Menus
Can I use "leftovers" in my facility?
Any food that is leftover (food that was meant to be served for a meal, but was not all served), should be used as follows: Leftovers should be covered, labeled and dated, then stored appropriately (refrigerated or frozen) within 1 hour. Leftovers must be cooled to less than or equal to 41 degrees F within 4 hours. Leftovers must be reheated to 165 degrees for a minimum of 15 seconds and then held at the proper temperature for service (>135 degrees F). Leftovers should not be used to make pureed food.
I am a chef at a palliative care residence, and we have a max of 9 patient rooms, with a turn over weekly. These patients are all different in their diet, some with swallowing problems, dryness, change in taste, pain, or loose teeth, many different cases. I change the menu daily and would like an idea, of a menu plan for all different kinds of patients. Also many patients get very bored with the same kind of foods. If you have any ideas, please let me know how I can keep an interesting and appetizing menu for these dying patients.
We have a few resources that might be helpful. Our Diet Instructions would provide information and copy ready handouts regarding some of the symptoms they experience and how they may be relieved, and the Diet Manual would provide you with guidance on special diet alterations. These tools can help you to create appropriate menus and provide helpful information for your patients. We also have a Quantity Cookbook which may be helpful that has servings for as few as 10 people.
Recipes
I have been through numerous websites on the internet and yours is the most informative. I am a Dietary Manager, and I need something for my cooks to show how much liquid, bread, thickener, etc. to add to meats, vegetables, fruits, etc. for pureed diets. Do you have anything like this, or would you know where I can find it?
Our new Dysphagia Diet Solutions manual provides specific recipes and guidelines for dysphagia diets (consistency alterations for pureed and mechanically altered foods).
Do you have any sources of recipes for fortified/enhanced foods?
We have a number of fortified/enhanced recipes available in our book, Healthy Weights. In addition, Dysphagia Diet Solutions also has recipes and ideas for food fortification/enhancement.
Consistency Altered Diets
What is the consensus on the use of pureed bread for pureed diets? Our reference diet manual allows sliced bread on the pureed diet, if tolerated. Our current menu cycle notes that the sliced bread and plain cookies and cake may be served whole, pureed or soaked in milk or slurry. We like to allow the sliced bread and cake whenever possible in order to improve the appearance of the food on the plate. Since some residents on pureed diets have the diet order due to chewing problems, this is acceptable for them. But some residents are on the diet due to swallowing problems and they may not be able to tolerate regular bread and cake. Our philosophy has been to work with the SLPs to individualize the diet and provide the appropriate consistency for residents with swallowing problems. Pureed bread is not always a very acceptable product to serve, but we are thinking about offering the puree bread mix for all of the pureed diets, unless the diet order specifically states that whole bread, cake or cookies can be served.
My recommendation would be to puree all bread and baked goods (cake, cookies, etc.) on a pureed diet. Soaking cake or cookies, etc., in milk creates two different textures-- which is very difficult for a person with dysphagia to handle and may cause choking. Slurries are great if they are done properly, but often times food service workers do not soak the bread item all the way through with the slurry, which again may create two different textures (one being dry and crumbly and difficult to swallow). The new pureed bread products on the market (Darlington Farms, Hormel, Novartis/Nestle, Rubicon) appear to be a great alternative if facilities do not want to puree their own bread. Cream of wheat can also be used as a substitute-- you can add other foods/flavors to it to make it taste better (cinnamon and sugar, margarine and garlic salt, margarine and jelly, etc.) And many of the manufacturers have recipes to go with their products which can help you create numerous recipes from breakfast items to desserts. Of course, it is wonderful that you are working closely with the SLP to meet the needs of each individual—this is always best.
I am searching for information on not allowing ice cream, sherbet, and gelatin for people on thickened liquids. I reviewed the ADA Manual Dysphagia Diet section and couldn't find any information there. The only other information I have is from a state diet manual that included ice cream and sherbet as a "thick" liquid but then footnoted these items as being unstable liquids that will separate into a thin liquid when placed in the mouth.
The ADA publication, "National Dysphagia Diet: Standardization for Optimal Care" includes the following notation on each diet level: These foods are considered thin liquids and should be avoided if thin liquids are restricted: Frozen malts, milk shakes, frozen yogurt, eggnog, nutritional supplements, ice cream, sherbet, regular or sugar free gelatin, or any foods that become thin liquid at either room (70 degrees F) or body temperature (98 degrees F)." Dysphagia Diet Solutions includes information on the National Dysphagia Diet, thickened liquids, preparation methods and detailed recipes for all levels of consistency alterations.
