173-4-05 Meal service.

(A) “Meal service” means a service through which a congregate nutrition program, a home-delivered nutrition program, or a restaurant and grocery meal service provides a safe and nutritious meal to consumers to help sustain health through a congregate nutrition program, home-delivered nutrition program, or restaurant and grocery meal service.

(B) Minimum requirements for a meal service:

(1) Dietary guidelines and dietary reference intakes:

(a) The provider shall only provide a meal that complies with the most recent “Dietary Guidelines for Americans” which are published by the secretaries of the United States department of health and human services and the United States department of agriculture and found on http://www.health.gov/dietaryguidelines.

(b) The provider shall provide a meal that meets one-third of the dietary reference intakes (DRIs), which are a comprehensive set of nutrient reference values based on healthy persons for assessing and planning individual and group diets. The food and nutrition board, institute of medicine, and the national academy of sciences establishes DRIs and lists them on http://fnic.nal.usda.gov/.

(2) Menu planning:

(a) In general:

(i) The provider shall assure that all menus meet the meal requirements of this rule.

(ii) The provider shall only offer a menu that is approved by a LD.

(iii) The provider shall only offer menu substitutions that are approved by a LD.

(iv) The provider shall list the serving size for each food item on each production menu.

(b) Methods for determining nutritional adequacy: The provider shall offer a menu to consumers that is nutritionally adequate as determined by nutrient analysis, menu patterns, or a combination of both. “Nutrient analysis” means a process by which food, beverage, and supplement intake are evaluated for nutrient content over a specific period of time that is based upon standard references for nutrients in the component foods. “Menu pattern” means a menu-planning tool used to identify the types and amounts of foods that are recommended to meet specific nutritional requirements. Of these options, the preferred method is to determine nutritional adequacy by means of nutrient analysis.

(i) Nutrient-analysis method: The provider shall only determine the nutritional adequacy of a meal by means of nutrient analysis if:

(a) The provider’s nutrient-analysis software has been approved by the LD of the AAA with which the provider has entered into a provider agreement to provide a meal service;

(b) The leader nutrients and target values fall within the compliance range for the adjusted DRI nutrient-value requirements established by “Table 1” of this rule. The target values for each leader nutrient are based upon one meal per day (one-third of the DRI) for the average older population served by the nutrition program. The provider using the nutrient analysis option shall meet the compliance range for leader nutrients in the daily menu or as averaged based on the week’s menu for ten out of the fourteen leader nutrients; and,

Table 1

LEADER NUTRIENTS TARGET VALUES COMPLIANCE RANGES

Calories 685 calories 600-800 calories

Protein 19 gm No less than 17 gm

Fat 23 gm No more than 25 gm

Vitamin A 300 & 181;g No less than 234 & 181;g

Vitamin B6 0.57 mg No less than 0.5 mg

Vitamin B12 0.8 & 181;g No less than 0.7 & 181;g

Vitamin C 30 mg No less than 25 mg

Vitamin D 3.33 & 181;g No less than 2.5 & 181;g

Calcium 400 mg No less than 360 mg

Magnesium 140 mg No less than 107 mg

Zinc 3.7 mg No less than 2.66 mg

Sodium 767 mg No more than 1350 mg

Potassium 1050 mg No less than 700 mg

Fiber 9 gm No less than 6 gm

(c) When serving two meals to a consumer in one day, the target values and compliance ranges are doubled (two-thirds of the DRI). When serving three meals to a consumer in one day, the target values and compliance ranges are tripled (one hundred per cent of the DRI).

(ii) Menu-pattern method: The provider shall only determine the nutritional adequacy of a meal by means of a menu pattern if the provider complies with the following requirements:

(a) All meals: The only menu pattern a provider shall use is the menu pattern in “Table 2” of this rule.

