Texas Department of Aging and Disability Services
Nursing Facility Requirements for Licensure and Medicaid Certification Handbook
Revision: 07-3

Subchapter L

§19.1101  Dietary Service

The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs of each resident.

§19.1102  Staffing

The facility must employ a qualified dietitian either full-time, part-time, or on a consultant basis.

(1)
A qualified dietitian is one who is qualified based upon either:
(A)
registration by the Commission on Dietetic Registration of the American Dietetic Association; or
(B)
licensure, or provisional licensure, by the Texas State Board of Examiners of Dietitians. These individuals must have one year of supervisory experience in dietetic service of a health care facility.
(2)
If a qualified dietitian is not employed full-time, the facility must designate a person to serve as the director of food service who receives frequently scheduled consultation from a qualified dietitian.
(3)
The designated director of food service is responsible for the overall operation of the dietary service. If the director is not a qualified dietitian, he must receive consultation from a qualified dietitian. The director of food service must participate in regular conferences with the administrator and with the registered nurse who has responsibility for the resident and the resident's plan of care. In conferences concerning the resident's plan of care, the director of food service must provide information about approaches to identified nutritional problems. The director of food service should make recommendations and assist in developing personnel policies.
(4)
The director of food service must be at least:
(A)
a qualified dietitian;
(B)
an associate-in-arts graduate in nutrition and food management (such as Dietetics, Home Economics, or Restaurant Management);
(C)
a graduate of a dietetic technician or dietetic assistant training program approved by the American Dietetic Association, or the Dietary Manager's Association, whether conducted by correspondence or in a classroom;
(D)
a person who has completed a state-agency-approved 90-hour course in food service supervision; or
(E)
a person who has training and experience in food service supervision and management in a military service equivalent in content to the programs in subparagraphs (A)-(D) of this paragraph and has had his training credentials evaluated and approved by the nutrition program specialist of the Texas Department of Human Services' Long Term Care-Regulatory.

§19.1103  Sufficient Staffing

The facility must employ sufficient dietary support personnel who are competent to carry out the functions of the dietary service.

§19.1104  Dietary Consultant Requirements

(a)
The facility must ensure a qualified dietitian is available as frequently and for such time as is necessary to assure each resident a diet that meets the daily nutritional and special dietary needs of each resident, based upon the acuity and clinical needs of the resident. The facility must ensure that monthly dietary consultant hours are provided, at a minimum, as follows:
(1)
facility population: 60 residents or under - eight hours;
(2)
facility population: each additional 30 residents or fraction thereof - four hours.
(b)
To meet the consultant-hour requirement, time is accrued and counted exactly as rendered.
(c)
The qualified dietitian must be a part of the interdisciplinary team conducting assessment and care planning where indicated by the individual resident's needs.
(d)
The facility must outline consultant services in a signed contract. This requirement does not apply to facilities which employ a qualified dietitian on their staff.

§19.1107  Menus and Nutritional Adequacy

(a)
Menus must:
(1)
meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences;
(2)
be prepared at least one week in advance;
(3)
be written for each type of diet ordered in the facility, in accordance with the facility's diet manual;
(4)
be written or completely evaluated by the facility's dietitian or consultant dietitian;
(5)
vary from week to week, taking the general age-group of residents into consideration; and
(6)
be followed. Any substitutions must be documented as required in subsection (d) of this section.
(b)
A qualified dietitian may accept diet orders and changes from the physician.
(c)
The facility must ensure that a current diet manual, approved by the facility dietitian or the consultant dietitian, is readily available to dietary service personnel and the supervisor of nursing service. To be current, the diet manual must be no more than five years old.
(d)
The facility must retain records of menus served and food purchased for 30 days. A list of residents receiving special diets and a record of their diets must be kept in the dietary area for at least 30 days.
(e)
The facility must post the current week's menu:
(1)
in the dietary department, including therapeutic diet menus, so employees responsible for purchasing, preparing, and serving foods can use it; and
(2)
in a convenient location so the residents may see it.
(f)
The dietary department must keep a seven-day supply of staple foods and a two-day supply of perishable foods at all times. The facility is allowed the flexibility to use food on hand to make substitutions at any interval as long as comparable nutritional value is maintained. Any substitution of menu items must be recorded on the day of use. See also §19.1719(o)(1) of this title (relating to Other Rooms and Areas) for information concerning storage areas.
(g)
Accommodation of resident needs. The facility must provide:
(1)
table service for all who can and will eat at the table, including wheelchair residents;
(2)
firm supports, such as over-bed tables, for serving trays to bedfast residents;
(3)
sturdy tray stands of proper height to residents able to be out of bed for their meals;
(4)
special eating equipment and utensils for residents who need them; and
(5)
prompt assistance for residents who need help eating.
(h)
An identification system, such as tray cards, must be available to ensure that all diets are served in accordance with physician's orders.

