.21 Dietetic Services.

A. Services Provided. Services may be provided directly by the facility or the facility may contract with a food management company, a caterer, or another facility. The facility and the food management company (or caterer or facility providing service) shall comply with these regulations. Food service personnel shall comply with COMAR 10.15.03 Food Service Facilities.

B. Supervision.

(1) In a nursing home with more than 50 beds, overall supervisory responsibilities for the food service department and food production shall be assigned to a full-time qualified dietetic service supervisor. It shall be the responsibility of the supervisor to delegate relief duties to an individual qualified to serve as relief as stated in Regulation .09I of this chapter.

(2) In a nursing home with 50 or fewer beds, exceptions may be made by the Department to allow the supervisor to share cooking responsibilities with the full-time cook.

C. Consultation.

(1) If the supervisor is not a licensed registered dietitian, the individual shall receive regularly scheduled consultation from a licensed registered dietitian. In all instances sufficient consultation shall be provided to fulfill all required responsibilities.

(2) There shall be a signed agreement between the facility and the consultant dietitian specifying hours and frequency of service responsibilities, and registration number if applicable.

(3) Consultation services shall be documented by written reports.

D. Staffing.

(1) A sufficient number of food service personnel shall be employed to perform efficiently the functions of the food and nutrition service and meet the dietary needs of the residents.

(2) Working hours shall be scheduled to ensure that the nutritional needs of the residents are met.

(3) Nursing, housekeeping, laundry, or other personnel may not be used as food service staff. Exceptions, such as in a culture change setting, shall be based on the written approval of the Department. The kitchen may not be used for any purpose other than the preparation of food.

E. Adequacy of Diet.

(1) The food and nutritional needs of residents shall be met in accordance with physicians’ orders.

(2) To the extent medically possible, the “Recommended Dietary Allowances” of the Food and Nutrition Board, Commission on Life Sciences, and National Research Council, adjusted for age, sex, and activity, shall be observed.

(3) The “Diet Manual for Long-Term Care Residents”, as published by the Department, or any other similar reference material that contains food allowances and guides for regular and therapeutic diets, shall be used.

F. Therapeutic Diets. Therapeutic diets shall be planned, prepared, and served as prescribed by the attending physician:

(1) Therapeutic diets shall be planned by a licensed registered dietitian;

(2) Preparation and serving shall be supervised by a qualified dietetic supervisor; and

(3) A current diet manual shall be available to medical, nursing, and dietetic staff.

G. Frequency and Quality of Meals.

(1) At least three meals or their equivalent shall be offered daily, at regular times, with not more than 14-hour intervals between the substantial evening meal and breakfast.

(2) A substantial evening meal is an offering of three or more menu items at one time, one of which includes a high quality protein such as meat, fish, eggs, or cheese. This meal represents at least 20 percent of the day’s total nutritional requirements.

(3) To the extent medical orders permit, bedtime nourishments shall be offered routinely to all residents.

(4) If a four or five meal a day plan is used, the meal pattern to provide this plan shall be approved by the Department.

H. Advance Planning and Posting of Menus.

(1) Residents shall be given the opportunity to participate in planning menus. Menus shall be written at least 1 week in advance.

(2) The current week’s basic menu shall be posted in one or more easily accessible places in the food services department and in the common areas.

(3) Menus shall include alternatives of similar nutritive value that give residents the opportunity to choose meals that they prefer. The dietary preferences of a resident shall be ascertained, including preferences arising from a resident’s religious, cultural, and ethnic heritage, and efforts shall be made to meet those preferences.

I. Menus Served as Planned. Food sufficient to meet the nutritional needs of patients shall be prepared as planned for each meal. When menu changes are necessary, substitutions shall provide equal nutritional value.

J. Retention of Records. Menus as served and records of food purchased for consumption by patients shall be filed on the premises for a period of 30 days.

K. Preparation of Food.

(1) Foods shall be prepared by methods that conserve nutritive value, flavor, and appearance, and shall be served at proper temperatures, in a form to meet individual needs.

(2) Standardized recipes adjusted to appropriate yield shall be followed. Standardized recipes are those recipes which have been tested by the nursing home or another source and that ensure consistent quality and quantity.

L. Resident-Directed Meal Pattern. If a resident-directed meal pattern is provided, the following is required:

(1) Counseling the residents regarding the risks and benefits of a resident-selected diet which is documented within the medical record; and

(2) Approval of the pattern by both the resident’s physician and a licensed registered dietitian.