Table 2

FOOD TYPES BREAKFAST or BRUNCH LUNCH or DINNER

Meat or meat alternate 1-2 servings 2-3 servings

Vegetables or fruits 2 servings 3 servings

Bread or bread alternate 2 servings 2 servings

Milk or milk alternate 1 serving 1 serving

Desserts/baked goods 1 serving (optional) 1 serving (optional)

Accompaniments (e.g., condiments, sauces, spreads) 1-2 servings 1-2 servings

Beverages (e.g., water and other beverages)Optional Optional

(b) Double classification: Although the provider has the option to classify some individual food items as belonging to one food type or another in “Table 2” of this rule, the provider may only classify a single serving of any individual food item in any single meal as part of one type. For example, although the provider may classify a serving of dried beans as either a meat alternate or vegetable, the provider may not classify dried beans as both a serving of a meat alternate a vegetable in the same meal. Also, although the provider may classify cheese as either a serving of a meat alternate or a serving of a milk alternate, the provider may not classify cheese as both a serving of a meat alternate and a milk alternate in the same meal.

(i) The provider shall not serve high-fat and high-sodium processed meats (e.g., hot dogs, bologna, or sausage) more than twice per month.

(ii) The provider shall serve a variety of meat and meat alternates to help meet the DRI requirements for protein, iron, vitamin B6, vitamin B12, and zinc.

(iii) The provider may serve meatless meals that contain eggs; dried beans, peas, or lentil soups or entrees; tofu-based products; or vegetarian lasagna provide variety, contain costs, and assist with special dietary needs, so long as they meet the DRI requirements for protein.

(iv) When planning a meal under the menu-pattern method, the provider may use the guidelines on http://aging.ohio.gov/information/nutrition/nutritionguidelinesandresources.to determine one serving of meat or meat alternate.

(d) Vegetables and fruits:

(i) Throughout each week, the provider shall serve a variety of fruits and vegetables, in particular, from all five sub-groups: the dark-green sub-group, the orange sub-group, the legumes sub-group, the starch sub-group, and the other sub-group.

(ii) The provider shall consider all vegetables (and full-strength vegetable juices) and all fruits (and full-strength fruit juices) to be vegetables and fruits. The provider shall consider cranberry juice a fruit even if it is not full-strength cranberry juice.

(iii) The provider shall prefer usage of fortified juices, low-sodium vegetable juice, or tomato juice over other juices.

(iv) The provider shall consider one-half cup of cooked, dried beans, peas, or lentils; one-half cup of full-strength (i.e., one hundred per cent) vegetable juice; or, one cup of raw, leafy vegetables as one serving of vegetables.

(v) The provider shall consider a serving of soup, stew, casserole, or other combination dish a serving of a vegetable only if the soup, stew, casserole, or other combination dish contains at least one-half cup of vegetables.

(vi) The provider shall not consider rice, spaghetti, macaroni, or noodles a vegetable.

(vii) The provider shall consider a medium-sized apple, a banana, an orange, or a pear; one-half cup of full-strength fruit juice; or, one fourth of a cup of dried fruit to be one serving of fruit.

(viii) The provider shall consider a menu item to be a serving of fruit if one serving of the item contains at least one-half cup of fruit (e.g., fruit cobbler).

(ix) The provider shall only consider fresh fruit, frozen fruit, or canned fruit (packed in its own juice, with light syrup, or without sugar) to be fruit.

(e) Bread or bread alternates:

(i) The provider shall prefer to serve a variety of enriched and/or whole-grain bread products, particularly those high in fiber.

(ii) The provider shall not consider starchy vegetables (e.g., potatoes, sweet potatoes, corn, yams, and plantains) a serving of bread or a bread alternate.

(iii) The provider shall not consider breading on meat (or a meat alternate) or on vegetables a serving of bread or a bread alternate.

(f) Milk or milk alternates:

(i) The provider shall prefer to use low-fat milk, calcium-fortified milk, or milk alternatives.

(ii) The provider shall not consider juice both a serving of fruit and a serving of milk in the same meal.

(iii) The provider shall not consider cheeses or tofu both a meat and a milk alternative in the same meal.

(g) Desserts and baked goods (if provided in meal):

(i) The provider shall prefer to serve healthier desserts that include fruit, whole grains, low-fat products, and/or products with limited sugar content.

