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Therapeutic Diet Orders: State Status and Regulation

TDO State Status

The below chart is a resource for Academy members considering seeking privileges to order therapeutic diets in the hospital setting. We have sought to identify all relevant statutes and regulations related to therapeutic diet ordering in each state and provide a brief analysis of each state’s relevant law. In the event that state regulators perceive additional statutes or regulations to be relevant, we are available to work with affiliates. We encourage RDNs to become familiar with their relevant state regulations and statutes, including the interpretation of the extent of their scope of practice.

States are color coded in a stoplight fashion to indicate:

Green:
There do not appear to be statutory or regulatory impediments to qualified RDNs seeking hospital privileges to order therapeutic diets.

Yellow:
There are not definitive impediments to obtaining privileges. However, certain statutory or regulatory language exists leading us to recommend affiliates work with state regulators to ensure their interpretation of relevant statutes and regulations will enable qualified RDNs to see privileges for therapeutic diet.

Red:
Specific statutory or regulatory impediments exist that preclude RDNs from taking full advantage of the opportunities presented by the revised CMS rule.


The Academy will be working with affiliate leaders to remove existing impediments through statutory or regulatory changes.

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

 


Alabama

Status: Red

Licensure:

Section 5 of the Alabama licensure act permits broad authorities for RDNs "upon referral or directive of a licensed physician."

Hospital Regulations:

420-5-7-.14 (3)(a): "Therapeutic diets shall be prescribed by the practitioner or practitioners responsible for the care of the patients."

Recommendation:

The hospital regulations for therapeutic diets track the prior version of the CMS rule and likely need to be revised to align with the new rule. Given existing Alabama regulatory language for hospitals, 420-5-7-.14(3)(a) could appropriately be revised to "All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian as authorized by the medical staff."

Practice Tips: Order Writing and Privileging

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Alaska

Status: Yellow

Licensure:

None

Hospital Regulations:

7 AAC 12.720(a): "A facility that provides dietetic services, with the exception of frontier extended stay clinics, must comply with the provisions of this section. (b) Except as provided in (p) and (q) of this section, a facility must employ (1) a full-time dietitian who is registered by the American Dietetic Association;"

7 AAC 12.720(d): "The dietetic service must provide food of the quality and quantity to meet the patient's needs in accordance with physician's orders and, to the extent medically possible, to meet the National Research Council's Recommended Dietary Allowances, 10th edition (1989), adopted by reference."

Recommendation:

Given the requirement that the dietetic service must be in accordance with the physician's orders we recommend working with the Alaska Department of Health and Social Services, Health Facilities Licensure to determine whether 7 AAC 12.720 would allow RDNs to order therapeutic diets and if not, to revise it to align with the new CMS rule.

Practice Tips: Order Writing and Privileging

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Arizona

Status: Yellow

Licensure:

None

Hospital Regulations:

R-9-10-227(5): "Dietary services are provided under the direction of an individual qualified to direct the provision of dietary services according to hospital policies and procedures;"

R-9-10-227(9): "A medical staff member documents an order for a diet for each patient in the patient’s medical record;"

Recommendation:

Although it is possible that qualified Arizona RDNs could begin ordering therapeutic diets if hospital policies and procedures allow, the requirement that "a medical staff member documents order for a diet for each patient" may mean that the RDN would have to become a medical staff member (defined as "physicians and other health care providers as defined in medical staff bylaws") to make the order. We recommend working with the Arizona Dept. of Health Services Office of Medical Facilities to clarify the meaning of the regulation and perhaps revise R-9-10-227(9) to: "A medical staff member or qualified registered dietitian as authorized by the medical staff documents an order for a diet for each patient in the patient's medical record;"

Practice Tips: Order Writing and Privileging

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Arkansas

Status: Yellow

Licensure:

None

Hospital Regulations:

Section 17 (A)(9): "Diets shall be in writing and signed by a physician or a mid-level practitioner if privileged by the Medical Staff and Governing Body. Notification according to facility policy shall be made to the Nutrition Services Department on a timely basis, kept current and include current date, the patient's name, room number and diet order."

Clinical dietitian/nutritionist "Shall be a registered dietitian, or registry eligible, and evaluate and oversee the delivery of effective nutritional care based on current, recognized nutritional practices Section 17(D)(1)."

Section 17(D)(3)(b)(5) notes: "The patient care plan shall include Any requests to the physician for alterations or modifications to the ordered diet's nutrient content, consistency, administration route/method or meal pattern as served in the hospital in order to meet the nutritional needs and/or special feeding needs of the patient."

Recommendation:

Arkansas regulations appear to allow mid-level practitioners (such as qualified RDNs) to write and sign diets if privileged to do so by the Medical Staff and Governing body. However, given the language in Section 17(D0(3)(b)(5) regarding requests for alteration or modification, we recommend working with the Arkansas Department of Health for assurance that Section 17(A)(9) sufficiently aligns with the new CMS rule to allow RDNs to become privileged to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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California

Status: Red

Licensure:

2586(a): "Notwithstanding any other provision of law, a registered dietitian, or other nutritional professional meeting the qualifications set forth in subdivision (e) of Section 2585 may, upon referral by a health care provider authorized to prescribe dietary treatments, provide nutritional and dietary counseling, conduct nutritional and dietary assessments, and develop nutritional and dietary treatments, including therapeutic diets, for individuals or groups of patients in licensed institutional facilities or in private office settings."

2586(g): "For purposes of this section, "health care provider" means any person licensed or certified pursuant to this division, or licensed pursuant to the Osteopathic Initiative Act or the Chiropractic Initiative Act."

Hospital Regulations:

Section 70055: "Dietitian. Dietitian means a person who is registered or eligible for registration as a registered dietitian by the American Dietetic Association." Section 70271 "Dietetic service means providing safe, satisfying and nutritionally adequate food for patients with appropriate staff, space, equipment and supplies."

Section 70273(a): "The dietetic service shall provide food of the quality and quantity to meet the patient's needs in accordance with physicians' orders..."

Section 70273(b): "Policies and procedures shall be developed and maintained in consultation with representatives of the medical staff, nursing staff and administration to govern the provision of dietetic services. Policies shall be approved by the medical staff, administration and governing body. Procedures shall be approved by the medical staff and administration."

