CMS SOM App. H, Tag V545

address, but not be limited to, the following: (2) Nutritional status. The interdisciplinary

Page 212 of 420

team must provide the necessary care and counseling services to achieve and sustain an

effective nutritional status. A patient’s albumin level and body weight must be measured at

least monthly. Additional evidence-based professionally-accepted clinical nutrition

indicators may be monitored, as appropriate.

Interpretive Guidance § 494.90(a)(2)

The facility must have established target goals for patients’ albumin levels and monitor each

patient’s body weight trends. Other nutritional markers, including but not limited to sodium,

calcium, phosphorus, and potassium, should also be routinely monitored. Facilities may use

additional nutritional markers and assessments as determined by the IDT. At the time of

publishing these regulations (April 15, 2008, 73 FR 20369), two methods of measuring albumin

were in use, each with a different range.

If the patient record indicates a trend of problems in the patient’s nutritional status, the IDT

must develop and implement an outcome-oriented plan of care to address these issues. For

example, if the patient’s albumin levels are consistently below target levels, an individualized

plan of care should be developed to address the possible causes (e.g., inadequate dialysis, poor

understanding of diet, limited access to nutritious food, fluid volume overload). To meet the

requirement to “achieve and sustain an effective nutritional status,” the medical records of

patients with outcomes lower than the expected standard should demonstrate continuing efforts

tailored, implemented, assessed for success, and revised to address the individual patient

challenges in this area. In the event the patient has a wasting disease, cachexia, or chronic

inflammation contributing to a poor nutritional state, the plan of care should acknowledge these

as limiting factors in achieving and sustaining the goal for nutritional status.

While it is not expected or required for facilities to provide nutritional supplements, the dietitian

is expected to assist patients in achieving their nutritional goals by providing education,

counseling, and encouragement.

The requirements for patient assessment of nutritional status are at V509.