(ii) The provider shall consider one-half cup of fruit and one-half cup of simple dessert (e.g., pudding, gelatin desserts, ice cream, frozen yogurt, ice milk, and sherbet) to be a serving of dessert or a baked good.

(iii) The provider shall prefer to serve fresh, frozen, or canned fruits that are packed in juice or light syrup as a dessert item in addition to the serving of fruit that may be provided as another part of the meal.

(iv) The provider shall not serve cakes, pies, cobblers, and cookies more than twice per week.

(h) Accompaniments:

(i) The provider shall consider one teaspoon of fortified margarine, butter, mayonnaise, or vegetable oil; or one tablespoon of salad dressing to be a serving of an accompaniment.

(ii) The provider shall not serve more than two servings of fats and oils in a meal. Fat used as an ingredient in a menu item is not counted.

(i) Beverages: Although servings of a beverage are optional, the provider shall prefer to serve water and other beverages with meals for proper hydration.

(3) Ingredient information: The provider shall offer information on the ingredient content of meals served through a system that is approved by the AAA.

(4) Consumer choice: The provider shall offer a consumer who receives a meal service the opportunity to make choices about the meals served by using one or more of the following methods:

(a) At a minimum, allow each consumer to choose from two of the following:

(i) Meat and meat alternates;

(ii) Vegetables and fruits;

(iii) Bread or bread alternates;

(iv) Milk or milk-alternates;

(v) Desserts and baked goods (if offered); or,

(vi) Entrees consisting of servings of meat and meat alternates combined with servings of other foods.

(b) Allow consumers to select an alternative meal type (e.g., boxed lunch, frozen meal, or vacuum-packed meal) that has the same nutrient content of a regular meal or follows the meal pattern for a regular meal; or,

(5) Alternative meals: Before a provider may offer alternative meals, the provider shall determine the need, feasibility, and cost effectiveness of offering alternative meals by using the knowledge and expertise of a LD, by listing serving sizes of food items in alternative meals in menus, and by obtaining the approval for the alternative meal plan and any menu substitutions and substitution lists from the LD. The provider shall only provide alternative meals that meet the following:

(a) Therapeutic meals:

(i) The provider may only provide a therapeutic meal as ordered by a physician, or another healthcare professional with prescriptive authority, as part of a treatment of a disease or a clinical condition to eliminate, decrease, or increase certain foods or nutrients in the diet.

(ii) The provider may only provide a therapeutic meal if the physician’s order is on file with the provider or the AAA.

(iii) The physician or case manager of the AAA shall review the written order for a therapeutic meal and update it according to the physician’s order.

(iv) The provider shall assure that the therapeutic diet contains nutrients consistent with the diet order by either utilizing nutrient analysis or by obtaining a list of food items from the physician or an LD.

(b) Dysphagia therapeutic meals:

(i) The provider may provide a dysphagia therapeutic meal for someone with a diagnosed neurological condition that makes oral or pharyngeal swallowing difficult or dangerous. The provider shall make the dysphagia meal with a consistency that is specific to the consumer’s needs.

(ii) The physician or other healthcare professional with prescriptive authority shall order either a level one (pureed) or level two (chopped or ground) dysphagia therapeutic diet. The order shall include thickening agents, if required.

(i) The provider shall take the following principles into consideration when planning a diabetic meal using carbohydrate choices: The amount of carbohydrates consumed and the timing of meals, rather than the source of the carbohydrates, are the keys to controlling blood-sugar levels. One carbohydrate choice is equivalent to fifteen grams of carbohydrates. Carbohydrates are found in bread/starch, milk, fruit, starchy vegetables, and desserts.

