Accreditation & Regulatory Journal
March 2024

News You Can Use

March’s Compliance Tip of the Month

The compliance tip of the month for March is focused on Dietary (Nutrition) Services. Specifically, the requirements around the approval of menus 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 showing an approval by the dietician. This is particularly problematic in an 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 organizations to evaluate the menu approval process in order to identify a compliance issue, 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 nutrients 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
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

Conferences and Sponsorships

Save the dates: September 24 – 26, 2024
Location: San Antonio, Texas at Pedrotti’s Ranch
Save the Date for 2024 Accreditation & Regulatory Summit
Each month we will publish fun facts about CIHQ and its history in our CIHQ Accreditation & Regulatory Journal. The facts will be in different locations within the Journal but will all be housed in a box with a game-themed border. Search the Journal to learn interesting facts! At the Summit, teams will compete against each other for the level of knowledge and the team that knows the most will win a fun and exciting prize. In February, the bordered box began traveling to different pages of the Journal.
Stay tuned in to your journal for facts and fun about us! We can’t wait to see all of you at the Summit! More Summit information will be sent as it is finalized and made available. This is the event that you won’t want to miss!
CIHQ to Attend Palooza in March
CIHQ’ longtime partner RLDatix is hosting their annual Palooza in Orlando, FL March 11-14, 2024. This is the official conference for RL Datix customers to come together to collaborate and grow. Rick Curtis will speak, participate in an Executive Roundtable discussion, and preside over a HUB Quarters jam session.
Richard Curtis to be Featured Speaker at NALTH
CIHQ is a long-time supporter of The National Association for Long Term Hospitals. NALTH has a goal to support its members in the areas of advocacy, education & communication, research, and networking. CIHQ will take the booth to the SPRING 2024 LTCH Clinical Education Conference in Nashville, March 27-29. NALTH is Rick is slated to speak at their fall conference in October in National Harbor, MD.
CIHQ to Sponsor for TORCH
For the 3rd year in a row, CIHQ will attend the Texas Organization of Community and Rural Hospitals (TORCH) Spring conference in Arlington, TX on April 2-4, 2024. If you’re attending, stop by the booth!
CIHQ to Sponsor ASAM
We will also sponsor The American Society of Addiction Medicine (ASAM) Annual Conference in Grapevine (DFW) April 4-7. For 55 years, ASAM has been convening the addiction treatment community to showcase best practices and the latest science, research, and innovations in the field. This is our first time attending ASAM; looking forward to it!
Lead Surveyor Gina Miller to be Featured Speaker at TSMSS
Gina Miller will present at the Texas Society for Medical Services Specialists (TSMSS) on the Riverwalk in San Antonio, April 10-12. Their vision is to be recognized as a leading organization that promotes patient safety through education, certification, and professional growth of medical services specialists. We understand many HACP credential holders attend this event and look forward to seeing them! Stop by the booth and say hello!
CIHQ to Sponsor the Association of Children’s Residential & Community Services
Another first-time conference, CIHQ will also sponsor The Association of Children’s Residential & Community Services (ACRC) Annual Conference in Phoenix May 5-9. ACRC provides a network of learning, support, and advocacy for quality residential interventions for children. They are dedicated to being a powerful voice for best practices and innovation in the field. We are looking forward to this opportunity!
CIHQ to Attend the Indiana Rural Health Association’s Annual Conference
CIHQ is able to accredit Critical Access Hospitals (CAH), and we look forward to attending Indiana RURAL Health Association’s Annual Conference in French Lick, IN on June 10- 12. A voice for rural residents of Indiana, the theme this year is, “Leveraging Opportunities for Change”.
CIHQ to Sponsor SIPS Scrub Ball
SIPS Consults has been a CIHQ partner since 2022. Each year, they celebrate and pay tribute to healthcare heroes at the ScrubBall in Dallas, June 20-22. Education, encouragement, and validation enhances job satisfaction and motivation. Ask for a tour of the SIPS training facility if you’re in the Dallas area; they are dedicated to training Sterile Processing Department staff.
Richard Curtis will be a Featured Speaker and ACRM’s Annual Conference
The American Congress of Rehabilitation Medicine (ACRM) Annual Conference, “Progress in Rehabilitation Research: Translation to Clinical Practice” will be held October 31 – Nov 4 in Dallas, TX. Attendees will have the opportunity to hear Rick Curtis and other highly acclaimed professionals present on all things rehabilitation.
Richard Curtis Keynote Speaker for Small and Rural Hospital Summit
Rick Curtis will be the keynote speaker for Louisiana Hospital Association’s Leadership Conference, Nov 6-7 in Baton Rouge. Their mission is to provide a unified voice that promotes and enhances the quality of rural health in Louisiana; their vision is to work toward ensuring all Louisiana residents have access to high quality healthcare and the opportunity to live a healthy life.