander drinking water and cooking fuel on coffee or tea if the
water and fuel supplies are limited.
7. To cook large quantities of food on single camp stove or burner, stagger

the meal hours.
8. Hand grind, cube, or mince raw whole meats prior to cooking to reduce
cooking time.
9. In the event power is available for the range and ovens, hot breads, and
hot vegetables can be added to the menu. If water supply is also in normal
amounts, hot beverages shall be served along with the meals.
• Disaster Feeding Plan

1. In the event of a disaster or emergency in which the ability to procure or
prepare foods in this facility is impaired, the Dietary Manager shall set up
temporary feeding procedures.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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2. Such procedures will be reflective of the severity and type of disaster:
shall procurement, though not the ability to prepare foods be impaired, then
hot emergency meals shall be prepared and served. Shall the ability to
prepare foods, and or not procure them be impaired, then room temperature
emergency meals shall be prepared and served. The following Disaster
Menu outlines emergency meals for a 3-day period, or 7-day period, per
state* regulations, and may be served either hot or cold.
3. An adequate supply of canned or processed meats or meat substitutes,

fruits, fruit juices, vegetables, dry cereal, crackers, peanut butter, jelly,
cookies and powdered milk shall be in this facility to serve nutritionally
adequate meals for at least three (3) days, or seven (7) days, per state*
regulations, in case of emergency. These standards shall be determined per
person (patients and staff members) as listed on the following Disaster Menu.
Emergency water: One (1) gallon drinking water per day per every
resident and staff member on duty.
Emergency water is supplied by:
NOTE: Fresh and/or frozen foods shall always be used first if available.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
DISASTER MENU
Amounts Per Person
Meal Serving Size 3-day 7-day
Breakfast
Fruit juice (orange, grapefruit or tomato) 6 oz 2 ¼ cups 5 ¼ cups
Peanut Butter 2 Tbsp 3/8 cups 7/8 cup
Saltine crackers 2 pkgs 6 pkgs 14 pkgs
Or or or or
Bread 1 slice 3 slices 7 slices
Dry Cereal ¾ cup 2 ¼ cups 5 ¼ cups
Milk Powdered 1 oz 3 oz 7 oz
Milk 1 cup 3 cups 7 cups
Water
Noon Meal
Canned Meat (tuna, ham, chicken) 3 oz 9 oz 1 1/3 pounds
Canned Potato ½ cup 1 ½ cups 3 ½ cups
Or or or or
Canned Vegetables ½ cup 1 ½ cups 3 ½ cups
Canned Fruit ½ cup 1 ½ cups 3 ½ cups
Graham Crackers 2 pkgs 6 pkgs 14 pkgs
Water
Evening Meal
Peanut Butter 2 Tbsp 3/8 cup 7/8 cup
Jelly 1 Tbsp 3 Tbsp 7 Tbsp
Saltine Crackers 2 pkgs 6 pkgs 14 pkgs
or or or or
Canned Fruit ½ cup 1 ½ cups 3 ½ cups
Cookies 2 each 6 each 14 each
Water
3 oz 9 oz 1 1/3 pounds
or ½ cup 1 ½ cups 3 ½ cups
Canned Meat (tuna, ham, chicken) or or or
Canned Potato 1 slice 3 slices 7 slices
or ½ cup 1 ½ cups 3 ½ cups
Bread ½ cup 1 ½ cups 3 ½ cups
Canned Vegetables 2 each 6 each 14 each
Canned Fruit 1 oz 3 oz 7 oz
Cookies 1 cup 3 cups 7 cups
Milk Powdered
Milk
Water
H.S. Snack

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Graham Crackers 2 pkgs 6 pkgs 14 pkgs
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4. A three (3) day, or seven (7) day, per state* regulations, supply of puree
products shall be available, i.e., meat, fruits, vegetables.
Meal Serving Size 3-day 7-day
Breakfast
Thicken if necessary
Pureed Meat 2 oz 6 oz 14 oz
Slurred Dry Cereal ¾ cup 2 ¼ cups 5 ¼ cups
Slurred Saltine Crackers 2 pkgs 6 pkgs 14 pkgs
or or or or
Slurred Bread 1 slice 3 slices 7 slices
With jelly 2 Tbsp 3/8 cup 7/8 cups
Thickened if necessary
Water
Noon and Evening Meals
Pureed Meat 3 oz 9 oz 1 1/3 pounds
Slurred Saltine Crackers 2 pkgs 6 pkgs 14 pkgs
or or or or
Slurred Bread 1 slice 3 slices 7 slices
Pureed Vegetables ½ cup 1 ½ cups 3 ½ cups
Pureed Fruit ½ cup 1 ½ cups 3 ½ cups
Slurred Cookies 2 each 6 each 14 each
Thickened if necessary
Water

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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5. This facility shall maintain at least a three (3) day, or seven (7) day, per
state* regulations, supply at all times of the following items in case of
emergency:
• 9” plates
• 10 ounce bowls
• 8 ounce cups
• Plastic knives, forks, and spoons
• Napkins
• Paper towels
• Disposable room trays
• Disposable steam table pans

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Fire Prevention
POLICY
Employees must be alert to fire hazards and must act promptly and intelligently when
dangerous conditions are detected.
PROCEDURE
• Enforce the No Smoking regulations.

• Keep all areas clean and free of non-essential combustible material.
• Recognize the hazards of essential combustible and flammable materials, i.e.,
gases, chemicals, greases, etc.
• Know the location and operation of all the fire fighting equipment.
• Keep equipment in the work area clean and in good condition.
• Know exactly what you shall do if you detect a fire.
• Keep fire doors closed at all times except for doors with magnetic door holders.
• Keep exits clear at all times.
• If automatic magnetic door holders fail to function, immediately report the
situation to the Maintenance Department. Omit propping doors open as a
solution to the malfunction problem.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Fire Extinguisher Instructions
POLICY
Every employee will know what type of fire extinguisher to use and what to do in case of
a fire.
PROCEDURE
• Fire Suppression
In the event of fire, use appropriate extinguisher and proceed to extinguish the
fire if possible. Each class of fire calls for specialized action. All portable fire
extinguishers shall be labeled to indicate the class of fire on which it shall be
used. Fires are classified according to the nature of the burning material and
shall be Class A, B, or C.
1. Class A – Any fire in ordinary combustible material such as wood, paper,

cloth, mattresses, etc. Use pressurized water.
2. Class B – Any fire in flammable liquids such as fuel oil, gasoline, cooking fats,
greases, paints, ether, acetone, etc. Use CO2
3. Class C – Any fire involving live electrical equipment. Use CO2
• Extinguishers
1. Pressurized Water Extinguisher
Use only on Class A fires. Range: 30-40 feet.

• Remove from wall (kept in wall holder with fire hose).
• Twist and pull out safety pin on the handle.
• Carry to fire.
• Squeeze the handles together at the top.
• Direct nozzle so that discharge is at the base of the fire.
• Do not replace extinguisher in holder until maintenance has checked it.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Fire Extinguisher Instructions
2. Carbon Dioxide Extinguishers (painted red)
Use only Class B and C fires. Range 4-6 feet.
• Remove from wall.

• Twist and pull out safety pin on the handle.
• Carry to fire.
• Squeeze the handles together at the top.
• Direct horn so discharge is over the surface of the flames.
• Apply in short spurts.
• Do not replace extinguisher until maintenance has checked it.
3. Fire Hose
If three persons are available to operate the hose:
• Two persons shall take the nozzle end of the hose and extend it to the
fire. Be sure to pull all of the hose off the rack.
• The third person remains at the hose rack and opens the valve upon
signal from the first person. Direct fog in direction of fire.
• What to do in case of fire
1. Immediately send an alarm from the nearest fire alarm box by breaking glass.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Fire Extinguisher Instructions (continued)

2. Remove from immediate danger any patient in close proximity to fire or
smoke.
3. Go to nearest phone and page fire alert signal and state location.
4. Close doors and windows.
5. Obtain a fire extinguisher and use it on the fire. Use wet blankets if
necessary.
6. Don’t use the elevator.
7. Turn off any oxygen cylinders, gas valves, and all electrical appliances.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Prevention of Back Injury

POLICY
The Dietary Department will make every effort to prevent back injury. This will include
orientation and training employees in proper body mechanics, as well as providing and
maintaining a safe work environment to prevent back injury.
PROCEDURE
• Each new employee will receive training in proper body mechanics and lifting
techniques. These will be reviewed with the employee as part of annual in-
service training.
• Each employee is responsible for following the guidelines presented.
• The Dietary Department will use standard guidelines in teaching back injury
prevention.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Standard Guidelines Prevention of Back Injury

• Never bend from the waist; always bend hips and knees (to lower your center of
gravity).
• Never lift an object any higher than your waistline.
• Never carry anything heavier than you can manage with ease.
• Avoid sudden movements; attempt to move smoothly.
• Avoid carrying unbalanced loads; if you must, change sides frequently (i.e.,
carrying a child on one hip for a time; then changing to the opposite hip).
• Never lift and twist at the same time.
• Avoid pushing when it is better to pull.
• Always turn to face the object or person you are going to lift.
• Always carry heavy objects close to your body. Before lifting, get close to the
object first (shortening the resistance arm).
• When reaching, spread your feet; advance one foot in the direction of reach (to
widen base of support).
• When reaching overhead, always use a stool or small stepladder.
• When pushing, exert force toward the middle of the object; set trunk muscles (to
use less energy); lean toward or back against the object, slowly straightening
your legs before pushing.
• When pulling, have one foot close to the object and the other foot back, being
sure to transfer the weight from forward to back foot. Grasp the object toward
the middle, bend your knees and keep your back straight while pulling.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Standard Guidelines Prevention of Back Injury (continued)

• Lift by straightening your legs. Legs are stronger than trunk muscles; never use
your back for support.
• If two people are lifting together, always synchronize your motions. Count 1-2-3
lift, or use another mutually understood signal to coordinate your movements.
• When in doubt about the load – GET HELP!

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Preventing Falls
POLICY
Falls in any work environment can be common if unsafe practices are used. The
Dietary Department wants to ensure that all employees use safe habits to prevent falls.
PROCEDURE
• Spilled food or liquid will be cleaned up immediately.
• Employees shall wear shoes with rubber soles and low heels.
• Climbing on shelves is strictly prohibited. When reaching overhead or for upper

shelves, stools, stepladders, or stands will be used for safe reaching.
• A box, crate, or chair will never be used to stand on.
• Storerooms and other work areas will be kept free of any debris on the floors.
This will be everyone’s responsibility.
• Halls and passageways will be well lighted.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Accident Prevention In Food Transport

POLICY
Accidents may and can happen as food is transported from the central kitchen to the
dining room. Not only can this cause injury to the employee, but can also cause harm
to the patients.
All Dietary Department employees will follow safe practices when transporting food.
PROCEDURE
• When wheeling food carts, all carts will be kept to the right in corridors and
hallways. Extra care will be used at intersecting corridors and swinging doors. In
passing through doorways, a cart will always be pulled through. At no time shall
a cart be pushed through an intersection or swinging doorway.
• Employees will not overload carts, trays or liquid containers.
• Food will remain covered when in transit.
• At no time shall food carts be left where they block halls, doorways, or fire exits.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Accident Prevention in Cooking and Baking

POLICY
Burns, cuts, and falls are accidents most prevalent in cooking and baking. All Dietary
Department employees will practice safe techniques to prevent accidents in cooking
and baking.
PROCEDURE
• Handles of cooking utensils (pots, pans, and skillets) will be parallel to the front of
the range and will not protrude into the aisle or over open flame or hot burners.
• Dry oven pad or mitts will be used when handling hot utensils; if wet they can
cause steam burns.
• Hands shall be dry and free from grease when handling pots, pans, and knives.
• Before lighting a gas oven, the oven door shall be opened for a few minutes to
allow any gas leakage to escape.
• Hoods, flues, and canopies over cooking areas shall be kept free from grease.
Floors will be kept free of grease and other moisture.
• All employees will learn and memorize the location of the fire extinguisher and its
proper use.
• Caution shall be used in lifting pot lids to prevent steam burns on hands or face.
Lids or covers shall be lifted toward the body so that the steam rises toward the
hoods or flues.
• Employees shall never attempt to move oversized or heavy containers of food

alone; two people shall always move these to prevent strain on one person.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Accident Prevention in Cooking and Baking (continued)

• Hot water, coffee or tea will be drawn from an urn by opening the spigot slowly to
prevent splashes. Employees shall not leave the urn while liquids are being
drawn.
• Any hot water shall be tested before placing your hands in it.
• Long handled spoons and forks will be used when stirring foods in kettles or
testing food in ovens.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Accident Prevention in Food Preparation

POLICY
Cuts and falls are accidents that occur most often during food preparation. All Dietary
Department personnel will follow safety precautions to prevent accidents in food
preparation.
PROCEDURE
• Knives will be kept sharp.
• Correct knives will be used for each job.
• All cutting will be done away from the body.
• Do not try to catch a falling knife.
• Knives will not be placed in a sink filled with soapy water.
• After knives are used, they shall be immediately washed, rinsed, sanitized, and
permitted to air dry and promptly stored. At no time shall a knife be left in a sink
of soapy water.
• Knives will be kept in protective racks or cases when not in use.
• Knives or cleavers shall never be used to open jars.
• The knife guard on the meat slicing machine will be checked for proper
placement before each use.
• Hands will not be put into mechanical equipment when it is in motion.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Accident Prevention in Food Preparation (continued)