(ii) If the provider uses a menu pattern to plan a diabetic meal using carbohydrate choices, the provider:

(a) Shall limit a consumer to four to five carbohydrate choices per meal;

(b) Shall allow a consumer no carbohydrate choices for meat or meat alternates. Dried beans, peas, and lentils are considered starchy vegetables;

(c) Shall allow one carbohydrate choice per serving of starchy vegetables and use the same items and serving sizes listed in paragraph (B)(2)(b)(ii)(d) of this rule. Starchy vegetables include baked beans; corn; corn-on-the-cob; cooked, dried beans (e.g., garbanzo beans, pinto beans, kidney beans, white beans, split peas, black-eyed peas, navy beans, and soy beans); lima beans; lentils; mixed vegetables with corn; peas, plantain; potato; sweet potato; winter squash (e.g., acorn, butternut, pumpkin); and yams;

(d) Shall allow one carbohydrate choice per serving of fruit. One carbohydrate choice equals one piece of a small or medium-sized fresh fruit; one-half cup of unsweetened, frozen fruit; one-half cup of unsweetened, canned fruit; one-half cup of unsweetened fruit juice; one-fourth cup of dried fruit; or one-half cup of cranberry juice cocktail;

(e) Shall allow one carbohydrate choice per serving of milk, yogurt, or soy beverage; but do not allow any carbohydrate choice for cheese or tofu. One carbohydrate choice is equivalent to one cup of buttermilk, low-fat milk, or skim milk fortified with vitamins A and D; one cup of lactose-reduced or lactose-free milk; six ounces of yogurt; or one cup of soy beverage that is enriched with calcium and vitamins A and D;

(f) Shall allow one carbohydrate choice per serving of desserts or baked goods. One carbohydrate choice equals one ounce or a two-inch square of an unfrosted brownie or cake, two small plain cookies, one-half cup of ice cream or frozen yogurt; one-half cup of sugar-free pudding; or, a slice of pie that is one-sixteenth of an eight-inch-diameter pumpkin or custard pie; and,

(g) May use the guidelines on http://aging.ohio.gov/information/nutrition/nutritionguidelinesandresources.to plan a meal using carbohydrate choices.

(d) Modified meals:

(i) The provider may only provide a modified meal if the nutritional adequacy of the meal is determined by nutrient analysis or the menu pattern.

(ii) A modified meal may be provided to a consumer without a order from a health care professional.

(iii) If the provider offers modified meals, the provider shall offer:

(a) Lower-sodium substitutions for foods containing 480 mg of sodium (or more) per serving;

(b) Dental soft substitutions that are chopped, ground, or pureed and that are similar in nutritive value, but have a softer consistency to help with chewing;

(d) Low-fat, low-cholesterol substitutions, if the regular menu item is high in fat and cholesterol according to the standards established in the national cholesterol education program diet or the heart-healthy diet program. “Heart-healthy diet” means a diet that involves a decrease in the consumption of foods high in cholesterol and fat compared to an average diet.

(i) Foods that are high in fat include fatty meats (e.g., ribs, regular hamburger, bacon, sausage, cold cuts, salami, bologna, corned beef, hot dogs, fried meats, fried fish, chicken skin, turkey skin); sauces and gravies; fried vegetables; whole milk dairy products (e.g., whole milk, two per cent milk, whole-milk yogurt, ice cream, cream, half and half, cream cheese, sour cream, whole-milk cheeses); high-fat bakery items (e.g., biscuits, croissants, pastries, doughnuts, pies, cookies, muffins) and solid fats (e.g., butter, stick margarine, shortening, lard).

(ii) Foods that are high in cholesterol include organ meats

(e.g., liver).

(iii) The provider shall not offer a consumer receiving a modified meal food that includes egg yolks more than twice per week.

(e) Vegetarian meals:

(i) The provider may provide any of the following categories of vegetarian diets:

(a) “Vegan diet” (i.e., “total vegetarian diet”) means a diet of only foods derived from plants (e.g., fruits, vegetables, legumes (dried beans and peas), grains, seeds, and nuts).

(b) “Lacto-vegetarian diet” means a diet of only foods derived from plants and also cheese and other dairy products.

(d) “Semi-vegetarian diet” means a diet that does not include red meat, but includes chicken, fish, plant foods, dairy products, and eggs.

(ii) The provider may only provide a vegetarian meal if the meal has the same nutrient content of a regular meal or follows the meal pattern for a regular meal as closely as possible.

(f) Salad bar or soup and salad bar meals:

(i) The provider may provide a salad bar or soup and salad bar meal service that allows consumers to serve themselves a partial or complete meal from an array of cold foods or a combination of hot and cold foods contained in a piece of equipment designed to maintain foods at proper temperatures.

