Good food is essential to good health. Whether you are in an assisted living facility, independent living, or hospital setting, the quality of your meals is critical to maintaining your health and well-being.
As a foodservice professional, it's essential to understand the regulations that govern food service in these different settings. The laws and regulations are complex (and vary quite a bit depending on where you live and what kind of establishment you work in), but it’s important to understand these intricacies if you want to keep people safe.
In this blog post, we'll take a closer look at the food service regulations for assisted living, independent living, and hospital settings so that you can provide better nutrition, better service, and a safer environment for everyone.
Special thanks to Alison Dankovich, MS RDN LD, Non-Commercial Business Solutions Specialist at Gordon Food Service, for contributing her expertise to this content.
Why Food Safety Matters in Assisted Living, Independent Living, and Hospitals
As a food service professional, you understand the importance of food safety for everyone’s health and well-being.
However, food safety takes on even greater significance in settings like assisted living, independent living, and hospitals, where vulnerable populations such as seniors are not only present, but the chief population.
Seniors (those 65 or older) face more dramatic potential health impacts from foodborne illness. That’s because their digestive and immune systems are less efficient than those of younger adults, making them more likely to succumb to bacteria, viruses, and other pathogens.
Seniors are also more likely to suffer from chronic conditions like diabetes and cancer, which increases the risk of succumbing to foodborne illnesses.
Therefore, good food safety practices are essential to reduce the risk of infection for these most vulnerable populations.
Breaking Down the Basic Definitions
Before diving deeper into the foodservice regulations for various healthcare settings, we need to break down what these communities actually are. Let’s look at what assisted living, independent living, nursing homes, and hospitals are (and how they’re regulated) at the most general level before we explore the comparison between regulations and it further.
Assisted living can be found under a variety of labels, including adult foster care and personal care homes, depending on the state concerned. Not all communities that refer to themselves as assisted living operate in the same way.
Each assisted living community has its own set of regulations, ranging from who can be admitted to what services can be accessed. Some assisted living providers are more like extensions of their residents' previous homes, while others are more structured and offer more comprehensive services.
Assisted living communities provide help with activities of daily living (ADLs) such as bathing, dressing, eating, and medication management. The degree of aid required varies depending on the individual's needs. Assisted living providers, on average, have a lower caregiver-to-resident ratio than nursing homes.
Some assisted living communities have designated dining spaces, while others do not. As a result, the regulations governing dining services can vary significantly. The specific services provided by assisted living communities also differ widely.
Assisted living communities are governed by state-based regulation from the licensing to the enforcement phase.
Providers can be inspected every 12 to 24 months, but some states require inspections every six months, while others require inspections every 60 months.
State authorities pay attention to three primary factors when evaluating an assisted living facility: the bodily, emotional, and social well-being of residents. Residents' medical and health records are frequently used as part of the assessment as well.
Independent living and assisted living are two terms that are often used interchangeably, but what many people don’t realize is that they aren’t actually the same.
Independent living provides seniors with a range of living options, as residents typically require less care than assisted living residents. In independent living, seniors are capable of managing routine daily activities such as showering, cooking, and cleaning but may require some assistance with other tasks as needed.
Such tasks might include medication monitoring, transportation, or housekeeping. Nevertheless, patients can maintain their independence while receiving only the help they need.
With independent living, residents have a wide range of housing options to choose from. Whether it’s apartment-style or housing co-ops, independent living communities offer more options to fit a range of needs and preferences.
You may also see independent living referred to as senior apartments, active adult communities, retirement communities or homes, or 55+ communities.
Most states require the same regulations for both independent and assisted living providers. The only difference is that in independent living, meal times and formats aren’t usually as prescribed.
For example, residents often have their own private living areas with community spaces available for gatherings and social activities.
Independent living communities also offer a wide range of foodservice options.
