Accreditation & Regulatory Journal
November 2022

News You Can Use

November’s Compliance Tip of the Month

The compliance tip of the month for November is focused on Dietary (Nutrition) Services. Specifically, the requirements around the approval of menu’s by the dietician.
The challenge for organizations begins when they are asked by a surveyor to provide evidence that the diet menus have been reviewed and approved by the hospital dietician. Organizations can be cited at a standard level deficiency when they are unable to provide the evidence.
Acceptable evidence can simply be a signature indicating approval or meeting minutes indicating an approval by the dietician. This is particularly problematic in organization where the service may be provided via contract or written agreement. While the holder of the contract may have approved the menu’s it is the onus of the hospital’s full or part-time dietician to approve them.
The CMS regulation is included below. Additionally, the CMS interpretive Guidelines are included for further clarification.
CIHQ encourages organization to evaluate the menu approval process in order to identify a compliance issue and develop and implement a plan to eliminate the potential for a deficiency to be cited during survey.

CMS Regulation

§482.28 Condition of Participation: Food and Dietetic Services
§482.28(a)(2) - There must be a qualified dietitian, full-time, part-time or on a consultant basis.
Interpretive Guidelines §482.28(a)(2)
A qualified dietitian must supervise the nutritional aspects of patient care. Responsibilities of a hospital dietitian may include, but are not limited to:
  • Approving patient menus and nutritional supplements;
  • Patient, family, and caretaker dietary counseling;
  • Performing and documenting nutritional assessments and evaluating patient tolerance to therapeutic diets when appropriate;
  • Collaborating with other hospital services (e.g., medical staff, nursing services, pharmacy service, social work service, etc) to plan and implement patient care as necessary in meeting the nutritional needs of the patients;
  • Maintaining pertinent patient data necessary to recommend, prescribe, or modify therapeutic diets as needed to meet the nutritional needs of the patients.
Qualification is determined on the basis of education, experience, specialized training, State licensure or registration when applicable, and maintaining professional standards of practice.
If the qualified dietitian does not work full-time, and when the dietitian is not available, the hospital must make adequate provisions for dietary consultation that meets the needs of the patients. The frequency of consultation depends on the total number of patients, their nutritional needs and the number of patients requiring therapeutic diets or other nutritional supplementation.
Additional Information is provided below to give some direction regarding the resources that should be considered when evaluating the nutritional needs of the patient population.
§482.28 Condition of Participation: Food and Dietetic Services
§482.28(b) Menus must meet the needs of patients.
(1) Individual patient nutritional needs must be met in accordance with recognized dietary practices.
Interpretive Guidelines §482.28(b)(1)
Each hospital patient for whom the hospital is providing one or more meals or nutrition must have their nutritional needs met in a manner that is consistent with recognized dietary practices. Affected patients include all inpatients and those patients in outpatient status, including the provision of observation services, whose stay is sufficiently long that they must be fed. According to the U.S. Department of Agriculture’s (USDA) Food and Nutrition Center the nationally recognized source for recommended dietary intakes allowances is the Institute of Medicine Food and Nutrition Board’s Dietary Reference Intakes (DRIs), which are designed to provide recommended nutrient intakes for use in a variety of settings. The DRIs are a set of four reference values:
  • Recommended Dietary Allowance (RDA) is the average daily dietary intake of a nutrient that is sufficient to meet the requirement of nearly all (97-98%) healthy persons.
  • Adequate Intake (AI) for a nutrient is similar to the Estimated Safe and Adequate Daily Dietary Intakes (ESADDI) and is only established when an RDA cannot be determined. Therefore a nutrient either has an RDA or an AI. The AI is based on observed intakes of the nutrient by a group of healthy persons.
  • Tolerable Upper Intake Level (UL) is the highest daily intake of a nutrient that is likely to pose no risks of toxicity for almost all individuals. As intake above the UL increases, risk increases.
  • Estimated Average Requirement (EAR) is the amount of a nutrient that is estimated to meet the requirement of half of all healthy individuals in the population.
USDA provides access to an interactive DRI tool and DRI tables at
Meeting individual patient nutritional needs may include the use of therapeutic diets. Therapeutic diets refer 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 (e.g., sodium or potassium), or to provide mechanically altered food when indicated.
Patients must be assessed for their risk for nutritional deficiencies or need for therapeutic diets and/or other nutritional supplementation.
Examples of patients who may have specialized dietary needs and may require a more detailed nutritional assessment include, but are not limited to:
  • All patients requiring artificial nutrition by any means (i.e., enteral nutrition (tube feeding), total parenteral nutrition, or peripheral parenteral nutrition);
  • Patients whose medical condition, surgical intervention, or physical status interferes with their ability to ingest, digest or absorb nutrients;
  • Patients whose diagnosis or presenting signs/symptoms indicates a compromised nutritional status (e.g., anorexia nervosa, bulimia, electrolyte imbalances, dysphagia, malabsorption, end stage organ diseases, etc.);
  • Patients whose medical condition can be adversely affected by their nutritional intake (e.g., diabetes, congestive heart failure, patients taking certain medications, renal diseases, etc.).
Patients who refuse the food served should be offered substitutes that are of equal nutritional value in order to meet their basic nutritional needs.
The care plan for patients identified as having specialized nutritional needs must address those needs as well as monitoring of their dietary intake and nutritional status. The methods and frequency of monitoring could include one or more of the following, as well as other methods:
  • Patient weight (BMI, unintended weight loss or gain)
  • Intake and output
  • Lab values