Section 70273(e): "Therapeutic diets shall be provided as prescribed by a person lawfully authorized to give such an order and shall be planned, prepared and served with supervision and/or consultation from the dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food values to make appropriate substitutions when necessary."

Recommendation:

Given the requirement that the dietetic service must be in accordance with the physician's orders we recommend working with the California regulators to determine whether California will allow RDNs to order therapeutic diets and if not, to revise it to align with the new CMS rule. Caution is also urged given the language in section 2586(g) defining "health care provider" as someone licensed or certified and the language in 2586(a) regarding who is authorized to prescribe therapeutic diets.

Practice Tips: Order Writing and Privileging

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Colorado

Status: Red

Licensure:

None

Hospital Regulations:

6 CCR 1011-1 Chap 04 Part 16.101(3): "A registered dietitian shall be responsible for the nutritional aspects of care, including but not limited to, the evaluation of the nutritional status and needs of patients, the review of modified and special diets for nutritional adequacy, and patient counseling." 16.102(1)(a) "The nutritional needs of the patients shall be met in accordance with recognized dietary standards and in accordance with orders of the licensed independent practitioners responsible for the care of the patient."

16.102(1)(c): "Therapeutic diets and nourishments shall be served as prescribed by the attending licensed independent practitioner."

Recommendation:

Colorado's Standards for Hospitals and Health Facilities (6 CCR 1011-1 Chap 04) Part 16 contains language for therapeutic diets similar to the prior version of the CMS rule and may need to be revised to align with the new rule. Given existing Colorado regulatory language for hospitals and the requirement that a registered dietitian is "responsible for the nutritional aspects of care" under 16.101(3), 16.102(1)(a) could be revised to the effect of "The nutritional needs of the patients shall be met in accordance with recognized dietary standards and in accordance with orders of the licensed independent practitioners responsible for the care of the patient or qualified registered dietitians as authorized by the medical staff." Part 16.102(1)(c) could be revised to "Therapeutic diets and nourishments shall be served as prescribed by the attending licensed independent practitioner or qualified registered dietitian as authorized by the medical staff."

Practice Tips: Order Writing and Privileging

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Connecticut

Status: Yellow

Licensure:

Chapter 384b Sec. 20-206m(5): "Dietetics or nutrition practice" means the integration and application of the principles derived from the sciences of nutrition, biochemistry, food, physiology, and behavioral and social sciences to provide nutrition services that include: (A) Nutrition assessment; (B) the establishment of priorities, goals, and objectives that meet nutrition needs; (C) the provision of nutrition counseling in health and disease; (D) the development, implementation and management of nutrition care plans; and (E) the evaluation and maintenance of appropriate standards of quality in food and nutrition. The term "dietetics or nutrition practice" does not include the administration of nutrition by any route other than oral administration and does not include the issuance of orders for laboratory or other diagnostic tests or orders intended to be implemented by any person licensed pursuant to chapter 378 of the general statutes."

Sec. 20-206q.: "Verbal orders from physicians. When a physician conveys an order for a diet or means of nutritional support to a certified dietitian-nutritionist by verbal means for a patient in an institution defined in section 19a-490, such order shall be received and immediately committed to writing in the patient's chart by the certified dietitian-nutritionist. Any order so written may be acted upon by the institution's nurses and physician assistants with the same authority as if the order were received directly from the physician. Any order conveyed in this manner shall be countersigned by the physician within twenty-four hours unless otherwise provided by state or federal law or regulations."

Hospital Regulations:

Sec. 19-13-D5(h): "(1) Adequate space, equipment and qualified personnel shall be provided to ensure proper selection, storage, preparation and serving of regular and special diets to patients at regularly scheduled hours. (2) Menus shall be prepared and posted and shall meet state department of health requirements for basic nutritional needs."

Recommendation:

Connecticut's definition of dietetics or nutrition practice as excluding "the administration of nutrition by any route other than oral administration and does not include the issuance of orders for laboratory or other diagnostic tests or orders intended to be implemented by any person licensed pursuant to chapter 378 of the general statutes" means that a statutory change is likely required to enable qualified RDNs to order laboratory tests and encourage consultation with Connecticut regulators as to whether the limitation of the "administration" of enteral and parenteral nutrition is interpreted as a limitation of the ability of RDNs to order enteral and parenteral nutrition. In addition, the language in Sec. 20-206q may allow RDNs to dispense with physician countersigning orders if Connecticut interprets the newly revised CMS rule to allow it.

Practice Tips: Order Writing and Privileging

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Delaware

Status: Green

Licensure:

None

Hospital Regulations:

None found to date other than a bill to amend Section 1164: "Every residential health facility must at all times provide nutrition and dietetics staffing adequate to meet the care needs of each resident. The staffing level must, at a minimum, include a full-time food service manager. Any food service manager hired after July 1, 2001 must be a registered dietitian or a certified dietitian/nutritionist, a registered dietetic technician, a certified dietary manager, or must have a Bachelor of Science or associate degree in food service management or related field. The educational requirements shall be met provided that if an insufficient pool of applicants exists, other qualifications may be deemed acceptable in accordance with regulations promulgated by the Department. A sub-acute transitional care unit of an acute care hospital, with 30 beds or fewer, is exempt form the provisions of this subsection provided that other licensed personnel perform the duties of this function."

Recommendation:

According to the Director, Office of Health Facilities Licensing and Certification, "The Delaware hospital regulations do not include any language that would preclude a RDN from performing this task"

Practice Tips: Order Writing and Privileging

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District of Columbia

Status: Yellow

Licensure:

None

Hospital Regulations:

22-B2028: "Each hospital shall provide for the daily nutritional needs of all patients, including the provision of any diets ordered by a medical practitioner."

Recommendation:

Because hospitals in the District of Columbia are one of the few facilities that do not specify that therapeutic diets must be prescribed by a physician, we recommend confirming with the DC Department of Health that there are no hospital regulations that preclude hospitals from privileging qualified RDNs from independently ordering therapeutic diets.

Practice Tips: Order Writing and Privileging

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Florida

Status: Red

Licensure:

468.516: "Practice requirements (1)(a) A licensee under this part shall not implement a dietary plan for a condition for which the patient is under the active care of a physician licensed under chapter 458 or chapter 459, without the oral or written dietary order of the referring physician. In the event the licensee is unable to obtain authorization or consultation after a good faith effort to obtain it from the physician, the licensee may use professional discretion in providing nutrition services until authorization or consultation is obtained from the physician."