(ii) A salad bar served as a meal accompaniment shall offer at least three raw vegetables, one of which is deep green or orange; two fruits; two salad dressings, one of which is low fat; one mixed salad that contains fruits or vegetables like coleslaw, waldorf salad, etc. This counts as two servings of fruits or vegetables.

(iii) A salad bar served as a meal replacement shall offer four raw vegetables, one of which is deep green or orange; two fruits; two meats or meat substitutes; a calcium source equivalent to eight ounces of milk per serving; two salad dressings; and two servings from the bread group; and one dessert. This counts as a full meal if all menu requirements are met.

(iv) A soup and salad bar served as a meal replacement shall meet the criteria under paragraph (B)(5)(f)(iii) of this rule and contain one soup that is a lower-sodium and lower-fat soup.

(v) The provider shall obtain the approval of a LD before serving a salad bar or soup and salad bar meal.

(g) Ethnic or religious meals:

(i) The provider may provide an ethnic or religious meal to meet the particular dietary needs arising from religious requirements, cultural backgrounds, or ethnic backgrounds.

(ii) The provider shall only provide an ethnic or religious meal if the meal has the same nutrient content of a regular meal or follows the meal pattern for a regular meal unless restricted by religious requirements or ethnic background.

(h) Breakfast and brunch-style meals: A provider may only offer a breakfast or brunch-style meal if the breakfast or brunch-style meal has the same nutrient content of a regular meal or follows the breakfast meal pattern.

(i) Sacked lunches and boxed lunches:

(i) The provider may only provide a sacked or boxed lunch that has the same nutrient content of a regular meal or follows the meal pattern for a regular meal.

(ii) The provider may only provide a sacked or boxed lunch if the provider includes a use by date.

(j) Frozen, vacuum-packed, cooked-chilled, and modified atmosphere packed (MAP) meals: A “vacuum-packed” meal is a prepared, pre-cooked meal that is packaged in a container in which all the air is removed before the container is sealed to prolong the shelf life and preserve the flavor. A “modified atmosphere packed” (“MAP”) meal is a prepared, pre-cooked meal in which a combination of gases (e.g., oxygen, carbon dioxide, nitrogen) are introduced into the package at the time it is sealed to extend the shelf life of the food package:

(i) The provider may only provide a frozen, vacuum-packed, cooked-chilled, or MAP meal that has the same nutrient content of a regular meal or follows the meal pattern for a regular meal.

(ii) If the frozen, vacuum-packed, cooked-chilled, or MAP meal is intended as a second meal, the two meals served that day shall together meet two-thirds of the DRI.

(iii) The provider shall refrigerate frozen, vacuum-packed, cooked-chilled meals, and MAP meals during delivery to the consumer.

(iv) The provider shall provide written preparation instructions for the consumer.

(v) The provider shall label the meal with the use by date or expiration date on the meal package.

(vi) The provider may only provide a frozen, vacuum-packed, cooked-chilled, or MAP meal to a consumer if the consumer’s assessment stipulates that the meal is appropriate.

(k) Non-perishable, emergency, and shelf-stable meals. A “shelf-stable meal” is a meal that is non-perishable, ready-to-eat, stored at room temperature, and eaten without heating. Shelf-stable meals use commercially-produced, approved sources (e.g., canned food, dried foods, or ultra-high temperature pasteurized items such as shelf-stable milk, shelf-stable puddings, shelf-stable juices, and shelf-stable creamers):

(i) Every provider of a congregate or home-delivered nutrition program shall develop a written plan for continuing services for the congregate and home-delivered meal service during a weather-related emergency or other emergency. At a minimum, in the plan, the provider shall explain how it plans to enact one of two strategies:

(a) Distribute information to consumers on how a consumer may stock his/her emergency food shelf; or,

(b) Distribute shelf-stable meals to consumers for storage on a consumer’s emergency food shelf.

(ii) The provider may only provide a non-perishable, emergency, or shelf-stable meal that has the same nutrient content of a regular meal or follows the meal pattern.

