academy comments to cms re revised long term care regulations

7/26/2019 Academy Comments to CMS Re Revised Long Term Care Regulations

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6/20/2016 Academy Comments to CMS re Revised Long Term Care Regulations

http://www.eatrightpro.org/resource/news-center/on-the-pulse-of-public-policy/regulatory-comments/revised-long-term-care-regulations

Academy Comments to CMS re Revised Long

Term Care RegulationsSeptember 14, 2015

Andrew Slavitt, MBA

Acting Administrator, Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-1614-P

P.O. Box 8010

Baltimore, MD 21244-8010

RE: Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit

comments to the Centers for Medicare & Medicaid Services (CMS) regarding its proposed rule of

July 16, 2015, "Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care

(LTC) Facilities" (the "proposed rule"). Representing over 90,000 registered dietitian nutritionists

(RDNs), nutrition dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the

Academy is the largest association of food and nutrition professionals in the United States

committed to improving the nation's health through food and nutrition across the lifecycle. Many

of our members work in long-term care facilities (LTC) and provide home and community-based

services to ensure the elderly and at-risk populations meet their nutrition needs.

The Academy enthusiastically supports the bulk of the highly resident-focused proposed rule,

which aligns with previously submitted recommendations of the Academy and the Pioneer

Network. We expect the proposed rule will improve the quality of life and health outcomes for

residents of LTC facilities. Noted below are several suggestions for rening and improving the

rule, including necessary recommendations to ensure food and nutrition services sta have the

competencies needed to perform their duties safely and eectively.

I. Resident Rights ( 483.10)

This proposed rule encourages a culture change towards a more resident-focused approach

towards long term care. The Academy of Nutrition and Dietetics advocates for registered dietitian

nutritionists to assess and evaluate the need for nutrition interventions tailored to each person's

medical condition, needs, desires and rights. "Improving quality of life and quality of care,

allowing choices in daily living, and assisting individuals to make informed health care decisions

are all major goals of culture change and person-centered care. Involving individuals in choices

about food and dining such as food selections, dining locations, and meal times can help them

maintain a sense of dignity, control, and autonomy." We applaud CMS for proposing to revise its

regulations in accordance with this resident-focused philosophy.

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A. Special Foods and Meals ( 483.11(d)(6)(ii)(L)(1) and (2))

The Academy supports CMS's proposal "to clarify that the facility may not charge for special food

and meals ordered for a resident by a physician, physician assistant, nurse practitioner, clinical

nurse specialist, dietitian or other clinically qualied nutrition professional." Client satisfaction is

critical; this is their home and supports the residentcentered concept of care. In addition to many

of our members believing it is their duty to provide residents with everything they need during

their stay, our members report that client satisfaction improves oral intake, nutritional status,

quality of life and well-being and is likely to result in fewer hospitalizations.

Comparable and reasonable substitutions, as determined by the RDN, should be permitted. The

Academy seeks conrmation that the special food and meals purchased for a resident must be in

alignment with a required specic diet order as a therapeutic diet for the items not to be charged.

In addition, we seek guidance as to whether facilities may require residents or their families to

provide their own special supplements or functional foods if the facilities do not have them in

their formulary.

B. Right to Refuse Treatment ( 483.10(b)(4))

It is the position of the Academy of Nutrition and Dietetics that individuals have the right to

request or refuse nutrition and hydration as medical treatment. Registered dietitian nutritionists

should work collaboratively as part of the interdisciplinary team team to make recommendations

on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as

active members of institutional ethics committees. RDNs have an active role in determining the

nutrition and hydration requirements for individuals throughout the life span. When individuals

choose to forgo any type of nutrition and hydration (natural or articial), or when individuals lack

decision-making capacity and others must decide whether or not to provide articial nutrition and

hydration, RDNs have a professional role in the ethical deliberation around those decisions.

"RDNs' understanding of nutrition and hydration within the context of nutritional requirements

and cultural, social, psychological, and spiritual needs provide an essential basis for ethical

deliberation. RDNs, as health care team members, have the responsibility to promote use of

advanced directives. RDNs promote the rights of the individual and help the health care team

implement appropriate therapy." Other sta members must ensure they are meeting the

nutritional and hydration needs of residents and are following through on existing systems that

accurately document whether a resident has refused treatment. Once an RDN has engaged the

resident, his or her family, and other sta in discussions about the resident's decision to refuse

nutrition and/or hydration, it is essential to suciently document any resident's refusal of

treatment of adequate meals, snacks, or uids to protect the resident and caregivers.