• Floors will be kept as dry as possible by always wiping up spills immediately.
• Food containers, pots and pans will be kept where they will not be tripped over.
• The meat slicing machine will be used only by those persons who have been
taught the proper operating procedure. Persons under the age of 18 will not be
permitted to use the slicer.
• Broken china or glass will not be picked up with bare hands;’ always use a brush
and dustpan.
• Chipped dishes or glassware of any kind will be discarded immediately, as it is

unsafe and unsanitary to use them.
• China or glassware shall never be put in the pot and pan sink as they can be
easily chipped or broken by metal pans.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Accident Prevention in Serving Food

POLICY
Burns, bumps and falls are injuries that occur most often in serving food. All Dietary
Department personnel will take appropriate measures to prevent accidents in serving
food.
PROCEDURE
• Unnecessarily hurrying and/or running will not be permitted.
• Employees handling hot liquids or foods will move carefully to prevent collisions
and will give a warning when passing behind someone.
• Employees shall always wear shoes with rubber soles and low heels (no sandals,
moccasins, etc.).
• Drawers or cupboard doors shall never be left open.
• Trays, dishes, pots, and pans shall always be set away from the edge of counter
tops. Serving spoons, and handles of cooking utensils shall always be parallel to
the edge of the counter tops.
• Long sleeved hand protectors as well as oven mitts or pot holders will be worn
when removing pans from steam tables to prevent steam burns. When removing
pans from the steam tables, use a spoon or other utensil to pry the right side of
the pan up, get a firm grip on the left side of the pan and lift pan straight up with
both hands so the steam will rise away from you.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Can Opening Procedures

POLICY
The Dietary Department will maintain safe practices to ensure safety among employees.
Improperly opened cans can present a hazard for employees.
PROCEDURE
• Wipe lid of can.
• Completely remove lid with the use of a bench type can opener.
• Dish out product.
• Place lid in opened can and place in garbage receptacle. At no time shall the lid
and can be deposited separately in the garbage.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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General Food Ordering

POLICY
Designation of companies or vendors through which the facility may, under normal
conditions, order food supplies is the responsibility of the Dietary Manager and
Administrator. The Dietary Manager, under the supervision of the Administrator, is
responsible for ordering all food and nonfood supplies necessary to adequately maintain
dietary services and to meet local, state, and federal requirements regarding supplies
on hand at all times.
PROCEDURE
• Specifications and guidelines for ordering all supplies used in the Dietary
Department are set up by the menu purchase guide.
• All deliveries are received by the Dietary Manager or by the Dietary Department
designee. Delivered supplies are checked against the original order. The
delivery slip or invoice is signed by the person receiving and checking the
merchandise delivered.
• Orders are inspected when received to ensure quality, quantity, and condition.
Meats, poultry, and fish are weighed if possible. If spoiled or defrosted food is
received, it is refused and returned at time of delivery.
• The ordering of nonfood supplies such as paper products and chemical supplies
is done by the Dietary Manager through designated vendors. There will be a 3-
day supply of paper products maintained at all times.
• Dietary utensils and minor equipment are ordered by the Dietary Manager with
approval of the Administrator.
• Under normal operating conditions, the following minimum inventory is available

on the premises for both regular and therapeutic diets, based on state and
federal requirements:
Staples: 7 days
Perishables: 3 days
Disposables: 3 days
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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General Food Ordering (continued)
• Food is procured from sources that have been approved or are considered
satisfactory by the health authorities. Food is clean, wholesome, and unspoiled.
Meat and meat products are purchased from suppliers who comply with local,
state and federal laws and regulations.
• It is advisable that deliveries be received at least one (1) day prior to scheduled
menu usage.
• The Dietary Manager (or designee) is responsible for:

1. Supervising all food orders.
2. Doing periodic inspections of food materials received. Particular

emphasis is placed on meats to ensure quality, condition, and weight.
3. Processing invoices and submitting for payment.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Weekly Ordering
POLICY
The Dietary Manager is responsible for the weekly ordering of all food and supplies.
This responsibility may be delegated to a trained employee.
PROCEDURE
• Compare amount recorded for each item in inventory record (amount on hand) to
amount needed on cycle menu for each vendor.
• Par levels shall be established for commonly used items. Order these items if
the amount on hand is less than or equal to par level.
• Write items ordered on purchase order.
• Call in order to each vendor. Include the following:
1. Name and address of care center.
2. Delivery date.
3. Quantity ordered, package, and brief description of product.
4. Customer number, if applicable.
• Retrain purchase orders for a minimum of six (6) months.
• Vendor-provided order form may be substituted for standard form.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Food Specifications
POLICY
Written specifications have been developed for food items regularly purchased in
accordance with the facility purchasing policy in order to accurately identify the type and
quantity of food purchased and to serve as a guide in purchasing.
Refer to Purchase Guides per menu program.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Credit Memo
POLICY
Unless the vendor provides an accurate credit memo, the Dietary Manager will prepare
a credit memo in the following instances:
1. Billed for food or supplies not received.
2. Billed for incorrect food or supplies received (incorrect package, product or

substituted item) which are being returned to the company.
3. Billed for damaged food or supplies that are being returned to the company.
4. Billed for food or supplies incorrectly priced.
PROCEDURE
• Check Product Return Sheet and vendor’s invoices weekly and complete the
necessary Dietary credit memos using the standard Dietary Credit Memo form:
• Complete “Dietary Credit Memo”* as follows:
• Call vendors to confirm credit and arrange for pickup date for items if necessary.
1. Care center name and date credit memo completed
2. Vendor name and date item was received
3. Purchase order number and invoice number
4. Customer number and salesperson number
5. Description of product and product stock number
6. Quantity and price (unit or case price)

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Credit Memo (continued)

7. Reason for returning the product
8. Date credit received
9. Signature of person completing Dietary Credit Memo
• Each Dietary Credit Memo will be filed in vendor invoice file until credit has been
received. When credit is indicated on monthly statement, the date of the
statement is written on the Dietary Credit Memo.
• Credit memos that have already been processed (credit received) will be filed in
a master file for a period of time not to exceed one (1) year.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Emergency and Special Purchases

POLICY
Petty cash funds are available for limited purchases not accounted for through the
regular purchasing methods.
PROCEDURE
• When a purchase of food or supplies is made a sales slip or register receipt

detailing the items purchase, to include vendor’s name and the date, must be
submitted to the Administrator or his designee before money will be refunded to
purchaser.
• With proper documentation, petty cash will be released to purchaser on the date
the slip is submitted.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Dietary Cost Control

POLICY
The Dietary Manager is responsible for operating the Dietary Department within an
annual fiscal budget. The budget is prepared and shall be reviewed at least annually by
the Administrator, the Dietary Manager, and the Dietitian.
PROCEDURE
• The annual budget is divided into the following categories:

1. Food
2. Labor
3. Supplies
4. Equipment
5. Activities and/or special functions
6. Supplements
7. Small ware
• Adequate funds shall be allocated for purchasing food and supplies and securing
labor to assure patients receive nutritious and varied meals.
• As necessary, expenditures shall be planned and executed to provide Dietary

staff with equipment of the type and in the amounts needed for proper food
preparation, serving and storage, proper dishwashing and for appropriate eating
utensils.
• The Dietary Manager shall maintain cost control records.
• The food and supply costs are per patient day shall be computed on a weekly or
monthly basis by the Dietary Manager or other personnel appointed by the
Administrator.
• No food ordered for the facility shall be diverted or taken from the facility.
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Use of Budget Control Forms
POLICY
It is the responsibility of the Dietary Manager to manage the department within the
allotted budget for food and nonfood supplies. The Dietary Cost Control Form is used
to insure that food cost is within the allotted budget.
PROCEDURE
This form is to be completed and submitted to the Administrator as instructed below:
• The Dietary Manager shall daily write, in the appropriate column of the “Daily
Cost Control Form,”* the date, purchase order number, vendor, and total of
purchase. A running budget balance is noted. A separate Daily Cost Control
Form is used for each cost category.
• At the end of the month, the Dietary Manager shall total purchases. This is the
“Total Purchased This Month.”
• The Dietary Manager shall write the money received, or credit given, for meals
sold to guests and/or staff; and subtract from “Total Cost” to obtain “Net
Expense”.
• The Dietary Manager shall divide the “Net Expense” by “Total Patient Days” to
obtain “Expense Per Patient Day (PPD).” Total number of patient days is
obtained by adding together the daily census for the month. This total can be
obtained from the office personnel.
• From the Dietary Department current budget, the Dietary Manager writes “Budget
Per Patient Day.”
• The Dietary Manager shall find the difference between “Expense Per Patient
Day” and “Budget Per Patient Day” and record as “Difference”.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Use of Budget Control Forms (continued)

• If appropriate (when actual costs and budgeted costs vary considerably), the
Dietary Manager shall note the reasons for the differences, and action, if any, to
be taken.
• Figure average food expense for month using separate form for raw food,
supplies, supplements, small ware, etc.
• Dietary Manager shall sign the “Daily Cost Control”* form and submit this form to
Administrator, retaining a copy for her/his file.
• Dietary Manager shall receive and maintain a copy of all invoices for food and
supplies.
• The “Labor Tracking”* form is kept and turned in to Administrator at the end of
the month.
• The “Labor Tracking” form is used to adjust labor hours PPD daily per census.
Turn into Administrator daily.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Physical Inventory
POLICY
To define a method for taking a physical inventory which is a detailed list of all the
types, amounts, and costs of foods and supplies on hand on a specified day.
PROCEDURE
• List, by general categories, all foods and all supplies on hand on the “Physical
Inventory Form.”* List the items in the same sequence that foods and supplies
are arranged in the storeroom. Leave space for several different types of foods
under the (general category head).
• Complete the item sizes.
• Duplicate the list for future inventory use.
• Count the number of each item on hand. Write the amount in the “Quantity on
Hand” column.
• Using the most recent invoices, list the unit cost for each item.
• Multiply the Unit Cost by the Quantity on Hand to obtain the Total Cost per item.
• Add together the total item costs on each inventory page. Write this figure at the
bottom of the page.
• Date all inventory forms.
• Add together the inventory costs for all pages to obtain the total value of foods
and the total value of supplies on hand. This is needed for the Computation of
Annual Raw Food and Supplies Cost per Patient Day.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Physical Inventory (continued)

• The physical inventory must be taken annually, either on the first day of the new
fiscal year, or the last day of the old fiscal year. Some corporations require
monthly inventories. If so use Monthly Food Cost Sheet.
• The benefit of the physical inventory is to verify that storeroom supplies are
remaining constant; and to accurately calculate the costs of food and supplies
used by the Dietary Department during a given period of time.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Annual Raw Food and Supplies Costs

Per Patient Day
POLICY
To calculate the annual cost per patient day of raw food and supplies consumed.
PROCEDURE
• Opening Inventory Amount.
• The total cost of food on hand and of supplies on hand shall be calculated
separately on the first day of the fiscal year. These total costs are obtained from
the Dietary Department Physical Inventory Form. Write these figures on the first
line of the “Annual Raw Foods and Supplies Worksheet.” Write the date that the
physical inventory was taken.
• Purchases During the Year.
• The cost of all food purchases during the fiscal year shall be added together.
The cost of all supply purchases shall be added together. These two figures
shall be inserted on the line “Purchases During Year.” Costs are available from
invoice, or the Dietary Department Weekly Budget Control Form.
• Closing Inventory Amount.
• On the last day of the fiscal year a complete physical inventory of all food and all
supplies on hand shall be taken. Use the Dietary Department Physical Inventory
Form. Write the total costs for all foods and all supplies on hand on the line
“Closing Inventory Amount.” Note the date that inventory was taken.
• Cost of Food and Supplies Consumed.
• The “Closing Inventory Amount” shall be subtracted from “Cost of Goods

Available.” This figure is the “Cost of Food and Supplies Consumed” during the
fiscal year.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Per Patient Day (continued)
• Total Number Patient Days.
• The patient census for each day of the year shall be added together to obtain the
“Total Number of Patient Days” for the year; or this figure can be obtained from
office personnel. Write this figure on the “Total Number of Patient Days” line.
• Cost Per Patient Day.
• “Cost of Food and Supplies Consumed” shall be divided by the “Total Number of
Patient Days” to obtain the average “Cost per Patient Day” for food and supplies.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Worksheet
Food Supplies
Opening Inventory Amount $ $
Date
Purchase During Year + $ + $
Cost of Goods Available = $ $
Closing Inventory Amount - $ - $
Date
Cost of Food and Supplies Consumed $ $
Year
Total Number of Patient Days
Cost Per Patient Day $ $

Food Supplies

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Cost Information – Special Functions

