The Academy has received numerous questions from RDs about being “cited” by state surveyors and during mock surveys by the Joint Commission field surveyors concerning therapeutic diet orders.
This is not due to any change in therapeutic diet regulations but rather a renewed enforcement of the existing Centers for Medicare & Medicaid Services Hospital Conditions of Participation for Food and Dietetic Services and its regulations and interpretive guidelines.
Originally implemented in 1986, the therapeutic diet regulation was highlighted and reissued in October 2008 in the Medicare State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. It states that in accordance with state law and hospital policy, a dietitian may assess a patient’s nutritional needs and provide recommendations or consultations for patients, but the patient’s diet must be prescribed by the practitioner responsible for the patient’s care, which means a Licensed Independent Practitioner. There are four kinds of LIPs: medical doctors, doctors of osteopathic medicine, advanced practice registered nurses and physician assistants.
In addition to the overarching reasons—such as quality of care and patient safety—for ensuring regulations are followed appropriately, surveyors themselves are held accountable for enforcing regulations. In February, state surveyors completed CMS regional training on privileging, including the therapeutic diet regulation and the need for its strict adherence.
Does that mean that no RDs can write therapeutic diet orders? Not necessarily.
The decision about who can write therapeutic diet orders is up to the hospital facility and based on your state’s dietetic and nutrition services licensure law. Contact your state board of nutrition and dietetics and department of health for clarification. Make sure you fully understand what is permitted by law and expected of you regarding therapeutic diet order writing and accepting verbal orders, in addition to tube feedings, parenteral nutrition and supplements, or simple diet changes. Verify that these functions are approved by your facility’s medical executive committee with clear criteria written within hospital policies and procedures as well as your department of nutrition and dietetics services. A facility and medical staff may deem privileging necessary for RDs who complete medical tasks such as calculating parenteral nutrition formulas and then recommending or writing diet orders. Other issues to address are whether you have liability and malpractice insurance for the diet order writing accountability and if your hospital’s legal team will defend you in cases that include diet orders.
Research what other policies exist in your facility. You may need to meet with your hospital’s medical director, risk management or quality team and look at the legal scopes of practice for other allied health professionals in your hospital per their state licensure laws. What are respiratory therapists, speech therapists, occupational therapists, physical therapists, pharmacists and registered nurses permitted to do in your facility? These are some factors that help your facility decide whether to create a policy allowing RDs to write therapeutic diet orders.
Other accepted methods to assist with patient-centered, timely nutrition care are the use of protocols, standing orders or a preprinted order set approved by the medical staff. These are used by physicians and designated approved hospital practitioners such as RDs. Protocols are specific to specialized patient services such as critical care, coronary care and nephrology care. Standing orders must be documented as an order in the patient’s medical record, but the timing of such documentation should not be a barrier to effective emergency response, timely and necessary care or other patient safety advances. A preprinted order set assists qualified practitioners as they write orders and is not the same as a protocol. The order set functions as a menu of medications or actions from which RDs can make selections to be applied to a particular patient. Preprinted order sets (also computerized) are permitted by CMS as these play a role in promoting optional treatments of patients with certain conditions. Protocols, standing orders and preprinted order sets must be authenticated by the practitioner responsible for the care of the patient.
The Academy is pursuing avenues to bring clarity and interpretation around the therapeutic diet regulation. In the meantime, familiarize yourself with all regulations and policies pertaining to nutrition and diet therapy in your state and facility, to ensure not only compliance but safe, effective and equitable patient care.
Centers for Medicare and Medicaid Services Memos from the Survey and Certification Group
CMS has issued the following memos regarding hospital staff medical privileging, therapeutic diet orders, authentication of verbal orders and standing orders.