Hospital Regulations:

59A-3.2085(r): "Dietetic services shall be provided in accordance with written orders by the individual responsible for the patient and appropriate information shall be recorded in the patient's medical record."

Recommendation:

The language in the dietetics statute section 468.516 related to dietary orders and the language in Florida's hospital regulation 59A-3.2085® appear to require changes to both before Florida RDNs are able to independently order therapeutic diets.

Practice Tips: Order Writing and Privileging

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Georgia

Status: Yellow

Licensure:

None

Hospital Regulations:

111-8-40-.23(c)(3): "Therapeutic diets shall be prescribed by the member of the medical staff responsible for the care of the patient."

Recommendation:

Georgia regulations will currently allow qualified RDNs to order therapeutic diets if they are appointed to the medical staff and determined to be "responsible for the care of the patient," but a regulatory change will be required to otherwise allow qualified RDNs to be privileged to order therapeutic diets without becoming a member of the medical staff or without being responsible for the care of the patient.

Practice Tips: Order Writing and Privileging

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Hawaii

Status: Red

Licensure:

None

Hospital Regulations:

§11-93-8(c): "All modified diets shall be: (1) Prescribed by the patient's physician with a record of the diet as ordered kept on file."

§11-93-8(d): "Therapeutic diets shall be planned by a qualified dietitian, as prescribed by the patient's physician."

§11-93-51: "'Dietitian' means a person who: (1) Is registered by the American Dietetic Association under its requirements in effect on the day of publication of this provision; or (2) Is eligible for examination to become a registered dietitian."

Recommendation:

Hawaii hospital regulations appear to need to be revised to reflect the changes in the new CMS rule to the effect of: §11-93-8(c) "All modified diets shall be: (1) Prescribed by the patient's physician or qualified dietitian privileged by the hospital to do so with a record of the diet as ordered kept on file;" and §11-93-8(d) "Therapeutic diets shall be planned by a qualified dietitian, as prescribed by the patient's physician or qualified dietitian privileged by the hospital to do so."

Practice Tips: Order Writing and Privileging

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Idaho

Status: Red

Licensure:

None

Hospital Regulations:

16.03.14(002)(11): "Dietitian (Qualified Consultant). A person who: (12-31-91) a. Meets the requirements for registration by the Commission on Dietetic Registration of the American Dietetic Association under its requirements in effect on March 9, l976; or (10-14-88) b. Has a baccalaureate degree with major studies in food and nutrition or dietetics, has one (1) year of supervisory experience in the dietetic service of a health care institution, and participates annually in continuing dietetic education."

16.03.14(320)(06): "Modified Diets. All diets, including general diets, shall be ordered by the attending physician."

Recommendation:

Idaho hospital regulations appear to need to be revised to reflect the changes in the new CMS rule to the effect of: 16.03.14(320)(06) "Modified Diets. All diets, including general diets, shall be ordered by the attending physician or qualified dietitian privileged by the hospital to do so."

Practice Tips: Order Writing and Privileging

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Illinois

Status: Green

Licensure:

Illinois limits the provision of enteral and parenteral nutrition to a subset of licensed dietitian nutritionists.

Hospital Regulations:

Section 250.1610(b): "The dietetic department shall be directed by a full-time person who is qualified by dietetic and food service management training and experience, preferably a registered dietitian, whose responsibilities shall include, but are not limited to, the following: 1) developing written policies and procedures to include but not necessarily be limited to: . . . C) medically prescribed diet orders and alterations in diets or diet schedules such as holding trays, late trays, and times for accepting diet changes;"

Section 250.1630(b): "Menus shall be planned, and followed, to meet the nutritional needs of patients in accordance with physicians' orders. . ."

Section 250.1640(a): "All diets shall be ordered by the patient's attending physician and/or a registered dietitian with the attending physician's confirmation. Diet orders shall be recorded in the patient's medical chart. (b) All diet orders shall be sent to the dietetic service department in writing.  Each diet order shall have sufficient pertinent information to enable the dietetic service to serve the diet as prescribed by the physician."

Section 250.1660: Therapeutic (Modified) Diets contains no specific specification as to the practitioner able to order therapeutic diets.

Recommendation:

Illinois does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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Indiana

Status: Red

Licensure:

IC 25-14.5-1-10: Definition of medically prescribed diet requires them to "performed as initiated by or in consultation with a physician. . ."

Hospital Regulations:

410 IAC 15-1.5-1(d)(1): "Therapeutic diets shall be prescribed by the practitioner responsible for the care of the patient.

Recommendation:

The hospital regulations for therapeutic diets track the prior version of the CMS rule and likely need to be revised to align with the new rule. Given existing Indiana regulatory language for hospitals, 410 IAC 15-1.5-1(d)(1)could be appropriately revised to "Therapeutic diets shall be prescribed by the practitioner responsible for the care of the patient or by a qualified dietitian as authorized by the medical staff."

Practice Tips: Order Writing and Privileging

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Iowa

Status: Green

Licensure:

None

Hospital Regulations:

481-51.20(2)(b): "The food service shall provide food of the quality and quantity to meet the patient’s needs in accordance with the qualified health practitioner’s orders . . ."

5120(2)(e): "Therapeutic diets shall be provided as prescribed by the qualified health care practitioner and shall be planned, prepared, and served with supervision or consultation from the licensed dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food to make appropriate substitutions when necessary."

Recommendation:

Iowa does not appear to have any impediments to qualified RDNS seeking hospital privileges to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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Kansas

Status: Yellow

Licensure:

None

Hospital Regulations:

K.A.R. § 28-34-1a(f): "'Dietitian' means a person who is licensed in Kansas as a dietitian."

28-34-14(d): "The food and nutritional needs of patients shall be met with the recommended dietary allowance of the food and nutrition board of the national research council and in accordance with physician's orders."

Recommendation:

Given the requirement that the dietetic service must be in accordance with the physician's orders we recommend working with Kansas regulators to ascertain whether Kansas would allow RDNs to order therapeutic diets and if not, to revise it to align with the new CMS rule.

Practice Tips: Order Writing and Privileging

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Kentucky

Status: Green

Licensure:

None

Hospital Regulations:

902 KAR 20:016 Section 1(10): "Registered, certified or registry-eligible dietician" means a person who is certified in accordance with KRS Chapter 310."