POLICY
Cost information will be maintained on all food requested from the Dietary Department.
PROCEDURE
• The Dietary Manager will cost-out all items requested.
• All cost information will be given to the requesting department.
• The requesting department will review and approve cost information and turn into
the business office for appropriate expensing.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Safeguarding the Dietary Department
POLICY
The Dietary Department will maintain strict measures to prevent theft and/or pilferage,
as well as to control operating costs.
PROCEDURE
• The Dietary Department will be locked after hours and will remain locked until the
next scheduled shift.
• The Dietary Manager will designate employees who will have keys to the
department and will maintain a log of those employees who have keys.
• The Dietary Manager will make periodic inspections of the food storage areas,
checking current stocked items against expected usage.
• Food, departmental items, empty boxes or containers cannot leave the kitchen
area without prior authorization from the Dietary Manager.
• Employees will not be allowed to purchase any food and/or other items from any
vendors that deliver stock to the facility.
• Any unauthorized personnel will not be permitted in the food storage or Dietary
kitchen areas.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Medical Nutrition Therapy: Nutritional

Screening of High Risk Patients
POLICY
The Dietitian Technician/Manager will screen each patient’s chart within 24 hours of
admission for patients at high nutritional risk. If the data falls into the screening criteria,
a Nutritional Assessment will be completed (see following page).
PROCEDURE
• The Dietary Technician/Dietary Manager will check all patient records for the
following:
1. Blood sugar of glucose of 200 or more
2. Diagnosis of Malnutrition, Active Ca, Liver Failure, Renal Failure and

Stroke
3. Patient receiving tube feeding or TPN.
4. Albumin less than 3.0
5. NPO/Clear liquids more than 3 days
6. 90% of IWR or less
7. Surgical patients age 65 or over with low weight or low albumin or poor
food intake.
• Dietary Manager or Consulting Registered Dietitian to assess information and

complete assessment form if patient has any of the above.
• Dietary Technician, Dietary Manager, or Consulting Registered Dietitian is to

assess information and complete assessments within 24 hours of identification.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Nutritional Assessment
POLICY
The Dietary Technician, Dietary Manager or RD will complete a nutritional assessment

on all patients who are determined to be at nutritional risk by nutritional screening within
48 hours of identification.
PROCEDURE
• Patient determined to be at nutrition risk through nutrition screening are referred

to the dietary manager or dietitian for nutritional assessment.
1. Patient on enteral feedings will receive a nutritional assessment by a

dietitian. When the dietitian is not at the facility, assessments will be faxed
to the facility.
2. Patient on TPN receive a nutritional assessment by a dietitian. When the

dietitian is not at the facility, assessments will be faxed to the facility.
3. All other nutritionally-at-risk patients are assessed by the dietary

technician/manager and referred to the dietitian as needed.
• Nursing staff will request a nutrition assessment of any patient consuming less
than 50% of meals for more than 3 days by contacting the dietary manager or
dietitian.
• The dietary manager or dietitian completes the nutrition assessment within 48

hours of referral.
• The following data is gathered and utilized in the nutrition assessment:
1. Food intolerances and allergies.
2. Religious, cultural, ethnic, and personal food preferences.
3. Conditions that may affect indigestion, absorption, or use of nutrients.
4. Anthropometric measurements and evaluations (i.e. weight compared to

height and weight history)

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Nutritional Assessment (continued)

5. Diet prescription or number of days NPO
6. Nutritional implications of selected lab tests or their results
7. Medications that may affect nutritional status
8. Adequacy of nutrient intake: current, previous, and required
9. Physical examination for manifestations of nutrient deficiency or excess
10. Need for nutrition education and discharge instructions
• The assessment process for an infant, child or adolescent is individualized

utilizing:
1. Patient’s developmental age, length or height, head circumference, and

weight.
2. The effect of the family or guardian on the patients condition
3. The family’s or guardian’s expectations for and involvement in the

patient’s assessment, initial treatment, and continuing care
• Patients are monitored and reassessed per nutrition care practices during their
hospital course.

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Nutrition Plan of Care

POLICY
An interdisciplinary nutrition therapy plan is developed and periodically updated for

patients determined to be at nutrition risk.
PROCEDURE
• After assessing patients identified to be at nutrition risk, a nutrition therapy plan is

developed to meet identified needs and placed in the patient’s chart.
• The patient’s nutrition therapy plan defines:
• Patient’s progress is periodically evaluated against care goals and the plan of
care, and when indicated the plan, goals, or approaches are revised.
• When care is not planned to meet all identified needs, decisions not to address
certain needs are justified in patient records.
• A nutrition therapy plan is not ordinarily developed for patients receiving only a
regular diet by mouth.

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Nutritional Education
POLICY
Education on nutrition and modified diets is provided to patients/families within 24 hours

of physician referral, or when the need for education is identified in the nutrition
assessment or by the staff. When appropriate, counseling is interdisciplinary.
PROCEDURE
• Nutrition education can be initiated by physician referral, nursing staff, or the

dietary department.
• The need for nutrition education is communicated to the dietary department and
acted upon within 24 hours.
• The patient’s learning needs, abilities, preferences, and readiness to learn are
assessed. The assessment considers:
1. Cultural and religious practices
2. Beliefs and values
3. Literacy, education level, and language barriers
4. Emotional barriers
5. Desire and motivation to learn
6. Physical and cognitive limitations
7. The financial implications of care choices
• The patient’s and family’s responsibilities regarding the patient’s ongoing health
care needs are explained. These include:
1. Providing information
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Nutritional Education (continued)

2. Asking questions
3. Following instructions
4. Accepting consequences of not following instructions
5. Following hospital rules and regulations
6. Acting with consideration and respect
• Priorities are set for learning needs.
• The patient/family is instructed by the dietary technician/manager and other staff

as appropriate per hospital guidelines/diet manual.
• The education process is interactive, continuously eliciting feedback.
• A variety of methods are utilized to meet the patient’s/family’s educational needs:
1. Direct Teaching
2. Educational materials (pamphlets, videos, etc.)
3. Community resources
4. Program referrals
Note: Disabilities and language barriers are taken in to account.
• A progress note will be written in the patient’s record after education is

completed. The note will include:
1. Who was educated
2. The subject of the instruction

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Nutritional Education (continued)

3. What educational materials were utilized
4. Evaluation of patient’s/family’s understanding
5. Evaluation of expected compliance
6. Name and number of source provided in case of questions/concerns later

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Nutrition Monitoring
POLICY
Each patient’s response to nutrition care is monitored.
PROCEDURE
• The following disciplines collaborate on nutrition care monitoring:
1. A licensed independent practitioner

2. A Dietary Technician/Dietary Manager or dietitian, using information from the
nutritional assessment and the medical record, helps the practitioner to
suboptimal responses or potential adverse events, and evaluates the
effectiveness of the nutrition therapy plan.
3. A nurse monitors and reports the effect of nutrition care on an ongoing basis
4. The pharmacist helps the practitioner and dietary manager or dietitian identify
potential drug-nutrient interactions
• Monitoring includes the following activities:
1. Recording the patient’s percent consumption of food at each meal and the
percent consumption of nutrition products
2. Reviewing the patient’s therapeutic regimen including the appropriateness of
food and nutrition products and the administration route weekly
3. Drawing conclusions and communicating them to those responsible for the
patient’s care.
4. Documenting conclusions and interdisciplinary conference results in the
medical record.
5. Reassessing and revising the patient’s nutrition therapy
6. Reviewing patient’s who are not receiving adequate intake every 2-3 days
7. Reviewing patients on transitional feedings from parenteral to enteral or oral,
or vice versa daily.

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Nutrition Reassessment
POLICY
Patients are reassessed at regular intervals during the course of care to evaluate
nutrition therapy effectiveness and appropriateness.
PROCEDURE
• The dietary manager or dietitian will complete nutrition reassessment per goal
time frames for those patients for whom a nutrition therapy plan has been
developed.
• The dietary manager or dietitian will complete a nutrition reassessment at least

every 7 days on those patients determined to be at nutritional risk.
• The dietary manager or dietitian will complete a nutrition reassessment when a

significant change in a patient’s condition or diagnosis occurs.
• The reassessment shall:
1. Summarize information gathered in the reassessment
2. State and interpret new facts that have nutritional significance
3. Review and update current nutritional status
4. Record pertinent information regarding changes made to nutrition

reassessment when a significant change in a patient’s condition or diagnosis
occurs

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Nutrition Discharge Planning

POLICY
Discharge planning focuses on meeting patients’ nutritional needs after discharge.
PROCEDURE
• The discharge process includes assessing the patient’s needs at the time of
discharge and arranging for services to meet them as needed.
• When indicated, discharge instructions are given to the patient/family to develop

a workable plan of care following the patient’s release from the hospital.
Discharge education includes:
1. A helping the patient/family understand the patient’s treatment and the

need for continuing care;
2. Teaching the patient/family what they need to know about care after
discharge;
3. Making life-style changes and;
4. Managing continuing care.
5. The roles of all involved disciplines.
• When a patient is discharged, a description or copy of the diet

information/instruction information is provided to the organization/individual
responsible for the patient’s continuing care. This information includes a
summary of care provided and progress toward goals.

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Medical Nutrition Therapy Practice

Guidelines: Diabetic Mellitus, Type 1, Newly Diagnosed
Diabetic Mellitus, Type 2, Newly Diagnosed
The overall goal is a collaborative treatment with the patient and clinical members of the
health care team to assess the individual, to identify goals, to intervene to achieve those
goals, and to evaluate the outcomes.
IN-PATIENTS:
• Assist the patient with diabetes in making changes in nutrition and/or exercise
habits leading to metabolic control.
• Assist the patient to be able to maintain as near-normal blood glucose levels as
possible by balancing food intake with insulin or oral glucose-lowering
medications and activity.
• Assist the patient to achieve optimal serum lipid levels.
• Assist the patient to achieve a reasonable weight. Reasonable weight is defined
as the weight an individual and health care provider acknowledge as achievable
and maintainable, both short-term and long-term. This weight may not be the
same as the traditionally defined or ideal body weight.
• Assist the patient in learning how to prevent and treat the acute complications of
insulin-treated diabetes such as hypoglycemia, short-term illness, and exercise-
related problems, and of the long-term complications of diabetes such as renal
disease, autonomic neuropathy, hypertension, and cardiovascular disease.
Outcomes Anticipated:
• The patient will be able to identify foods on specific food lists (exchanges).
• The patient will understand the importance of meal timing and the maximum time
between meals.
• The patient will understand the importance of exercise to control blood glucose.
• The patient will understand how to compensate for exercise-induced
hypoglycemia.

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Diabetic Mellitus, Type 2, Newly Diagnosed (continued)
• The patient will understand how to compensate for hypoglycemia.

• The patient will be able to select the menu correctly.
• The patient will be able to write at least 1 day’s menu.
• The patient will be able to understand how to achieve optimal serum lipid levels.
• The patient will be able to understand how to achieve and maintain a reasonable
weight and that weight may not be the same as the traditionally defined desirable
or ideal body weight.
• The registered dietitian will consider the individual’s cultural and ethnic
background, their lifestyle, and their evaluation of quality of life in working with
the patient and/or the family to achieve a well-balanced nutrition program (3
meals, 1-3 snacks) for patient’s use that will ultimately achieve a distribution of
50% or more of carbohydrate, 10-20% protein, 30% or less fat (with less than
10% of energy from saturated fats, up to 10% of energy of polyunsaturated fats,
and 10% of the energy from monounsaturated fats. Thee nutrition plan shall be
tailored to address any metabolic abnormalities. It shall provide the patient with
the opportunity to acquire the knowledge and skills necessary to change or
maintain eating habits.
Medical nutrition therapy and type 1 diabetes:
• A meal plan based on the individual’s usual food intake shall be determined and
used as a basis for integrating insulin therapy into the usual eating and exercise
patterns.
• It is recommended that the individual’s using insulin therapy eat at consistent
times synchronized with the time-action of the insulin preparation used.
• Individuals need to monitor blood glucose levels and adjust insulin doses for the
amount of food usually eaten. Intensified insulin therapy, such as multiple daily
injections or use of an insulin pump, allows considerable flexibility in when and
what individuals eat. With the latter (intensified therapy), insulin regimens shall
be integrated with lifestyle and adjusted for deviations from usual eating and
exercise habits.
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Medical nutrition therapy and type 2 diabetes:
• The emphasis shall be placed on achieving glucose, lipid, and blood pressure
goals.
• Monitoring glycemic and lipid status and body weight is essential to assess the
effectiveness of any nutrition recommendations.
• Weight loss and the use of hypocaloric diets to achieve weight loss usually
improved short-term glycemic levels and have the potential to increase long-term
metabolic control, but the goal of achieving and maintaining a reasonable weight,
particularly when combined with exercise.
• If obesity and weight loss are the primary issues, a reduction in dietary fat intake
is an efficient way to reduce caloric intake and weight, particularly when
combined with exercise.
• If elevated low density lipoprotein cholesterol is the primary problems, a diet in
which less than 7% of total fat and dietary cholesterol is less than 200 mg/day
shall be implemented.
• If elevated triglycerides and very low-density lipoprotein cholesterol and the
primary problems, a diet in which 10% or less of the energy from
monounsaturated fats, and a more moderate intake of carbohydrate shall be
implemented.
• If elevated triglycerides and very-low-density lipoprotein cholesterol in the obese
individual are the problems, the fat contents of the diet may need to be limited
further than outlined above.
Other Considerations:
• Sucrose: Scientific evidence has shown that the use of sucrose as part of the
meal plan does not impair blood glucose control in individuals with type 1 or 2
diabetes.
• Non-nutritive Sweeteners: Those approved by the FDA are safe to consume by
all persons with diabetes.
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• Fiber: Intake recommendations for person with diabetes are the same as for the
general population – 20 to 35 gm dietary fiber from a wide variety of food
sources.
• Sodium: Intake recommendations for the person with diabetes are the same as
for the general population – 3,000 mg or less per day. For persons with mild to
moderate hypertension, 2,400 mg or less/day is beneficial in alleviating
gestational hypertension.
• Alcohol: Intake recommendations for persons with diabetes are the same as for
the general population. Abstention from alcohol shall be advised for persons with
a history of alcohol abuse or during pregnancy. Guidelines regarding the use of
alcohol are available from the registered dietitian upon request.
• Vitamins and Minerals: When dietary intake is adequate, there is generally no
need for additional vitamin and mineral supplementation for the majority of
persons with diabetes. The registered dietitian is available to determine if dietary
intake is adequate.
Session 1: Assessment, Care Plan, have resident answer Knowledge Assessment,

