Section 150.009 - Dietary Service(A) All facilities shall provide adequate dietary services to meet the daily dietary needs of residents in accordance with written dietary policies and procedures. (1) Dietary services shall be directed by a food service supervisor and shall be organized with established lines of accountability and clearly defined job assignments.(2) Dietary services shall be provided directly by the facility, or facilities may contract with an outside food company provided the facility and the food company comply with 105 CMR 150.000; provided the facility or the company has a qualified dietitian who serves, as required in 105 CMR 150.000; and provided the facility and the dietitian provide for continuing liaison with physicians and the nursing staff.(3) In a SNCFC, the dietary services shall provide all residents with a nutritionally adequate diet designed to help them reach their proper physical developmental level and their full feeding potential. The care plan shall indicate procedures instituted to restore an appropriate nutritional level.(B) All facilities shall provide sufficient numbers of adequately trained personnel to plan, prepare and serve the proper diets to residents.(1) A full or part-time dietitian shall be employed to direct and supervise the dietary services or there shall be a written agreement with a dietitian on a consultant basis to provide these services.(a) Facilities providing Level I or II care shall provide a dietitian for a minimum of four hours a week for a single unit and an additional two hours per week for each additional unit.1. A SNCFC shall provide a dietitian who has training or experience in nutrition of children for a minimum of six hours a week for a single unit and an additional two hours a week for each additional unit.2. Facilities providing Level III care shall provide a dietitian for a minimum of two hours per week for each unit.(b) Facilities providing Level IV care shall have an arrangement for the provision of dietary services as needed.(c) The visits of the dietitian shall be of sufficient duration and frequency to provide consultation, evaluation and advice regarding dietary personnel, menu planning, therapeutic diets, food production and service procedures, maintenance of records, training programs and sanitation.(d) A written record shall be kept on file in the facility of dates, time, services rendered and recommendations made by the consultant.(2) Facilities providing Level I, II or III care shall provide a fulltime food service supervisor. He or she may be the cook or the chef, but he or she shall spend a portion of his or her time in management functions. Facilities providing Level IV care shall provide a cook as needed to meet residents' dietary needs. (a) The food service supervisor shall be responsible for supervising food service personnel, the preparation and serving of food and the maintenance of proper records. (b) There shall be proper supervision of the dietary service during all hours of operation. When the food service supervisor is absent during hours when other food service personnel are on duty, a responsible person shall be assigned to assume his or her job functions.(3) All facilities shall employ a sufficient number of food service personnel and their working hours shall be scheduled to meet the dietary needs of the patients. (a) Food service employees shall be on duty over a period of 12 or more hours.(b) Food service employees shall be trained to perform assigned duties.(c) In facilities providing Level I or II care, food service employees shall not regularly be assigned to duties outside the dietary department.(d) Work assignments and duty schedule shall be posted and kept current.(e) All dietary personnel (including tray servers) shall be 16 years of age or older.(4) All food service personnel shall be in good health, shall practice hygienic food handling techniques and shall conform to 105 CMR 590.000: State Sanitary Code Article X -Minimum Sanitation Standards for Food Service Establishments.(a) All food service personnel shall wear clean, washable garments, shoes, hairnets or clean caps, and keep their hands and fingernails clean at all times.(b) Personnel having symptoms of communicable disease, including acute respiratory infections, open infected wounds, or known to be infected with any disease in a communicable form or in a carrier state, shall not be permitted to work.(c) Employees shall not use tobacco in any form while engaged in food preparation or service, or while in equipment washing, food preparation or food storage areas.(C)Therapeutic Diets. (1) All facilities with residents in need of special or therapeutic diets shall provide for such diets to be planned, prepared and served as prescribed by the primary care provider.(2) All therapeutic diets shall be planned, prepared and served with consultation from a dietitian.(3) All therapeutic diets shall be precise as to the specific dietary requirements or limitations. (4) A current diet manual shall be readily available to residents' primary care providers, dietary service personnel and the supervisor of the nursing services. There shall be evidence from the diets served that the manual is used and related to posted diets.(5) All persons responsible for therapeutic diets shall have sufficient knowledge of food values to make appropriate substitutions when necessary. All substitutions made on the Master Menu for therapeutic diets shall be recorded in writing.(6) The dietitian and food service supervisor in conjunction with the nursing staff and other relevant personnel shall review therapeutic diets (with particular attention to their acceptance by the resident) and shall make appropriate recommendations to the residents' primary care providers and staff. Therapeutic diets shall be reviewed in facilities as follows:(a) Level I and II, at least every 30 days and more frequently if indicated.(b) Level III, at least every three months.(c) Level IV, at least every three months.(7) All therapeutic diet menus shall be approved by the dietitian and kept on file for at least 30 days.(8) Residents to whom therapeutic diets are served shall be identified in the dietary records.