Section 11(b)(7): "Orders for diet, diagnostic tests, therapeutic procedures, and medications, including patient limitations, signed and dated by the medical staff member or other ordering personnel acting within the limits of their statutory scope of practice"

Section 4(3)(d): "Every diet, regular and therapeutic, shall be prescribed in writing, dated, and signed by the attending medical staff member or other ordering personnel acting within their statutory scope of practice. Information on the diet order shall be specific and complete and shall include the title of the diet, modifications in specific nutrients stating the amount to be allowed in the diet, and specific problems that may affect the diet or eating habits."

Recommendation:

Kentucky does not appear to have any impediments to qualified RDNs seeking hospital privileges to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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Louisiana

Status: Red

Licensure:

Section 103 of Louisiana's rules define Nutritional Assessment as "the evaluation of the nutritional needs of individuals and groups based upon appropriate biochemical, anthropometric, physical and dietary data to determine nutrient needs and recommend to the primary health care provider appropriate nutritional intake including enteral and parenteral nutrition regardless of setting, including but not limited to ambulatory settings, hospitals, nursing homes and other extended care facilities."

Hospital Regulations:

§9303: "Registered Dietitian―a dietitian who is qualified based on registration by the Commission on Dietetic Registration of the American Dietetic Association and licensing by the Louisiana Board of Examiners in Dietetics and Nutrition."

§9379(A): "Food and dietetic services shall be under the supervision of a registered dietitian, licensed to practice in Louisiana, who is employed either full time, part time or on a consulting basis."

§9381(B): "Therapeutic diets shall be prescribed by the practitioner(s) responsible for the care of the patient."

Recommendation:

The hospital regulations for therapeutic diets track the prior version of the CMS rule and likely need to be revised to align with the new rule. Given existing Louisiana regulatory language for hospitals, section 9381(b) could be appropriately revised to "Therapeutic diets shall be prescribed by the practitioner(s) responsible for the care of the patient or by a qualified dietitian as authorized by the medical staff." Section 103 of Louisiana's dietetics licensure rules may also need to be revised to indicate the qualified RDN is able to order appropriate nutritional intake.

Practice Tips: Order Writing and Privileging

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Maine

Status: Green

Licensure:

None

Hospital Regulations:

No pertinent regulations identified.

Recommendation:

Maine's Department of Health and Human Services reports that they do not have independent regulations for Food and Dietetic Services (1.5.6), but instead abide by federal CMS Conditions of Participation. Thus, RDNs in Maine should feel comfortable working with their hospitals to obtain privileges to independently order therapeutic diets in Maine. (Contact Mike Swan at Maine's DHHS with any concerns about Maine's state hospital regulations.)

Practice Tips: Order Writing and Privileging

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Maryland

Status: Yellow

Licensure:

None

Hospital Regulations:

10.07.02.13(E): "The food and nutritional needs of patients shall be met in accordance with physicians' orders."

10.07.02.13(F) "Therapeutic diets shall be planned, prepared, and served as prescribed by the attending physician . . ."

Recommendation:

The hospital regulations for therapeutic diets track the prior version of the CMS rule and likely need to be revised to align with the new rule. Given existing Maryland regulatory language for hospitals, section 10.07.02.13(E) could be appropriately revised to "The food and nutritional needs of patients shall be met in accordance with physicians' orders or orders from a qualified dietitian as authorized by the medical staff."

Practice Tips: Order Writing and Privileging

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Massachusetts

Status: Green

Licensure:

None

Hospital Regulations:

No pertinent regulations identified.

Recommendation:

Massachusetts does not appear to have any impediments to qualified RDNs seeking hospital privileges to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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Michigan

Status: Green

Licensure:

None

Hospital Regulations:

No pertinent regulations identified.

Recommendation:

Michigan does not appear to have any impediments to qualified RDNs seeking hospital privileges to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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Minnesota

Status: Green

Licensure:

None

Hospital Regulations:

4640.2800 Subpart 1. Supervision: "The dietary department shall be under the supervision of a trained dietitian or other person experienced in the handling, preparation, and serving of foods; in the preparation of special diets; and in the supervision and management of food service personnel."

Recommendation:

Community residential settings allow a "person's physician or dietitian" to prescribe special dietary needs. There does not appear to be an impediment in Minnesota.

Practice Tips: Order Writing and Privileging

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Mississippi

Status: Yellow

Licensure:

Mississippi regulations limit the ability to insert nasogastric tubes or initiate intravenous lines.

Hospital Regulations:

Subchapter 52 Entries Rule 41.52.1: All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) responsible for ordering, providing, or evaluating the service furnished. All orders/entries must be dated, timed, and authenticated promptly by the prescribing physician or another physician responsible for the care of the patient, even if the order did not originate with him or her.

Rule 41.40.2: There shall be written policies and procedures for food storage, preparation, and service developed by a qualified dietitian (preferably meeting the American Dietetic Association's standards for qualification).

Recommendation:

Although there are no clear impediments to RDNs in Mississippi pursuing privileges to order therapeutic diets, we encourage consultation with Mississippi regulators regarding the language related to the authentication of orders and how that may impact the ordering process.

Practice Tips: Order Writing and Privileging

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Missouri

Status: Yellow

Licensure:

None

Hospital Regulations:

19 CSR 30-20.011(28): "Qualified dietitian—An individual who is registered by the Commission on Dietetic Registration of the American Dietetic Association or who has the documented equivalent in education, training and experience, with evidence of relevant continuing education."

19 CSR 30-20.090(9): "Menus shall be planned, written and followed to meet the nutritional needs of the patients as determined by the recommended dietary allowances (RDA) of the Food and Nutrition Board of the National Research Council, National Academy of Sciences or as modified by physician's order."

Recommendation:

The hospital regulations for therapeutic diets may need to be revised to align with the new rule. Given existing Missouri regulatory language for hospitals, section 19 CSR 30-20.090(9) could be appropriately revised to "Menus shall be planned, written and followed to meet the nutritional needs of the patients as determined by the recommended dietary allowances (RDA) of the Food and Nutrition Board of the National Research Council, National Academy of Sciences or as modified by physician’s order or orders from a qualified dietitian as authorized by the medical staff."

Practice Tips: Order Writing and Privileging

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Montana

Status: Green

Licensure:

None

Hospital Regulations:

37.106.1124(1)(c) (Medical Assistance Facility): "A therapeutic diet for a patient must be prescribed by the practitioner responsible for the care of that patient."