CIHQ Accreditation Program Website Gets a Facelift

At CIHQ it is very important to continually strive to grow and improve our company. Over the last three years we have been working in the background to streamline our accreditation process and access to the accreditation programs. Part of that improvement includes a redesign of our web pages. You can check out our accreditation program’s new and improved main public page at . We have worked diligently to enhance our users experience.
Screenshot of our old site.
Screenshot of our NEW and IMPROVED site.
Take a look around and let us know what you think. Please send your thoughts and comments to Traci Curtis at .
We could stop here but we won’t. In the coming months we will be redesigning your facilities CIHQ extranet site and the Corrective Action Plan software. We will keep you updated as the work progresses. The newly designed platform should be seamless. While things make look a bit fresher and newer the functionality of all that you currently have will still be there.

CIHQ Applications to CMS as an Accrediting Organization and Expansion of Accreditation Programs - Update

CIHQ is on track for redesignation by CMS as an approved accrediting organizations for hospitals. Here is a timeline of the steps involved in the application process.
  • Submission of the Application – Submitted May 2022
  • CMS Notification that Application is Complete – Published in the Federal Register July 21, 2022
  • CMS Virtual Office Review – Performed August 15 – 16, 2022
  • CMS Notification of Survey Process and Office Review Results – Received 8/29/2022
  • CMS Survey Process and Office Review Approval – Received 9/28/2022
  • Observation/Shadow survey – Cancelled Due to Lack of CMS Budget Approval for FY2023. The maximum term for the redesignation by CMS is six years however, they are not allowed to award the full term if the observation survey cannot be conducted.
  • CMS to Publish Final Decision on or before December 22, 2022.
CIHQ is expanding its accreditation programs to Critical Access Hospitals. The application was submitted on October 4, 2022. The application has been deemed complete by CMS and the review of the CIHQ standards crosswalk to CMS CoP for CAH has begun. We will keep you updated as we move through this process. We have completed the five pilot surveys and wish to thank them for allowing us to pilot our process in their hospital.
  • Northeastern Vermont Regional Hospital
  • Jackson County Hospital District
  • Glen Medical Center
  • Union County General Hospital
  • Pawnee Valley Community Hospital
Next steps will be a virtual office review, and shadow survey (dates to be determined)
An application from CIHQ will be submitted in the coming weeks to be designated as an accrediting organization for all psychiatric hospitals. We have completed three of the five pilot surveys. We will keep you updated as we get closer to submission of the application.

CIHQ Heads to the Missouri State Hospital Association

CIHQ is headed to help the Missouri State Hospital Association celebrate 100 years of helping hospitals at it annual convention. As an Education Sponsor, CIHQ will attend the event and participate as a sponsor and vendor. The convention will be held at Margaritaville, Lake Resort at the Lakes of the Ozarks. This will be the second time that CIHQ has attended the event.

The stories of our past shape what and who we are today.
They also set the stage for our future.
At MHA’s 100th Annual Convention, we will reflect on how a century of progress — and our stewardship of that history — provides a springboard for the coming chapters of our story.
Throughout our 100th year, MHA has been featuring difference-makers within our organizations — individuals emblematic of our hospitals’ values. They demonstrate our collective commitment to touching lives while improving both health and care. These Exceptional People-Extraordinary Stories will be shared throughout the convention.
Together, we will celebrate our 100-year effort to make hospitals stronger. We will focus on the people and values that brought us to today, and those who will take us through the next 100 years and beyond.

CIHQ - Sponsor of the American Medical Rehabilitation Providers Association

CIHQ just sponsored and attended the @American Medical Rehabilitation Providers Association’s 2022 Fall Educational Conference & Expo, October 9-12, in St. Louis. The focus of the conference was on the latest and most innovative strategies to keep rehabilitation professionals ahead of the curve, provide the highest quality of care, and share advocacy efforts in the interest of inpatient rehabilitation hospitals and units, outpatient rehabilitation centers, and other medical rehabilitation providers. CIHQ was the only accrediting organization in attendance and we made many new friends and contacts.
Rick Curtis presented Regulatory Compliance, Accreditation Matters, and Other Critical Topics AND Inculcating a Culture of Quality & Regulatory Compliance. This event celebrated AMPRA’s 25th Anniversary.