481—58.24 (135C) Dietary.
	 58.24(1) Organization of dietetic services. The facility shall meet the needs of the residents and provide the services listed in this standard. If the service is contracted out, the contractor shall meet the same standard. A written agreement shall be formulated between the facility and the contractor and shall convey to the department the right to inspect the food service facilities of the contractor. (III)
	  a.   	 There shall be written policies and procedures for dietetic services that include staffing, nutrition, menu planning, therapeutic diets, preparation, service, ordering, receiving, storage, sanitation, and staff hygiene. The policies and procedures shall be made available for use by dietetic services. (III)
	  b.   	 There shall be written job descriptions for each position in dietetic services. The job descriptions shall be made available for use by dietetic services. (III)
	 58.24(2) Dietary staffing.
	  a.   	 The facility shall employ a qualified dietary supervisor who:
	 (1) 	 Is a qualified dietitian as defined in 58.24(2)“e”; or
	 (2) 	 Is a graduate of a dietetic technician training program approved by the American Dietetic Association; or
	 (3) 	 Is a certified dietary manager certified by the certifying board for dietary managers of the Dietary Managers Association (DMA) and maintains that credential through 45 hours of DMA-approved continuing education; or
	 (4) 	 Has completed a DMA-approved course curriculum necessary to take the certification examination required to become a certified dietary manager; or
	 (5) 	 Has documented evidence of at least two years’ satisfactory work experience in food service supervision and who is in an approved dietary manager association program and will successfully complete the program within 12 months of the date of enrollment; or
	 (6) 	 Has completed or is in the final 90-hour training course approved by the department. (II, III)
	  b.   	 The supervisor shall have overall supervisory responsibility for dietetic services and shall be employed for a sufficient number of hours to complete management responsibilities that include:
	 (1) 	 Participating in regular conferences with consultant dietitian, administrator and other department heads; (III)
	 (2) 	 Writing menus with consultation from the dietitian and seeing that current menus are posted and followed and that menu changes are recorded; (III)
	 (3) 	 Establishing and maintaining standards for food preparation and service; (II, III)
	 (4) 	 Participating in selection, orientation, and in-service training of dietary personnel; (II, III)
	 (5) 	 Supervising activities of dietary personnel; (II, III)
	 (6) 	 Maintaining up-to-date records of residents identified by name, location and diet order; (III)
	 (7) 	 Visiting residents to learn individual needs and communicating with other members of the health care team regarding nutritional needs of residents when necessary; (II, III)
	 (8) 	 Keeping records of repairs of equipment in dietetic services. (III)
	  c.   	 The facility shall employ sufficient supportive personnel to carry out the following functions:
	 (1) 	 Preparing and serving adequate amounts of food that are handled in a manner to be bacteriologically safe; (II, III)
	 (2) 	 Washing and sanitizing dishes, pots, pans and equipment at temperatures required by procedures described elsewhere; (II, III)
	 (3) 	 Serving of therapeutic diets as prescribed by the physician and following the planned menu. (II, III)
	  d.   	 The facility may assign simultaneous duties in the kitchen and laundry, housekeeping, or nursing service to appropriately trained personnel. Proper sanitary and personal hygiene procedures shall be followed as outlined under the rules pertaining to staff hygiene. (II, III)
	  e.   	 If the dietetic service supervisor is not a licensed dietitian, a consultant dietitian is required. The consultant dietitian shall be licensed by the state of Iowa pursuant to Iowa Code chapter 152A.
	  f.   	 Consultants’ visits shall be scheduled to be of sufficient duration and at a time convenient to:
	 (1) 	 Record, in the resident’s medical record, any observations, assessments and information pertinent to medical nutrition therapy; (I, II, III)
	 (2) 	 Work with residents and staff on resident care plans; (III)
	 (3) 	 Consult with the administrator and others on developing and implementing policies and procedures; (III)
	 (4) 	 Write or approve general and therapeutic menus; (III)
	 (5) 	 Work with the dietetic supervisor on developing procedures, recipes and other management tools; (III)
	 (6) 	 Present planned in-service training and staff development for food service employees and others. Documentation of consultation shall be available for review in the facility by the department. (III)
	  g.   	 In facilities licensed for more than 15 beds, dietetic services shall be available for a minimum of a 12-hour span extending from the time of preparation of breakfast through supper. (III)
	 58.24(3) Nutrition and menu planning.