37.106.2171(4) (Developmentally Disabled): "The client's interdisciplinary team, including a qualified dietitian and physician, must prescribe all modified and special diets including those used as a part of a treatment to manage inappropriate client behavior."

37.106.2805(29) (Assisted Living): ''Therapeutic diet' means a diet ordered by a physician or practitioner as part of treatment for a disease or clinical condition or to eliminate or decrease specific nutrients in the diet, (e.g., sodium) or to increase specific nutrients in the diet (e.g., potassium) or to provide food the resident is able to eat (e.g., mechanically altered diet)."

Recommendation:

There is no identified regulation governing therapeutic diets in the hospital setting in Montana (37.106.311 appears to have been repealed). Language for therapeutic diets in other settings differs.

Practice Tips: Order Writing and Privileging

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Nebraska

Status:Yellow

Licensure:

172 NAC 61-00(7)(a)(5) refers to "physician's diet order."

172 NAC 61-028 definition of Medical Nutrition Therapy includes diet modification and specialized nutrition support.

Hospital Regulations:

9-006.06C Nutrition: Each hospital must provide for the daily nutritional needs of all patients, including the provision of any diets ordered by a medical practitioner.

9-006.09H Dietary Services: Dietary services must be provided directly or through written agreement to meet the general nutritional needs of patients and must be supervised by a registered dietitian.

Recommendation:

Nebraska does not appear to have any specific limitation as to who can order therapeutic or specialized diets, although the administrative code's reference to "physician's diet order" may need to be expanded to reference qualified medical nutrition therapists privileged by the hospital to order therapeutic diets.

Practice Tips: Order Writing and Privileging

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Nevada

Status: Yellow

Licensure:

NRS 640E.07(1) definition of the "practice of dietetics" is sufficiently broad to include the ordering of therapeutic diets.

NAC 449.544(2)(c) requires consultation with the physician when recommending patient diets.

NAC 449.544(5): "A therapeutic diet served to a patient by a facility must be prescribed by the attending physician of the patient."

Hospital Regulations:

NAC 449.337(2): "The menu for a patient must meet the nutritional needs of the patient in accordance with: (a) Recognized dietary practices; and (b) The orders of the practitioners responsible for the care of the patient."

NAC 449.337 (7): "A hospital shall ensure that persons who are responsible for therapeutic diets have sufficient knowledge of food values to make appropriate substitutions when necessary."

NAC 449.339(5-7): "5. A patient must receive a therapeutic diet when it is determined that he or she has a nutritional problem. 6. The director of the dietary service shall develop and carry out policies and procedures for nutritional care and dietetic services. The policies and procedures must be readily available to nursing, dietary and medical staff. The director shall evaluate the policies and procedures for nutritional care and services provided by the dietary service on a regular basis and revise those policies and procedures as necessary. 7. If it is determined that the nutritional status of a patient is at risk, nutritional care for that patient must be: (a) Planned and provided based on an assessment of his or her nutritional status by a licensed dietitian or the attending physician, or both; and (b) Integrated into his or her plan of care."

Recommendation:

Nevada's dietetics licensure regulation NAC 449.544(5) needs to be revised to allow qualified licensed dietitians to order therapeutic diets in addition to the "attending physician of the patient." Nevada's hospital regulations appear to have no specific requirement that a physician order the therapeutic diet, merely that the therapeutic diet be in accordance with orders from the practitioners responsible for the care of the patient.

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New Hampshire

Status: Yellow

Licensure:

State licensure statutes and regulations do not specify which practitioners are responsible for ordering therapeutic diets.

326-H:6 "Scope of Practice. – Licensed dietitians shall be authorized to practice applications from food, nutrition, biochemistry, physiology, management, behavioral, and social sciences used in the treatment of illness, injury and other medical conditions, and the maintenance of human health."

Hospital Regulations:

He-P 802.03(x): "'Dietitian' means a person who is licensed under RSA 326-H."

He-P 802.03(ax): "'Orders' means prescriptions, instructions for administering or discontinuing treatments, special diets or therapies given by a licensed practitioner, or other health professional according to their legally authorized scope of practice."

He-P 802.18(h): "Hospitals shall provide dietary services that include: . . . (2) Diets that are in accordance with the orders of patients' licensed practitioners;"

Recommendation:

Because New Hampshire's includes language stating that diets must be "in accordance with the orders of patients' licensed practitioners," it is important to confirm with the DHHS that this would merely assure consistency between therapeutic diets ordered by RDNs and any superseding order by a physician. New Hampshire allows "other health professional[s] according to their legally authorized scope of practice" to order special diets or therapies.

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New Jersey

Status: Yellow

Licensure:

None

Hospital Regulations:

§ 8:43G-10.6(c): "A physician shall write a specific dietary order for each patient."

§ 8:43G-10.6(f): "Patients' nutritional needs for food and food supplements shall be met, in accordance with physician orders."

Recommendation:

New Jersey hospital regulations likely need to be revised unless a physician's diet order upon a patient's admitting is sufficient to meet the requirement in section 8.43-10.6©

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New Mexico

Status: Yellow

Licensure:

New Mexico licenses dietitians, nutritionists, and nutrition associates. Hospital regulations suggest a dietitian is required to supervise dietary services. Definition in 61-7A-3(G) for "'nutritional assessment' means the evaluation of the nutritional needs of individuals and groups based upon appropriate biochemical, anthropometric, physical and dietary data to determine nutrient needs and recommend appropriate nutritional intake, including enteral and parenteral nutrition;"

Hospital Regulations:

7.7.2.6 NMAC P.: "'Dietician' means a person who is eligible for registration as a dietitian by the commission on dietetic registration of the American dietetic association, or who has a baccalaureate degree with major studies in food and nutrition, dietetics, or food service management."

7.7.2.28(2): Therapeutic diets shall be prescribed by an authorized individual in written orders on the medical record.

7.7.2.28(3): Nutritional needs shall be in accordance with physicians' orders and, to the extent medically possible, in accordance with the "recommended daily dietary allowance" of the food and nutrition board of the national research council, national academy of sciences. A current edition of these standards shall be available in the dietary service.