Many communities, for instance, offer dining services requiring little preparation, such as take-out meals or restaurant-style dining with scheduled meal times. In addition, communities may run a grocery shopping service, where caregivers and/or staff members will assist in procuring groceries. Some residents prepare all of their meals themselves, while others rely on the facility to prepare meals for them.
Nursing homes provide long-term care for individuals who require constant medical attention and assistance with activities such as bathing, dressing, feeding, and taking medication.1 These long-term care communities provide residents with the most intensive support, and often house patients who have serious conditions like dementia or Alzheimer’s and can no longer care for themselves.
Nursing homes provide 24/7 medical care and assistance. Nurses are always on staff, and residents can have access to a doctor or other healthcare providers as needed. This means that residents have access to medical care around the clock, which is especially useful in times of emergency.
Nursing homes typically offer food service in a cafeteria-like setting. These communities usually have a dietitian on staff to ensure that residents receive the necessary nutrition and are accommodating to residents with specific dietary needs. The meals provided in nursing homes contribute to the overall health and well-being of the residents, supporting physical health and social engagement.
Nursing homes are governed by federal and state laws to provide protection against potential hazards. Nursing homes must provide a safe and secure environment for their residents, especially those with physical or cognitive impairments. These providers are inspected regularly to ensure compliance with regulations relating to hygiene, food safety, and health and safety measures.
Another benefit of nursing homes is that they provide protection for their residents through the residents' rights enshrined in the 1987 Nursing Home Reform Law. Nursing homes participating in Medicare and Medicaid must follow these rights. It’s important to note that assisted and independent living communities, along with hospitals, must also follow these regulations if they are serving food and receive funding from Medicare/Medicaid.
The law stipulates the rights of residents in areas such as participation in their care, privacy and confidentiality, transfers and discharges, visits, dignity, respect, independence, and freedom of choice. This law ensures that residents receive the best possible care while in the community–and that, of course, also includes the meals that are prepared there.
The CMS (Centers for Medicare and Medicaid Services) provides guidance for nursing homes and assisted living communities that accept Medicare and Medicaid. This is provided in the form of the State Operation Manual, which is updated annually.
As an example, in the State Operations Manual, it is noted that "all hospital kitchens should have a food service permit, a permit sign should be posted in the kitchen, and the permit should be posted in a prominent location where it can be viewed by patients and their visitors."2 There may be regulations surrounding food storage, preparation, cooking, and service to patients as well.
A hospital provides 24-hour medical and personal care to patients. It can offer both a short-term and long-term setting, and may include rehabilitation services and skilled nursing communities.
However, to be certified by the Centers for Medicare and Medicaid Services (CMS), hospitals must follow strict federal regulations that govern their operations.1
These federal regulations are non-negotiable, meaning that some states may add additional regulations but cannot subtract from the federal guidelines.
One example is the unannounced inspections each state conducts once every 15 months to ensure compliance. Any identified deficiencies must be corrected before certification can be maintained.
The Joint Commission is the most common regulator of hospitals at the larger level, but each state may have additional regulations as well, so it's important to review these regulations before starting work in a hospital.
An Overview of Regulations for Healthcare Communities
Now that you know what each of these settings is, let’s look at what regulations apply to all of them-and how they differ across the board.
1. Kitchens in Nursing Homes and Other Communities Are Inspected–But Perhaps Not Often Enough
If you're a food service professional working in a healthcare facility, you already know that regulations can be strict. Health inspectors can visit at any time to ensure that your kitchen is up to code.
Nursing homes have to be inspected regularly, but the exact frequency varies depending on the state's regulations. Assisted living communities also typically receive an inspection every 12 to 24 months.
However, because so much of this is dictated at the state level, there is often a wide variation in how often inspections occur. This means some communities may have their kitchens inspected more often than others.
Studies show that nursing home kitchens, in particular, are probably not inspected as often as they should be.3 On average, these kitchens are only inspected about once a year.
This is alarming because, again, these providers serve a vulnerable population who may be at a higher risk for foodborne illnesses. That’s why it’s a good idea for any kitchen to have a plan in place for routine independent inspections (outside of what’s required by the regulations) to ensure everything is up to snuff.