(D)Adequacy of Diets. All diets shall conform to the resident's primary care provider's orders and, shall meet the dietary needs of the resident.(a) The dietitian, in consultation with the consulting pediatrician and nursing service, shall determine the diet and feeding plan for each resident in a SNCFC for whom a therapeutic diet is not ordered.(b) When a resident has been receiving infant formula prior to admission to a SNCFC, the resident shall be fed the same type of formula until his or her feeding program is planned and any changes in formula or diet ordered.(E)Quality of Food. (1) At least three meals that are nutritious and suited to special needs of residents shall be served daily.(2) Meals shall be served at regular times, with not more than a 15-hour span between a substantial evening meal and breakfast. Breakfast shall not be served before 7:00 A.M.; the evening meal shall not be served before 5:00 P.M. When a five-meal plan is in effect, the main evening meal shall not be served before 4:00 P.M.(3) Appropriate between-meals snacks and bedtime nourishment shall be offered to each resident.(4) Only pasteurized fluid milk and fluid milk products shall be used or served; dry milk products may be used for cooking purposes only.(5) All milk and milk products for drinking purposes shall be served from the original container or from a sanitary milk dispenser. Milk served from a dispenser shall be homogenized.(6) Cracked or dirty eggs shall not be used. Egg nog shall be pasteurized. Eggs shall be refrigerated at all times.(F)Planning of Menus and Food Supplies.(1) Menus shall be planned and written at least one week in advance. The current week's menus, including routine and special diets, and any substitutions or changes made shall be posted in one or more conspicuous places in the dietary department.(2) Records of menus as served shall be filed and maintained for at least 30 days.(3) Daily menus shall provide for a sufficient variety of foods, and no daily menu shall be repeated twice in one week.(4) Menus shall be adjusted for seasonal changes, and shall reflect dietary restrictions or preferences. Appropriate special menus shall be planned for holidays and birthdays.(5) An adequate supply of food of good quality shall be kept on the premises at all times to meet resident needs. This shall mean supplies of staple foods for a minimum of a one-week period and of perishable foods for a minimum of 48 hours.(6) All food shall be maintained at safe temperatures. Food stored in a freezer shall be wrapped, identified and labeled with the date received and shall be used within the safe storage time appropriate to the type of food and the storage temperature. If not used within an appropriate time limit, the food shall be discarded.(7) Records of food purchased and a perpetual inventory of food supplies shall be kept on file.(8) Menus shall be planned and food supplies maintained so nutritionally adequate alternate meal can be provided at all times. Alternate meal plans shall be varied at least every week and posted with other menus.(9) All facilities shall plan and post a Disaster Feeding Plan and staff shall be familiar with it. This plan shall include alternate methods and procedures to be used when equipment is not operable, including proper sanitation of dishes and utensils.(G)Preparation and Serving of Food. (1) All foods shall be prepared by methods that conserve the nutritive value, flavor and appearance.(2) A file of tested recipes, adjusted to appropriate yield, shall be maintained, shall be utilized in preparing food and shall correspond to items on the posted menus.(3) Foods shall be cut, chopped, ground or blended to meet individual needs.(4) House diets shall be appropriately seasoned in cooking and this shall include salt.(5) Convenient and suitable utensils, such as forks, knives, tongs, spoons, or scoops, shall be provided and used to minimize direct handling of food at all points where food is prepared or served.(6) Equipment shall be provided and procedures established to maintain food at a proper temperature during serving and transportation. Hot foods shall be hot, and cold foods cold, when they reach the residents.(7) Food shall be served in a home-like, pleasant, clean, relaxing and quiet atmosphere.(8) Individual tray service shall be provided for residents who are unable to leave their rooms or who do not wish to eat in the dining room. In a SNCFC, resident shall eat in the dining area unless contraindicated by the child's condition.
(9)Trays. (a) Food shall be served on dishes and shall not be in direct contact with trays.(b) Trays shall be washable and of a type that can be sanitized.(c) Flat trays shall be served with a washable or disposable tray mat.(d) Trays shall be large enough to accommodate all of the dishes necessary for a complete meal, arranged and served attractively.(e) Trays set up in advance of meal time shall be adequately covered to prevent contamination and shall not contain perishable food.(f) Trays shall be stored in a clean and sanitary manner.(g) There shall be a visible resident identifier on each tray.(h) Trays shall rest on firm supports such as overbed tables for bedfast residents or sturdy tables or tray stands of proper height for residents able to be out of bed. T.V. tray stands are not permitted.(10) The main meals of a day, morning, noon and evening, shall be attractively served on non-disposable dinnerware of good quality, such as ceramic, china, china-glass, glass, ironstone, melamine plastic or other materials that are durable and aesthetically pleasing.(11) An adequate supply of trays, glassware, dishes, and flatware for individual patient or resident use shall be available at all times. Discolored, chipped or cracked dishes, glassware or trays shall not be used. Flatware of good quality shall be provided and kept in good condition.(12) At the main meal, the main course shall be served on a dinner plate at least eight inches in diameter or its equivalent.(13) Clean napkins shall be provided for all residents at all meals, between-meal snacks and bedtime nourishment.