§19.1108  Food

Each resident must receive and the facility must provide:

(1)
food prepared in accordance with established professional food preparation practices and by methods that conserve nutritive value, flavor, and appearance;
(2)
adequate amounts of food that is palatable, attractive, and at the proper temperature;
(3)
food prepared in a form designed to meet individual needs;
(4)
substitutes of similar nutritive value to residents who refuse food served, and
(5)
food that is prepared and served on schedule.

§19.1109  Food Intake

Food intake of residents must be monitored and recorded as follows.

(1)
Deviations from normal food and fluid intake must be recorded in the clinical records. See also §19.1911(12)(B)(vi) of this title (relating to Contents of the Clinical Record) for information concerning dietary intake and clinical records.
(2)
In-between meals and bedtime snacks, and supplementary feedings, either as a part of the overall care plan or as ordered by a physician, including caloric-restricted diets, must be documented using the point, percentage, or other system consistently facility-wide. See also §19.1911(12)(B)(vi) of this title (relating to Contents of the Clinical Record) for information concerning dietary intake and clinical records.

§19.1110  Frequency of Meals

(a)
Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community.
(b)
There must be not more than 14 hours between a substantial evening meal and breakfast the following day, except as provided in subsection (d) of this section.
(c)
The facility must offer snacks at bedtime daily. Routine snacks that are not ordered by the physician and are not part of the plan of care do not need to be documented as accepted or rejected.
(d)
When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day, if a resident group agrees to this meal span and a nourishing snack is served.

§19.1111  Sanitary Conditions

(a)
The facility must:
(1)
procure food from sources approved or considered satisfactory by federal, state, and local authorities;
(2)
store, prepare, and serve food under sanitary conditions, as required by the Texas Department of Health food service sanitation requirements; and
(3)
dispose of garbage and refuse properly. See also §19.318(j)-(l) of this title (relating to Other Rooms and Areas) for information concerning dietary physical plant.
(b)
Dietary service personnel must be in good health and practice hygienic food-handling techniques. Persons with symptoms of communicable diseases or open, infected wounds may not work.
(c)
Dietary service personnel must wear clean, washable garments, wear hair coverings or clean caps, and have clean hands and fingernails.
(d)
Routine health examinations must meet all local, state, and federal codes for food service personnel.

§19.1113  Paid Feeding Assistants

(a)
State-approved training course. The facility may use a paid feeding assistant, if the paid feeding assistant has successfully completed a state-approved training course that meets the requirements of §19.1115 of this chapter (relating to Requirements for Training of Paid Feeding Assistants) before feeding residents. The facility must not use any individual working in the facility as a paid feeding assistant unless that individual has successfully completed the state-approved training course for paid feeding assistants.
(b)
Supervision. A paid feeding assistant must work under the supervision of a registered nurse or a licensed vocational nurse. In an emergency, a paid feeding assistant must call a supervisory nurse for help. A paid feeding assistant can only feed residents in the dining room.
(c)
Resident selection criteria.
(1)
The facility must ensure that a paid feeding assistant only feed residents who have no complicated feeding problems, which include difficulty swallowing, recurrent lung aspirations, and tube or parenteral/IV feedings.
(2)
The facility must base resident selection on the charge nurse's assessment and the resident's latest assessment and plan of care.

§19.1115  Requirements for Training of Paid Feeding Assistants

(a)
Minimum training course contents. A state-approved training course for paid feeding assistants must include, at a minimum, 16 hours of training in the following:
(1)
feeding techniques;
(2)
assistance with feeding and hydration;
(3)
communication and interpersonal skills;
(4)
appropriate response to resident behavior;
(5)
safety and emergency procedures, including the Heimlich maneuver;
(6)
infection control;
(7)
resident rights; and
(8)
recognizing changes in residents that are inconsistent with their normal behavior and the importance of reporting those changes to the supervisory nurse.
(b)
Maintenance of records. The facility must maintain a record of all individuals used by the facility as paid feeding assistants who have successfully completed the state-approved training course for paid feeding assistants. At a minimum, documentation must include the date and location of the course, the name of the trainer, and a statement that the course was successfully completed.
(c)
Repeat training. If paid feeding assistants seek employment at a facility other than the facility at which they were trained, they will not be required to repeat the state-approved training course if documentation of successful course completion, as outlined in subsection (b) of this section, is given to the hiring facility.