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(a) Personnel.
(1) Generally. The food service department shall be under the supervision of a person skilled in the selection, handling, preparation and serving of food and the supervision and management of food handlers. There shall be a sufficient number of cooks, dishwashers and maids to properly prepare three (3) well-balanced meals daily.
(2) Clothing, etc. It is mandatory that all cooks and food handlers wear clean garments (uniforms are desirable) and hair nets or clean caps, and keep their hands and fingernails clean at all times.
(3) Education and Instruction. Adequate instructions for employees in acceptable and sanitary food handling practices are required. Educational material and services are available from the department.
(4) Standards and Inspections. All institutions caring for six (6) or more persons shall comply with grade A standards established by the county board of health in its regulations for eating and drinking establishments. All institutions shall be inspected regularly by the department as to the cleanliness of food and food containers and as to the protection of food from spoilage.
(b) Physical facilities.
(1) Generally. There are seven (7) major phases of work including: Receiving of food and supplies, storage, preliminary preparation, cooking, serving, return of soiled dishes and dishwashing, and garbage disposal. All or part of these units may be provided in the main kitchen.
(2) Location:
a. The food service department shall be located in the main building or an attached building. It is recommended that it be located on the ground floor. If the food service rooms are located below the ground floor, adequate light and ventilation shall be provided by windows.
b. To facilitate receiving food supplies and the disposal of waste, a convenient outside entrance shall be planned.
c. No toilet rooms or sleeping rooms shall open directly into any kitchen or ward serving pantry.
(3) Space. Space requirement varies from twelve (12) square feet to as much as thirty (30) square feet per bed depending upon the type of patient served.
a. There shall be an aisle of at least three (3) feet between working areas, and wider is desirable if the aisle is used as a passageway.
b. Ceiling height shall be at least eight (8) feet, and higher is desirable.
(4) Storage.
a. The amount of storage space needed is dependent upon frequency of deliveries. It is recommended that its location be within easy access to the receiving area and the kitchen.
b. The storeroom shall be cool, well ventilated and fitted with metal shelving, metal bins or covered galvanized cans for storage of staple foods.
c. All supplies shall be stored off the floor and away from the wall so as to allow for cleaning. All precautions shall be taken against the invasion of rodents and insects, the seepage of dust and water leakage or other sources of contamination. Care shall be exercised in the rotation of stored foods so that the sold stock is used first.
(5) Refrigeration.
a. Where delivery is on a bi-weekly basis, a space of one and one-half (1 1/2) to two (2) cubic feet per person, including personnel, is required. Size would have to be adjusted to other schedules of delivery.
b. Where separate refrigeration can be provided, recommended temperatures for storing perishable foods are: thirty-two (32) degrees to thirty-eight (38) degrees Fahrenheit for meats, forty (40) degrees Fahrenheit for dairy products and forty-five (45) to fifty (50) degrees Fahrenheit for fruits and vegetables. If it is impracticable to provide separate refrigeration, the temperature shall be maintained at forty (40) degrees Fahrenheit or less.
(c) Preparing and serving food.
(1) Normal Diet.
a. A well-balanced diet of good quality food, correctly prepared and sufficient in quantity to meet the nutritional needs of the patients shall be served three (3) times daily. This shall include for each day:
1. Three (3) cups of milk per person.
2. Two (2) servings of fruit (one citrus).
3. One (1) to two (2) servings of meat, poultry or fish.
4. A minimum of four (4) eggs weekly.
5. Two (2) tablespoons of butter or fortified margarine.
6. Cereals or bread (whole wheat or enriched) every meal.
7. Potatoes once a day.
8. Two (2) servings of vegetables (one (1) leafy green or yellow), in addition to potatoes.
9. Simple desserts (stewed or canned fruit, custard or pudding, ice cream, etc.)
b. The method of serving food shall be such that the food reaches the patient in good condition. Hot foods should be served hot; cold foods should be served cold.
c. Special attention shall be given to the texture of food given patients without dentures or with poor dentures because of their difficulty of mastication.
d. A time schedule for service of meals to patients and personnel shall be established, and it is recommended that meals be served approximately five (5) hours apart but it shall not be longer than fourteen (14) hours from the evening meal until breakfast.
(2) Therapeutic or Special Diets. Therapeutic diets shall be provided as ordered by the patient's physician as part of the course of treatment of the patient. Therapeutic or special diets as ordered by physicians shall be posted in the kitchen.
(3) Menus.
a. Menus shall be planned and written one (1) week in advance in order to insure variety and an adequate diet. This help to plan kitchen work efficiently and to facilitate marketing. A copy of menus shall be posted in the kitchen.
b. Menus showing food actually served each day shall be recorded and kept on file. Nursing and care homes with five (5) beds or less are excepted from his requirements.