	  a.   	 Menus shall be planned and followed to meet the nutritional needs of each resident in accordance with the physician’s orders and in consideration of the resident’s choices and preferences. (II, III)
	  b.   	 Menus shall be planned to provide 100 percent of the daily recommended dietary allowances as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. A current copy of the Simplified Diet Manual published by Blackwell Publishing, Ames, Iowa, shall be available and used in the planning and serving of all meals. (II)
	  c.   	 At least three meals or their equivalent shall be served daily, at regular hours comparable to normal mealtimes in the community. (II)
	 (1) 	 There shall be no more than a 14-hour span between a substantial evening meal and breakfast except as provided in subparagraph (3) below. (II, III)
	 (2) 	 The facility shall offer snacks at bedtime daily. (II, III)
	 (3) 	 When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast of the following day. The current resident group must agree to this meal span and a nourishing snack must be served. (II)
	  d.   	 Menus shall include a variety of foods prepared in various ways. The same menu shall not be repeated on the same day of the following week. (III)
	  e.   	 Menus shall be written at least one week in advance. The current menu shall be located in an accessible place in the dietetic service department for easy use by persons purchasing, preparing and serving food. (III)
	  f.   	 Records of menus as served shall be filed and maintained for 30 days and shall be available for review by department personnel. When substitutions are necessary, they shall be of similar nutritive value and recorded. (III)
	  g.   	 A file of tested recipes adjusted to the number of people to be served in the facility shall be maintained. (III)
	  h.   	 Alternate foods shall be offered to residents who refuse the food served. (II, III)
	 58.24(4) Therapeutic diets.
	  a.   	 Therapeutic diets shall be prescribed by the attending physician. A current therapeutic diet manual shall be readily available to attending physicians, nurses and dietetic service personnel. This manual shall be used as a guide for writing menus for therapeutic diets. A licensed dietitian shall be responsible for writing and approving the therapeutic menu and reviewing procedures for preparation and service of food. (III)
	  b.   	 Personnel responsible for planning, preparing and serving therapeutic diets shall receive instructions on those diets. (III)
	 58.24(5) Food preparation and service.
	  a.   	 Methods used to prepare foods shall be those which conserve nutritive value and flavor and meet the taste preferences of the residents. (III)
	  b.   	 Foods shall be attractively served. (III)
	  c.   	 Foods shall be cut up, chopped, ground or blended to meet individual needs. (II, III)
	  d.   	 Self-help devices shall be provided as needed. (II, III)
	  e.   	 Table service shall be attractive. (III)
	  f.   	 Plasticware, china and glassware that are unsightly, unsanitary or hazardous because of chips, cracks or loss of glaze shall be discarded. (III)
	  g.   	 All food that is transported through public corridors shall be covered. (III)
	  h.   	 All potentially hazardous food or beverages capable of supporting rapid and progressive growth of microorganisms that can cause food infections or food intoxication shall be maintained at temperatures of 41°F or below or at 140°F or above at all times, except during necessary periods of preparation. Frozen food shall be maintained frozen. (I, II, III)
	  i.   	 Potentially hazardous food that is cooked, cooled and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165°F for 15 seconds. (I, II, III)
	  j.   	 Food must be reheated to 165°F within no more than two hours after the heating process begins. (I, II, III)
	  k.   	 Cooked potentially hazardous food shall be cooled:
	 (1) 	 Within two hours, from 140°F to 70°F; and
	 (2) 	 Within four hours, from 70°F to 41°F or less. (I, II, III)
	 58.24(6) Dietary ordering, receiving, and storage.
	  a.   	 All food and beverages shall be of wholesome quality and procured from sources approved or considered satisfactory by federal, state and local authorities. Food or beverages from unlabeled, rusty, leaking, broken or damaged containers shall not be served. (I, II, III)
	  b.   	 A minimum of at least a one-week supply of staple foods and a three-day supply of perishable foods shall be maintained on the premises to meet the planned menu needs until the next food delivery. Supplies shall be appropriate to meet the requirements of the menu. (III)
	  c.   	 All milk shall be pasteurized. (III)
	  d.   	 Milk may be served in individual, single-use containers. Milk may be served from refrigerated bulk milk dispensers or from the original container. Milk served from a refrigerated bulk milk dispenser shall be dispensed directly into the glass or other container from which the resident drinks. (II, III)
	  e.   	 Records which show amount and kind of food purchased shall be retained for three months and shall be made available to the department upon request. (III)
	  f.   	 Dry or staple items shall be stored at least six inches (15 cm) above the floor in a ventilated room, not subject to sewage or wastewater backflow, and protected from condensation, leakage, rodents or vermin in accordance with the Food Code, 1999 edition. (III)
	  g.   	 Pesticides, other toxic substances and drugs shall not be stored in the food preparation or storage areas used for food or food preparation equipment and utensils. Soaps, detergents, cleaning compounds or similar substances shall not be stored in food storage rooms or areas. (II)
	  h.   	 Food storage areas shall be clean at all times. (III)
	  i.   	 There shall be a reliable thermometer in each refrigerator, freezer and in storerooms used for food. (III)
	  j.   	 Foods held in refrigerated or other storage areas shall be appropriately covered. Food that was prepared and not served shall be stored appropriately, clearly identifiable and dated. (III)
	 58.24(7) Sanitation in food preparation area.