Document
Session 2: Give diet instruction, review Knowledge Assessment answering questions,

Document understanding
Session 3: Invite patient to education classes if held by the hospital
OUT PATIENTS:
• Same as above regarding Goals/Outcomes

• Follow up, answering questions either by phone or appointment
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Medical Nutrition Therapy Practice Guidelines:

Chronic Renal Failure - Hemodialysis
IN-PATIENTS:
Goals for Self-management Training:
• Assist the patient with renal problems in making changes in nutrition habits
leading to improved renal control.
• Assist the patient to be able to understand the importance of controlling the
intake of protein in their diet, to be able to identify foods which contain protein
and the protein amounts contained in specific portions of various foods, to be
able to identify foods containing little or negligible protein, to understand the
differences between complete and incomplete proteins, and to understand the
importance of spacing protein quantities throughout the day.
• Assist the patient to be able to understand the importance of limiting the intake of
potassium and phosphorus in their diet, to be able to identify foods which contain
potassium and phosphorus.
• Assist the patient to be able to write at least one day’s menu.
• If diabetic, patient will be able to understand how to increase the fat and
allowable carbohydrate in the diet to obtain adequate calories and still achieve
optimal urea nitrogen levels.
and maintainable, both short-term and long-term. This weight may be the same
as the traditionally defined or ideal body weight.
• Assist the patient in learning how to prevent, treat and treat the acute
complications of renal problems such as hypertension and of the long-term
complications of cardiovascular disease.
• Assist the patient to improve overall health through optimal nutrition.

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Chronic Renal Failure – Hemodialysis (continued)
• The patient will understand the difference between types of proteins, the
importance of spacing protein throughout the day, and how to consume adequate
calories.
• The patient will understand what foods contain protein and how these foods
effect the lab values.
• The patient will understand what foods contain potassium and/or phosphorus and
how these foods affect the lab values.
body weight and that weight may not be the same as the traditionally defined
desirable or ideal body weight.
The registered dietitian will consider the individual’s cultural and ethnic background,
their lifestyle, and their evaluation of quality of life in working with the patient and/or the
family to achieve a well-balanced nutrition program (3 meals, 1-3 snacks) for protein
sources and adequate calories. Protein needs will be calculated by the Registered
Dietitian.
The nutrition plan shall be tailored to address any metabolic abnormalities. It shall
provide the patient with the opportunity to acquire the knowledge and skills necessary to
change or maintain eating habits.
meal plan does not impair blood urea control in individuals with renal problems.
• Non-Nutritive Sweeteners: Those approved by the FDA are safe to consume by
all persons with renal problems.
• Fiber: Intake recommendations for persons with renal problems are the same as
for the general population – 20 to 35 g. dietary fiber from a wide variety of food
sources.

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Chronic Renal Failure – Hemodialysis (continued)
• Sodium: This is usually controlled and unless restricted, intake recommendations

for persons with renal problems are the same as for the general population –
3,000 mg. or less per day. For persons with mild to moderate hypertension
2,400 mg or less per day is recommended.
• Alcohol: Intake recommendations for persons with renal problems are the same
as for the general population. Abstention from alcohol shall be advised for
persons with a history of alcohol abuse or during pregnancy. Guidelines
regarding the use of alcohol are available from the registered dietitian upon
request.
• Vitamins and Minerals: The registered dietitian is available to determine if dietary
intake is adequate. When dietary intake is adequate, there is generally no need
for additional vitamin and mineral supplementation for the majority of persons
with renal problems.

Document

and Document understanding
OUT PATIENTS
• Same as above regarding Goals/Outcome
• Follow up, answering questions either by phone or appointment

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Guidelines: Pre-End Stage Renal
IN-PATIENTS:

• Assist the patient and/or family members in making changes in nutrition habits
leading to alleviation of such symptoms as nausea, vomiting, diarrhea,
constipation, loss of appetite, taste changes, difficulty swallowing, or weight loss.
• Assist the patient and/or family members to be able to identify five foods the
patient can tolerate in their diet.
• The patient will be able to achieve a reasonable weight. Reasonable weight is
defined as the weight an individual and health care provider acknowledge as
achievable and maintainable, both short-term and long-term. This weight may not
be the same as the traditionally defined or ideal body weight.
• The patient will be able to identify five foods the client can tolerate in their diet.
• The patient will be able to identify which foods result in sick symptoms as
nausea, vomiting, diarrhea, and constipation.
• The patient will understand why there is a loss of appetite.
weight. This weight may not be the same as the traditionally defined desirable or
ideal body weight.

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Guidelines: Pre-End Stage Renal (continued)
family to achieve a well-balanced nutrition program (3 meals, 1-3 snacks) for patient use
that will ultimately provide adequate calories, protein, and shall provide the patient with
the opportunity to acquire the knowledge and skill necessary to change or maintain
eating habits.
meal plan does not impair food urea control in individuals with renal problems.

all persons with renal problems.
for the general population – 20 to 35 grams dietary fiber from a wide variety of
food sources.
• Sodium: This is usually controlled and unless restricted, intake recommendations

for persons with renal problems are the same as for the general population –
3,000 mg. or less per day. For persons with mild to moderate hypertension,
2,400 mg or less per day is recommended.
• Alcohol: Intake recommendations for persons with renal problems are the same
as for the general population. Abstention from alcohol shall be advised for
request.
• Vitamins and Minerals: The registered dietitian is available to determine if dietary

intake is adequate. When dietary intake is adequate, there is generally no need
for additional vitamin and mineral supplementation for the majority of persons
with renal problems.
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Guidelines: Pre-End Stage Renal (continued)
Document

and document understanding
OUT PATIENTS:
• Same as above regarding Goals/Outcomes and regarding Sessions

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Guidelines: Patients At Nutritional Risk
IN-PATIETNS:
Definition of Nutritional Risk:
• Those patients with a 3.0 or less lab value for albumin
• Those patients below 90% ideal body weight or with significant weight loss
• Those NPO over 3 days
• Those on clear liquid diets over 3 days.
• Those of geriatric age and surgical patient
• Those patients who are tube fed or on TPN
• Those patients with Pressure Ulcer
• Assist the patient with low body weight or weight loss and/or albumin lab in
making changes in nutrition habits leading to improved oral intake. Evaluate
needs of patients who are on TF or TPN.

and maintainable, both short-term and long-term. This weight may not be the
same as the traditionally defined or ideal body weight.

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Guidelines: Patients At Nutritional Risk (continued)
• Assist the patient in learning how to prevent, treat and treat the acute
complications of low body weight and/or low albumin lab value such as poor
and/or delayed healing, pressure ulcer.
• The patient will be able to select a well-balanced diet while in the hospital
• The patient will understand the importance of snacks to achieve weight gain
and/or improve albumin value.
• The patient will understand the importance of continued intake of well-balance

meals and/or snacks when discharged.
body weight and that weight may not be the same as the traditionally defined
desirable or ideal body weight.
that will ultimately achieve an intake of calories and protein to achieve weight gain
and/or improve albumin lab value. The nutrition plan shall be tailored to address any
metabolic abnormalities. It shall provide the patient with the opportunity to acquire the
knowledge and skills necessary to change or maintain eating habits.

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Total Parenteral Nutrition/Peripheral Parenteral
Nutrition/Enteral Nutrition
The overall goal is a collaborative treatment with the patient and clinician members of
the health care team to assess the individual, to identify goals, to intervene to achieve
those goals, and to evaluate the outcomes.
IN-PATIENTS:

and maintainable, both short-term and long-term and may not be the same as the
traditionally defined desirable or ideal body weight.
• Assist the patient to improve overall health through assisted nutrition.
• Assist the patient to achieve and/or maintain normal lab values for albumin,
lymphocytes, calcium, RBC, HGB, HCT, etc.
• The patient will be able to gain/maintain a reasonable weight
• The patient will be able to achieve and/or maintain normal lab values.
The registered dietitian will assess the caloric needs of the patient based on ideal body
weight for height for activity for injury and the need for supplements using current
knowledge of medical nutrition therapy and scientific theory.
This registered dietitian will consider the individual’s needs and suggest an assisted
feeding program for patient use that will ultimately provide adequate calories, protein,
and nutrients.
This registered dietitian will document the patient’s tolerance to the assisted feeding
program. This registered dietitian will make plans for monitoring the patient.

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Total Parenteral Nutrition/Peripheral Parenteral
Nutrition/Enteral Nutrition (continued)
Session 1: Assessment, care plan and document
Session 2: Give diet instructions and document understanding
OUT PATIENTS:
• Same as above regarding goals/outcomes/sessions

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Nutritional Parameters for Pediatric

Patients in ICU/IMCU
• Obtain height and weight.
1. Evaluate if below 90th percentile for age.
2. Request Nutritional Consult by registered dietitian if below the 90th

percentile.
• Monitor if NPO is over 2 days, if no clear liquids over 3 days, if on full liquids over
5 days. (This is already being done on all in-patients regardless of age.)
1. Request diet change from physician if on clear or full liquids over days
specified above.
2. If NPO but bowel sound are present, request physician order enteral
nutrition if patient is unable to eat.
3. If NPO but no bowel sounds are present, request physician to order TPN
or PPN.
4. If eating poorly (less than 75% of all trays), request nutritional evaluation
by registered dietitian.
• If pediatric patient sustained major injuries, burns, or has a fever, request

nutritional evaluations by registered dietitian for supplements or snacks between
meals.

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Cancer Side Effects – Radiation or Chemotherapy
health care team to asses the individual, to identify goals, to intervene to achieve those
IN-PATIENTS:
• Assist the patient and/or family members in making changes in nutrition habits
leading to alleviation of such symptoms as nausea, vomiting, diarrhea,
constipation, loss of appetite, taste changes, difficulty swallowing, or weight loss.
• Assist the patient and/or family members to be able to identify five foods the
patient can tolerate in their diet.

be the same as the traditionally defined desirable or ideal body weight.
• The patient will be able to identify five foods the patient can tolerate in their diet.
• The patient will be able to identify which foods result in sick symptoms as
nausea, vomiting, diarrhea, and constipation.
• The patient will understand why there is a loss of appetite.
• The patient will understand why there are taste changes.
• The patient will understand how to adjust texture of food if having difficulty
swallowing.

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Cancer Side Effects – Radiation or Chemotherapy
(continued)
• The patient will be able to write a menu for at least 1 day.
weight. This weight may not be the same as the traditionally defined desirable or
ideal body weight.
that will ultimately achieve adequate calories, protein, and nutrients in addition to
alleviating the side effects described above as much as possible. The nutrition plan
shall provide the patient with the opportunity to acquire the knowledge and skill
necessary to change or maintain eating habits.
The registered dietitian will document the patient’s significant other response and
progress in understanding the diet.
The registered dietitian will make plans for monitoring the patient.

persons with cardiac problems. The registered dietitian is available to determine
if dietary intake is adequate.
Session 1: Assessment, Care Plan, Document
Session 2: Give diet instruction, Document understanding
Session 3: Invite patient to education classes if held by hospital
OUT PATIENTS
Session 1: Follow up, answering questions either by phone or appointment.

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Cardiac Rehab/Cardiac
IN-PATIENTS:
• Assist the patient with cardiac problems in making changes in nutrition and/or
exercise habits leading to improved cardiac control.
• Assist the patient to be able to maintain as near-normal blood pressure as

possible by balancing sodium content of foods intake with activity.
• Assist the patient to achieve optimal serum lipid levels.

be the same as the traditionally defined or ideal body weight.
• The patient will understand the difference between unsaturated and saturated
fats
• The patient will understand which foods contain cholesterol
• The patient will understand which foods raise blood cholesterol
• The patient will be able to identify the amount of fat recommended on a low-fat
diet.
• The patient will be able to identify foods considered high in sodium content.
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Cardiac Rehab/Cardiac (continued)
• The patient will be able to understand the role of fiber and cholesterol.
• The patient will understand how to read food labels including how to calculate
percentage of fats in foods.
• The patient will understand how to make recipe modifications for low-fat/low
sodium/low cholesterol diet.
• The patient will understand the concept of the food pyramid and portions.
• The patient will be able to select their menu correctly.
• The patient will be able to understand how to achieve optimal serum lipid levels.
weight and that weight may not be the same as the traditionally define desirable
or ideal body weight.
that will ultimately achieve a distribution of 50% or more carbohydrate, 10-20% protein,
30% or less fat (with less than 10% of energy from saturated fats, up to 10% of energy
for polyunsaturated fats, and 10% or energy from monounsaturated fats.
The emphasis shall be placed on achieving lipid, and blood pressure goals. Monitoring
lipid status and body weight is essential to assess the effectiveness of any nutrition
recommendations.