(4) Distribution of Food.
a. A satisfactory method of food distribution shall be provided. In institutions of more than one (1) story, where more than six (6) patients above the first floor receive bedside tray service, a dumbwaiter or elevator or ward serving pantries shall be provided.
b. Cracked and chipped china shall not be used.
(5) Domestic Animals. Domestic animals are not permitted in any place where food is prepared or served.
(d) Dining rooms.
(1) Lighting an Ventilation. Dining rooms shall be well lighted and ventilated.
(2) Location. It is recommended that dining rooms be located adjacent to the kitchen in order to facilitate the serving of food.
(3) Space, etc. Dining areas shall be adequate for both patients and personnel. Twelve (12) square feet per person is recommended whether dining room or cafeteria service is used. When wheel chair patients are fed in the dining room, greater floor space per person will be necessary. The kitchen shall not be used as a dining room for patients or personnel.
(e) Milk supply.
(1) Source. The source of supply and distribution shall be approved by the state department of health or local authority. Pasteurized milk shall be used.
(2) Storage. Milk must be stored in tightly-covered containers.
(f) Ice. Ice that is used in direct contact with food and drink shall be obtained from sanitary sources and handled in a sanitary manner.
(g) Cleansing of food containers.
(1) Generally. Centralized dishwashing is advocated, even with decentralized food service, because it limits noise on floors, lessens the number of employees required and allows for better control of breakage, and supervision of operation.
(2) Separate Room. A separate room for dishwashing is desirable. It should be compact, light and airy.
(3) Location of Dishwashing Unit. The dishwashing unit may be directly adjacent to the dining room; however, in locating the unit care shall be taken so that the service of soiled dishes will not interfere with the routing of service.
(4) Equipment.
a. Provision of a three-compartment sink or a dishwashing machine in the dishwashing unit is mandatory. Nursing and care homes with five (5) beds or less may use a two-compartment sink with a spray rinse.
b. The dishwashing unit shall also include tables for soiled and clean dishes, storage cupboards and trucks for transporting dishes to and from the unit. If dishwashing is decentralized, provision of a three-compartment sink and tables or a dishwashing machine in each serving pantry is mandatory.
(5) Procedure.
a. All food containers shall, following the last preceding use, be washed until visibly clean in warm water containing an ample quantity of soap or alkaline cleanser.
b. After cleaning, all food containers shall be rinsed with clear running water or immersed in a suitable receptacle containing clear water.
c. All food containers, after cleaning and rinsing, shall be disinfected by one of the following procedures:
1. Immersion in water at a temperature of not less than one hundred eighty (180) degrees Fahrenheit for not less than one (1) minute, or
2. Immersion in a solution containing not less than one hundred (100) parts per million available chlorine for one (1) minute and allowed to drain on a wire or corrugated metal rack.
d. After cleaning, rinsing and disinfecting, the food containers shall be stored in such a manner as not to become contaminated before reuse.
e. The wiping of food containers after washing, rinsing and disinfecting is prohibited.
f. The results obtained with dishwashing machines shall be equal to those obtained by the method outlined above.
(h) Facilities for personnel.
(1) Handwashing Facilities. It is mandatory that handwashing facilities be provided in all kitchens, ward serving pantries and washrooms used by food handlers. They shall be equipped with an adequate supply of soap, disposable towels, and hot and cold running water. The use of the common towel is prohibited. Hands shall not be washed in sinks where food is prepared.
(2) Lockers. Lockers or cloakrooms for personnel shall be provided and wraps shall not be hung in the kitchen area.
(3) Rest Rooms. Rest rooms shall be provided for personnel. (Mont. Co. Code 1965, § 89-44; 1980 L.M.C., ch. 27, § 1.)
Cross reference-Eating and drinking establishments, Ch. 15.
Admission policies shall be as set forth in the regulations of the state department of health. In addition thereto, the following requirements shall apply:
(a) Physician's statement required prior to admission of patient. Every operator of a nursing home and care home shall obtain a statement from a licensed physician as to the health condition and medical and nursing needs of a patient before such patient is admitted. Such statement shall include evidence from a physician satisfactory to the county health officer that the patient is free from tuberculosis in a communicable state.
(b) Discretion to be exercised. Institutions shall exercise discretion to avoid admitting patients whose condition indicates the need for a type of service and care that is not available in the institution. (Mont. Co. Code 1965, § 89-45; Ord. No. 6-101; Res. No. 6-1684.)