	  a.   	 Unless otherwise indicated in this chapter or 481—Chapter 61, the sanitary provisions as indicated in Chapters 3, 4 and 7 of the 1999 Food Code, U.S. Public Health Service, Food and Drug Administration, Washington, DC 20204, shall apply.
	  b.   	 Residents may be allowed in the food preparation area. (III)
	  c.   	 The food preparation area may be used as a dining area for residents, staff or food service personnel. (III)
	  d.   	 All food service areas shall be kept clean, free from litter and rubbish, and protected from rodents, animals, roaches, flies and other insects. (II, III)
	  e.   	 All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosion, cracks and chipped areas. (II, III)
	  f.   	 There shall be effective written procedures established for cleaning all work and serving areas. (III)
	  g.   	 A schedule of cleaning duties to be performed daily shall be posted. (III)
	  h.   	 An exhaust system and hood shall be clean, operational and maintained in good repair. (III)
	  i.   	 Spillage and breakage shall be cleaned up immediately and disposed of in a sanitary manner. (III)
	  j.   	 Wastes from the food service that are not disposed of by mechanical means shall be kept in leakproof, nonabsorbent, tightly closed containers when not in immediate use and shall be disposed of frequently. (III)
	  k.   	 The food service area shall be located so it will not be used as a passageway by residents, guests or non-food service staff. (III)
	  l.   	 The walls, ceilings and floors of all rooms in which food is prepared and served shall be in good repair, smooth, washable, and shall be kept clean. Walls and floors in wet areas should be moisture-resistant. (III)
	  m.   	 Ice shall be stored and handled in such a manner as to prevent contamination. Ice scoops should be sanitized daily and kept in a clean container. (III)
	  n.   	 There shall be no animals or birds in the food preparation area. (III)
	  o.   	 All utensils used for eating, drinking, and preparing and serving food and drink shall be cleaned and disinfected or discarded after each use. (III)
	  p.   	 If utensils are washed and rinsed in an automatic dishmachine, one of the following methods shall be used:
	 (1) 	 When a conventional dishmachine is utilized, the utensils shall be washed in a minimum of 140°F using soap or detergent and sanitized in a hot water rinse of not less than 170°F. (II, III)
	 (2) 	 When a chemical dishmachine is utilized, the utensils shall be washed in a minimum of 120°F using soap or detergent and sanitized using a chemical sanitizer that is automatically dispensed by the machine and is in a concentration equivalent to 50 parts per million (ppm) available chloride. (II, III)
	  q.   	 If utensils are washed and rinsed in a three-compartment sink, the utensils shall be thoroughly washed in hot water at a minimum temperature of 110°F using soap or detergent, rinsed in hot water to remove soap or detergent, and sanitized by one of the following methods:
	 (1) 	 Immersion for at least 30 seconds in clean water at 180°F; (II, III)
	 (2) 	 Immersion in water containing bactericidal chemical at a minimum concentration as recommended by the manufacturer. (II, III)
	  r.   	 After sanitation, the utensils shall be allowed to drain and dry in racks or baskets on nonabsorbent surfaces. Drying cloths shall not be used. (III)
	  s.   	 Procedures for washing and handling dishes shall be followed in order to protect the welfare of the residents and employees. Persons handling dirty dishes shall not handle clean dishes without first washing their hands. (III)
	  t.   	 A mop and mop pail shall be provided for exclusive use in kitchen and food storage areas. (III)
	 58.24(8) Hygiene of food service personnel.
	  a.   	 Personnel, if involved in dietetic services, shall be trained in basic food sanitation techniques, shall be clean and wear clean clothing, including a cap or a hairnet sufficient to contain, cover and restrain hair. Beards, mustaches and sideburns that are not closely cropped and neatly trimmed shall be covered. (III)
	  b.   	 Personnel shall be excluded from duty when affected by skin infections or communicable diseases in accordance with the facility’s infection control policies. (II, III)
	  c.   	 Employee street clothing stored in the food service area shall be in a closed area. (III)
	  d.   	 Food preparation sinks shall not be used for hand washing. Separate hand-washing facilities with soap, hot and cold running water, and single-use towels shall be used properly. (II, III)
	  e.   	 The use of tobacco shall be prohibited in the food preparation area. (III)
	 58.24(9) Paid nutritional assistants. A paid nutritional assistant means an individual who meets the requirements of this subrule and who is an employee of the facility or an employee of a temporary employment agency employed by the facility. A facility may use an individual working in the facility as a paid nutritional assistant only if that individual has successfully completed a state-approved training program for paid nutritional assistants. (I, II, III)
	  a.   	 Training program requirements.