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Weight loss and the use of hypocaloric diets to achieve weight loss usually improve
short-term lipid levels and have the potential to increase long-term lipid control. The
goal of achieving and maintain a reasonable weight needs to remain the main objective.
If obesity and weight loss are the primary issues, a reduction in dietary fat intake is an
efficient way to reduce caloric intake and weight, particularly when combined with
exercise.
If elevate low-density lipoprotein cholesterol is the primary problem, a diet in which less
that 7% of total energy is from saturated fat, 30% of less of the energy are from total fat,
and the dietary cholesterol is less than 200 mg per day shall be implemented.
If elevated and very-low-density lipoprotein cholesterol are the primary problems, a diet
in which 10% or less of the energy is from saturated fat, 10% or less of the energy is
from polyunsaturated fats, and 20% of the energy from monounsaturated fats, and more
moderate intake of carbohydrate shall be implemented.
If elevated triglycerides and very-low-density lipoprotein cholesterol in the obese

individual are the problems, the fat contents of the diet may need to be limited further
than outlined above.
meal plan does not impair blood lipid control in individuals with cardiac problems

all persons with cardiac problems.
for the general population – 20 to 35 grams dietary fiber from a wide variety of
food sources.
• Sodium: Intake recommendations for persons with cardiac problems are the
same as for the general population – 3,000 mg. or less per day. For persons with
mild to moderate hypertension, 2,400 mg or less per day is recommended.

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• Alcohol: Intake recommendations for persons with cardiac problems are the
same as for the general population. Abstention from alcohol shall be advised for
request.

persons with cardiac problems. The registered dietitian is available to determine
if dietary intake is adequate.
Session 1: Assessment, care plan, has resident answer Knowledge Assessment, and
document

and document understanding
OUT PATIENTS
• Follow up answering questions either by phone or appointment

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Home Discharge Instructions

POLICY
The Dietary Manager will provide instructions to patients discharged to home requiring
special dietary instructions in order to insure that continuity of nutritional care is
maintained for patients discharged to home.
PROCEDURE
• Social Service or Nursing Department will inform the Dietary Manager of

estimated date of discharge.
• The patient will be instructed and given a diet instruction sheet to take with
her/him. Diet instructions may be given to relatives or others that may be
providing meals to the patient.
• The Dietary Manager completes and signs the discharge instructions form. In the
Dietary Manager’s absence, the Charge Nurse will do so.
• A copy of the Home Discharge Instructions form given will become part of the
medical record.

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Diet Counseling
POLICY
The Dietitian and/or Dietary Manager will provide special diet counseling to patients
and/or responsible parties when appropriate.
PROCEDURE
• Special diet counseling can be requested by the patiently, physician, or Director

of Nursing.
• Requests will be transmitted on a standard diet order form.
• Special diet counseling will be initiated by the Dietary Manager or Dietitian when
beneficial and appropriate.
• When counseling has been completed, a progress note will be written indicating
date of counseling and patient response.

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Patients Need for Palliative Care

POLICY
Patients at need for Palliative Care will receive optimal quality of life by management of
physiological symptoms as well as psychological, spiritual, and social issues.
• Palliative Care is the active total care of a patient when cure is no longer
possible. The goal is optimal quality of life for patients and families by
management of physiological symptoms as well as psychological, social and
spiritual issues. Palliative nutrition therapy focuses on patient enjoyment, relief of
symptoms, and maintenance of energy and strength. Optimizing nutrition status
to delay, decline is an appropriate goal if in accordance to patient/caregiver
wishes. It is important to have clear advance directives regarding hydration and
nutrition. Palliative care is just as energetic as curative care, abolishing the
philosophy that nothing more can be done. A dignified, natural death is the
ultimate outcome. An interdisciplinary team approach is essential to optimal
palliative intervention.
1. Provide favorite foods. Small frequent meals are often better tolerated.
2. Smaller plates and cups can make small portions look more complete.
3. Make eating area as attractive as possible.
4. Encourage patients to wash and dress for meals if possible.
5. Encourage eating at table when possible and eating with others.
6. Monitor patient likes and dislikes as tastes and preferences can change
frequently.
7. Do not push food. If patient does not feel like eating, remove food without
incident.
8. Encourage activity to stimulate appetite.
9. Let the patient be in control.
10. Documentation of weight loss or degree of malnutrition is recommended
when appropriate to denote decline or show appropriateness of hospice
care. When repletion is not a goal; weight loss shall not be stressed in
communication with the patient unless it is their desire to do so. Monitor
needs for diet modification in relation to symptoms.
11. Special diets are only to be used to control symptoms or increase comfort.

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Criteria for Intervention With Abnormal Labs

POLICY
Abnormal labs for geriatrics will be reviewed and intervened on appropriately.
PROCEDURE
• When the following labs appear they will be put on the nutrition intervention list
for RD:
1. Hgb(M) < 12.0 gm/dl }

(F) < 10.00 gm/dl } MCV up or down indicator
2. Hct(M) < 37.0% } Refer to RD for type of anemia –

disregard
(F) < 31.0% } when patient has diagnosis of
Thalassemia
3. Glucose 1) Criteria noted by MD or

2) <70 mg/dl or > 200 mg/dl if on oral hypoglycemic
agent
4. Albumin < 3.5 g/dl or as indicated as low based on the lab used
5. K+ > 6 mEq/L or <3.5 mEq/L
6. Na < 130 mEq/L (130 mEq/L is considered hyponatremia)
7. Elevated BUN – Intervene if serum creatinine is > 1.5 mg/dl

Then use GFR formula to calculate protein needs, unless on
dialysis
8. Magnesium < 1.3 or > 2.0 mEq/L
• In calculating hydration status, consider the following guidelines:
1. Labs which can be indicators for dehydration are: ↑ Hct, ↑ Hgb, ↑ RBC, ↑
Na, ↑ Cl, ↑ specific gravity of urine, ↑ total protein, ↑ Transferrin, ↑ BUN, ↑
BUN/creat, and ↑ albumin.
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Criteria For Intervention With Abnormal Labs (continued)

2. Labs can be altered by factors other than hydration, therefore recommend
utilizing serum Osmolality formula which denotes fluid status.
♦ Osmolality formula is as follows:
Osmolality = (serum Na (mEq/1) x 2) + Glucose(mg/dl)

+BUN(mg/dl)
18 2.8
♦ An Osmolality of less than 285 mOsm/1 indicates water excess, an
osmolality of greater than 295 mOsm/l indicates water
deficit.
3. Consult with nursing regarding fluid intake and output, glucose levels and
potential fluid losses. Refer to doctor. Follow hydration protocol.

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Recommendation to Nursing/Fax Consultation
POLICY
When a nutritional problem is observed by the Dietitian and a change in diet order is
needed, the Dietary Recommendation form is to be used. Requests from facilities and
RD recommendations by phone consultation must be in writing and be kept confidential
and private.
PROCEDURE
• In making dietary recommendations, use the “Dietary Recommendation”* form

and note room number, patient’s name, nutritional problem, and
recommendation.
• Date the form and given recommendations to the Charge Nurse and DON.
Nursing is to return the completed recommendation form to the Dietary Manager
within 72 hours. Follow Best Practice Guidelines in making recommendations.
Follow state regulations regarding scope and practice of the Dietary Manager’s
ability to make recommendations.
• A facility may call their Dietary Consultant for consultation regarding tube
feeders, TPN, weight loss, pressure ulcers, abnormal labs, dialysis, etc. Avoid
verbal recommendations.
1. The “Dietitian Fax Consultation”* form (Form 127) shall be filled out by the
DM, DT, or RN and faxed to the RD. Be sure to contact the RD before
faxing to assure availability. This is to be treated as confidential/private
information.
2. The RD will complete the “Enteral Feeding Review”* for TF or the “NAR
Sub acute”* (Form 109) and the Dietary Recommendation Form and fax to
the facility within 24 hours or sooner where possible. The Dietitian is to
shred the “Dietitian Fax Consultation,” “Enteral Feeding Review,” or any
other assessment forms and recommendations left in her possession in
order to protect the privacy of patients. Do not do fax consultation by
email.
3. File the Dietitian Fax Consultation, Enteral Feeding Review for TF or the
NAR Sub acute forms in the dietary section of the medical record.
4. The facility shall follow up promptly on the RD recommendation.
5. Fax consults are based on the information provided by the facility.

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Recommendation to Nursing/Fax Consultation (continued)

6. If in a public place, the Dietitian shall be at the fax machine waiting for the
fax consultation. The fax cover sheet shall indicate the confidentiality of
the information in the “Dietitian Fax Consultation” and that it is intended
only for the use of the individual named on the fax. The fax cover sheet
shall also indicate that if the fax was received in error, the sender shall be
notified by telephone and the original of the transmittal be destroyed
immediately.
7. When faxing information regarding patients, be sure to attach the
confirmation of the fax to the original fax to assure that the correct party
has received this information.

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Nutrition Intervention Request Form

POLICY
The Dietary Manager is to keep a list of patients on the “Nutrition Intervention Request
Form”* that the Dietitian is to review on the next consultation.
PROCEDURE
• The Dietary Manager is to note on “Nutrition Intervention Request Form”*

patients who screened high risk.
• The Dietitian will review and assess their nutritional status within 48 hours of
identification and note date assessed on Nutrition Intervention Form.
• A copy of the “Nutrition Intervention Request Form”* is kept in the Nutrition
Intervention

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Refusal of Treatment
POLICY
It is the policy of Cochise Regional Hospital that each patient has the right to refuse
treatment. A POA signature will be required if patient is not his/her POA.
PROCEDURE
• When the patient refuses a medication, treatment procedure, a diet order or

liquid modification, the refusal is to be immediately reported to the witnessing
employee’s supervisor and the exact refusal documented in the patient’s clinical
record.
• The attached form is to document the patient’s refusal of treatment when the
refusal is consistent and persistent. Progress notes will also contain
documentation, instance by instance, of the patient’s refusal. This form is to
become part of the clinical record and the sign off on the refusal of treatment
form. The physician shall then write a new diet order without the restriction. If this
is not obtained, then the patient will be advised of their doctor’s clinical judgment.
• The patient shall be informed of the health problem(s) created by refusal of

treatment. Documentation of the counsel if required.
• Patients who have refused treatment and who have signed a refusal of treatment
form will have this reviewed with them on a quarterly basis. Such reviews will be
documented on the patient’s care plan. A new “Refusal of Treatment Form” will
be completed annually.
INTERPRETIVE GUIDELINE 483.10 (B) (4)
“The patient’s refusal of treatment must be persistent and consistently documented in

the patient’s record. Refusals shall also be countered by discussions with the patient of
the health and safety consequences of the refusal and the availability of any therapeutic
alternatives that might exist.”

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Refusal of Treatment Form

I , do hereby refuse the use of the following M.D. order for
.
I fully understand that the recommended treatment is for my benefit and safety. I have
been informed, by the staff of this facility, of the reasons for the diet or consistency
modification ordered by my physician. I have also been informed of the alternatives
available (if any) and the implications of my refusal.
I have been informed of the following reasons for the diet/consistency modifications my
physician has ordered for me:
I have been informed that the implications of my refusal are as follows:
_________________
I have been offered the following alternatives and have refused them:
I take full responsibility for this decision and waive all liability against the facility,
, by exercising my right to refuse treatment.
Patient’s Signature Date
Responsible Party Date
Physician Date
Speech Therapist Date
Nursing Staff Representative Date

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Fluid Restriction
POLICY
To provide patients who have a written physician order for fluid restriction an
appropriate amount of fluid each day while allowing nursing adequate fluid to supply
mediations, etc. each shift.
PROCEDURE
• Physician’s order for fluid restriction is a diet order and must be reported in the
usual manner to the Dietary Department.
• For a diet with fluid restrictions, the following distribution is used by nursing and
dietary.
Fluid Total By Shift Total Breakfast Lunch Dinner
Restriction Nursing Dietary
150 cc day
1000 cc 300 cc 150 cc eve 700 cc 360 cc 180 cc 160 cc
0 noc
150 cc day
0 noc
150 cc day
0 noc
150 cc day
0 noc
150 cc day
0 noc
150 cc day
0 noc
150 cc day
100 cc noc
190 cc day
120 cc noc
240 cc day
120 cc noc
290 cc day
120 cc noc
340 cc day
120 cc noc
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Hydration Protocol
POLICY
Patient will be provided sufficient fluid intake to maintain hydration and health.
PROCEDURE
• Each patient will be assessed for fluid need by one of the following methods:
1. 30 cc/kg body weight except patients with renal or cardiac distress. With a
diagnosis of CHF without diuretic use 20-25 cc/kg per day.
For those 130% or greater of IWR use this formula: (10 kg x 100 ml) + (10kg x 50 ml) +
(patient’s wt in kg – 20 kg x 15 ml) = adjusted needs for obesity.
For elderly never give less than 1500 cc/day.
For pediatrics see Clinical Charting Handbook for reference.
• In the nutritional review process, identify patients with a diagnosis of dehydration

or at risk of dehydration, i.e. those on diuretics, dependent on staff for provision
of fluids and intake of food, enteral nutrition support, poor intake, poor cognitive
skills, reduced mobility, fever, etc.
• Develop a plan of care for patients that are dehydrated or at risk of dehydration.
• Obtain beverage preferences and on each tray serve those beverages permitted
by their diet order.
• Offer 8 oz water each meal, 16 oz milk per day, 6 oz juice at breakfast and HS
snack, and (preferably) decaffeinated coffee or tea on each tray if desired. On
each room tray send the coffee or hot tea in an insulated coffee mug with a lid to
ensure less chance of patients burning themselves. In the dining rooms staff
members will pour hot beverages at the dining room tables. Do not leave hot
beverages in the dining rooms for patients to help themselves due to the danger
of burning themselves. Beverages containing caffeine cannot be counted as cc’s
of fluid. Recommend decaffeinated beverages.