Every institution shall make provision for every patient to receive medical care by a physician when needed. Every operator of a nursing home and hospital shall promptly provide medical or nursing care whenever required for any patient. If any patient becomes acutely ill or shows a sudden mental deterioration, the next of kin, or some person responsible for the care and maintenance of the patient or designated by him shall be notified at once. Any specific order given by a physician for the treatment or care of any patient shall be reduced to writing by the operator of the institution or by the physician and no medical treatment shall be rendered patients except upon the order of a physician. (Mont. Co. Code 1965, § 89-46.)
(a) Rooms.
(1) Location; Light. Each patient's room shall be an outside room with a satisfactory amount of natural light.
(2) Outside Door. Each patient's room shall have a door opening into an exit or into a hall leading to an exit.
(3) Inside Rooms. Patients shall not be kept in rooms in which the only means of outside communication is through another room. Nursing and care homes with five (5) beds or less are excepted from this requirement.
(4) Internal Access. Each room must have internal access to the rest of the building.
(5) Basement Rooms. Patients shall not be kept in rooms extending below the ground level.
(6) Segregation for Privacy. Where both male and female patients are admitted, the rooms shall be segregated so as to allow for privacy.
(7) Isolation Rooms. There shall be made available one or more rooms which shall be used for isolation of patients with communicable diseases and for seriously ill or terminal cases. Nursing and care homes with five (5) beds or less are excepted from this requirement.
(b) Floor and window space.
(1) Floor Space. Beds shall be spaced so as to provide adequate room for nursing procedures, and to prevent transmission of infection. The following allowance of floor space is considered a minimum:
Rooms for only one (1) patient, one hundred (100) square feet.
Rooms for two (2) or more patients, eighty (80) square feet per bed.
Care homes may calculate day-room space up to twenty-five (25) percent of the required floor area.
The usable floor area for floors having sloping walls shall be calculated for bed occupancy only for that area having a ceiling height of eight (8) feet and fifty (50) percent of the area having a ceiling height between four (4) feet and seven (7) feet six (6) inches; provided, that at least fifty (50) percent of the total area has a ceiling height of eight (8) feet. Beds shall be placed at least three (3) feet apart.
(2) Window Area. The window area shall not be less than ten (10) square feet per bed. Half of this shall be openable.
(c) Furnishings.
(1) Bed, Mattress and Pillows. A bed, mattress and pillows shall be provided for each patient.
(2) Bedding and Linen. A sufficient supply of clean bedding and bed linen shall be in use and available at all times.
(3) Chair and Dresser, etc. In addition to the bed, the patient unit shall be provided with at least one (1) chair and either a dresser, locker or compartment bedside table to accommodate the patient's personal possessions such as toilet articles and clothing.
(4) Cleaning and Disinfection. After the discharge of each patient the complete unit shall be thoroughly cleaned, including all articles of equipment that were used for the special care of the patient; such articles as bedpans and thermometers shall be disinfected.
(d) Signal system. A signal system shall be maintained for patients to use in calling nurses and attendants. Hand bells are acceptable for use in small institutions. (Mont. Co. Code 1965, § 89-47.)
(a) Space requirements.
(1) Cleaning and Storage of Nursing Supplies and Equipment. There shall be adequate space and facilities for the proper cleaning and storage of nursing supplies and equipment. This space shall be removed from patient contacts and kept stocked and in order so that the contents are easily available for use by the nurse or attending staff. Care homes having five (5) beds or less are excepted from this requirement.
(2) Storage and Preparation of Medicines. Suitable provisions shall be made for the storage and preparation of medicines. Care homes having five (5) beds or less are excepted from this requirement.
(b) Equipment and supplies for bedside care. There shall be sufficient equipment for nursing care according to the type of patient. The following is not a complete list of nursing equipment needed for the care of patients, the aim, rather, has been to include certain minimum essentials and point out special precautions which shall be taken in their use.
(1) Linen.
a. The following articles of linen are required for the treatment or care of the patient and to keep the bed in a comfortable and sanitary condition:
Large sheets
Draw sheets*
Pillow slips
Bedspreads
Bath towels
Face towels
Bath blankets*
Wash cloths
Bedpan covers*
Mattress covers
Hot water bottle covers*
Ice cap covers*
Bath mats
*Care homes with five (5) beds or less are excepted.
b. Individual towels and wash cloths shall be provided for each patient.
c. Bedpan covers shall not be used interchangeably.
(2) Utensils and Other Supplies Needed.
a. There shall be individual wash basins, mouth wash cups and drinking glasses for each patient.
b. In addition to the above articles there shall be the following articles for general use*:
Mouth thermometers
Rectal thermometers
Hypodermic syringes and needles
Bath thermometers
Hot water bottles
Ice caps
Enema apparatus
Douche apparatus
Scales
Urinals
Bedpans
Rubber sheeting
Rectal tubes
Catheters
First aid dressings
Tongue depressors
Applicators
Rubber rings
Side boards for beds
Wheelchairs
Curved basins
Clinical medicine glasses
Covered water pitchers
*Care homes having five (5) beds or less are excepted from this requirement.
c. Hot water bags shall be covered before placing in beds or on a patient. The greatest care shall be exercised in their use to see that water is not too hot and bags are not leaking. The water shall not be over one hundred twenty (120) degrees Fahrenheit.
d. A bath thermometer shall be used to test water.
e. Electric heating pads shall not be used.