Recommendation:

Because New Mexico's rules include language stating that diets must be "in accordance with the orders of patients' licensed practitioners," it is important to confirm with state regulators that this would merely assure consistency between therapeutic diets ordered by RDNs and any superseding order by a physician. New Mexico allows "authorized individuals" to order therapeutic diets. The "in accordance with" language combined with the broad "authorized individual" (as opposed to physician/practitioner responsible for the care of the patient) language suggests those two requirements are separate.

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New York

Status: Yellow

Licensure:

Education content requirements include Section 52.2(a)(1)(v) "food service management, including but not limited to such topics as human resources, planning, purchasing, preparation and service, delivery, and sanitation; (vi) diet modifications;"

Hospital Regulations:

405.23(b)(5): "A dietitian, full-time, part-time or on a consultant basis shall supervise the nutritional aspects of patient care and assure that quality nutritional care is provided to patients."

405.23(c)(1): "Therapeutic diets shall be prescribed by the practitioner or practitioners responsible for the care of the patients."

Recommendation:

Requires updating of 405.23(c)(1) "Therapeutic diets shall be prescribed by the practitioner or practitioners responsible for the care of the patients or qualified dietitian privileged to do so."

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North Carolina

Status: Green

Licensure:

One can become a licensed dietitian nutritionist in North Carolina without meeting the standards required to be a "qualified dietitian" under the hospital regulations.

Hospital Regulations:

10A NCAC 13B .1902(27): "'Qualified Dietitian' means a person who meets the standards and qualifications established by the Committee on Professional Registration of the American Dietetic Association. . ."

10A NCAC 13B .3001(11): "Dietitian" means an individual who is licensed according to G.S. 90, Article 25, or is registered by the Commission on Dietetic Registration (CDR) of the American Dietetic Association. . ."

10A NCAC 13B .3001(31): "Nutrition therapy" ranges from intervention and counseling on diet modification to administration of specialized nutrition therapies as determined necessary to manage a condition or treat illness or injury. Specialized nutrition therapies include supplementation with medical foods, enteral and parenteral nutrition.

10A NCAC 13B .4705(c): "Therapeutic diets and enteral and parenteral nutrition therapy shall be prescribed in written orders on the medical records and provided as ordered."

Recommendation:

There do not appear to be any statutory or regulatory impediments to qualified dietitians seeking to obtain privileges to order therapeutic diets in North Carolina.

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North Dakota

Status: Green

Licensure:

North Dakota has different scopes of practice for dietitians and nutritionists; nutritionists in North Dakota practice "general nutrition services" rather than dietetics. Nutrition care services definition at 43-44-01(8)© includes "Providing nutrition counseling to meet both normal and therapeutic needs."

Hospital Regulations:

33-07-01.1-19(1)(h): "Regular and therapeutic diets must be prescribed in writing by the licensed health care practitioner. Regular and therapeutic menus must be planned in writing and served as ordered, with supervision or consultation from the dietitian."

Recommendation:

There do not appear to be any statutory or regulatory impediments to qualified dietitians seeking to obtain privileges to order therapeutic diets in North Dakota.

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Ohio

Status: Green

Licensure:

Chapter 4759.01(A)(1) states that the practice of dietetics and nutrition includes "Nutritional assessment to determine nutritional needs and to recommend appropriate nutritional intake, including enteral and parenteral nutrition."

Hospital Regulations:

Do not appear to have any regulations related to dietary department of hospitals.

Recommendation:

There do not appear to be any statutory or regulatory impediments to qualified dietitians seeking to obtain privileges to order therapeutic diets in Ohio.

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Oklahoma

Status: Red

Licensure:

Title 59 O.S., Section 1722(3): "'Dietetics' means the professional discipline of applying and integrating scientific principles of nutrition pursuant to different health, social, cultural, physical,psychological, and economic conditions to the proper nourishment, care, and education of individuals or groups throughout the life cycle. The term includes the development, management, and provision of nutritional services."

435:35-1-4(b)(8): "Developing and implementing plans of nutritional care for individuals, both enteral and parenteral, based on assessment of nutritional needs."

Hospital Regulations:

310:667-17-1. Organization (a)(1): "The licensed/registered dietitian shall be responsible for approval of menus, including modified diets. . ."

310:667-17-3(a): "At least three (3) palatable meals or their equivalent shall be served daily, at regular times with not more than fifteen (15) hours between a substantial evening meal and breakfast. Menus shall be planned and followed to meet nutritional needs of patients, in accordance with physicians' or licensed independent practitioners' orders. . ."

310:667-17-3(b): "Diets shall be prescribed by the physician or licensed independent practitioner responsible for the care of the patient. All modified diets shall be prescribed by the patient's physician or licensed independent practitioner according to the latest edition of the Oklahoma Diet Manual or other equivalent approved diet manual."

Recommendation:

To enable RDNs in Oklahoma to order therapeutic diets, 310:667-17-3(b) should be revised to the effect of: "Diets shall be prescribed by the physician or licensed independent practitioner responsible for the care of the patient or by a qualified dietitian privileged by the hospital to do so. All modified diets shall be prescribed by the patient's physician or licensed independent practitioner or by a qualified dietitian privileged by the hospital to do so according to the latest edition of the Oklahoma Diet Manual or other equivalent approved diet manual."

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Oregon

Status: Green

Licensure:

None

Hospital Regulations:

333-520-0020(2): "A hospital shall: (b) Employ supportive personnel competent to carry out the functions of the dietary service, including a full-time director with overall supervisory responsibility for the dietary service and who is: (A) A qualified dietitian who is registered by the Commission on Dietetic Registration of the American Dietetic Association;"

333-520-0020(2)(e): "Provide dietetic services to patients in accordance with a written order by the responsible physician, or other health care practitioner authorized within the scope of his or her professional license, and record appropriate dietetic information in the patient's medical record including the following:. . . "

Recommendation:

There is no definitive preclusion of RDN's ability to order therapeutic diets, and they could be considered a "health care practitioner authorized within the scope of his or her professional license."

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Pennsylvania

Status: Red

Licensure:

"Medical nutrition therapy" means the component of nutrition therapy that concerns determining and recommending nutrient needs based on nutritional assessment and medical problems relative to diets prescribed by a licensed physician, including: (i) tube feedings; (ii) specialized intravenous solutions; (iii) specialized oral solutions"

Hospital Regulations:

§ 111.2: "The service shall be under the full-time direction of a person who is trained and experienced in food services administration and dietary management."