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Hydration Protocol (continued)

• Hydration carts or other methods determined by the facility are recommended
between meals. Have an unsweetened drink, i.e. diet punch, diet lemonade, or
ice water and rotate through the facility offering beverages to each patient. Be
sure that fluid restricted patients and thickened liquid patients are identified. Have
thickened liquids available on the hydration cart. Snow cones and popsicles
could be given as part of an activity a couple times per week. Use Hydration Cart
List to note patients who are at risk of dehydration or who are dehydrated to
assure extra hydration.
• In calculating fluids available or consumed by a patient, it is important to

recognize that nearly all foods contain water. Most fruits and vegetables contain
up to 95% water and many meats and cheeses contain at least 50% water. Also,
water is generated from the energy of nutrients in food during metabolism. With
an intake of 75-100% of meals per day, foods will furnish approximately 700-
1,000 cc plus metabolic water 200 to 300 cc to total 900-1,300 cc/d plus liquids
on the trays and in-between meals. Foods that are liquid at room temperature,
i.e., gelatin, sherbet, etc. also offer extra hydration. Per facility policy, these
liquids will be counted.
A normal regular diet furnishes:

Breakfast Lunch Dinner Bedtime
8 oz water 8 oz water 8 oz water 6 oz juice
8 oz milk 8 oz C/T* 8 oz milk ----------
6 oz juice --------- 8 oz C/T* ----------
8 oz C/T* --------- ----------- ----------
(900 cc) + (480 cc) + (720 cc) + (180 cc) = 2280 cc
Total
* Decaffeinated – Coffee/Tea
Source: UNDERSTANDING NUTRITION. Whitney & Rolfes Sixth Edition

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Hydration Protocol (continued)
• Fluid measurements of common containers and foods:

Containers:
2 fl oz glass/cup
60 cc
4 fl oz glass/cup
120 cc
6 fl oz glass/cup
180 cc
8 fl oz glass/cup
240 cc
10 fl oz glass/cup
300 cc
12 fl oz glass/cup
360 cc
1 quart (32 fl oz) 950
cc
1 liter
1000 cc
Reference:
1 oz
30 cc
1 Tbsp
15 cc
1 Tsp
5 cc
Foods:
Gelatin (1/2 c)
120 cc
Ice Cream/Sherbet (4 oz)
60 cc
Fruit Ice/Sorbet (3 oz) 75
cc
Popsicle
90 cc
Yogurt (1/2 c) 90
cc
Soup (6 oz)
165 cc

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Dietary Member of Quality Assurance Committee

POLICY
The Dietary Department Manager participates as a member of the facility’s Quality

Assurance Committee.
PROCEDURE
• The quality assurance program of the Dietary Department is under the

responsibility of the Dietary Department Head.
• The Dietary Department Head appoints a committee of dietary employees

(including the consultant RD) to develop a written quality assurance plan for the
department.
• The committee will identify indicators from important Aspects of Care.
• Each indicator will be measurable in actual numbers.
• A threshold of accepted level of performance shall be set for each indicator.

Thresholds to be 0 – 100%.
• The department head will collect data for monitoring and evaluating all aspects of
QA activity.
• The sample size will be specified in the departmental QA plan.
• The frequency of data collection will be specified on the yearly plan.
• The departmental QA plan will be evaluated yearly and a new plan and calendar
made for the following year.
• A minimum of a quarterly report will be made to the Facility QA Committee.

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Quality Assurance Calendar

POLICY
“Quality Assurance Calendar” * will be prepared annually.
PROCEDURE
• The indicators developed by the departmental QA Committee will be listed.
• The performance threshold for each indicator will be shown in the appropriate
space, as a percentage.
• The date the quarterly report is due will be indicated under the appropriate month
showing the date due in the column headed due.
• When the report is completed the performance level will be shown under the
appropriate month in the “perf” column as a percentage.
• The QA Calendar is kept in the Quality Assurance Manual.

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Patient Satisfaction Survey

POLICY
To assure quality food service a quarterly Patient Satisfaction Survey will be conducted.
PROCEDURE
• Approximately 10% of the patients will be surveyed quarterly using the “Patient
Satisfaction Survey”.*
• The surveys will be summarized on the “Patient Satisfaction Survey Summary.”
• These results can be averaged quarterly and used on the Quality Assurance
reports.
• Action shall be taken to correct reoccurring problems.
• Surveys and Summary shall be placed in the Quality Assurance Manual.

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Quality Assurance Report

POLICY
A report will be written to the QA Committee a minimum of each quarter on each

indicator.
PROCEDURE
• On the date shown on the yearly QA Calendar a “Quality Assurance Report”* will
be written on each indicator.
• The “Quality Assurance Report”* will be written showing actual numbers

monitored and numbers out of compliance. A percentage will be calculated to
compare to the threshold.
• The method of collecting the data will be shown.
• The findings will be reported numerically. Those cases not meeting standards
will be investigated and the findings reported.
• The corrective action will be shown when the threshold is not met. It must be a
change in procedure that involves an action to improve quality of care.
• Follow up to monitor the effectiveness of the action is to be shown.
• File Quality Assurance Reports in Quality Assurance Manual.

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Quality Assurance Manual

POLICY
There shall be a Quality Assurance Manual established in the Dietary Department.
PROCEDURE
The Quality Assurance Manual is to include:
• QA plan (departmental) with list of yearly indicators, objectives, method of

reviewing, and thresholds.
• Calendar showing yearly dates for reporting to QA Committee (usually quarterly)
• Copies of quarterly reports for indicators (Report necessary only when below
threshold)
• NAR/QI Summaries
• Satisfaction Surveys
• Meal Temperature/Test Tray/Cooling Monitor
• Refrigerated Units
• Dish machine Temperatures and Pot & Pan Testing

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The Ten Step Monitoring

And Evaluation Process
• Assign responsibility;
• Delineate scope of care;
• Identify important aspects of care;
• Identify indicators related to these aspects of care;
• Establish thresholds for evaluation related to the indicators;
• Collect and organize data;
• Evaluate care when thresholds are reached;
• Take actions and improve care;
• Assess the effectiveness of the actions and document improvement; and
• Communicate relevant information to the organization-wide quality assurance

program.

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Dietary Department Quality Assurance Plan

Facility: Cochise Regional Hospital Effective Date:
POLICY
The Dietary Department strives to provide the patients, visitors, and employees with a
safe environment and meet their nutritional care in order that the hospital can provide
the health services necessary to complete its role in the community.
This is accomplished by providing continuous assessment, monitoring, and reevaluation

of quality and appropriateness of nutritional care.
RESPONSIBILITY
The Dietary Department is operated by the hospital. An independent hospital contracted

dietitian will be responsible for the Quality Assurance and Performance Improvement
activity for the Dietary Department with assistance from the Director of the Dietary
Department.
The dietitian oversees that the standards of care identified by this department are
consistently adhered to throughout.
SCOPE OF SERVICES
• Evaluation of quality and appropriateness of nutritional care
• Education of patients and families
• Management of information
• Evaluation of inpatient food service
As an integral part of this plan, processes for improvement, indicators, targets for
improvement, and data source are documented on the Key Functions and Trend
Analysis forms for this department.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Dietary Department Quality Assurance Plan (continued)

ANALYSIS OF DATA
The results of this data will be analyzed at each step of performance improvement. The
findings of the data will help us reach conclusions about the action we need to take for
the process to develop specific recommendations for action and then initiate
improvements based on the analysis of the data.
Stage One: The data on our indicators will give us a benchmark for improvement and
allow us to identify process flaws and poor results.
Stage Two: In processes where we identify process flaws or poor outcome, we will use
the data to help identify root cause of the flaws, poor results or non-compliance with our
standard.
Stage Three: As we implement process improvements, we will use the data to compare
our improvements since we initiated the improvements. We will also use the data to
assure that we are maintaining the improvement.
QUALITY ASSURANCE/PERFORMANCE ACTION
Out improvement activities will involve staff from Dietary and other departments.
Process improvements will involve a variety of strategies that include:
• Corrective action by the director or staff.
• Performance improvement teams of departmental staff members.
• Ad hoc interdepartmental performance improvement teams as necessary.
ASSESSMENT OF EFFECTIVENESS AND CONSOLIDATION
Monitoring is continued to assure that the action taken has improved the process and
that the improvement is being maintained. The department managers list the actions
that they will take to assess the effectiveness of corrective action:

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Dietary Department Quality Assurance Plan (continued)

The following elements shall be included:
• Document new procedure in writing.
• Train existing staff in the new procedures.
• Orient new employee to the new procedure.
• Continue monitoring the process on a set schedule.
After improvements have been implemented, we will continue to monitor the results of
the improved process to assure that the improvement is maintained.
In addition to the follow up measurements, we will institute the following actions to

assure continued improved performance:
• Any process improvement will be documented. If a new procedure is required,

we will draft it and communicate to hospital employees, department managers,
and members of Dietary and Medical Staff.
• All personnel involved will receive training on the new procedure.
• New employee orientation and refresher training will include the new procedure.
REPORTING
Improvement activities will be documented and reported through the hospital’s channels
of communication as identified in the policy and procedure for QA Reporting.

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Quality Assurance/Performance
Improvement Reporting Process
Facility: Cochise Regional Hospital Effective Date:
POLICY
• Quality Assurance/Performance Improvement Worksheet (Form A) will be used
monthly to monitor the quality of care given by the dietary department. Choose at
least four key functions per year to monitor.
• The Quality Assurance/Performance Improvement Trending Sheet (Form B) is a
record of compliance to the key functions/performance measures by month for
each department. The trending sheet is to be completed monthly, maintained in
Departmental QA manuals and a copy forwarded to the QA Department/QA
Coordinator.
1. Top triangle under each month is for the number of charts, patients, trays,
temperatures, charts, or sanitation lists reviewed.
2. The bottom triangle is for percent of compliance.
Example: If 10 patients reviewed and 5 met criteria being monitored, 50%

would be in compliance.
• Departmental monthly meeting minutes (Form C) must reflect discussion and

recommendations/actions with staff for each threshold not met. Minutes of
meetings are to be maintained in Departmental QA manuals.
• Complete Quarterly Performance Improvement report sheet (Form D) for each
key function being reviewed. This report is to be maintained in the Departmental
Quality Assurance Manual and a copy forwarded to the QA Department.
• At the end of the year, complete the Annual Department Performance
Improvement Review (Form E).
• Review of forms * needed:
1. Form A Quality Assurance/Performance Improvement Worksheet
2. Form B Quality Assurance/Performance Improvement Trending Sheet
3. Form C Departmental Monthly Minutes
4. Form D Quarterly Performance Improvement Report
5. Form E Annual Performance Improvement Review

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Performance Indicators
Dietary Department:
NUTRITIONAL CARE
Key Function: Evaluation of Nutrition Screening
Sample Size: Minimum 20 charts per month Data Source: Medical Record
1. Was screening done within 24 hours of admission?
Threshold/Benchmark: 90% Disciplines Involved: Dietary Staff, Nursing Staff
2. Were nutritional problems identified?
3. If problems identified , was a nutrition assessment completed?
4. Was action initiated to correct the nutritional problem:
Key Function: Evaluation of appropriateness of diet order to diagnosis

Sample Size: Minimum 20 charts per month Data Source: Medical Record
1. Did the diet provide adequate calories?
Threshold/Benchmark: 100% Disciplines Involved: Dietary Staff, Physician
2. Was adequate protein being provided?
Threshold/Benchmark: 100% Disciplines Involve: Dietary Staff, Physician
3. Was the diet order in according with the hospital approved diet manual?
Threshold/Benchmark: 100% Disciplines Involved: Dietary Staff

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Performance Indicators (continued)

4. If not, were alternative recommendations communicated to physician?
Key Function: Evaluation of nutrition education
Sample Size: All patients with physician ordered Data Source: Medical Record
diet instruction
1. Patient referred by physician order given instructions within 24 hours

(weekends/holidays exempt)
2. Patient’s receipt of written educational material documented in medical record
3. Patient’s verbalization of understanding diet information documented in medical record
Key Function: Evaluation of quality and appropriateness of nutritional care given to patients on
tube feedings or on TPN
Sample Size: All patients on tube feeding or TPN Data Source: Medical Record
1. Was current order evaluated for appropriateness?
2. If inadequate or not tolerated, was an alternate recommendation made?
Threshold/Benchmark: 100% Disciplines Involved: Dietary Staff, Nursing Staff,

Physician

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3. Was dietitian’s recommendation communicated to physician?
Threshold/Benchmark: 100% Disciplines Involved: Dietary Staff, Nursing

Staff,
Physician
4. Was the recommendation followed up on?