As a food service manager, you may want to implement a Hazard Analysis and Critical Control Points (HACCP) system.4 HACCP is a proactive approach to food safety that identifies potential hazards and takes steps to prevent them before they occur.
By implementing a HACCP system, foodservice professionals can ensure that their kitchens are in compliance with regulations and that they are taking proactive steps to prevent contamination.
2. Providers That Receive Medicare or Medicaid Funding (Regardless of the Type) Must Meet Certain Standards
One of the most important regulations to be aware of is that communities that receive Medicare or Medicaid funding (regardless of the type) must meet certain standards, as mentioned earlier in this post.
These standards include having written policies and procedures that address:
the availability of a diet manual and therapeutic diet menus to meet patients' nutritional needs
the frequency of meals served
the system for diet ordering and patient trays delivery
accommodations for non-routine occurrences such as parenteral nutrition, change in diet orders, and nutritional supplements
In addition, the food and dietetic services must be integrated into the provider's QAPI program and infection control programs, and there must be guidelines for acceptable hygiene practices of food service personnel and kitchen sanitation.
It is important to note that these standards apply whether the food and dietetic services are provided by the hospital directly, through a contractual agreement, or by an off-site vendor.
The provider must also be in compliance with federal and state licensure requirements for food and dietary personnel, as well as food service standards, laws, and regulations.
There are a few different ways that a community can meet this requirement. Depending on the credentials and training of the dietary manager, they could work part-time with the assistance of a full-time dietitian.
Regardless of how this arrangement is worked out, the director must be qualified in and meet all applicable regulations. They must be trained in safety practices for food handling, emergency food supplies, orientation, work assignments, supervision of work, and personnel performance.
3. Adherence to the FDA’s Food Code and HFAP
Another important regulation to be aware of is the Food and Drug Administration's (FDA) Food Code.5 This code provides guidance on proper food handling and preparation to prevent foodborne illness.
Healthcare providers must comply with the Food Code and conduct regular monitoring of food temperatures, storage, and sanitation practices to ensure the safety of patients.
In addition to federal and state regulations, healthcare providers must also comply with accrediting organizations such as The Joint Commission or the Healthcare Facilities Accreditation Program (HFAP).6,7
These organizations have their own standards related to food and dietetic services that must be met in order to maintain accreditation. It is important to review and understand the requirements of the accrediting organization specific to your facility.
4. Menus Must Meet Dietary Needs
According to the Centers for Medicare & Medicaid Services (CMS), each hospital patient for whom the hospital provides one or more meals or nutrition must have their nutritional needs met in a manner that is consistent with recognized dietary practices.2
This includes inpatients and those in outpatient status, such as those receiving observation services, whose stay is long enough to require feeding.
The nationally recognized source for recommended dietary intake allowances is the Institute of Medicine Food and Nutrition Board’s Dietary Reference Intakes (DRIs), which are designed to provide recommended nutrient intake for use in a variety of settings.8 The DRIs consist of four reference values:
Recommended Dietary Allowance (RDA): the average daily dietary intake of a nutrient that is sufficient to meet the requirement of nearly all healthy persons.
Adequate Intake (AI): for a nutrient, the AI is only established when an RDA cannot be determined. The AI is based on observed intakes of the nutrient by a group of healthy persons.
Tolerable Upper Intake Level (UL): the highest daily nutrient intake level that is likely to pose no risk of adverse health effects to almost all individuals in the general population.
Estimated Average Requirement (EAR): the average daily nutrient intake level that is estimated to meet the requirements of half of the healthy individuals in a particular life stage and gender group.
It is important for healthcare providers to consult these guidelines when planning their menus to ensure that patients are receiving an appropriate balance of nutrients.
Regulations set in place by CMS require healthcare providers to have policies and procedures in place for patients with unique dietary needs or allergies. Menus for patients with specific food allergies or dietary restrictions must be clearly labeled, and alternative menu options must be provided.
