DI 2.2.1.1 Policy and Procedure Shriners

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SHRINERS HOSPITAL FOR CHILDREN SHREVEPORT

NUTRITION SERVICES

POLICY AND PROCEDURE MANUAL

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TABLE OF CONTENTS

Responsibility / Scope of Nutrition Services

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TABLE OF CONTENTS

Hazardous Materials/Waste NTS-14.1

Personnel Management NTS-15.1

Personnel Management - Attendance and Promptness NTS-15.1.1 Personnel Management - Nutrition Services Designee NTS-15.2 Personnel Management - Employee Conduct and Ethics NTS-15.3 Personnel Management - General Rules for Personal Hygiene NTS-15.4

Employee Orientation NTS-16.1

Employee Orientation - Training and Education of Staff NTS-16.2

In-Service Education NTS-17.1

Securing Department NTS-18.1

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SHRINERS HOSPITALS FOR CHILDREN 3100 SAMFORD AVENUE, SHREVEPORT, LA 71103

MISSION STATEMENT

The mission of the Shriners Hospitals for Children - Shreveport is to:

 recognize the physical, spiritual and psycho-social age specific needs of our patients as infants, young children, and adolescents.

 provide quality care for orthopedic patients ages birth to eighteen to include diagnosis, treatment and rehabilitation.

 provide nurturing family centered care environment that supports the unique individual needs of each child and family recognizing that the integrity of each family unit must be maintained during hospitalization of the child.

 provide comprehensive treatment utilizing a coordinated multi-disciplinary team approach.

 provide continuity of care for all patients by collaborating with community services and resources.

 provide education and training for orthopedic surgeons, nurses and rehabilitation therapists and other allied health personnel.

 perform clinical research related to orthopedic conditions.

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SHRINERS HOSPITALS FOR CHILDREN 3100 SAMFORD AVENUE, SHREVEPORT, LA 71103

VISION STATEMENT

The Shriners Hospitals for Children - Shreveport strives to be an international center of excellence in pediatric orthopaedic treatment, research, and education, utilizing a family centered care approach.

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Shriners Hospitals for Children

3100 Samford Avenue, Shreveport, Louisiana 71103

PHILOSOPHY NUTRITION SERVICES

 Nutrition Services of Shriners Hospitals - Shreveport accepts the responsibility to work cooperatively with other departments, other health professionals and ancillary services to improve patient care services as a part of the total Hospital Quality Management Program.

 Nutrition Services strives to offer the highest level of nutritional care to the patients in order to prevent malnutrition, reduce patient's hospitalization and convalescence and assist each patient to attain his/her optimum health by modification of his/her eating habits through nutrition education.

 The Nutrition Services Director participates in Continuing Education Programs in order to keep current on advanced trends in therapeutic diets and new medical technology.  The Nutrition Services staff participates in on-going in-service education programs and

orientation for new employees in order to maintain qualified personnel.

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RESPONSIBILITY / SCOPE OF SERVICE NUTRITION SERVICES

Nutrition Services of Shriners Hospitals for Children - Shreveport, under the direction of a full- time Registered Dietitian:

 is responsible for maintaining an effectively organized Food Service Department which provides quality age appropriate nutrition based on knowledge of growth and

development for all patients (infants, children and adolescents) in accordance with the current Recommended Dietary Allowances of the Food and Nutrition Board of the National Academy of Science, and in accordance with the physician's orders.

 is responsible for providing quality food service in the cafeteria for employees, patient's families and guests.

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PATIENT MEAL SERVICE NTS-01.1

Department: Nutrition Services

Date Originated: March 1994 Date of Revision: September 2000 Reviewed: 9/00, 9/01; 9/02; 9/03; 9/04; 9/05; 8/06: 1/10; 1/13

POLICY

Three meals or meal equivalents are served daily to all in house patients, at scheduled meal times, not to exceed 15 hours between the evening meal and breakfast.

PROCEDURES

1. TYPES OF SERVICE USED:

a. Tray service to patient’s room at breakfast.

b. Cafeteria style service in the Central Activity Area for lunch. c. Cafeteria style service in the Dining Room for dinner.

2. SERVING TIME :

a. Breakfast will be served at 7:45 A.M. - 8:15 A.M. b. Noon meal will be served at 11:30 A.M. - 12:00 P.M. c. Evening meal will be served at 5:00 P.M. - 5:30 P.M. 3. TRANSPORTATION OF TRAYS TO THE PATIENTS:

a. The Nutrition Services staff, transports food using preheated enclosed portable serving tables to and from the designated serving areas at designated times. The portable serving table is preheated 30 minutes before meal service.

b. All foods are served by the Nutrition Services staff in designated meal areas; patient’s, parents or a nursing assistant carry the food tray to the table where the child has chosen to eat, or to the patient’s bedside for breakfast or if the patient is on bed rest.

Author: Denise P. Smith, MS, LDN, RD

Stakeholders Involved in Development, Review, and or Revision: __________________________________

_____________________________________ __________________________________ _____________________________________

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PATIENT MEAL SERVICE – REFRESHMENTS FOR ACTIVITIES NTS-01.1.1 Department: Nutrition Services

Date Originated: February 1989 Date of Revision: April 1994

Reviewed: 9/94; 9/96; 10/97; 10/98; 11/99; 9/00; 9/01; 9/02; 9/03; 9/04; 9/05; 8/06; 1/10; 1/13

POLICY

To enhance the theme of an activity or to provide appropriate food service for special event, such as birthdays, out-trips, slumber parties, and theme days Nutrition Services will make every effort to provide refreshments as requested.

PROCEDURE

All food served to patients is wholesome, prepared in a safe manner and is planned into the day's total nutritional intake.

No food from an outside source is to be given to patients unless arrangements have been made through the Dietitian.

Child Life is to send Nutrition Services Request at least 24 hours in advance for a birthday cake, and no less than 48 hours to request items for any other activity, all requests are subject to the Dietitian’s approval and availability.