Staff,
Physician
Key Function: Evaluation of quality and appropriateness of nutritional care given to

patients with decubitis ulcers.
Sample Size: All patients with decubitis Data Source: Medical

Record
2. If inadequate or not tolerated, was an alternate recommendation made?

Staff, Physician
3. Was dietitian’s recommendation communicated to physician?

Staff, Physician

Staff, Physician

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Key Function: Evaluation of Nutritional Assessment
Sample Size: Minimum 20 charts per month Data Source: Medical

Record
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1. Was diet evaluated for appropriateness?

Staff, Physician
2. Were patient’s nutritional needs assess and noted as to being met or not met?

Staff
3. If not met, was intervention communicated to the physician?

Staff, Physician

Staff, Physician
Key Function: Evaluation of quality and appropriateness of nutritional care given to

patients with (any one of the following):
Liver failure Surgery and > 65 years with low weight or albumin <
3.0
Renal failure Ideal body weight at 90% or less
Active Cancer Albumin 3.0 or less
Malnutrition Glucose of 200 or more
Stroke
Sample Size: Minimum 20 charts per month Data Source:

Medical Record

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Staff, Physician
2. Were patient’s nutritional needs assessed?

Staff
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3. If not met, was intervention communicated to the physician?

Staff, Physician

Staff, Physician
Key Function: Evaluation of patients NPO or on supplemental clear liquids greater than
3 days
Sample Size: all patients NPO or on clear liquids Data Source:
Medical Record
1. Have these patients been pricked up and tracked on the NPO and/or clear liquid
monitoring form?

Staff, Pysician
2. Was a Nutritional Assessment completed with 24 hours from Day 3?

Staff
3. Was an intervention communicated to the physician?

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Staff, Physician
4. Was the recommendation followed up on ?

Staff, Physician
ORGANIZATIONAL PERFORMANCE IMPROVEMENT
Key Function: Evaluation of inpatient food service
Sample Size: 20 patients on hospital diet Data Source:

Medical Record
excluding tube feeding patients
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1. Was the food taste and presentation acceptable?
2. Was the food temperature satisfactory?
Threshold/Benchmark: 90% Disciplines Involved: Dietary Staff,

Nursing Staff
3. Was the food amount adequate?
4. Was the meal time schedule satisfactory?
Key Function: Evaluation of appropriateness of diet order to diagnosis
Sample Size: Minimum 20 charts per month Data Source:

Medical Record
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1. Did the diet provide adequate calories?
2. Was adequate protein being provided?
3. Was the diet order in accord with the hospital approved diet manual?
4. If not, were alternative recommendations communicated to the physician?
Key Function: Evaluation of Sanitation

Data Source: Sanitation checklist of entire kitchen
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1. Was monthly sanitation survey done by Registered Dietitian?
Threshold/Benchmark: 100% Disciplines Involved: RD, Dietary Staff
2. If sanitation problems are identified with a sanitation score of < 90%, daily
sanitation checks done with checklist until > 95% compliance.
Sample Size: 20 days

Key Function: Evaluation of Trayline Accuracy
1. Has monthly trayline survey been done by Registered Dietitian?
Threshold/Benchmark: 100% Disciplines Involved: RD, Dietary Staff
2. If trayline problems are identified with a score of < 90%, daily meal inspections
are done with until > 95% compliance.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
Sample Size: 20 days
Key Function: Evaluate foods being served at appropriate temperatures
1. Have temperatures been recorded two times on every trayline for one month?
Threshold/Benchmark: 100% Disciplines Involved: RD, Kitchen Staff
2. Have incorrect temperatures been corrected?
Sample Size: 20 days of temp charts Data Source: Temperature Forms
3. If temperature problems are identified on food temperature form or through

satisfaction survey, do bedside temperature study until > 95% compliance.

Sample Size: 20 days of tests Data Source: Bedside Temperature
Form

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Dietary Department Quality

Assurance Philosophy
PURPOSE
The purpose of the quality assurance program is to ensure that the quality and
appropriateness of services provided by the Food Service Department meets the
identified standards and requirements.
PHILOSOPHY
Patients have the right to expect and professionals have the responsibility to ensure that
the services provided to patients are consistent with accepted standards of quality and
appropriate care. The Dietary Department will set accepted standards of performance
and monitor them to provide a baseline for improvement of services through revisions of
current practices and correction of performance to meet the intent of existing standards.
PROCEDURE
The departmental representatives will writ the standards of care and the critical
indicators used for monitoring compliance with the standards. Data are collected against
critical indicators, results are reviewed, and corrective actions are taken.
REPORTING
Routine data collection reports are done by the Dietary Manager/Dietary Technician and
monthly reports are compiled. The Dietary departmental committee meets and
discusses the results and action taken. The meetings are documented and minutes kept
of the meetings. A monthly report will be collected using indicators by the QA manager
for trending, analysis and identification of problems that need to be resolved. These will
be taken to the appropriate committees for recommendation.
CRITICAL INDICATOR AND CRITERIA
Critical indicators will be identified from discussions with the staff, patients and family.
They will be measurable in actual numbers to reflect solid practice of patient care as
defined in the policies and procedures of the Dietary Department. Each indicator will
have data collected monthly by the Dietary Manager. Action will be taken on areas
deemed necessary.
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Patient Rights – General Information

POLICY
The Dietary Department will make every effort to carry out the Patient Bill of Rights to its
fullest extent and will follow specific guidelines pertaining to patient rights.
PROCEDURE
• The Dietary Department will maintain guidelines that clarify a dietary application
of patient rights.
• Patient right guidelines will be part of the Dietary Policy and Procedure Manual.
• All employees will be oriented to the dietary application of the patient rights.
These will be reviewed with all employees on an annual basis during inservice.
• The Dietary Manager will be responsible for ensuring that patient rights are
carried through to the Dietary Department.
• Violation of a patient’s right by any employee will be considered a serious offense

and will be dealt with accordingly to ensure that it does not happen again.

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Patient Involvement In Nutritional Services

POLICY
The Dietary Department will make every effort to assist patients in the management of
their nutritional needs and environment. Systems will be developed that will allow
patients to voice their concerns and make suggestions.
PROCEDURE
• The Dietary Manager will maintain an attitude of cooperation and concern.
• The Dietary Manager will take immediate action on concerns and suggestions.
• The Dietary Manager will be responsible for evaluation of changes to ensure

patient concerns have been addressed.

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Information about Rights
POLICY
Upon admission, all patients will be informed of their legal rights at the facility. A written
statement of the applicable rights and responsibilities set forth, will be provided to all
patients. Reasonable accommodations shall be made for those patients with
communication impairments and who speak a language other than English. Current
facility policies and survey results will be made available to all patients, their guardians
or chosen representatives. The Data Privacy Act and Vulnerable Adult Act and federal
and state regulations will serve as sources for patient rights.
PROCEDURE
• Upon admission, patients will be given a brief explanation of their rights in

relation to Dietary and nutritional services. The Dietary Manager and/or Social
Worker will be responsible for this. This will include, but may not be limited to:
1. Right to refuse dietary restriction.
2. Right to participate in planning their nutritional treatment.
• Recent survey results, including dietary services, will be available to all patients,
their guardians or chosen representatives upon request.
• All dietary staff will be informed of patient rights as part of their job orientation
and in-service education.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Courteous Treatment
POLICY
The Dietary Department will ensure that patients are treated with courtesy and respect
for their individuality by all dietary staff.
PROCEDURE
• Patients will be addressed with their preferred name. Nicknames or general

names will not be used.
• All dietary requests and concerns will be addressed in a courteous manner. Any
request given to a dietary staff member by any patient will be promptly
addressed. Those concerns that cannot be addressed by the Cook or Dietary
Aide shall be communicated to the Dietary Manager.
• All family concerns regarding dietary services shall be courteously and promptly
addressed. If it cannot be promptly addressed, it shall be communicated to the
Dietary Manager.
• All patients will be referred to by their names and not by their diet name. (Rather
than saying “John Doe is a 1500 calorie diabetic,” the patient will be referred to
as “John Doe, who is on a 1500 calorie diabetic diet.”
• Patient case discussion and care plan review will take place in the facility at the
appropriate times and meetings. Employees will not discuss the dietary care
plan or any patient during breaks, in hallways, or in other inappropriate areas.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Appropriate Health Care

POLICY
Patients will have the right to appropriate medical, personal, and nutritional care based
on individual needs. Appropriate care for patients means care designed to enable
patients to achieve their highest level of physical and mental well being.
PROCEDURE
• Diet that is Appropriate to their Medical Condition.
• All patients will receive a diet which meets their nutritional needs. The Consultant
Dietitian will address the appropriateness of the diet ordered. Any diet that
appears to be inappropriate for the needs of the patient will be discussed with the
attending physician.
• Accuracy of Therapeutic Diet.
• Each patient has the right to receive a correct diet. Therapeutic diets will be
written by the Consultant Dietitian. The dietary staff will have the responsibility of
following the diets as written. The Dietary Manager has the responsibility to
ensure diet accuracy by dietary staff.
• Restorative Care.
• The patient has a right to restorative care to attain their highest physical and
mental functioning. Each patient will be assessed to identify nutritional needs.
Goals and approaches will be formulated to help them achieve their highest
physical and mental well being.
• Diet Progression.
• All efforts will be made to progress the diet from a textured, altered diet (blended,
mashed, soft) to a regular diet. The texture alteration will be part of the care plan.
The nursing and dietary assessment will help to identify the textures needed.
Progression of diet texture will be attempted and diet consistency will be part of
the attending physician’s order.
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Physician’s Identity
POLICY
Patients will have or be provided, in writing, the name, business address, telephone
number, and specialty, if any, of the attending physician responsible for the coordination
of their care. In cases where it is medically inadvisable (as documented by the attending
physician in a patient’s care record), the information shall be provided to the patient’s
guardian or other person designated as his representative by a patient.
PROCEDURE
• A patient will be provided with the name, address, and business telephone
number of the physician responsible for coordinating his plan of care.
• If a patient is unhappy with his/her diet, they will be provided, in writing, the name
and business telephone number of the physician responsible for coordination of
his care. The Director of Nursing, Dietary Manager, Consultant Dietitian, or
Charge Nurse can give this information to the patient. Any information requested
by individuals who are not the patient’s guardian or designated by the patient as
their representative, will be directed to the Charge Nurse.
• Facility and dietary staff shall attempt to act as advocates for the patients,
communicating any concerns to the Dietary Manager and attending physician.
Right to refuse care shall be considered and implemented. Concerns relating to
diet acceptance shall be reviewed with the Director of Nursing and Consultant
Dietitian. Adequate documentation of patient concerns and communication to the
attending physician shall be maintained. Every effort will be made to provide a
proper diet acceptable to all patients.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Information About Treatment

POLICY
Patient will be provided with complete and current information concerning their
diagnosis, treatment, alternatives, risks and prognosis, by their physicians, as required
by the physician’s legal duty to disclose. This information will be provided in terms and
language patients can reasonably be expected to understand. Patients may be
accompanied by a family member or other chosen representative. This information will
include the likely medical or major psychological results of the treatment and its
alternatives. In cases where it is medically inadvisable (as documented by the attending
physician in a patient’s care record), the information will be given to the patient’s
guardian or other person designated by the patient as his representative.
PROCEDURE
• Every patient will have the opportunity to receive diet instruction if they so
choose. The Dietary Manager shall begin initial instruction. This may be followed
up with a more detailed consultation by the Consultant Dietitian upon his/her visit.
• With the patient’s permission, family or significant others may review the
consultation and/or instructions about a patient’s diet.
• Documentation of teaching and/or consultation will be maintained in the medical

record.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Participation in Planning Treatment

POLICY
Patients will have the right to participate in the planning of their health care. This right
includes the opportunity to discuss treatment and alternatives with individual caregivers;
the opportunity to request and participate in formal care conferences, and the right to
include a family member or other chosen representative. In the event that the patient
cannot be present, a family member or other representative chosen by the patient will
be included in such conferences.
PROCEDURE
• Patients will have the right to attend patient care conferences and participate in
planning their treatment.
• Every effort will be made to ensure that the goals and approaches developed will
be in agreement with the patient. Approaches shall not be used unless they have
been discussed with the patient.
• If the patient cannot discuss goals and approaches, a representative chosen by

the patient or designated family member will be included in the development of
the nutritional care plan.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Freedom from Abuse

POLICY
Patients will be free from mental and physical abuse as defined in the Vulnerable Adults
Protection Act. “Abuse” means any act which constitutes assault, sexual exploitation, or
criminal sexual conduct or the intentional and non-therapeutic infliction of physical pain
or injury, or any persistent course of conduct intended to produce mental or emotional
distress. Every patient shall also be free from non-therapeutic chemical and physical
restraints, except in fully documented emergencies, or as authorized in writing after
examination by the patient’s physician, for a specified and limited period of time and
only when necessary to protect the patient from self injury or injury to others.
PROCEDURE
• At no time will food service be withheld from patient or, at no time will any
alteration of type of food service be used to modify a patient’s behavior.
• Facility staff may choose to serve dessert last during meal service to those
patients who may habitually consume their dessert first, thereby preventing them
from not eating the nutritional part of their meal. At no time shall dessert item be
totally withheld from a patient if he does not eat his main meal.
• Food will not be used as a means for behavior change if it results in a course of
conduct that produces mental or emotional distress.
• Every effort will be made by the hospital to provide a diet that the patient is
pleased with.

