General

Assisted living facilities with 17 or more beds are required to follow the food service facility regulations.  The food service regulations require any place where food or drinks are prepared on the premises for service or sale must have a valid license.  ALF providers must give a copy of this license to OHCQ as part of the application process.  In Baltimore City, the Department of Health requires that ALFs with 6 or more beds have a license.  Separate licenses are required for each facility For more information, contact your local health department.

Here is the legal background for these requirements.
ALFs with 17+ beds required to comply COMAR 10.07.14.38 F(2).  Also see the definition of a food service facility Health-General § 21-301 and the requirement for separate licenses. Health-General § 21-305.

The American Dietetics Association recommends that “diet prescriptions for long term care residents be liberalized”.  The ADA mentions that facilities are adopting new attitudes toward providing care and are involving residents in menu planning, dining location and schedules.

According to a national study, the most frequent complaints involving assisted living facilities involve medication administration, menu quality, discharge eviction planning/notice, dignity/respect of staff, and equipment/building problems. (Report to Congress. Long-Term Care Ombudsmen Report, Fiscal Year 2004. Washington, DC: U.S. Department of Health and Human Services, Administration on Aging).

New federal dietary guidelines - Updated every 5 years, the most recent update is the 2005 update of the guidelines an 84 page pdf file. Also see the 61-slide power point summary designed for professionals. You can save it or view it on-line. The American Dietetic Association offers a short 2 page comparison of the 2000 and the 2005 guidelines.

"MyPyramid"

• Revised Food Pyramid  - materials for professionals on the new USDA food pyramid. Includes interactive educational materials.
• Suggested Food Intake by 12 Different Calorie Levels (PDF)- The USDA summary for professionals that breaks down the MyPyramid nutrition guidelines by different calories levels. Useful table. Also see a sample 7 day 2000 calorie menu.
• Suggested Calorie Levels Based on Age and Activity Level. (PDF) – An easy-to-use table based on the MyPyramid guidelines.
• “MyPyramid Tracker” Tool for Monitoring a Diet Plan Over Time - from the USDA. Center for Nutrition Policy and Promotion. Although it was designed for individual consumers, it could provide a very useful tool to track and analyze a menu plan of a small ALF. You must register, and the system will allow you to track information for up to one year. It is designed for the user to enter a day’s worth of dietary information. It then compares that daily menu plan with current nutritional guidance and related nutrition messages and information. It could be used by an ALF operator to:
  • (1) supplement the advice of a dietitian-nutritionist and
  • (2) provide valuable menu planning information through an analysis of a menu plan over a period of time. One would need to enter the information on a regular basis. However, the effort involved would bring the use of a sophisticated tool to a small business.

Find out the nutrition value of common foods - The USDA National Nutrient Database provides technical nutritional information on a wide range of food products including fast food. The database also includes reports on foods by single nutrients, such as calcium. Not a particularly user-friendly interface.

An interactive on-line menu planner helps to plan meals to target specific calorie requirements (from the National Heart Lung and Blood Institute).

Calculate the % of fat, protein, and carbohydrate to maintain, lose or gain weight - A daily nutrition calculator from Blue Cross/Blue Shield/Wellmark.

Calculating Portions of Food

• Downloadable portion control picture card (PDF)
• Pictures of food portions with nutrition facts  A commercial weight loss business offers pictures of many common snack and prepared foods.

Interactive Quizzes to Train Staff to Recognize Appropriate Portions

• “Portion Distortion” Quizzes for Staff Training - Two quizzes from the National Heart Lung and Blood Institute that test knowledge of portion and serving sizes. You can download the quizzes or ask staff to view them on-line. Interesting and interactive tools from the National Heart Lung and Blood Institute.
• Serving Size Surprise Game - a quick quiz from Aetna Insurance that covers 15 common foods. It is useful because it compares the correct portion of a food to common objects such as a baseball. It also relates the food to the USDA pyramid.

"Rate Your Plate" -  a quick interactive quiz from the University of Connecticut that allows you to test the nutritional value of a sample plate of food that you select from a limited set of options. Mostly useful to see the analysis of the plate in 4 areas: food label, 12 nutrients, food guide pyramid and the dietary guidelines.

Maryland Diet Manual for Long-Term Care - ordering information for the $25 manual distributed by OHCQ.  The ALF license application packet notes that all "providers must be familiar with the healthy diet requirements as described in" this manual.  Operators must submit a written statement to that effect.

Sample Meal Planner Chart (Balt. Co)

Maryland Farmers Markets - a county-by-county listing of farmers’ markets from the MD Department of Agriculture.

Community Supported Agriculture – This is a growing resource for consumers and small businesses like ALFs to provide fresh vegetables from local farmers. A CSA farm is supported through members of the community who purchase a share of the farm’s production for the year.