(c) Restraints.
(1) When Permitted. Restraints shall be applied only as an essential measure to prevent the patient from harming himself or others, after alternative measures have been proven unsuccessful.
(2) Physician's Order-Required. There shall be a written order signed by a physician approving the use of restraints either at the time they are applied to the patient, or in case of emergency, as soon as possible and not more than twenty-four (24) hours after they have been applied by the person in charge of the institution.
(3) Same-Time Limitation; Additional Orders. The physician's order for restraint shall not extend beyond twenty-four (24) hours. If restraint is required beyond this period the physician's order shall be written at twenty-four-hour intervals.
(4) Form. The form of restraint used shall not cause injury to patients.
(5) Locking Doors-Generally. Patients shall not be kept behind locked doors, that is, doors which patients cannot open, unless a patient becomes too difficult to manage, in which case the room shall be located on the first floor and the door shall not be locked with a key.
(6) Same-By Patients. Patients shall not be permitted to lock doors to their rooms.
(d) Handling and storage of medicines.
(1) Generally. All medicines and stimulants shall be plainly labeled and stored in a specially designated, well-illuminated locked medicine cabinet, closet or storeroom and be accessible only to nursing personnel. The medicine cabinet or closet shall be located near running water to facilitate the preparation of doses.
(2) Narcotics, etc. Narcotics, sedatives and other dangerous drugs shall be securely locked and accessible only to the nurse in charge.
(3) Old Medications. Old medications including prescriptions for patients who have left the institution shall be discarded.
(e) Handwashing facilities. There shall be adequate handwashing facilities with soap and a sufficient supply of linen or paper towels so that a fresh towel can be used for every handwashing. The use of a common towel is prohibited. (Mont. Co. Code 1965, § 89-48.)
(a) Medical attendance.
(1) Patient's Physician. All persons admitted to any nursing or convalescent home shall be under the care of a licensed physician. The name, address and telephone number of the physician attending each patient shall be recorded for ready reference.
(2) Emergency Physicians. All institutions shall arrange for one (1) or more licensed physicians to be called in an emergency.
(3) Physician's Order for Medication or Treatment. No medication or treatment shall be given except on the written order of a physician.
(4) Physicians' Visits. Patients in nursing homes shall be visited by a licensed physician at least every two (2) months.
(b) Nursing service.
(1) Head Nurse. Nursing homes shall have a qualified nurse responsible for the nursing service. A qualified nurse shall mean a graduate nurse registered in this state, or a practical nurse licensed in this state; provided, that a graduate nurse eligible for registration in this state or a practical nurse eligible for licensure in this state may be considered qualified for three (3) months pending registration or licensure in this state.
(2) Personnel Generally; Minimum Bedside Care Required. Sufficient personnel shall be employed to give adequate care to patients both day and night. A minimum of two (2) hours of bedside care per patient per day is required.
(3) Relief Personnel. Provisions shall be made for relief personnel during vacation or other relief periods.
(4) Circulative Nurses; Emergency Procedures.
a. In institutions located in structures equipped with an automatic sprinkler system approved by the fire marshal, a minimum of one (1) nursing employee for each twenty-five (25) patients shall be circulating throughout the institution at all times.
b. In institutions located in structures not equipped with an approved automatic sprinkler system, a minimum of one (1) nursing employee for each twenty-five (25) patients shall be circulating throughout the institution at all times; provided, that between the hours of 11:00 p.m. and 7:00 a.m. one (1) nursing employee for each fifteen (15) patients shall be circulating throughout the institution at all times and be available in case of fire or other emergency. However, in calculating the number of nursing employees required to be circulating at all times between the hours of 11:00 p.m. and 7:00 a.m., in addition to at least one (1), credit of one-half person may be allowed from sixteen (16) to forty-five (45) patients for an employee, owner, operator or licensee who is actually on the premises and is able and readily available to respond to emergencies.
c. All persons assigned duties in nursing homes shall be instructed in emergency procedures and as to the locations of all patients and means of evacuation in emergencies.
(5) Personal Attention and Care of Patients. Each patient shall be given such personal attention and care including personal attention and care including personal hygiene, as is ordered or indicated.
(c) Dental and specialized care. Dental care and other specialized forms of medical and surgical services shall be arranged for on the order of the attending physician. (Mont. Co. Code 1965, § 89-49.)
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