§ 111.3(a): "The dietary services shall have at least one qualified dietitian, either fulltime, part-time, or as consultant. The resume of the dietitian shall be included in the personnel files. The dietitian shall have training and experience in nutrition, therapeutic diets, and nutritional food service management."

§ 111.27: "Nutritional aspects of patient care. (a) The administration of the nutritional aspects of patient care shall be under the direction of a qualified dietitian. (b) Therapeutic diets, when appropriate, shall be prescribed in written orders on the medical record by the physician and shall be instructive, accurate and as complete as possible."

§ 111.27(e): "The dietitian shall be responsible for the development of a nutritional care plan in compliance with physician’ s orders to meet the needs of the patient for the maintenance of health, prevention of disease, and treatment through diet modification and normal nutritional counseling.

Recommendation:

Pennsylvania appears to require a statutory and regulatory change to allow qualified RDNs to order therapeutic diets in hospitals.

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Rhode Island

Status: Red

Licensure:

None

Hospital Regulations:

Section 22.1: "Each facility shall maintain a dietary service directed by a full-time person qualified by training and experience in organization and administration of food service."

Section 22.2: "Each hospital shall have at least one Registered Dietitian, licensed by the state, to direct nutritional aspects of patient care and to advise on food preparation and service."

Section 22.10: "All patient diets shall be ordered in writing by the physician."

Recommendation:

To enable qualified RDNs to independently order therapeutic diets, it appears that Rhode Island hospital regulation subsection 22.10 will need to be revised to the effect of "All patient diets shall be ordered in writing by the physician or qualified dietitian privileged by the hospital to do so."

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South Carolina

Status: Red

Licensure:

Section 40-20-20(3): Nutrition services includes "(g) implementing nutrition related orders under a protocol approved by the medical staff of a licensed health care facility. "Nutrition care services" does not include the retail sale of food products or vitamins and minerals."

Hospital Regulations:

Section 803: "The dietary services shall be under the direction of a dietitian or qualified food service supervisor who has a written agreement for consultation services by a dietitian. These services shall be organized with established lines of accountability and clearly defined job assignments. A qualified food service supervisor shall be a person who: 1. Is a graduate of a dietetic technician or dietetic assistant training program approved by the American Dietetic Association; or 2. Is a graduate of a State-approved course; or 3. Has training and experience in food service supervision and management equivalent in content to the programs in paragraph 1 or 2 above."

Section 805: "Diets shall be prepared in conformance with physicians' orders. A current diet manual shall be readily available to attending physicians, dietary service personnel and nursing personnel. A. Diets shall be prescribed, dated and signed by the physician."

Recommendation:

Section 805(A) will need to be revised to allow qualified RDNs privileged by their hospital to independently order therapeutic diets to the effect of "Diets shall be prescribed, dated and signed by the physician or qualified dietitian privileged by the hospital to do so."

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South Dakota

Status: Red

Licensure:

South Dakota differently licenses dietitians and nutritionists, relevant to the question of what qualifications hospitals will require when privileging practitioners to order therapeutic diets.

Hospital Regulations:

44:04:01:01(14): "'Dietitian,' a person who is registered with the Commission on Dietetic Registration of the American Dietetic Association and holds a current license to practice in South Dakota pursuant to SDCL chapter 36-10B;"

44:04:01:01(68): "'Therapeutic diet,' any diet other than a regular diet that is ordered by a physician as part of the treatment for a disease or clinical condition to increase, decrease, or to eliminate certain substances in the diet, and to alter food consistency;"

Recommendation:

South Dakota regulation 44:04:01:01(68) will need to be revised to the effect of "'Therapeutic diet,' any diet other than a regular diet that is ordered by a physician or qualified dietitian privileged by the hospital to do so as part of the treatment for a disease or clinical condition to increase, decrease, or to eliminate certain substances in the diet, and to alter food consistency;"

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Tennessee

Status: Red

Licensure:

63-25-105: "Development of therapeutic dietary regimens. No therapeutic dietary regimen may be developed unless pursuant to the appropriate orders and/or referral of licensed practitioners of medicine, osteopathy, chiropractic, dentistry or podiatry when incidental to the practice of their respective professions."

Hospital Regulations:

Rule 1200-8-1-.01(25): "Dietitian. A person currently licensed as such by the Tennessee Board of Dietitian/Nutritionist Examiners. Persons exempt from licensure shall be registered with the American Dietetics Association pursuant to T.C.A. §63-25-104."

Rule 1200-8-1-.06(9)(c): "There must be a qualified dietitian, full time, part-time, or on a consultant basis who is responsible for the development and implementation of a nutrition care process to meet the needs of patients for health maintenance, disease prevention and, when necessary, medical nutrition therapy to treat an illness, injury or condition. Medical nutrition therapy includes assessment of the nutritional status of the patient and treatment through diet therapy, counseling and/or use of specialized nutrition supplements."

Rule 1200-8-1-.06(9)(e)(1): "Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the patients."

Recommendation:

It appears that Tennessee requires both a statutory and regulatory change to enable RDNs to order therapeutic diets in the hospital setting.

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Texas

Status: Red

Licensure:

711.1(13): "Dietetics--The professional discipline of applying and integrating scientific principles of food, nutrition, biochemistry, physiology, management, and behavioral and social sciences under different health, social, cultural, physical, psychological, and economic conditions to the proper nourishment, care, and education of individuals or groups throughout the life cycle to achieve and maintain the health of people. The term includes, without limitation, the development, management, and provision of nutrition services."

711((19): "Nutrition assessment--The evaluation of the nutritional needs of individuals and groups based on appropriate biochemical, anthropometric, physical, and dietary data to determine nutrient needs and recommend appropriate nutritional intake including enteral and parenteral nutrition. An important component of medical nutrition therapy."