5. Some States Require Food Safety Certifications
Some states require food safety certifications for healthcare communities.
For example, Colorado and Minnesota have regulations that require each assisted living facility to have at least one individual who is a Certified Food Protection Manager (CFPM).9
In Minnesota, this credential can be obtained by taking an approved food safety course, passing the exam, and then applying for the credential from the Minnesota Department of Health.
The CFPM does not need to be always on-site when food is being prepared and served, but they must provide training for and oversight of the people performing food preparation activities.
6. Most States Also Have Universal Handwashing and Health/Hygiene Regulations, Along With Those for Time and Temperature Control
Handwashing and hygiene regulations are standard across all healthcare providers, including hospitals and assisted living communities. Each state has its own specific guidelines that must be followed, and providers must have processes in place to monitor and enforce these regulations.
For example, in Minnesota, all staff who have been ill with vomiting and/or diarrhea cannot work in a food establishment for at least 24 hours after their symptoms end.10
Another important regulation for healthcare communities is time and temperature control. This regulation ensures that food is stored and prepared at safe temperatures and within a certain time frame.
Each provider must have a system in place to monitor and record temperatures to ensure that food is being stored and prepared safely. This regulation is enforced heavily in nursing homes and hospitals, where everything is more standardized, with cafeteria-style operations that are all watched over by a trained supervisor.
7. Assisted Living Communities Have the Loosest Regulations
It’s important to note that, for better or worse, the regulations for assisted living providers tend to be looser.
A homelike environment is one of the reasons residents value assisted and independent living communities. However, this generally means residents have access to kitchens or kitchenettes–adding more variables to the food safety equation. Nursing homes or hospitals have the greatest ability to control for food safety, while assisted and independent living communities have less overall oversight.
The Centers for Medicaid and Medicare (CMS) contracts with each state to conduct onsite food storage and preparation inspections at long-term care communities, yet some states do not have food-service inspectors who are trained on institutional (versus restaurant) food safety standards as specified by the FDA.2,5
General Tips for All Healthcare Settings to Incorporate for Better Food Safety
Now that you know what the regulations are, here are some general tips that you can implement in any healthcare community to keep everyone safe:
Purchase from approved vendors: Purchase food products from vendors who follow HACCP (Hazard Analysis and Critical Control Points) procedures as outlined by the FDA.4 Ensure that the delivery is inspected carefully, and the products' temperatures must be accurate.
Ensure proper food storage and labeling: Label, cover, and store all foods properly, including expiration dates for all items.
Follow safe food handling procedures: Do this at all times to avoid cross-contamination. Be mindful of temperature danger zones.
Adhere to cooking recommendations: Cook foods at the appropriate temperature to kill microorganisms. Keep hot foods at 135 degrees and cold foods at 41 degrees. Take food temperatures and keep accurate logs.
Follow good serving guidelines: This includes wearing disposable gloves and always washing hands after handling money. Handwashing and allergen awareness also fall into this category.
How Trust20 Can Improve Food Safety in Healthcare Settings
In healthcare settings, food safety is not just a matter of best practice but an absolute necessity.
As professionals in the foodservice industry, we need to make sure that the food we serve is safe for consumption, even if the formal regulations aren’t always clear. This is particularly important in healthcare settings, where vulnerable patients rely on us to uphold high safety standards.
With Trust20’s products, foodservice professionals in healthcare can rest assured that they are doing everything possible to maintain the safety of their patients and staff.
1: Senior Living: Federal and State Nursing Home & Assisted Living Regulations
2: Centers for Medicare and Medicaid Services: State Operations Manual Appendix A- Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals
5: FDA: Food Code 2022
6: The Joint Commission: The Joint Commission
7: Healthcare Facilities Accreditation Program: ACHC
8: Office of Disease Prevention and Health Promotion: Dietary Reference Intakes
10: Minnesota Department of Health: Assisted Living Facility Food Code Highlights