Attachments: none

Professional References: none Regulatory References: none

Related Policies: CL 3.1, CL 3.2, CL 3.9, CL 4.2 Replaces:

_____________________________________ __________________________________ _____________________________________

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CAFETERIA MEAL SERVICE

NTS-01.2

Date Originated: January 1991 Date of Revision: January 2013

Reviewed: 9/94; 9/96; 10/97; 10/98; 11/99; 9/00; 9/01; 9/02; 9/03; 9/04; 9/05; 8/06; 1/10; 1/13

POLICY

The hospital cafeteria will provide breakfast, lunch and refreshment service to employees, medical staff, out patients, volunteers, family members and visitors.

CAFETERIA SERVICE PROCEDURE:

A. The cafeteria is open Monday through Friday for Breakfast and Lunch. CAFETERIA SERVICE HOURS:

Breakfast: 7:00 A.M. - 9:00 A.M. Lunch: 11:30 A.M. - 1:00 P.M.

The cafeteria provides food service to employees, medical staff, out- patients, volunteers, relatives of patients and visitors.

B. Coffee and tea are available free to all employees.

Attachments: none

Professional References: none Regulatory References: none Related Policies: none

Replaces:

_____________________________________ __________________________________ _____________________________________

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CAFETERIA MEAL SERVICE CATERING NTS-01.21.1

Date Originated: January 1991 Date of Revision: March 1994

Reviewed: 4/94, 5/96, 10/97 10/98, 11/99, 9/00, 9/01, 9/02; 9/03; 9/04; 9/05; 8/06; 1/10;1/13

POLICY

Nutrition Services will provide a limited food catering service to departments for Hospital related events and professional organizations as approved by the Administrator and Director of Nutrition Services.

PROCEDURE

The Department Director or their designee completes the food catering requisition and obtains approval signature from Administrator and forwards to Nutrition Services one month prior to event.

 Questions regarding price and availability should be directed to the Nutrition Services Director.

 The Nutrition Services Director will contact the requesting Director if an item is unavailable, for acceptable substitutions.

 Nutrition Services staff prepares and transports food to location and sets up according to instructions, they are not available for plate service.

 Nutrition Services staff returns for leftover food and dirty dishes at the end of the scheduled event.

 Environmental services and Maintenance should be contacted separately if services are required.

 The Nutrition Services Director completes the cost per unit, total cost and meal

equivalent columns after the event and forwards a copy to the requesting Director and to the Director of Fiscal Services for billing back to the requesting cost center.

Attachments: Special Function Catering Request Professional References: none

Regulatory References: none Related Policies: none

Replaces:

Stakeholders Involved in Development, Review, and or Revision:

__________________________________ _____________________________________

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CAFETERIA MEAL SERVICE – WEEKEND/HOLIDAY MEALS FOR PARENTS NTS-01.4 Department: Nutrition Services

Date Originated: March 1994 Date of Revision: January 2013 Reviewed: 1/00, 9/01; 9/02; 9/03; 9/04; 9/05; 8/06; 1/10;1/13

POLICY

Continental Breakfast is complimentary for parents daily. The weekend lunch and evening meals are complimentary for 2 parents and/or caregivers. The weekend policy is also used on hospital holidays.

1. Parent's meal will be served after all patient meals are served by the Dietary Aide and delivered by the Nursing Assistant.

2. Eating is not allowed in the patient rooms, except after surgery or when a child is confined to the room (such as an Isolated Patient).

3. Weekend and Holiday lunch and evening meals are served promptly. Parents must follow meal times to receive complimentary trays.

Lunch meal will be served at 11:30 A.M. - 12:00 P.M. Evening meal will be served at 5:00 P.M. - 5:30 P.M.

Attachments:

Replaces:

_____________________________________ __________________________________ _____________________________________

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CAFETERIA MEAL SERVICE

COMPLIMENTARY MEALS FOR PARENTS NTS-01.4.1

Date Originated: March 1994 Date of Revision: January 2010 Reviewed: 9/01; 9/02; 9/03; 9/04; 9/05 8/06,1/10;1/13

POLICY

A complimentary meal is provided at supper to two parent/legal guardians of each inpatient for the duration of the hospitalization.

PROCEDURE

1. Nutrition Services staff utilizes diet order sheet and admissions list to calculate number of meals to prepare and serve for the evening meal.

2. Nutrition Services staff will record the number of complimentary meals served each day on the monthly statistics sheet.

3. Parents who have special therapeutic dietary needs will be directed to the Registered Dietitian. Accommodations will be made on an individual basis with considerations made to necessity and availability of products needed.

Attachments: none

Replaces:

_____________________________________ __________________________________ _____________________________________

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CAFETERIA MEAL SERVICE - VENDING SERVICE NTS-01.6

Date Originated: January 1993 Date of Revision: January 2012 Reviewed: 1/00, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06; 1/10; 1/12

POLICY

The vending machines are owned and operated by a contract company. The company will ensure the safe sale of food dispensed through the vending machines. The company will provide a copy of the Inspection Report for Food Establishments conducted by the

Department of Health and Human Services to Shriners Hospitals of Shreveport upon request.

PROCEDURE

A. Contract Company

1. The vending company will service all vending machines.

2. The vending machines are cleaned and maintained regularly meeting the vending company’s policies.

3. The preparation, delivery, and storage of food will be done following the vending company’s policies. Temperature of potentially hazardous food is maintained at 45O _F

or below. (35O _{- 45}O _{F) Should the temperature go above 45}O_{F, all perishable items will}

be removed by the vending company and they will notify their maintenance department.

4. Expired dated food will be removed and perishable food rotated daily. 5. Cleaning of the exterior of the machines is done by the vending company.

B. Shriners Hospitals

The Food and Nutrition Services Department will ensure that the following procedures are met.

1. Provide the company space and utilities to operate the vending machines.

2. Provide the company a place to clean the interior parts of the vending machines as needed.

_____________________________________

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PATIENT CARE - NUTRITIONAL REQUIREMENTS NTS-02.1

Date Originated: March 1994 Date of Revision: January 2010 Reviewed: 1/95, 5/96, 10/97, 10/98, 11/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06; 1/10;1/13

POLICY

The patients nutritional needs are met in accordance with the current Recommended Dietary Allowances of the Food and Nutrition Board (1989 RDA), National Research Council, and in accordance with physicians orders.

PROCEDURES MENUS:

Menus are planned and/or approved by a Registered Dietitian.

Menus are written in advance and posted where they can be seen at all times while food is being prepared.

