Brenda RobinsonFood, nutrition, and dining take on new meaning as long term care regulatory requirements demand a closer look at what is being “served up.” The long-awaited Final Rule for Participation in Medicare and Medicaid programs from the Centers for Medicare & Medicaid Services (CMS) was published in the Federal Register on Oct. 4, 2016.
These new regulations reflect some key focus areas for food, nutrition, and dining. As CMS says, “Effective management and oversight of the food and nutrition service is critical to the safety and well-being of all residents of a nursing facility.”
The effective date for these new regulations was Nov. 28, 2016, and includes three phases and time frames for implementation. However, most of the food and nutrition service requirements are included in Phase I.
In addition to the new CMS requirements, “Nursing Homes Spice Up Food Offerings,” published Nov. 16, 2016, in U.S. News & World Report, captures the changes in customer expectations. The article addresses the nationwide trend of long term care facilities increasingly focusing on upgrading dining and serving residents with a healthy slice of home and dinner out.

The Food Service Movement

Food, nutrition, and dining have seen significant changes in food service innovation, increased customer knowledge of the role of nutrition in health, and the professional standards of using evidence-based, “best practice” medical nutrition therapy.

Trends in food service over the past 10 to 15 years reflect customers demanding a variety of foods, sustainable food sources, healthy food options, and a diverse range of dining atmospheres.

The new regulations require centers to explore reasonable options to meet their residents’ preferences. As centers strive to meet customer requests and provide “person-centered” care, it is not uncommon to see new offerings like specialty bakeries, bistros, short-order grills, and full restaurant-style dining.

All of these factors make it critical to have staff with competencies and skill sets to manage and provide oversight for success.

Nutrition Service Staffing And Meal Service

A key area in the new regulations includes the following language for §483.60 food and nutrition services, which says that the facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Person-centered care is a driving factor throughout all food, dining, and nutrition components.

Another focus area is on staff, who must have the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The requirements for a qualified dietitian or other clinically qualified nutrition professional, either full-time, part-time, or on a consultant basis, is outlined.

In addition, the requirements say that if a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.

This individual must meet the specified criteria no later than five years after Nov. 28, 2016, if they were already serving in that position, or no later than one year after Nov. 28, 2016, if designated after Nov. 28, 2016.

The facility and director of food and nutrition services are also required to schedule frequent consultations with a qualified dietitian or other clinically qualified nutrition professional. A member of the food and nutrition services staff must also actively participate as a member of the interdisciplinary team.

Support staff are also included in overall staffing requirements, with the directive that the facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Dietary Preference Requirements

While it is not new that therapeutic diets must be prescribed by the attending physician, the new regulations now allow the attending physician to delegate to a registered or licensed dietitian the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by state law.

Food and dining should include menus that meet the nutritional needs of residents in accordance with established national guidelines, be prepared in advance, and be followed.

Woven into the menus and meal planning is the need to reflect, based on a facility’s reasonable efforts, on the religious, cultural, and ethnic needs of the resident population, as well as input received from residents and resident groups. Menus are then to be updated periodically and reviewed by the facility’s dietitian or other clinically qualified nutrition professional for nutritional adequacy.

Person-Centered Theme

Person-centered care is reflected in the inclusion of the statement that nothing in the rule “limits the resident’s right to make personal dietary choices.”

Food is to be prepared by methods that conserve nutritive value, flavor, and appearance, the rule says, and beverages should be palatable, attractive, and at a safe and appetizing temperature.

In addition to meeting individual needs (allergies, intolerances, preferences), facilities are to offer appealing options of similar nutritive value, with sufficient drinks to maintain hydration.

Person-centered care is captured with requirements for frequency of meals, clarification of meal times, number of meals, specified hours, alternative meals, and availability of options based on the resident group and specific resident plan of care.

Food safety continues to be a focus as foodborne illness (sometimes called “foodborne disease,” “foodborne infection,” or “food poisoning”) is a common, costly—yet preventable—public health problem.

The Centers for Disease Control and Prevention estimates that each year roughly one in six Americans (or 48 million people) get sick, 128,000 are hospitalized, and 3,000 die of foodborne diseases. Adults 65 and older are at a higher risk for hospitalization and death from foodborne illness.

The new regulations clarify that a facility must procure food from sources approved or considered satisfactory by federal, state, or local authorities. This may include food items obtained directly from local producers and does not prohibit or prevent facilities from using produce grown in facility gardens. However, staff must use safe growing and food-handling practices, and the food produced has to be subject to compliance with applicable state and local regulations.

Once the food is in the facility, the facility should store, prepare, distribute, and serve it in accordance with professional standards for food service safety.

While this provision does not preclude residents from consuming foods not procured by the facility, the facility is required to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, plus proper disposition of garbage and refuse.

With the final rule now published, it is vital that providers assess their facility management and oversight of the food and nutrition service areas. Being familiar with the specifics of the regulations and providing leadership to incorporate “person-centered” and “best practice” food and nutrition services are more important than ever.
Brenda Richardson, MA, RDN, LD, CD, FAND, is a long term care nutrition expert and president at Brenda Richardson LLC. She can be reached at