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Food safety in assisted living: new skills needed; With more open dining arrangements than nursing homes, assisted living requires skilled food-safety specialists.

Compared with that of nursing homes, the dining model of assisted living is diverse. Residents may eat in common dining areas, restaurants, snack bars, or at home. Meals may travel farther and longer for delivery to apartments--with inherent sanitation risks. Staff involvement with meals often extends beyond the foodservice worker to a range of support personnel because home-delivered meals warrant monitoring to ensure temperature control and safe handling after delivery. And all of this occurs in a backdrop of heightened vulnerability.

Risk-management wisdom in this field dictates the presence of a qualified leader who recognizes hazards and knows how to control them. Under that person's auspices, a comprehensive sanitation program is also critical to risk management. It requires dynamic proficiency to synchronize policies and procedures with evolving FDA guidance and to implement proactive infection-control systems like Hazard Analysis Critical Control Points (HACCP) (see "Protecting residents from foodborne illnesses" by Jamie Stamey, RD, LDN, CFSP, Nursing Homes/Long Term Care Management, June 2006, p. 48, for a full discussion of HACCP). Not only is resident welfare at stake, but also the reputation, continued licensing, and core business survival of the facility.

Who are the likely candidates for this leadership role? With decades of experience serving elders food-safe meals, dietary managers are the logical choice for the FDA "person in charge."

Food in Assisted Living

Food is pivotal to the assisted living industry. It tops nearly every consumer checklist for facilities and, if done right, serves as a marketing magnet. But as assisted living facilities pioneer innovative meal-delivery models to woo and wow residents, a foodborne illness outbreak is always a looming crisis waiting to happen. It is a reality that has hit hard in several assisted living communities (as well as nursing homes) in recent years.


This is unsurprising, given the basic facts of the situation: Seniors are exceptionally susceptible to foodborne illness. Once afflicted, they are more likely to be hospitalized, with mortality rates climbing up to 10 times higher than those among the general population, according to data from the Centers for Disease Control and Prevention.

Some victims suffer long-term complications. The Food and Drug Administration (FDA) estimates that 2 to 3% of foodborne illnesses lead to chronic conditions, such as major organ damage, or Guillain-Barre syndrome, the progressively paralyzing nervous system condition that sometimes follows a foodborne Campylobacter infection.

The FDA places older adults in a category called highly susceptible populations--i.e., those most likely to suffer from a foodborne illness and to suffer serious complications or mortality as a result. Reasons for this vulnerability may include a natural decline in immune response with age, altered senses of taste and smell, poor digestive function, reduced stomach acid, poor nutrition, dehydration, medical conditions, and medications.

Assisted Living Regulations

Realizing that a foodborne illness outbreak can devastate an assisted living facility's reputation and can even generate lawsuits, sound foodservice sanitation serves as insurance against such a catastrophe. Regulations focus on this. Although assisted living regulations vary by state, nearly all refer assisted living administrators to state and local health codes for relevant sanitation standards.

In turn, these localized standards draw their guidance from a common source, the FDA Food Code. The FDA offers its code as a "model," to be adapted and adopted as science-based guidance for preventing foodborne illness in retail and institutional foodservice settings.

Recently, the FDA added stringent precautions to its advice for serving susceptible client groups. For example, in a nursing home or assisted living facility, only pasteurized eggs may be used in large-quantity recipes, juices must be pasteurized, and risky foods such as raw seed sprouts or undercooked burgers are taboo. More rigorous guidelines also apply to restricting activities of ill employees when they are serving susceptible groups.

In assisted living regulations state by state, a key common element is required staff training. Some states, such as Arkansas, Massachusetts, and Pennsylvania, require foodservice sanitation training for all employees as part of orientation. Many states in general do not limit foodservice sanitation education to foodservice workers, but apply it to additional staff members who may be providing hands-on care in the resident's home. In view of the challenges, some states direct administrators to bring in qualified experts to manage food safety.

"Person in Charge"

In fact, recent revisions of the Food Code have strengthened general requirements for a qualified person in charge of foodservice operations. Among other things, this leader must tackle five failures most likely to cause foodborne illness:

* unsafe sources

* improper holding time/temperature

* inadequate cooking

* poor personal hygiene

* contamination of equipment, food, or work areas

Moreover, as outlined by the FDA, risk management is a one-two punch:

1. Establish and enforce standard operating procedures designed to ensure safe practices in all phases of food management, including employee health and hygiene.

