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CAH Dietary Standards Have Changed

The dietary guidelines for CAHs were completely rewritten by CMS, starting at tag 279. If the CAH furnishes inpatient services, which most do, it must put procedures in place ensuring the nutritional needs of patients are met. A CAH is not required to prepare meals itself and could obtain the meals under contract. Most CAHs find it easier to prepare the meals themselves.

An order from the patient’s physician or other practitioner is needed for the patient’s diet. The hospital medical staff and board is also permitted to credential the dietician to order diet under tag 279. Hospitals cannot allow dieticians to order the patient’s diet but must include a policy and the person must be credentialed and privileged C&P. Diet includes therapeutic diet, supplemental feedings, TPN, or associated lab tests. The state must also not prohibit this practice. In states that have a qualified nutrition specialist, they can also be C&P to order diet. The CAH must follow the provider’s order.

The director of dietary services must be qualified based on education, experience, specialized and training. The director must be licensed and or registered if state law requires it.

The new standards also refer to swing bed patients, which most CAHs have. The dietician needs to ensure swing bed residents maintain acceptable parameters of nutritional status, such as maintaining their weight and an appropriate protein level.

The hospital must follow recognized dietary practices. Take, for example, the National Academy of Medicine’s Food and Nutrition Board’s Dietary Reference Intake. It references four values including the recommended dietary allowance, which is the average dietary intake of nutrition for healthy people.

The Department of Agriculture and the Department of Health and Human Services publishes the Dietary Guidelines for Americans every five years. A draft of the 2015 edition is available here.

Therapeutic diets help to meet the patient’s nutritional needs, such as the 2 Gram Low Sodium diet or a 1500 Calorie ADA diet. Patients must be assessed to determine if they need a therapeutic diet or if they have other nutritional deficiencies. The assessment may be included in the patient’s care plan and may mention the need to monitor food intake, I&O, lab values or daily weights.

Often during the nursing admission assessment, a nutritional screen is done. The results may prompt a consult with dietary. CMS lists some situations that may prompt a more comprehensive nutritional assessment by the dietician, including:

  • Patient has a medical or surgical condition that interferes with their ability to digest or absorb nutrients like a gluten problem or Crohn’s disease.
  • Patients have signs and symptoms indicating a risk for malnutrition such as anorexia nervosa, bulimia, electrolyte imbalance, or end stage renal disease.
  • Patients have a medical condition that adversely affects their intake and so they need a special diet such as heart failure, diabetes, or renal disease.
  • Patients may be receiving artificial nutrition like tube feeding or TPN.

Information on the IOM’s DRI or Dietary Reference Intake is available here.