(iii) The provider may only provide a non-perishable, emergency, or shelf-stable meal if the provider includes a use by date or an expiration date with the meal.

(6) Medical food and food for special dietary use:

(a) Medical food:

(i) The AAA shall determine the need, feasibility, and cost-effectiveness of establishing a service for implementing medical food by using the knowledge and expertise of a LD.

(ii) Under the “Orphan Drug Amendment of 1988,” Public Law 100-290, medical food is formulated to be consumed or administered internally under the direction of a physician and is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.

(iii) Medical food is not intended for the general public.

(iv) Examples are enteral products that treat:

(a) Kidney disease (dialyzed patients with chronic or acute renal failure);

(b) Liver disease (liver dysfunction, and encephalopathy);

(d) Lung disease (chronic obstructive pulmonary disease, and acute respiratory distress syndrome).

(b) Food for special dietary use:

(i) The provider shall determine the need, feasibility, and cost-effectiveness of establishing a service for implementing food for special dietary use by using the knowledge and expertise of a LD.

(ii) Under the “Food, Drug, and Cosmetics Act,” 21 U.S.C. 350(c)(3), food for special dietary use means a particular use for which a food purports or is represented to be used, including, but not limited to:

(a) Supplying a special dietary need that exists by reason of a physical, physiological, pathological, or other condition, including, but not limited to, the condition of disease, convalescence, allergic hypersensitivity to food, being underweight, being overweight, or the need to control the intake of sodium or simple sugars; or,

(b) Supplying a dietary need by a food for special dietary use as the sole item of the consumer’s diet.

(iii) Food for special dietary use is intended for the general public and may be used as a supplement to a normal diet or as a meal replacement.

(iv) Examples of food for special dietary are:

(a) Thickened liquids used for dysphasia;

(b) Gluten-free products for those with celiac sprue;

(d) High-calorie liquid supplements;

(e) High-calorie, high-protein liquid supplements for those with fluid restrictions;

(f) High-calorie puddings; or,

(g) A meal replacement with additional calcium for those at risk of fractures or recovering from fractures.

(i) Only offer a consumer medical food or food for special dietary use if a physician, or healthcare professional with prescriptive authority, has prescribed the food for the consumer no more than ninety calendar days ago;

(ii) Keep any prescription for the food on file with the provider or the AAA;

(iii) Ask the physician, or healthcare professional with prescriptive authority, who has written a prescription for the food to review and update the prescription every ninety calendar days; and,

(iv) Rely upon LDs for oversight for consumers who receive medical food or food for special dietary use, who may use the food in the following ways:

(a) It may replace a meal for a consumer if it is ordered by a physician or healthcare professional with prescriptive authority and meets one-third of the DRI, except in cases where the consumer’s nutrition care plan dictates otherwise; or,

(b) It may be needed as an addition to a complete meal, or to replace one item in the menu pattern. The combined meal plus the medical food or food for special dietary use shall meet one-third of the DRI, except in cases where the consumer’s nutrition care plan dictates otherwise.

(7) Dietary supplements: The AAA shall not allow dietary supplements nor reimburse a provider for them unless they qualify as medical food or food for special dietary use under paragraph (B)(6) of this rule. Under the “Dietary Supplement Health and Education Act of 1994,” 21 U.S.C. 321, dietary supplements are intended for ingestion in pill, capsule, tablet, or liquid form.

(1) Congregate nutrition program: A unit of service is one meal prepared and served under this rule and rule 173-4-04 of the Administrative Code.

(2) Home-delivered nutrition program: A unit of service is one meal prepared and delivered under this rule and rule 173-4- 04.1 of the Administrative Code.

(3) Restaurant and grocery meal service: A unit of service is one meal acquired under this rule and rule 173-4- 04.2 of the Administrative Code.

Effective: 03/23/2009

R.C. 119.032 review dates: 07/31/2013

Promulgated Under: 119.03

Statutory Authority: 173.02; 173.392; Section 305 (a)(1)(C) of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006; 45 C.F.R. 1321.11

Rule Amplifies: 173.392, Sections 336 and 339 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006