2. Have a "proactive manager" who implements risk-management strategies through all phases of food management.

As noted, the FDA endorses the systematic approach called HACCP, which constitutes sound prevention because it focuses on prioritizing and managing critical process components that can go awry, leading to foodborne illness. Today, the certified food protection manager has an expanded role in steering the operation clear of a multitude of sanitation pitfalls.

Employee Health

Not only food, but people, can transmit foodborne illness. Consider this example last year from an assisted living operation in the Midwest: County health experts investigating a foodborne illness outbreak pinpointed the likely source as a foodservice worker permitted to prepare food while suffering from diarrhea. The outbreak peaked three days later, by which time 10 residents were stricken, and 4 were hospitalized.

Rather than an exception, this is a paradigm for foodborne illness outbreaks. It has happened in nursing homes and in schools, on college campuses and on cruise ships, in every state of the nation.

Responding to numerous outbreak scenarios, the FDA beefed up guidance concerning employee health in 2005. The FDA required a documented health policy for food handlers, documentation of routine handwashing, signed employee health agreements, and stringent precautions for keeping ill employees clear of foodservice operations. For example, a foodservice employee with diarrhea is not allowed to work in the kitchen of an assisted living facility, according to the FDA guidance.

Rising to the Challenge: CFPP Credentialing

As a professional organization whose members serve the eldercare industry, the Dietary Managers Association (DMA) rises to the challenge with its food protection credentialing program. Now nearly a decade old, the certified food protection professional (CFPP) credential is required of every dietary manager wishing to achieve certified dietary manager (CDM) status. Today, more than 12,000 CDMs/CFPPs work throughout the United States. Many dietary managers have built a broad base of experience in nursing homes, where they answer to both local health officials and state surveyors. Today, however, many CDMs/CFPPs are crossing over to the assisted living industry to apply their hands-on sanitation-management expertise in this more open setting.

The DMA training program, offered at colleges throughout the country, requires a core minimum of 16 hours of classroom training in foodservice sanitation, as well as 20 hours of supervised experience implementing food-safe management. To obtain the credential upon completion of training, a candidate must pass a national certification exam administered by ACT, the testing company responsible for the American College Testing program. The exam is built on competencies (table), with content drawn from the FDA Food Code.

Certified dietary managers achieve other competencies, as well. Their training in human resources management, education, and food-service systems translates into an ability not only to "know" the rules, but to devise viable foodservice systems and coach a work team to achieve ongoing regulatory compliance.

To maintain the CDM/CFPP credential, a dietary manager must complete 45 hours of continuing education every three years, including at least 5 hours in sanitation and food safety. The DMA offers extensive education for its members, with online courses, monthly magazine columns, and other publications designed to help credentialed members keep pace with techniques for protecting America's elders from foodborne illness.


If assisted living administrators ask themselves, "To find certified dietary managers, do I need to recruit from nursing homes?" The answer is an emphatic "No!" CDMs aren't found, they're developed, and the raw material for this is already in your facility. With the training and certification described above, you can post food safety sentinels for your facility from within your existing staff.

Robin Gaines, CDM, CFPP, is Vice-President of Support Services for Bartels Lutheran Retirement Community and chairperson of the Certifying Board for Dietary Managers. For further information, phone (319) 352-4540. To send your comments to the author and editors, please e-mail


Information Resources

Dietary Managers Association,

FDA Food Code,

FDA Food Code Adoption (by state),

FDA report on foodborne illness risk factors in foodservice (2004),

National Center for Assisted Living Regulatory Review,
Table. Certified Food Protection Professional (CFPP) Competencies

1. Purchase, receive, and store food following established sanitation
 and quality standards.
2. Protect food in all phases of preparation, holding, service, cooling,
 and transportation using HACCP guidelines.
3. Manage personnel and employee health according to the FDA Food Code.
4. Manage physical facilities to ensure compliance with safety and
 sanitation regulations.
5. Implement a food safety system that addresses crisis management.

Source: Certifying Board for Dietary Managers
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Title Annotation:featurearticle
Author:Gaines, Robin
Publication:Nursing Homes
Date:Aug 1, 2006
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