A 4 week cycle menu is presently being used. The menus are updated and revised to reflect seasonal changes and to increase variety.

Menu substitutions are of an equivalent nutritional value. PATTERN FOR REGULAR MENU:

This pattern follows the current Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council.

Breakfast Lunch Dinner

Fruit or Juice Meat, Fish or Poultry Soup or Juice Cereal (cooked or dry) Potato or substitute Meat or Substitute Meat or meat alternate Green or Yellow vegetable Potato or substitute Toast or other bread Salad Vegetable or Salad

Margarine Fruit Bread or substitute

Milk Bread or substitute Dessert

Milk Milk

NOURISHMENTS : Between meal snacks

 Completed nourishment requisitions are brought to the Nutrition Services Department by the ward clerk .

 The request is filled by a Nutrition Services employee, and the nourishment requisition form is initialed when completed.

 Nutrition Services is responsible for transporting the requisitioned nourishments to the unit kitchens daily.

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 Serving time: 10:00 a.m., 2:00 p.m., and 7:00 p.m. or PRN.  Foods kept in the unit kitchens include:

Infant formula Rice/Oatmeal Cereal in jars Crackers - graham and saltine Peanut butter

Fruit Juices Sprite Soups - Beef Broth, Chicken Broth Sugar

Milk Coffee and Tea Ice Cream Popsicles Jell-o Cereal

Strained Baby Foods - assorted meat, fruit and vegetables

Attachments: none

Replaces:

_____________________________________ __________________________________ _____________________________________

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PATIENT CARE - NOURISHMENT REQUISITIONS NTS-02.1.1

Date Originated: March 1994 Date of Revision: June 2013

Reviewed: 10/97, 10/98, 10/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 1/10; 6/13 POLICY:

Nourishment requisitions will be filled on a daily basis. PROCEDURE:

 Completed nourishment requisitions will be placed in the designated file rack

located in the Production Managers office.

 The nutrition aide or weekend foodservice worker is responsible for filling all

nourishment requisitions on a daily basis.

Attachments: Patient Nourishment Requisition Professional References: none

Replaces:

__________________________________ _____________________________________

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PATIENT CARE - THERAPEUTIC DIETS NTS-02.3 Department: Nutrition Services

Date Originated: March 1994 Date of Revision: September 1997 Reviewed: 10/97, 10/98, 10/99, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06; 1/10; 1/13

POLICY

Therapeutic diets will be in accordance with physician's orders and in compliance with the established diet principles of the Hospital Diet Manual.

PROCEDURE

 A reference copy of the Hospital approved Diet Manual is located in the out patient clinic, on the in patient unit and in Nutrition Services.

 The therapeutic diet menu patterns are written by the Registered Dietitian following the same pattern as the regular menu.

 A menu pattern is established for the individual patient's modification by the Dietitian and reviewed with Nutrition Services staff.

 Changes in the menu pattern are made as often as possible to satisfy the patient’s needs with regard to food preferences or individual eating behavior while maintaining compliance with therapeutic guidelines.

 Therapeutic diets requiring in between meal feedings have menu patterns that reflect the feeding time and content of the nourishment.

Attachments: none

Replaces:

_____________________________________ __________________________________ _____________________________________

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PATIENT CARE - ENTERAL FEEDING NTS-2.4 Department: Nutrition Services

Date Originated: March 1994 Date of Revision: January 2010 Reviewed: 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 7/08; 1/10;1/13

POLICY

Enteral feedings are provided by Nutrition Services according to the Physician’s order and in accordance with the Hospital Diet Manual.

Enteral feedings must be prepared, handled, and stored according to strict HACCP (Hazard Analysis Critical Control Points) guidelines; including critical control points, hazards, standards, and corrective actions that should be taken if standards are not met. PROCEDURE

 The Medical Staff may order enteral feedings for any patient who is admitted on an enteral feeding at home or considered to be at nutritional risk by classification or other indicators.

 The Registered Dietitian will calculate the nutritional requirement of the patient and document progress and tolerance on the Nutrition Assessment Form in SHCIS.  Ready to use formulas and enteral feedings are requested by Nursing Service by

entering an order is SHCIS. If the formula or enteral feeding product is a non-stock item, the Registered Dietitian will special order the product through Materials

Management or will obtain the item from a local supermarket. Stock items include Pediasure, Pediasure with Fiber, Ensure and Ensure Plus.

 Parents of patients that are on a enteral feeding at home (gastrostomy, etc.) are instructed by the clinic nurse and or Family Services on pre-admission interview to bring special formula product and personal physician's diet instructions upon

admission. Every effort will be made to follow established home feeding procedures.

Attachments: HACCP Standards for Enteral Feeding Professional References: none

Replaces:

__________________________________ _____________________________________

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PATIENT CARE - PERIPHERAL PARENTERAL NUTRITION INTERVENTION NTS-2.5 Department: Nutrition Services

Date Originated: March 1994 Date of Revision: January 2010 Reviewed: 9/00,9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 7/08; 1/10; 1/13

POLICY

Peripheral Parenteral Nutrition (PPN) will be available to those post surgical patients as ordered by the Medical Staff.

PROCEDURE

 Medical Staff may order a Dietary Consultation for PPN in any case where a patient is considered to be at nutritional risk by classification or other indicators.

 The Registered Dietitian will calculate the nutrition requirement of the patient and document progress and tolerance on the Nutrition Assessment Form in SHCIS. Attachments: none

Replaces:

_____________________________________ __________________________________ _____________________________________

Administrator: Kim Green Director of Pt. Services: Gail Rains, RN, MSN Chief of Staff: Dr. Richard McCall

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PATIENT CARE NUTRITION ASSESSMENT NTS-02.6

Date Originated: March 1994 Date of Revision: November 2010 Reviewed: 9/03, 9/04, 9/05, 8/06, 7/08; 10/09, 11/10

POLICY

Nutrition assessments will be done by a Registered Dietitian who meets state licensure requirements. The assessment will be age appropriate as determined by the practitioner’s knowledge of growth and development and age specific nutrient and feeding needs for infants, children and adolescents.

PROCEDURE

Patients are screened by nursing staff as a part of the admission assessment within 24 hours of admission.