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Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Confidentiality of Records
POLICY
Patients will be assured of the confidential treatment of their personal and medical
records, and, may approve or refuse their release to any individual outside the facility.
Patients shall be notified when personal records are requested by an individual outside
the facility and may select a representative to accompany them when they are the
subject of a personal interview.
PROCEDURE
• All dietary staff will respect a patient’s rights to confidentiality.
• Confidentiality, as it relates to dietary services, includes, but may not be limited

to:
• Any observations of a patient made by a dietary personnel throughout the normal

working day will not be discussed with other employees.
• Tray cards are part of normal business practices, however, computerized tray
cards, once sent out on the resident’s tray, and shall be destroyed upon their
return to the department. Plastic reusable tray cards are returned to dietary after
the meal service, sanitized and kept in the department in a location where non-
dietary personnel can not see them.
• Refer to the policy on Recommendations to Nursing and Fax Consultations

regarding confidentiality in the respect to RDs doing fax consultations.
• Dietary Managers, diet technicians and registered dietitians will keep

assessments, recommendations, fax consultations, various lists of residents, i.e.,
pressure ulcer, weights, labs, thickened liquids, etc. confidential and in a location
where the public can not see them. When resident information is no longer
needed, i.e. weight records, skin reports, etc., they must be shredded before
discarding.
• Dietitian Consultation Reports that have resident information included in the

contents must be filed in a confidential notebook or file not accessible to the
public
Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Responsive Service
POLICY
Patients will have the right to a prompt and reasonable response to their requests and
questions.
PROCEDURE
• If a patient shall request a change in diet, this shall be communicated

immediately to the Dietary Manager and attending physician.
• If a patient requests that a certain food be omitted from his/her diet, the Dietary
Aide, Cook, or Dietary Manager shall immediately add this information to the diet
order.
• Requests shall be screened for diet accuracy. If it is not within the therapeutic
diet order, the request shall be communicated to the Charge Nurse, Dietary
Manager and/or Consultant Dietitian for their review.
• If a patient has a question concerning diet, nutritional service or meals, every

effort will be made to promptly respond. This is the responsibility of any staff
member to whom the question is directed.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
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Personal Privacy
POLICY
Patients will have the right to every consideration of their personal privacy, individuality
and cultural identity, as related to their social, religious and psychological well being. All
staff will respect the privacy of a patient by knocking first on a patient’s door and
seeking consent before entering, except in an emergency or where clearly inadvisable.
PROCEDURE
• All facility staff will treat each patient’s room as the patient’s home. They will
knock first and seek consent before entering, unless a patient cannot respond or
in the case of an emergency.
• All dietary consultations with a patient will take place in a private area. Any time a
diet, weight, or nutritional concern is discussed with a patient, it shall be done in
private. Dietary consultation shall not take place in an area such as the dining
room, hallway, or day room with other patients or employees present, as it will
infringe upon an individual’s right to privacy.
• The Dietary Department will honor the nutritional concerns of a patient in relation
to religion. Cultural identity of the majority of patients will be reflected in the
menus. Individual cultural identity will be followed as much as possible.
• Any diet or nutritional concerns affecting a patient’s psychological well being will
be communicated to the attending physician. The Charge Nurse, Dietary
Manager and/or Consultant Dietitian will be responsible for this.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.236
Page 1 of 1
O: 2002
Grievances
POLICY
Patients will be encouraged and assisted, throughout their stay at the facility or their
course of treatment, in order to understand and exercise their rights as patients,
patients and citizens. Patients may voice grievances and recommend change in policies
and procedures and services to facility staff and others of their choice, free from fear of
restraint, interference, coercion, discrimination or reprisal, including threat or discharge.
Notice of the grievance procedure of the facility, as well as addresses and telephone
numbers for the Office of Health and Human Services and the area nursing home
ombudsman, pursuant to the Older Americans Act, Section 307 (a)(12), shall be posted
in a conspicuous place for patient’s perusal.
PROCEDURE
• Every effort will be made by the hospital to address a grievance or concern of a

patient.
• The Dietary Department will welcome comments and suggestions to improve or

change food and nutritional services provided.
• The Dietary Manager will maintain written records of comments, concerns and
suggestions. Written reports of solutions and corrective action will also be
maintained.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.237
Page 1 of 1
O: 2002
Choice of Supplies or Supplier

POLICY
Patients may purchase or rent goods and/or services (not included in their per diem
rate) from suppliers/vendors of their choice unless otherwise prohibited by law. The
suppliers/vendors shall ensure that these purchases are sufficient to meet the medical
or treatment needs of the patient.
PROCEDURE
• The patient has the right to purchase food items from an outside source for
consumption in his/her room, providing that he/she can store food in a sanitary
manner as not to violate sanitation standards as specified by local health
agencies.
• If the request for food items are beyond the scope of the facility and not within
budget constraints of the facility, the patient shall be informed that these items
are not within the per diem rate.
• The patient shall be encouraged by the facility staff to make choices that follow
the patient’s prescribed plan of care, although the ultimate decision of food
choice and supplier is left to the patient.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.238
Page 1 of 1
O: 2002
Accommodation of Needs
POLICY
The facility will assist the patient in attaining services in the facility with reasonable
accommodations of individual needs and preferences, except where health and safety
of the individual or other patients would be endangered. The facility will also give the
patient notice if the patient’s room or roommate is to be changed.
PROCEDURE
• Reasonable accommodations will be made by the Dietary Department to those

patients with food preferences. A food preference inventory will be conducted
during the Initial Nutritional Screen by the Dietary Manager.
• Substitutes of like calorie value will be offered to the patient if the planned menu
is refused. If the patient refused the nutritional substitute, a menu of like caloric
value will be offered.
• Staff will act as an advocate for the patient who is unhappy with the therapeutic
diet ordered by the attending physician. Staff will make sure the Dietary
Manager and/or attending physician is aware of this situation.
• Food purchased from vending machines, brought in by family or friends of the

patient, or ordered by the patient will be considered personal property of the
patient. Staff will assist patient in storage of food in a safe, sanitary manner.
• The facility will utilize adaptive feeding devices to accommodate the needs of a
patient with self-feeding limitations. Adaptive feeding devices will only be used
with the consent of the patient and made part of the patient’s plan of care.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.239
Page 1 of 1
O: 2002
Social Services
POLICY
Medically related social services to attain or maintain the practicable physical, mental,
and psychological well being of each patient will be provided by the facility.
PROCEDURE
• The Dietary Department will work closely with social services to maintain or
improve each patient’s ability to control everyday physical needs (appropriate
adaptive eating equipment) and mental and psychological needs (sense of
identity, coping abilities, and sense of purpose or meaning).
• All efforts will be made by the Dietary Department to maintain communication

with the social services department to see that any food, nutrition or dining
environment concerns of a patient are addressed.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.240
Page 1 of 1
O: 2002
Environment
POLICY
The facility will be maintained in a safe, clean, comfortable and homelike setting to allow
each patient to use his/her personal belongings as much as possible. Housekeeping
and maintenance service in the Dietary Department will maintain a sanitary, orderly and
comfortable dining area.
Adequate and comfortable lighting, temperature levels, and noise levels will be
maintained at all times in the dining area.
PROCEDURE
• Cleanliness will be maintained in the dining area through regular cleaning

procedures following each meal. This includes tables, chairs, and walls as they
become soiled.
• Safety of the dining area will be maintained through:
1. Maintenance of chairs and tables;
2. Day to day wiping up of spills or picking up items that may present a

safety hazard.
• A comfortable environment will be maintained by:
1. Maintaining temperature levels at 71ºF to 81ºF;
2. Maintaining good ventilation, but with no drafts;
3. Comfortable lighting levels; and,
4. Comfortable sound levels.
• A homelike environment will be maintained with attractive tables, décor, and a

pleasant dining area atmosphere.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.18
page 1of 2
O: 2002
FINGERNAILS
POLICY
Artificial fingernails, long nails, and polished nails with chipped or cracked polish, and all
forms of fingernail jewelry, are prohibited in direct patient care staff.
PURPOSE
To establish a policy governing the wearing of long, artificial, polished fingernails, or

fingernail jewelry in direct care staff.
Several studies have confirmed that the presence of long fingernails, artificial
fingernails, fingernail jewelry, and nails with chipped or cracked polish harbor bacteria
which can be transmitted person to person during care fingernails which are long,
artificial or polished are known to impede the use of good gloving technique, and
adequate hand washing. To prevent transmission, support good gloving technique, and
proper hand washing, it is the policy of Cochise Regional Hospital that these nails will
not be utilized by direct care staff.
Direct care staff means any employee, medical assistant, intern, student, physician, or
volunteer who has direct physical contact with the patient in providing for physical care
of the patient. Direct care staff will include nursing; including RNS, LPNs, and CNAs.
Direct care staff will also include Laboratory, Respiratory Therapy, Rehabilitation,
Dietary, Environmental Services and Radiology.
Long nails mean any fingernail, natural or artificial, which is longer than 3mm beyond
the growth surface of the natural nail.
Artificial means any applied fiberglass, acrylic, or other chemical overlay used to
lengthen or strengthen the nail which would create a seam or joining at the surface of
the nail.
Polish is any form of paint, coloration, or chemical applied to the surface of the nail.
Fingernail jewelry is any applied device used to enhance or decorate the nail, including
decals, and dangling hoops or rings placed through the nail.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14
1.M.18
page 2of 2
O: 2002
References:
Moolenaar, R.L et. Al. (2000). A prolonged outbreak of Pseudomonas aeruginosa

in a neonatal intensive care unit: Did Staff fingernails play a role in disease
transmission? Infection Control and Hospital Epidemiolov. (21). 80-85.
Schreiber, C., (1999, October, 11). Artificial nails a magnet for bacteria, Nurse
Week Retrieved from the World Wide Web, May 15, 2000
http://www.nurseweek.com/news/99- 10/50d.html
Wong, E.S., (2000) The epidemiology of contact transmission: Beyond

Semmeiweis. Infection Control and Hospital Epidemiology, (21). 77-79.

Reviewed: 08/05, 10/07, 11/07, 1/08, 10/08, 09/13, 06/14
Revised: 08/05, 10/07, 11/07, 1/08, 6/14

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Dietary Policies & Procedures

Purpose and Organization

Job Descriptions 1.M.04

Receiving, Inventory and Storage

Menu Planning and Nourishments

Effective Date: 2002

Equipment Operation, Infection Control and Sanitation

Effective Date: 2002

Safety and Emergency Procedures

Effective Date: 2002

Patient Rights and Quality of Life

Effective Date: 2002

Effective Date: 2002

Dietary Department Objectives

Dietary Department supervision is to be under the guidance of a full-time person

Effective Date: 2002

The Dietary Department will function within an organizational structure. The

Department heads are responsible to the Administrator.

Cooks and Dietary Aides are responsible to the Dietary Manager.

Dietary Aides are responsible to Cooks in the implementation of meals.

Department heads function in an equal working relationship with each other.

The Consultant Dietitian may make recommendations for departmental organization.

Effective Date: 2002

1. Quality Assurance Manual

• Temperature – Dish machine, food, refrigeration units, test trays – 1 year

2. Other Notebooks Needed

• Policy and Procedures Manual – update annually

• Current Diet Manual – approved annually (current within last 5 years)

• Inservice/Training Manual – Yearly Plan with monthly documentation and

• Recipe Manuals to correlate with menus and 11 x 17 menu notebook

• Dietary Reference Manual for Nursing

• Master Forms Manual

• MSDS Employee Informed forms

• Employee Files as needed

Effective Date: 2002

Effective Date: 2002

Effective Date: 2002

In-service Training Program

Effective Date: 2002

Federal Conditions of Participation recommend current and annual health examinations

Newly hired employees must have a TB test prior to starting employment.

An annual TB test must be performed with results located in personnel file.

An employee infected with any disease in a communicable form or having a presumably

Effective Date: 2002

1. Clean work clothing

2. Clean hands and fingernails

• Hands must always be washed prior to beginning work.

Effective Date: 2002

• Personnel having symptoms of communicable diseases or open infected

3. Head covering worn

Effective Date: 2002

Hand Washing and Glove Use

Hand Washing Procedure –

1. Hand washing is a priority for infection control.

3. Washing procedure (See Hand Washing Flow Chart)

Hand Washing Flow Chart

1. Get ready step 4. Brush and 6. Wash hands a

1. Get Ready Step

4. Brush and lather, particularly fingertips and fingernails.