711.4(b): (1) "A licensed dietitian, acting within the scope of his or her license and consistent with medical direction or authorization as provided in this section, may accept, transcribe into a patient's medical record or transmit verbal or electronically-transmitted orders, including medication orders, from a physician to other authorized health care professionals relating to the implementation or provision of medical nutrition therapy and related medical protocols for an individual patient or group of patients. In a licensed health facility, the medical direction or authorization shall be provided, as appropriate, through a physician's order, or a standing medical order, or standing delegation order, or medical protocol issued in accordance with Texas Occupations Code, Chapter 157, Subchapter A, and rules adopted by the Board of Medical Examiners implementing the subchapter. In a private practice setting, the medical direction or authorization shall be provided, as appropriate, through the physician's order, standing medical order, or standing delegation order of a referring physician, in accordance with Texas Occupations Code, Chapter 157, Subchapter A, and rules adopted by the Board of Medical Examiners implementing the subchapter. (2) A licensed dietitian, acting within the scope of his or her license and consistent with medical direction or authorization as provided in this section, may order medical laboratory tests relating to the implementation or provision of medical nutrition therapy and related medical protocols for individual patients or groups of patients. In a licensed health facility, the medical direction or authorization shall be provided, as appropriate, through a physician's order, or a standing medical order, or standing delegation order, or medical protocol, issued in accordance with Texas Occupations Code, Chapter 157, Subchapter A, and rules adopted by the Board of Medical Examiners implementing the subchapter. In a private practice setting, the medical direction or authorization shall be provided through the physician's order, standing medical order, or a standing delegation order of the referring physician, in accordance with Texas Occupations Code, Chapter 157, Subchapter A, and rules adopted by the Board of Medical Examiners implementing the subchapter."

Hospital Regulations:

Rule §133.2(15): "Dietitian--A person who is currently licensed by the Texas State Board of Examiners of Dietitians as a licensed dietitian or provisional licensed dietitian, or who is a registered dietitian with the American Dietetic Association."

Rule §133.41(1)(d)(B): "There shall be a qualified dietitian who works full-time, part-time, or on a consultant basis. If by consultation, such services shall occur at least once per month for not less than eight hours. The dietitian shall: (i) be currently licensed under the laws of this state to use the titles of licensed dietitian or provisional licensed dietitian, or be a registered dietitian; . . . (iii) supervise the nutritional aspects of patient care; (iv) make an assessment of the nutritional status and adequacy of nutritional regimen, as appropriate; . . . (vi) document nutritional status and pertinent information in patient medical records, as appropriate;"

Rule §133.41(3)(A): "Therapeutic diets shall be prescribed by the physician(s) responsible for the care of the patients."

Rule §133.41(3)(B): "Nutritional needs shall be met in accordance with recognized dietary practices and in accordance with orders of the physician(s) or appropriately credentialed practitioner(s) responsible for the care of the patients."

Recommendation:

It appears that Texas requires both a statutory and regulatory change to enable RDNs to order therapeutic diets in the hospital setting.

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Utah

Status: Yellow

Licensure:

None

Hospital Regulations:

R432-100-31(3)(a): "The food and nutritional needs of patients shall be met in accordance with the physician's orders."

Recommendation:

Given the requirement that the dietetic service must be in accordance with the physician's orders we recommend working with the Utah regulators to determine whether R432-100-31(3)(a) would allow RDNs to order therapeutic diets and if not, to revise it to align with the new CMS rule.

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Vermont

Status: Green

Licensure:

None

Hospital Regulations:

CVR 13-140-019, Sec. 3-948(d): "Provision shall be made for the preparation of special diets when prescribed."

Recommendation:

There does not appear to be any regulatory or statutory impediment to qualified RDNs in Vermont seeking privileges to order therapeutic diets.

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Virginia

Status: Green

Licensure:

None

Hospital Regulations:

12 VAC 5-410-260(B): "Each hospital shall have at least one dietitian, meeting the criteria of §54.1-2731 of the Code of Virginia"

12 VAC 5-410-260(F): "All patient diets shall be ordered in writing by a member of the medical staff."

Recommendation:

Virginia regulations will currently allow qualified RDNs to order therapeutic diets if they are appointed to the medical staff, but a regulatory change will be required to allow qualified RDNs to be privileged to order therapeutic diets without becoming a member of the medical staff.

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Washington

Status: Green

Licensure:

None

Hospital Regulations:

246-320-010(12): "'Dietitian' means an individual meeting the eligibility requirements for active membership in the American Dietetic Association described in Directory of Dietetic Programs Accredited and Approved, American Dietetic Association, edition 100, 1980."

246-320-201: "(2) Designate a registered dietitian responsible to develop and implement policies and procedures addressing nutritional care for patients; (3) Have a registered dietitian available to assess nutritional needs, based on patients' individual nutritional risk screen;"

Recommendation:

There does not appear to be any evident regulatory or statutory impediment to qualified RDNs in Washington seeking privileges to order therapeutic diets.

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West Virginia

Status: Yellow

Licensure:

None

Hospital Regulations:

64-12-7.3.e: "The food services department shall be under the direction of a full-time dietician or a person with training and experience in food service administration. Only a qualified dietician or other person with suitable training may direct the food services department.” 64-12-7.3.g. “There shall be a qualified dietician available on a full-time, part-time, or a consultant basis. A qualified dietician shall be registered or eligible for registration with the Commission on Dietetic Registration of the American Dietetic Association and be licensed in the State of West Virginia by the Board of Licensed Dietitians."

64-12-7.3.k: "All therapeutic diets, including between meal nourishments, shall be prepared and served as prescribed by the attending practitioner."

Recommendation:

Unless an RDN is deemed the attending practitioner, West Virginia regulation 64-12-7.3k will need to be changed to something similar to "All therapeutic diets, including between meal nourishments, shall be prepared and served as prescribed by the attending practitioner or qualified dietitian privileged by the hospital to do so."

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Wisconsin

Status: Red

Licensure:

None

Hospital Regulations:

DHS 124.16(5)(b): "Therapeutic diets shall be prescribed by the physician in written orders in the medical record."

Recommendation:

DHS 124.16(5)(b) will need to be revised to align with the new CMS regulation: "Therapeutic diets shall be prescribed by the physician or qualified dietitian privileged by the hospital to order therapeutic diets and notated in written order in the medical record."

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Wyoming

Status: Green

Licensure:

33-47-102(a)(vi): "'Medically prescribed diet' means a diet prescribed when specific food or nutrient levels need to be monitored, altered, or both, as a component of a treatment program from an individual whose health status is impaired or at risk due to disease, injury or surgery and may only be performed as initiated by or in consultation with a physician licensed in this state or an individual authorized by a state license to prescribe medical care;"

Hospital Regulations:

Chapter 12, Section 17(j): "'Dietitian' means a person who is registered by the Commission on Dietetic Registration and provides nutritional and dietary services."

Recommendation:

Wyoming does not appear to have any regulations precluding RDNs in hospitals from becoming privileged to order therapeutic diets.

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