Nutrition risk factors (as noted in Nutritional Screen in SCHIS) include:  Constipation

 Drooling

 Eating disorder  Enteral feedings

 Impaired nutrition Intake

 Intake <50% normal in last 3 days  Problem with sucking/chewing/choking

 Weight <5th percentile or >95th percentile

The nursing staff enters an order for a nutrition consult. Nutrition consults are completed by the Registered Dietitian within 72 hours. The Registered Dietitian completes a nutrition assessment form in SHCIS that will encompass the patient’s nutrition care plan.

Nutrition care plans may document any or all of the following:  Current diet order

 NCHS growth curve percentiles for height and weight for age  Usual weight and suggested weight for height

 % difference in usual and suggested weight for height  Food allergies/intolerances and/or drug -food interactions  Therapeutic diet modification

 Nutritional supplements  Evaluation of usual diet  Evaluation of eating behavior  Modified feeding requirements

 Tolerance and/or acceptance of hospital diet  Recommendations for nutrition intervention

 Patient/family education and understanding of material presented  Expected compliance to diet modification

 Follow-up progress and reassessment

Attachments: none

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Replaces: NTS 02.2

Author: Jamie Shaw LDN, RD 7/08

_____________________________________ __________________________________ _____________________________________

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PATIENT CARE - REASSESSMENT NTS-02.6.1

Date Originated: March 1994 Date of Revision: July 2008 Reviewed: 9/03, 9/04, 9/05, 8/06, 7/08, 1/10; 1/13

POLICY

Patients who met the criteria for further assessment and/or who were referred for assessment and/or nutrition intervention are periodically reassessed by the Registered Dietitian.

.

PROCEDURE

Patients who are receiving PPN or enteral nutrition or are being monitored while they are on a nutrition intervention program are documented under Nutrition Reassessent is documented in SHCIS.

Attachments: none

Replaces:

Author: Jamie Shaw LDN, RD 7/08

_____________________________________ __________________________________ _____________________________________

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PATIENT CARE - DIET ORDERS NTS-2.7

Date Originated: March 1994 Date of Revision: July 2008 Reviewed: 10/98, 10/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 7/08, 1/10

POLICY

All in patients will have a physician's order for an appropriate diet before receiving meals from Dietary.

PROCEDURE

1. Diet order is ordered by the physician and entered into SHCIS by the nursing staff.

2. All post-op clear liquid diets will be initiated by the physician and will progress to the pre-op diet as tolerated at the discretion of nursing service.

3. The usual progression of diets is as follows:  Clear liquid

 Full liquid  Surgical soft

 Regular (Infant, Toddler, Chopped, Blended)

 Full liquid and/or Surgical soft may be skipped for patients who are able to go directly to a Regular diet at the discretion of nursing service.

Attachments:

Replaces:

_____________________________________ __________________________________ _____________________________________

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PATIENT CARE – COMMUNICATION OF DIET ORDERS NTS-2.7.1 Department: Nutrition Services

Date Originated: January 1991 Date of Revision: July 2008

Reviewed: 5/96, 10/97, 10/98, 10/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 7/08, 1/10; 1/13

POLICY

Nursing service will communicate each patient’s current diet order to Nutrition Services by entering the order in SHCIS. Diet sheets are generated and sent to the printer in Nutrition Services.

PROCEDURE

 Each patient will have a diet order on the medical record upon admission and throughout their stay.

 Nursing Service enters the diet order in SHCIS. and revises the order throughout the patient’s stay as the order changes.

 Diet sheets are sent electronically to the printer in the nutrition service department three times daily with revisions as need prior to breakfast, lunch, and dinner.

 Patients who are not receiving oral intake are identified by Nursing Service on the Daily Diet Sheet as N.P.O.

Attachments: Patient Diet Order Guide Professional References: none

Replaces:

__________________________________ _____________________________________

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PATIENT DIET ORDER GUIDE

DIET DESCRIPTION OF COMMON DIETS AVAILABLE

Regular The regular diet is adequate in all nutrients. It is suitable for children capable of chewing, swallowing and eating a variety of texture.

Toddler Diet This is a regular diet with modifications to suit the needs of

children who are developing self feeding skills. This diet is adequate in all nutrients.

Infant Diet The infant diet is for children unable to chew and to digest foods. Diet includes infant formulas, strained baby food and infant cereals. This diet is adequate in all nutrients.

Chopped Diet A regular diet with each item chopped individually to specified requirements. Used for patients with moderate chewing and/or swallowing abilities.

Pureed Diet A regular diet with each item homogenized in the blender individually. Used for patients with difficulties chewing and/or swallowing.

Surgical Soft An adequate diet designed to be mechanically, chemically, and Diet thermally non-irritating and non-stimulating for patients with GI

High Protein, An adequate diet, higher in protein than regular diet.

High Protein, An adequate diet with increased protein and calorie value. Used High CHO, for patients that are underweight, malnourished, hyperthyroid,

have cirrhosis, infectious hepatitis, mononucleosis.

Low Protein Diet Inadequate in protein. For use in chronic renal failure, cirrhosis or chronic liver disease.

Low Cholesterol Adequate diet low in fat, saturated fats and cholesterol. Low Fat Used for the treatment of elevated blood cholesterol .

Low Fat Diet Adequate diet, high in CHO, normal protein and low in fat. Used for weight control and disturbances of biliary tract, hepatitis, and patients with high serum cholesterol.

Weight Reduction An adequate diet with restricted calories. Based on the Low

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PATIENT DIET ORDER GUIDE Page 2

DIET DESCRIPTION OF COMMON DIETS AVAILABLE

Diabetic Diets Adequate in all nutrients. Regular diet with no concentrated sweets, calorie and fat restriction. Please indicate insulin dosage if necessary so appropriate patterns can be planned. 1200, 1500, 1800, 2000, 2200 and 2500 calorie levels are available. Please indicate if another calorie level is needed.

Hypoglycemic Diet Adequate in all nutrients. A high protein, restricted CHO, moderate fat diet used in the treatment of functional hypoglycemia, reactive hypoglycemia. Dietary treatment of hyperinsulinism due to organic causes has only short term benefits.

