CMS SOM App. A, Tag A-0629

(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

http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes

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

Survey Procedures §482.28(b)(1)

• Can the dietician demonstrate how the menus meet the nutritional needs of patients.

For example, does the service rely upon DRIs, including RDAs, in developing

menus?

• Can the dietician demonstrate patients are assessed for special nutritional needs and

how the hospital assures the needs of those with specialized needs are met?

• When observing care in inpatient units (or observation units where meals are

provided) ask staff how patients are assessed for nutritional needs.

o Ask them how they monitor patients identified as having specialized needs.

o Is there evidence that therapeutic diets are provided as ordered?

Does the sample of patient records being reviewed include patients identified with special

nutritional needs? If not, ask to see records for several such patients. Determine if there is

evidence of monitoring the dietary intake and nutritional status of patients identified as having

special nutritional needs.