• Payment – Typically you pay for the share at the beginning of the season, and you receive weekly the produce that is ripe that week. Your “ share” is part of what pays for the farm operations and the farmer’s salary.
• Receiving the food - The food is usually picked up at the farm on a designated day and time. Some farms offer a delivery service. The exact produce will vary by season and local weather, etc.
• Advantages for ALF operators - The advantage for small ALFs is that the produce will be absolutely fresh. Also, a CSA will often grow non-commercial varieties of tomatoes and other vegetables that are often more flavorful but not suited for long-term storage and shipping. This may be useful to tempt residents who are “picky” eaters. A CSA membership may provide interesting variety in diet and menu planning or even an opportunity for mobile residents to participate in the trip to the farm to pick up the produce. Some farms will occasionally have a “pick your own” option for certain produce, such as strawberries.
• The downside of a CSA membership is that produce is only available during the growing season. Additionally, the payment for the share must be made at the beginning of the growing season. 
• Find a Maryland CSA farm near your facility through the US Department of Agriculture’s collection of directories. Scroll down the page for national and regional databases that you can search by city, state, or zip code.

As of 1/1/06 - Trans fats were required to be included on the label of commercially prepared foods plus FDA list of major sources of trans fat.

• Public health history of how the official guideline was created (from the Harvard Public Health Review).
• Trans fat restriction alert for Montgomery County ALFs

Over 500 frequently asked questions and answers on safe food handling and preparation.  Links to over 500 frequently asked questions found on federal, state, and local food safety web sites compiled by the FoodSafety.gov, an easy-to-use list organized by topic.

Resources for information and recipes for specialized diets:

• Gluten-free recipes – An individual diagnosed with celiac disease created this website with recipes that are gluten and wheat free. It also includes links to commercial resources for gluten-free products. A second website, Celiac Disease and Gluten-Free Diet Information Center, also started by an individual, contains gluten-free recipes. Neither are medical websites.
• Allergy-specific recipes – The Food Allergy & Anaphylaxis Network is a nonprofit that describes its membership as “families, dietitians, nurses, physicians, school staff, representatives from government agencies, and the food and pharmaceutical industries.” The website includes a few recipes and a holiday cookbook as well as allergy alerts issued by various food manufacturers.
• Diabetes-specific recipes – The American Diabetes Association offers recipes and nutritional information. 
• USDA Recipes and Menu Planning - The US Department of Agriculture includes useful recipes using lentils and peas, tips on introducing a vegetarian diet at an institution and portion control tips.
• Vegetarian Resource Group - a nonprofit that offers recipes and cookbooks to assist ALF staff to prepare interesting vegetarian meals.
• American Heart Association Cookbook and some tips for cooking with lower cholesterol

The Maryland regulations on food safety COMAR 10.07.14.20(A).

Finding the Maryland State Law on Food Safety

Hand Washing - Download a colorful poster reminding staff to wash their hands from the Clean Hands Campaign of the American Society for Microbiology

• Also see free, downloadable and colorful calendar with hand washing story graphics for each month from the Massachusetts Department of Public Health.
• More hand washing articles from the Centers for Disease Control and Prevention

Also see the fact sheets on protecting food in freezers during a power loss

For information on your local sanitation and safe food handling rules/resources, contact the health officer at your local Department of Health. Directory of county health offices and health department websites

Model Maryland Policy on Safe Food Handling Procedures - A good 2 page checklist from the Baltimore County Department of Health’s Assisted Living Manual

Tips on Where to Place a Thermometer to make sure that food is fully cooked from the U.S. Department of Agriculture.

21 Common Food Service Problems  - Clear and brief statements of 21 problems and solutions from the Alaskan Department of Environmental Health. Useful overview for Maryland ALF operators as well.

Food Safety Information Center  - Food safety resources for hand washing, food preparation and food handling for food service establishments from the U.S. Department of Agriculture (USDA).

• Searchable on-line database of nutritional information for over 260 Restaurant Chains  - A commercial weight loss business offers a useful interactive tools that includes a wide range of nutrient data and information including calorie count charts, fat content, fiber content and protein content. Mostly prepared foods and fast-food chains.

Tips on addressing the needs of older residents - simple tips from the USDA on how to help residents who have trouble chewing, loss of appetite or upset stomach.

Summary of the research on the use of fish oil capsule supplements to prevent heart attacks. This technical summary of recent research on this supplement for residents with coronary heart disease is not medical advice.  However, it is useful for residents to use in discussions with their physicians. 

Monitoring Resident Health - A useful fact sheet on how to recognize malnutrition and dehydration, designed for family member but very useful to ALF staff. Also see a related publication for professionals  from the National Coalition on Nursing Home Reform, a nonprofit advocacy group.

Date last reviewed (no legal content): 10/15//07 (MLAN/DL/AC)