(14) In a SNCFC, resident shall be helped to learn to feed themselves a variety of foods of different textures and in appropriate amounts. The amount and type of food and size of servings shall depend on the individual resident's abilities, feeding plan, age and preferences. No resident who is unable to do so, shall be required to feed himself.(15) Procedures shall be developed by the SNCFC staff, including rehabilitation services staff, for development and use of special methods of feeding residents with disabilities which involve feeding skills.(H) Single service disposable dishes, cups or cutlery shall not be used except as follows: (1) On a regular basis: only for between meal food services; in the preparation of individual servings of gelatin desserts, gelatin salads and puddings; in serving fruit juices, vegetable juices, milk, water and plastic holders with disposable inserts for use with hot beverages; and in serving relishes, jellies, condiments and seasonings.(2) On a temporary basis: for an individual with an infectious illness, or when kitchen areas are being remodeled, providing prior approval for use over a specified period of time has been received from the Department.(3) Disposable single service items shall comply with the following: (a) Cups, dishes, and bowls shall be made of non-absorbent materials such as molded or formed plastic and coated paper.(b) Single service items shall be rigid and sturdy.(c) Single service items shall be coordinated according to color and design and shall be aesthetically appealing.(d) Disposable flatware shall be full sized and heavy weight.(e) Single service items shall be used only once and then discarded.(f) All single service items shall be stored according to the manufacturer's instructions and handled and dispensed in a sanitary manner.(I)Dietary and Food Sanitation.(1) Sanitary conditions shall be maintained in all aspects of the storage, preparation and distribution of food.(2) All utensils, equipment, methods of cleaning and sanitizing, storage of equipment or food, the habits and procedures of food handlers, rubbish and waste disposal, toilet facilities and other aspects of maintaining healthful, sanitary and safe conditions relative to food storage, preparation and distribution shall be in compliance with local health codes and 105 CMR 590.000: State Sanitary Code Article X - Minimum Sanitation Standards for Food Service Establishments.(3) Effective written procedures for cleaning, disinfecting and sanitizing all equipment and work areas shall be developed and followed consistently so all equipment, including pots and pans, and work areas are clean and sanitary at all times.(4) Effective dishwashing techniques shall be used in all facilities. Kitchen workers shall be instructed in these and shall show evidence of knowing and practicing acceptable sanitary procedures.(5) All dishes, glasses and utensils used for eating, drinking, preparing and serving of food or drink shall be cleansed and sanitized after each use. After sanitization, all dishes shall be allowed to drain and dry in racks or baskets on a nonabsorbent surface. All facilities shall provide by January 1, 1972, an automatic dishwasher capable of handling the needs of the facility. In a dishwashing machine the temperature of the wash water shall be between 140ºF and 160ºF, with a final rinse at a temperature of 170ºF or higher.(6) The food service area shall be limited to authorized personnel.(7) Dry or staple food items shall be stored off the floor in a ventilated room not subject to sewage or waste water backflow, or contamination by condensation, leakage, rodents or vermin.(8) Poisonous and toxic materials shall be stored in locked cabinets used for no other purpose, or in a place separate from all food storage areas, food preparation areas and clean equipment and utensils.(9) All perishable food, including milk and milk products shall be adequately refrigerated, stored in a sanitary manner and properly spaced for adequate refrigeration.(10) Mechanical refrigeration capable of storing perishable and frozen foods shall be provided in sufficient amount to meet the needs of the facility.(11) The maximum temperature for the storage of all perishable foods shall be 45ºF. Freezers and frozen food compartments of refrigerators shall be maintained at or below minus 10º F.(12) A reliable thermometer shall be attached to the inside of each refrigerator, freezer, frozen food compartment, storeroom or other storage space used for perishable food or beverages.(13) Food shall be transported from main kitchens to auxiliary kitchens and to residents in suitable containers or conveyors.(14) Written reports of inspections by state and local health authorities shall be kept on file in the facility with the notations made of action taken by the facility to comply with any recommendations.(15) If pre-prepared meals or meals prepared off the premises are used, dietary areas and equipment shall be designed to accommodate the requirements for safe and sanitary storage, processing and handling.(16) Auxiliary kitchens and dishwashing facilities located outside the main dietary area shall comply with the standards specified for the main kitchen and dietary area.(17) No drugs shall be stored in the same refrigerator with food, and drugs shall not be added to foods in the kitchen.(18) Easily shredded, abrasive material, such as steel wool, shall not be used to clean food preparation equipment or utensils.(19) In a SNCFC, only pre-sterilized commercially prepared infant formula packaged for individual servings shall be used as infant formula. Adequate space, equipment and procedures acceptable to the Department for processing, handling and storage of commercially prepared formula shall be provided. In the event a special formula cannot be purchased in a prepared formula, prior approval shall be obtained from the Department for preparation of the formula in the facility.(20) Written procedures pertaining to the sanitary use of infant formula shall be developed. Protective nipple caps shall be removed only at the beginning of feeding; any unfinished formula left in a bottle at the time of feeding shall be disposed of immediately.Amended by Mass Register Issue 1361, eff. 3/23/2018.