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CMS Dietary Update

CMS recently published three changes to the hospital condition of participations (CoPs) under Appendix A.

Appendix A is the manual for larger hospitals. CMS first published the final regulation changes in the federal register that became effective July 11, 2014. These interpretive guidelines explain the changes were published in a CMS survey memo dated January 30, 2015. The manual will be amended to include these changes.

CMS has a separate manual for critical access hospitals under Appendix W. CMS has also rewritten all of the dietary standards for critical access hospitals in an advance memo dated Jan. 16, 2015.

CMS made changes to tag number 629 and 630 and tag 628 was deleted. The tag numbers appear in the upper hand corner in the manual.

The primary reason for the change was to allow the board and medical staff to have the option to credential and privilege (C&P) the dietician or qualified nutrition specialist to write an order for a patient’s diet. Diet includes whatever the patient’s diet is such as therapeutic diet, supplemental feedings, or TPN (enteral or parenteral nutrition).

Therapeutic diet refers to a diet ordered as part of the patient’s treatment for a disease or clinical condition to eliminate, decrease, or increase certain substances in the diet, such as potassium or sodium, or to provide mechanically altered food when indicated.

In the past, many physicians would order a consult with the dietician for a recommendation of a therapeutic diet. The dietician would then write a recommendation as a consult. If the nurse on duty or the dietician did not call the physician, the hospital could be at risk for a deficiency if it simply waited until the next day when the physician made rounds. The practitioner would generally adopt the recommendation. This process involved interrupting the physician. The verbal order then needed to be signed off. Now the dietician who is C&P to write orders can simply write the diet order. If the physician disagrees the order can always be amended.

So if C&P, the dietician or qualified nutritional specialist could order diet, which they are trained to do, without supervision or the approval of the physician or practitioner. However, it is important to note that this cannot be done by policy and procedure only. The qualified dietician must be credentialed and privileged by the medical staff and this must be approved by the board. The order must be documented in the medical record.

CMS notes that in some states this person may be referred to as a licensed dietician or a registered dietician. Registered dieticians may be defined to include one who is registered with the Commission on Dietetic Registration or as defined by state law.

The state must also not prohibit the practice of ordering the patient’s diet. The American Dietetics’ Association has a map showing the states that may prohibit this at

Tag 629 now states that the individual patient nutritional needs must be met in accordance with recommended dietary practices. Patients must be assessed for risk of nutritional deficiencies. If present then this may be in the patient’s plan of care. It could include the need to monitor intake, I&O, daily weights, or lab values.

CMS discusses the Institute of Medicine’s food and nutrition board’s dietary reference intake. This includes four reference values including the Recommended Dietary Allowance or the recommended dietary allowances, which is the average dietary intake of nutrition sufficient for healthy people.

Tag 629 also discusses when a patient may need a comprehensive assessment. In many hospitals, the RN does an admission assessment which includes a nutritional screen. This may prompt the dietician to do a nutritional assessment when indicated by the patient’s condition. This may include if the patient has a medical or surgical condition that interferes with the ability to digest and absorb nutrients. The patient may have symptoms indicating a risk for malnutrition, such as anorexia nervosa, bulimia, electrolyte imbalance, or end stage renal disease. The patient’s medical condition could be adversely affected by intake and need a special diet as those patients with heart failure, diabetes, or renal disease. Patient may be at risk if receiving artificial nutrition such as tube feedings, TPN, or peripheral parental nutrition.