	 (1) 	 A state-approved training program for paid nutritional assistants must include, at a minimum, eight hours of training in the following areas:
	  1. 	 Feeding techniques.
	  2. 	 Assistance with feeding and hydration.
	  3. 	 Communication and interpersonal skills.
	  4. 	 Appropriate responses to resident behavior.
	  5. 	 Safety and emergency procedures, including the Heimlich maneuver.
	  6. 	 Infection control.
	  7. 	 Resident rights.
	  8. 	 Recognizing changes in residents that are inconsistent with their normal behavior and reporting these changes to the supervisory nurse.
	 (2) 	 In addition to the training program requirements specified above, the training program must include at least four hours of classroom study, two hours of supervised laboratory work, and two hours of supervised clinical experience.
	 (3) 	 A facility that offers a paid nutritional assistant training program must provide sufficient supplies in order to teach the objectives of the course.
	 (4) 	 All paid nutritional assistant training program instructors shall be registered nurses. Other qualified health care professionals may assist the instructor in teaching the classroom portion and clinical or laboratory experiences. The ratio of students to instructor shall not exceed ten students per instructor in the clinical setting.
	 (5) 	 Each individual enrolled in a paid nutritional assistant training program shall complete a 50-question multiple choice written test and must obtain a score of 80 percent or higher. In addition, the individual must successfully perform the feeding of a resident in a clinical setting. A registered nurse shall conduct the final competency determination.
	 (6) 	 If an individual does not pass either the written test or competency demonstration, the individual may retest the failed portion a second time. If the individual does not pass either the written test or competency demonstration portion the second time, the individual shall not be allowed to retest.
	  b.   	 Program approval. A facility or other entity may not offer or teach a paid nutritional assistant training program until the department has approved the program. Individuals trained in a program not approved by the department will not be allowed to function as paid nutritional assistants.
	 (1) 	 A facility or other institution offering a paid nutritional assistant training program must provide the following information about the training program to the department before offering the program or teaching paid nutritional assistants:
	  1. 	 Policies and procedures for program administration.
	  2. 	 Qualifications of the instructors.
	  3. 	 Maintenance of program records, including attendance records.
	  4. 	 Criteria for determining competency.
	  5. 	 Program costs and refund policies.
	  6. 	 Lesson plans, including the objectives to be taught, skills demonstrations, assignments, quizzes, and classroom, laboratory and clinical hours.
	 (2) 	 The facility or other institution offering a paid nutritional assistant training program must submit the materials specified above for department review. The department shall, within ten days of receipt of the material, advise the facility or institution whether the program is approved, or request additional information to assist the department in determining whether the curriculum meets the requirements for a paid nutritional assistant training program. Before approving any paid nutritional assistant training program, the department shall determine whether the curriculum meets the requirements specified in this subrule. The department shall maintain a list of facilities and institutions eligible to provide paid nutritional assistant training. (I, II, III)
	 (3) 	 A facility shall maintain a record of all individuals who have successfully completed the required training program and are used by the facility as paid nutritional assistants. The individual shall complete the training program with a demonstration of knowledge and competency skills necessary to serve as a paid nutritional assistant. (I, II, III)
	 (4) 	 Upon successful completion of the training program, the facility or other institution providing the training shall, within ten calendar days, provide the individual with a signed and dated certificate of completion. A facility that employs paid nutritional assistants shall maintain on file copies of the completed certificate and skills checklist for each individual who has successfully completed the training program. (I, II, III)
	  c.   	 Working restrictions.
	 (1) 	 A paid nutritional assistant must work under the supervision of a registered nurse or a licensed practical nurse. In an emergency, a paid nutritional assistant must call a supervisory nurse for help on the resident call system. (I, II, III)
	 (2) 	 A facility must ensure that a paid nutritional assistant feeds only residents who have no complicated feeding problems. Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube, parenteral or intravenous feedings. The facility must base resident selection on the charge nurse’s assessment and the resident’s latest assessment and plan of care. (I, II, III)