I am a Speech Therapist currently working in long term care. I am interested in trying to implement the National Dysphagia Diet in some of the facilities I work in. I was wondering if you could tell me how to find some good information to present to the administrator and kitchen manager to explain the pros to using it?
Our book Dysphagia Diet Solutions would be an excellent resource for any facility that is trying to implement the National Dysphagia Diet (NDD). We have found that many facilities struggle with the implementation of the NDD. All diets must be shown on a menu spreadsheet with all staff educated to understand the levels. Terminology changes may be difficult for them to understand, and the actual preparation of the food requires additional training as well. Many small facilities use a simple blender (not a blixer or even a food processor!) and would be fearful of implementing NDD for fear that they could not meet the expectations of the diet. It is hard to get everyone on board as staffing, food costs, production changes, and lack of training for staff may be barriers to implementation.
Food Temperatures
What should the food/beverage temperature be at point of service in LTC?
F364 states that food is "palatable, attractive, and at the proper temperature." The interpretive guidelines state: “Is food served at preferable temperature (hot foods are served hot and cold foods are served cold) as discerned by the resident and customary practice? Not to be confused with the proper holding temperature."
If we only have 8-10 residents who eat in their rooms, are there any regulations about having to use closed food carts (since it would be in the hallway accessible to residents)? We would cover each individual cart but are concerned about holding adequate temps as well.
Food carts can be wheeled down the halls and food taken out at the room door. It would be best if food was covered--this will also help retain heat. You can refer to the US Food Code or your state food code (can be found on a web search).
Policies & Procedures
I have a question about policy regarding use of leftovers. Is there a state/fed reg that does not permit use of leftovers for pureed diets?
There is not a federal guideline which specifically prohibits use of leftovers for use in pureed diets. However, guidelines denote that food must be palatable, served at proper temperature, conserve nutrients, etc. The concern of using leftovers for pureed foods relates to food safety, quality and flavor more than anything else. See F364 in the federal interpretive guidelines: "Food prepared by methods that conserve nutritive value, flavor, and appearance; Food that is palatable, attractive and at the proper temperature". As far as state regulations go, you'd have to check your state guidelines, but I would assume that there is no specific mention of use of leftovers for puree--again it would be the application of quality, flavor and especially food safety--so it would be under those tags.
I have been asked to redo the policy and procedure manual for clinical nutrition in my facility. Do you have any ideas on what should be on the clinical side of the table of contents?
We have a Policy & Procedure Manual for use in long term care facilities and hospitals, and an Operations Manual for Assisted Living. You can view the table of contents on our website. Both manuals have a nutrition care section. You might consider purchasing one of these and save yourself a lot of time. The extended care P&P manual can be purchased with a CD ROM for customization--a great time savings!
I was told in the past that serving side dishes uncovered on a tray was acceptable if you are using a closed cart for the tray delivery. A state surveyor is telling us each food item needs to be covered even if it's transported in a closed cart. What are your thoughts?
Generally, if carts are cleaned and sanitized at least 1-3 times a day, and if foods are not carried any distance from the cart for service (carts are wheeled from room to room for example), then it is acceptable not to cover each item in a closed cart system. If the covering helps to maintain food temperatures, then you might want to reconsider covering certain hard to hold items.
Date Marking
When labeling and dating in most facilities do they use a discard date on items or do they label and date with an open date? We are having a tuff time agreeing on which is the best. Can you give us an idea of what most places do?
In our facilities it seems easier for them to do a "discard by" date for the food so there is no mistake about how long it should be kept. The "opened on" dating system leaves staff having to figure out when the product should be discarded (which may not be the best procedure). Facilities usually create a policy to determine how the dating is done in the foodservice department and that is the way they train the staff. Whatever your facility decides on, be consistent with it and make sure all staff are following the same procedure.
Handwashing/Gloves
When should foodservice workers wear gloves?
Gloves should be worn whenever a worker is directly handling a food item with the hands. Staff need to wash their hands before putting gloves on. Gloves need to be changed any time they touch any soiled item, contaminated surface, or after coughing or sneezing.
When passing out trays, buttering bread/ jelly, etc, in the dining room should the aides/kitchen staff wear gloves since they are touching the food and if so, do they need to switch gloves with each resident? They do wash their hands prior to working in the dining room and a sanitizer
is available as well.
I would recommend that if staff is touching any food to be served directly with their hands that they need to wear gloves. They only need to switch the gloves if they have contaminated them in any way (touching the resident or themselves, if the resident has eaten from the food that the staff member touched, touching the table, picking something else up with the gloves, sneezing on the gloves, etc.) Any time they change gloves, they should wash their hands. We have inservices for staff that might be helpful.