2 gram Sodium An adequate diet with a moderate reduction in the use of salt and omission of foods high in Na+. Used in cardiovascular disorders with moderate heart damage or patients unable to tolerate a more rigid restriction.

1 gram Sodium An adequate diet using no salt in food preparation

and foods of low to moderate Na+ content. Used in cardiovascular and renal diseases when edema is present.

500 mg Sodium An adequate diet with the lowest possible Na+ content.

Used in congestive heart failure, severe edema or hypertension. Lactose Free Deficient in calcium, riboflavin and vitamin D. Used in the treatment of Diet galactose intolerance. A lactose free formula or milk substitute should

be used to replace milk.

High Fiber Diet Adequate diet high in residue and fiber. Used for constipation in children with spina bifida and myelodysplasia.

Low Fiber, Adequate diet low in residue and fiber. Little seasoning is

Low Residue Diet used. Used for disturbances of GI tract, ulcerative colitis, colostomies, inflammatory diseases of large or small intestine, obstructive bowel lesions or diverticulosis.

PKU Diet Inadequate in protein, most vitamins and minerals. A low protein diet using a protein substitute (lofenalac). Used in children with phenylketonuria (PKU). A vitamin and mineral supplement is necessary.

Low Copper Diet An adequate diet eliminating foods with high copper content. Used in the treatment of Wilson’s Disease.

Low Potassium Diet Adequate with careful planning. Very monotonous and low in calories. For patients with Addison's Disease and other conditions characterized by retention of potassium.

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PATIENT CARE – TRAY IDENTIFICATION NTS-2.8

Date Originated: January 1991 Date of Revision: January 2010 Reviewed: 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06; 1/10; 1/13

POLICY

An organized system of identifying meal trays is established and utilized.

PROCEDURE

Nutrition Services employees prepare trays utilizing the diet order sheets generated from SCHIS for each patient at each meal. The diet order sheets are queued to the printer in the Nutrition Service Department and are automatically printed for each meal.

The diet order slip includes the patient’s name age and special instructions to the server based on the diet order received from Nursing Service.

Attachments:

Replaces:

_____________________________________ __________________________________ _____________________________________

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PATIENT/FAMILY EDUCATION – THERAPEUCTIC DIET COUNSELING NTS-3.1 Department: Nutrition Services

Date Originated: March 1994 Date of Revision: July 2008 Reviewed: 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 7/08; 1/10; 1/13

POLICY

Therapeutic diet counseling is provided by the Registered Dietitian to patients and/or families when a physician's order requests patient/family education.

PROCEDURE

 Printed educational material and individual diet instruction will be presented to patients/ families following the physicians order.

 Therapeutic diets presented will be in compliance with the hospital approved diet manual.

 Documentation of patient/family education will be entered as part of the nutrition assessment and will also be documented on the multidisciplinary patient/family education form. Entries will include an evaluation of patient/families understanding of the material presented, as evidenced by the ability to verbalize therapeutic guidelines, and expected level of compliance with recommended treatment.

 It is the patient/families responsibility to comply with the recommended therapeutic guidelines.

Attachments:

Replaces:

_____________________________________ __________________________________ _____________________________________

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PATIENT/FAMILY EDUCATION – FOOD DRUG INTERACTIONS NTS-3.2 Department: Nutrition Services

Date Originated: March 1994 Date of Revision: September 1997

Reviewed: 10/97, 10/98, 10/99, 9/00, 11/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06; 1/10; 1/13 POLICY

Patients/Families discharged on medication will receive information on potential drug-food interactions associated with the medication that has been prescribed.

PROCEDURE

Resource notebooks will be available in the Pharmacy, Nutrition Services , Inpatient Unit and the Outpatient Clinic with guidelines for all oral medications listed on the hospital formulary, plus any additional medications that are identified as patients are admitted on medications not included on the formulary.

The Pharmacist will send printed guidelines for Dulcolax tablets, Iron products, Furoxone, Fulvicin P/G, Reglan, Donnatal, Tetracyclines, and Zantac ( and any others as deemed appropriate by the pharmacist) to the Nursing Unit for staff education purposes when the initial dose of an oral medication is sent to the In Patient Unit.

The Pharmacist will notify the Registered Dietitian when a patient is admitted on a medication identified as needing nutrition intervention based on the identified high risk group of medications.

Identified high risk medications include; MAO inhibitors (Furoxone, Isoniazide), Iron preparations, and Tetracyclines. The patients’ diet will be modified appropriately. Nursing Service will identify patients being discharged on medication and will counsel patients and/or family on potential drug and food interactions utilizing medication information sheets provided by the pharmacy. Nursing staff will document that the information sheets have been given on the Nursing Discharge Summary.

Attachments: Food/Drug Interaction Instructions to Patients

Professional References: Patient Dosage Instructions -- by Steven Strauss, Ph.D., R.Ph Regulatory References: none

Related Policies: none Replaces:

_____________________________________ __________________________________ _____________________________________

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DRUG-FOOD INTERACTIONS Page 1 of 2

INSTRUCTIONS TO PATIENTS:

NOT TO BE USED WITH MILK/DAIRY PRODUCTS  Dulcolax

 Feosol  Fergon

 Iron salts and/or preparations  Kaon

 Kay Ciel

 Potassium salts and/or preparations  Tetracycline and/or preparations NOT TO BE USED WITH MINERAL OIL

 Calcium or Sodium Dioctyl Sulfosuccinate and/or preparations  Colace, Dorbantyl, Doxan, Doxidan, Doxinate,

 Dulcolax, Sulfasucidine, Sulfathalidine,  Vitamins A,D,E,K and/or preparations SWALLOW WHOLE, WITHOUT CHEWING

CHEW, DO NOT SWALLOW WHOLE (TABS., CAPS)  Aluminum Hydroxide Gel, Gaviscon,

 Erthromycin chewable, Orexin chewable

TO BE TAKEN WITHOUT REGARDS TO FOOD OR MEALS  Antiminth, Cleocin, Kafocin, Keflex

TO BE TAKEN ON AN EMPTY STOMACH  Crystoids, Duotrate, Lincocin, Peritrate TO BE TAKEN BEFORE MEALS

 Anticholinergics,

 Belladonna and/or preparations,  Preludin, Tenuate, Tepanil,  Serenium, Reglan

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Page 2 of 2

INSTRUCTIONS TO PATIENTS:

TO BE TAKEN AFTER MEALS, WITH FOOD Acetylsalicylic AcidIndocin, Quibron

Akineton

Iron salts and/orQuinamm

Aminophylline preparations, Raudixin Anturane

Isordil, Regroton

Azolid, Kaon Reserpine Bistrimat , Kay Ciel, Salicylates Butazolidin, Kemadrin, Serpasil Chloral Hydrate, K-lor, Sterazolidin Cyclospasmol, Kynex, Tandearil Dactilase, Macrodantin, Tolinase Diabinese, Marax, Troph-Iron Dilantin , Midicel, Trophite Dymelor, Mintezol, Urecholine Dyrenium, NegGram, Vibramycin Feosol, Oral Hypoglycemics, Zyloprim Fergon, Orinase

Flagyl, Pagitane Fulvicin ,Phenoxene Furadantin ,Ponstel

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FOOD PURCHASING NTS-4.1

Date Originated: September 1998 Date of Revision: January 2013 Reviewed: 12/06; 1/10; 1/13

POLICY

A supply of perishable and non-perishable foods to meet the requirements of planned menus for a minimum of three days shall be purchased from nationally based food distributors.

PROCEDURES

The Food Service Director/Food Production Manager are responsible for all food purchasing.

1) All orders for food shall be:

 Recorded on purchase order.

 Written to include all information as to quantity and unit and description of item.

 Purchase orders and signed invoices are clipped together by vendor's name and sent to the business office for payment by the Food Production

Manager/Director.

 Copy of purchase orders shall be kept on file for a year.

2) Frequency and type of purchasing is determined by Food Service Director based on patient census, clinic activity, special events, perishable food products and storage facilities.

3) Approved vendors for food purchases are as follows:  US Foods - (prime vendor)

_____________________________________ __________________________________ _____________________________________

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RECEIVING DELIVERIES NTS-4.2

Date Originated: September 1998 Date of Revision: June 2013 Reviewed: 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 1/10; 6/13

POLICY

To establish a uniform method of receiving and accounting for all deliveries made to the Nutrition Services Department.

PROCEDURE

The only authorized staff members allowed to receive deliveries are the Food Production Manager (FPM), the Director of Nutrition Services, or the AM or PM cook. The FPM will be notified first when a delivery arrives, if she is unavailable, the Director will then be notified. If neither the FPM or the Director are available, the cook will then receive the delivery.

When receiving deliveries from all food vendors, the following steps must be followed:  As the delivery person is arriving, retrieve the supervisor’s order guide from the clip

board in the diet office.

 Check each item against the driver’s invoice and against the order guide to make sure all items have been received. Visually look at each box to make sure it is not a “mis-pick” before driver takes items to proper location (freezer, refrigerator, dry storage).  Note shortages or “outs” on the order guide and have driver note them on the invoice.  Check all produce for acceptability. Return any item that does not meet specifications.  Return any item on the invoice that does not appear on the order guide, unless it has

been approved by the FPM or Director.

 When all items on invoice have been accounted for or returned, sign the invoice. The driver will then give you 2 copies of the invoice.

 Place both copies in the box on the FPM’s desk in the diet office.

 Notify FPM or Director of any shortages or “outs” so those items can be reordered before they are needed on the menu or the menu has to be modified to accommodate for the shortage.

 Do not accept non-food items delivered by a food vendor. These deliveries need to be routed to Materials Management for proper receiving via purchase order.

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RECEIVING DELIVERIES PAGE 2

 After deliveries are received, it is the responsibility of the Nutrition Services worker (porter) or designee to store all groceries received immediately. See storage policy (NTS-05.1) for correct storage procedures.

Attachments:

Professional References: none Regulatory References: none Related Policies: NTS – 5.1 Replaces:

_____________________________________ __________________________________ _____________________________________

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STORAGE NTS-5.1

Date Originated: November 1998 Date of Revision: January 2013 Reviewed: 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 1/10; 1/13

POLICY

Adequate area for food storage shall be provided. Dry or stapled food items shall be stored off the floor in a ventilated cool room not subject to sewage or waste water flow, or contamination by condensation, leakage, rodents, or vermin. Frozen and refrigerated food will be stored in a walk-in refrigerator/freezer that is keep at the correct temperature to insure food safety.

PROCEDURES:

 Open shelving 6-12 inches from floor will be used. No items will be stored higher than 18 inches from the ceiling.

 Shelving must be left uncovered to provide adequate air flow.

 The Porter, or designee in her absence, is responsible for storage of all received goods.

 Frozen items are to be stored immediately upon receipt. Refrigerated items are stored next. If time permits, dry storage items will be stored on the same day as they are received. If not, they will be stored first thing the next day.

 The stock is rotated in accordance with the FIFO system by the Nutrition Services staff as new stock is received. All received goods are dated on receipt.

 Separate storage areas shall be provided for:

 Canned food, dry staples such as flour, sugar, cake mixes, etc.  Refrigerated and Frozen foods

 Paper supplies  Linens

 Cleaning supplies

 All perishable foods are refrigerated/frozen at the appropriate temperature and in a timely, orderly and sanitary manner.

 A reliable thermometer shall be provided for each refrigerator/freezer in a clearly visible position.

 Accurate records will be kept to document storage temperature (zero degrees or less for freezer and 34 -35 degrees for general storage.

 Only food products may be stored in refrigerators.

 Food and non-food supplies are clearly labeled before storage. Items are stored in original containers where appropriate. Non-food supplies are stored in a separate area from food supplies altogether.

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_____________________________________ __________________________________ _____________________________________

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FOOD PREPARATION NTS-6.1

Date Originated: April 1994 Date of Revision: September 2000 Reviewed: 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 1/10; 1/13

POLICY

All food shall be prepared in accordance with quality standards for quantity food preparation under the direction of a Registered Dietitian or her designee.

PROCEDURE

 Standardized recipes from USDA and other tested recipes are kept in file in supervisor’s office and kitchen for cooks' use.

 Approved recipes for menu items are supplied and explained to cook.

 Cook prepares food needed for each meal according to proper cooking methods and proper food handling techniques.

