Hospitals and Long Term Care Facilities

The Long-Term Care Final Rule, published October 4, 2016, outlined that the attending physician may delegate prescribing a resident's diet to a qualified dietitian or other clinically qualified nutrition professional. The Final Rule stated the regulations will be rolled out in three phases, with some stipulations for food service director becoming effective gradually.

Long term care facilities do not have the same governance structure as hospitals, which can grant RDNs and qualified nutrition professionals independent order writing privileges if consistent with state laws. Therefore, the attending physician or designee must first delegate the authority to the RDN to manage the dietary order. Technically, the physician remains responsible for the diet order, although co-signing is not required, except by state law.

Under this rule, therapeutic diets are ordered by a physician, nurse practitioner, clinical nurse specialist, or physician assistant, but this task may be delegated to a "qualified dietitian or other clinically qualified nutrition professional." The medical professional retains responsibility for the order.

In §483.25(g), CMS defined a therapeutic diet as "a diet ordered by a physician or other delegated provider that is part of the 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."

RDNs should be able to order nutritional supplements for patients in accordance with state laws and regulations if the authority has been delegated by the attending physician or designee.

No. CMS defines the qualifications of the professionals who can write dietary orders by delegation as "qualified nutrition professionals", which could have a different meaning in different states. In Pennsylvania, for example, RD/RDNs and Certified Nutrition Specialists (CNS) are the professions permitted to write dietary orders by delegation.

In section §483.60, CMS defines "qualified dietitian" as "a qualified dietitian or other clinically qualified nutrition professional [providing services] either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who:

1. Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
2. Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
3. Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
4. For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law."

In the "Revision to State Operations Manual (SOM) Appendix PP for Phase 2, F-Tag Revisions, and Related Issues" effective November 28, 2017, CMS provided further guidance on this issue as part of F808. In LTC facilities, the terms "attending physician" or "physician" also include a non-physician provider (physician assistant, nurse practitioner, or clinical nurse specialist) involved in the management of the resident's care."

No. In order to implement the rule change, each facility must approve of the implementation and determine exactly what services the qualified dietitian or qualified nutrition professional can provide. This needs to be in writing and agreed upon between the nutrition professional, medical director, nursing director, administration, and other decision makers at each facility.

Yes, the rule stipulates that a nutrition professional be formally included on the interdisciplinary Care Plan team, revises requirements for assisted nutrition and hydration, specifies the role of non-physician medical providers, and clarifies the need to accommodate residents' food preferences.

Since few states specifically prohibit physicians from delegating orders, or prohibit RDNs from receiving such orders, such a map would have little value. We note that the primary limits are facility-based.