CMS SOM App. A, Tag A-0621

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.

Survey Procedures §482.28(a)(2)

• Review the dietitian’s personnel file to determine that he/she is qualified based on

education, experience, specialized training, and, if required by State law, is licensed,

certified, or registered by the State.

• If the dietitian is not full-time, determine that the number of hours spent working is

appropriate to serve the nutritional needs of the patients, and that the hospital makes

adequate provisions for a qualified consultant coverage when the dietitian is not

available.