 Cook prepares menu items for therapeutic diets according to proper cooking methods for each modified diet restriction.

 The following items are routinely prepared in addition to the planned menu items to allow for substitutions: Jello, green salads, assorted fruits and breads. Ice cream and sherbet are always available.

 Food is cooked as needed to ensure freshness and quality. Leftover foods are covered, dated and stored properly until used.

 Economy in preparation of food and proper usage of leftover foods are determined by cook under direction of supervisor.

 Expiration dates on food and food supplements are checked routinely to assure that expired products are not used.

Attachments:

__________________________________ _____________________________________

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DEPARTMENT SANITATION – CLEANING SCHEDULE NTS-7.1

Date Originated: April 1994 Date of Revision: September 1997 Reviewed: 10/97, 10/98, 10/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 1/10; 1/13

POLICY:

The Nutrition Services area shall be clean and orderly at all times. PROCEDURE:

A departmental cleaning schedule is posted in the food production manager’s office with daily, weekly and monthly cleaning assignments for all Nutrition Services staff. Each member of the staff is required to initial off on the schedule as each of their assignments are completed.

Completion of assignments are verified by the Director or designee and reviewed as a performance standard for each employee annually

ITEM TO CLEAN FREQUENCY BY WHOM

Dining Area

Floors Carpet sweep as needed

daily Cashier

Walls Twice monthly and as

needed Porter

Tables, Chairs, Highchairs As needed Cashier Serving Line Daily as needed Cashier Microwave Oven (2) Daily as needed Cashier Yogurt Machine Twice weekly Cashier Popcorn Machine Twice weekly Late Aide

Juice Machine Daily as needed Cashier, NS Aide Cappuccino Machine Daily as needed Cashier

Coffee Maker Daily as needed Cashier Food preparation Area

Walls Twice monthly Porter

Range Once daily Late Cook

Refrigerator Weekly Baker

Pass Thrus Weekly Baker

Mixers (2) Daily Baker

Sink After each use Porter

Can opener Daily Late Cook

Microwave After each use Early Aide

Kettles Daily when used User

Skillet Daily when used User

Toaster Daily when used Cashier

Slicer/Chopper Daily when used User

Conventional oven Weekly Porter

Steamers Weekly Porter

Fryers Weekly Porter

Walk in Refrigerator Weekly Early Cook

Walk in Freezer Monthly Porter

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Heated food cart Each time they are

returned from the unit Early/Late Aide Utility carts Weekly and after each use Early/Late Aide Vegetable storage bins Weekly Porter

Kitchen shelves As needed Staff as assigned

Vent Hood Twice monthly Porter

Storage shelves Bi annually Staff as assigned Pass thru warmer/refrigerator Weekly Baker

Kitchen drawers Weekly Early Aide

Apron storage Weekly Early Aide

Trash cans Weekly Porter

Paper storage Weekly Late Cook

Dry storage Weekly Late Aide

Chemical storage Weekly Porter

Vent-hood Twice monthly Porter

Attachments:

Professional References: none Regulatory References: none Related Policies:

Replaces:

_____________________________________ __________________________________ _____________________________________

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DEPARTMENT SANITATION – ICE MACHINE NTS-7.2

Date Originated: April 1994 Date of Revision: December 1997 Reviewed: 10/98, 10/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06; 1/10; 1/12

POLICY

Ice is protected from contamination.

PROCEDURE

Ice is removed with a sanitized scoop. Ice scoop is stored in a HACCP approved scoop holder.

Sliding door on ice maker is closed at all times.

Employees from other departments who come for ice are supervised by Nutrition Services staff to maintain sanitation of ice.

Routine cleaning of outside panels and sliding door is done weekly by Nutrition Services staff using hospital approved cleaner.

Inside cleaning/sanitizing of bin is done every 3 months. All ice is removed and disposed. The bin is cleaned with hospital approved cleaner. This quarterly cleaning is done by Nutrition Services with the help of maintenance.

Preventive maintenance is done on a monthly basis by the maintenance department.

Attachments:

Replaces:

_____________________________________ __________________________________ _____________________________________

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DISHWASHING – GENERAL GUIDELINES NTS-8.1

Date Originated: January 1991 Date of Revision: April 1994

Reviewed: 4/95, 5/96, 10/97, 10/98, 10/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 1/10; 1/13

POLICY:

Dishwashing procedures and techniques are well developed, understood, and carried out to meet state and local health codes.

PROCEDURE

The following guidelines are used for dishwashing.

I. Nutrition Services staff will wear protective gloves at all times while washing dishes. II. Procedures for machine washing:

A. Hospital approved chemicals used for pre-soak, silver ware, and dinnerware. B. Hospital approved detergent used for machine wash.

C. Temperature of water for machine wash in 140° F to 160° F D. Temperature of machine for rinse, 180° F to 200° F

III. Procedure for hand washing of dishes, pots and pans:

A. Wash, using automatically dispensed hospital approved detergent and a scrub brush to scrape the pots.

B. Rinse, in hot water.

C. Sanitize in hospital approved sanitizing solution in third sink of three- compartment-pot sink.

IV. Detergents:

The combination of a detergent-sanitizer in the wash water and a chemical sanitizer in the rinse water is recommended for both manual and mechanical dishwashing.

V. Infection Control: Dishwashing for Isolation Trays

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Attachments:

Replaces:

_____________________________________ __________________________________ _____________________________________

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DISHWASHING – MACHINE WASHING NTS-8.2

Reviewed: 4/95, 5/96, 10/97, 10/98, 10/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 1/10; 1/13

POLICY:

PROCEDURE

How to wash dishes properly by the use of a dish machine. A. Prepare soiled dishes for washing:

1. Separate glasses, flatware and china; stack trays, stack dishes.

2. Place flatware, egg dishes and casserole dishes into pre-soak sink or pan.

Flatware should not soak longer than 15 minutes. Long soaking can cause pitting in silver and stainless steel flatware.

3. Place glasses, china, soaked flatware and dishes into racks or stack. Overcrowding in the racks prevents effective washing. Do not overcrowd.

4. Spray with water (preflush) to rinse off soft food. This removes the bulk food and greases that makes it hard for you to keep the machine clean.

B. Wash the dishes:

1. Follow instructions for operating your dishwashing machine. 2. Your supervisor will give you an instruction sheet. Ask for it. C. Care for the clean dishes:

1. Always wash your hands before you touch the clean dishes.

2.Handle clean flatware in such a way as to not touch the bowls, tines, or blades. 3.Do not carry dishes in contact with your clothing. Use clean carts or self-leveling dish carts.

D. Keep the machine and dishwashing area clean.

1. It is the responsibility of the operator to keep the dishwashing machine and the area clean.

2. Each day remove wash arms and flush out with running water.

3. Remove scrap trays and clean under-spray, preferably after every meal and at least once a day.

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5. Use hose to wash down inside of machine.

6. Remove curtains, scrub with detergent and brush, rinse and hang to air dry. 7. Door-type machines should be left open to air dry.

8. Scrub the dish tables, racks and floors each day.

9. Report to your supervisor any needed repairs such as leaks, poor drainage, or loose parts.

Attachments:

Replaces:

_____________________________________ __________________________________ _____________________________________

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DISHWASHING – THREE COMPARTMENT SINK NTS-8.3

Reviewed: 4/95, 5/96, 10/97, 10/98, 10/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 9/06, 1/10; 1/13

POLICY:

PROCEDURE

How to hand wash dishes properly. A. Prepare soiled dishes for washing:

1. Separate glasses, flatware and dinnerware; stack trays. 2. Spray with water (pre-flush) too rinse off loose food.

3. Place the flatware, dinnerware and glasses into pre-soak sink or pans. 4. Place cups, glasses, dinnerware and soaked flatware n stacks.

5. Wash the dishes in the first sink:

B. Set up three compartment sink for washing:

1. Fill the first sink with hot water (120 F) to the desired level for washing, the automatic dispensary equipment will measure the correct amount of hospital

approved chemical into the water. Do not add any additional chemicals to the water. 2. Wash the dishes thoroughly inside and outside:

3. Use a clean sponge; a clean fiber brush will help to remove caked on food. 4. Place washed dishes in racks. Do not overcrowd. Over- crowding in the racks

prevents effective rinsing.

5. Drain the sink regularly, afterward clean the sink and refill with fresh hot water and detergent.

C. Rinse the dishes in the second sink:

6. Fill the second sink with fresh hot water.

7. Into the hot water plunge the rack of washed dishes and the basket or holders for flatware and hold for at least one- half minute. (If you count to 45 slowly, this will be one- half minute).

D. Sanitize the dishes in the third sink:

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9. Plunge the rack of washed dishes and the basket or holder of flatware beneath the hot water for at least one minute (count to 90).

10. Place racks on drain boards to air dry. If the temperature of the rinse water is kept high

E. Care for the clean dishes:

12. Do not carry dishes in contact with your clothing. Use clean carts or self- leveling dish carts.

13. Handle the clean flatware in such a way as to not touch the bowls, tines, or blades

14. Handle clean cups and glasses on the outside only, never put your hand inside the cup/glass.

F. Keep the dishwashing and storage area clean:

1. It is the responsibility of the Nutrition Services staff to keep the dishwashing area

clean.

2. After dishes are washed, scrub sides of the sink, the drain boards and tables with water to which a detergent and sanitizer have been added.

 Stiff brush helps remove scum at water lever.  Rinse the sinks and allow to drain.

 Drain boards should be scrubbed with detergent-sanitizer.

 Racks should be washed, rinsed and stacked to dry. Do not stand dish racks on the floor.

Attachments:

Replaces:

__________________________________ _____________________________________

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WASTE DISPOSAL NTS-9.1

Date Originated: April 1994 Date of Revision: September 1997 Reviewed: 10/98, 10/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06, 1/10; 1/13

POLICY:

All garbage shall be handled and stored in a sanitary manner until disposal. PROCEDURE

Procedure for disposal of garbage is:

 All wet garbage is put down the garbage disposal, except for high fiber or "stringy" produce which disposal blades will not mulch finely enough.

 Paper goods are carried in plastic bags to the incinerator.  Cans and bottles are carried in plastic bags to the dumpster.

 The nutrition service workers are responsible for carrying the garbage to the dumpsite.

 All garbage cans are washed with soap and water weekly and sprayed with a disinfectant. All garbage cans are kept covered with a lid as much as possible.  Grease is strained from all prepared foods and reserved in a 50 gallon barrel on the

receiving ramp. A local grease recycling service is called to pick up the grease when the barrel is full.

 Housekeeping is responsible for the garbage disposal on the week-ends.

Attachments:

Replaces:

_____________________________________ __________________________________ _____________________________________

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INFECTION CONTROL – HEALTH REQUIREMENTS & ORIENTATION NTS-10.1 Department: Nutrition Services

Date Originated: August 1989 Date of Revision: April 1994

Reviewed: 11/95, 5/96, 10/97, 10/98, 10/99, 9/00, 9/01, 9/02, 9/03, 9/04, 9/05, 8/06,1/10, 1/12

OBJECTIVES

To promote and protect the health of patients, employees and visitors through the application of safe practices not only in the nutritional aspect of nutrition services but in the practice of environmental and infection control, and safety in all areas of nutrition services. HEALTH REQUIREMENTS

Nutrition Services personnel must fulfill all pre-employment and annual health requirements according to regulations of the Infection Control Committee and Administration.

ORIENTATION AND INSTRUCTION OF PERSONNEL

Orientation of personnel to this department and instruction in department functions are performed by a qualified person such as the department head or a supervisor. Personnel are oriented and instructed at the time of hire, and at regular department in-service meetings in order to keep current in the area of sanitation, safety, and infection control. Attendance at in-service meetings is required and recorded.

Orientation and instruction shall include at least the following:  Asepsis (general, isolation).

 Cleaning and decontamination of equipment and environment.

 Proper handling, storing, preparation and serving of food. Care and storing of supplies.  Use, operation, care and maintenance of equipment. Manufacturer's instructions in

safety, and location of equipment manuals and other resource material.

 Electrical safety, fire safety, internal and external disaster plans and procedures, including specific assigned duties in case of a disaster.

 Incident reporting and emergency measures.

 The department has a library of manuals, texts, and resource material. Attachments:

Replaces:

_____________________________________

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