II. Transitions of Care ( 483.15)

Registered dietitian nutritionists play a critical role in transitions of care for individuals for whom

nutrition is a particularly essential part of the plan of care. Undernutrition and/or poor diet

compliance may contribute to negative outcomes in residents or patients with pneumonia, acute

myocardial infarction and heart failure and increase the likelihood of hospital readmission.

Collaboration among health care professionals including RDNs is critical to successful post-

acute transitional care plan development and implementation.

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We agree with CMS that the "type of documentation (that) is presently required for hospitals with

which the facility has a transfer agreement...is important regardless of the setting to which the

resident is being transferred or discharged," and we are pleased to see CMS more broadly

incorporate these communications into the transitions of care process for other facilities,

"whether it is an acute care hospital, a LTC hospital, a psychiatric facility, another LTC facility, a

hospice, home health agency, or another community-based provider or practitioner." These

proposed requirements to enhance communication between providers should reduce risks of

complications and adverse events for residents. We support this information being provided (in

non-emergency transitions) as soon as the transition of care is determined and encourage CMS to

require it suciently prior to discharge to enable the LTC facility to determine whether the facility

can meet the patient's/resident's needs.

A. Required Data Elements Should Include Nutrition Care Components

The Academy encourages CMS to include specic data elements in transitions of care

requirements, including:

Therapeutic diet order and oral nutrition supplement order history, including presentuse/status;

Enteral and total parenteral nutrition orders;

Oral intake history and acceptance of diet;

Food allergies and/or intolerances;

Food preferences, special diet restrictions, and other specic individualized needs to ensureaccommodation is possible;

Diet education the patient/resident or family has received in the past;

Ability to swallow and/or chew and conditions of teeth and any need for texture

modications; Pertinent height and weight history and any pertinent trends;

Progress notes completed during hospitalization;

Skin integrity, such as the presence and history of pressure ulcers and wounds;

Lab levels, including CRP level; and

Those in value sets in the National Library of Medicine's Value Set Authority Center createdby the steward "AND."

The Academy appreciates CMS's recognition of the value of utilizing certied Health IT to improve

transitions of care and notes that nutrition data will now be included in nine of the thirteen

"transitions of care" documents between facilities once the HL7 Consolidated Clinical Document

Architecture (C-CDA) Release 2 is put into operation. This development will ensure (when

implemented) that patients on a modied diet will have that data arrive at the hospital or other

connected facility upon transition and admission. The Academy has also worked to ensure

nutrition is included in multiple health IT standards, which are suggested for the 2015

Certication and Standards Criteria (supporting Stage 3 Meaningful Use).

B. Suggested Improvements in Transition and Discharge Planning


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The Academy respectfully suggests a number of additional strategies for improving transition and

discharge planning to help prevent hospital readmissions and improve quality of life across the

continuum of care. At the outset, Medical Nutrition Therapy (MNT) and other nutrition education

should not just include the patient or resident, but the family and/or caregiver as well. Too often,

nutrition education at discharge is limited to providing the patient/resident a sheet from the diet

manual. Discharge planning should include telephonic monitoring and follow-up care, including

follow-up with community-based services, such as Meals on Wheels, local senior centers, and

home care planning (e.g., ability to procure, cook, and eat food and who can assist with these tasks

if needed). MNT must be provided that meets clients' cultural and food preferences and budget

constraints and ensures clients have the skills and tools to monitor their own progress, such as

scales to weigh themselves and glucometers.

After developing a comprehensive nutritional care plan, RDNs should educate the food and

nutrition service sta and the nursing sta on proper implementation, which will assist residents

in understanding their nutritional needs and facilitate eective discharge. Regular access to

medical records with dietary and nutrition information is also essential.

C. Interdisciplinary Team Stang ( 483.21(b)(2)(ii))

The Academy supports the Position Statement on Interdisciplinary Team Training in Geriatrics: An

Essential Component of Quality Health Care for Older Adultsproviding that, "Interdisciplinary team

training (IDT) is an important component of ensuring quality geriatric care delivery, which can be

complex and time intensive, requiring coordination of many medical, psychosocial, and

therapeutic interventions and professionals." This position statement recognizes that, "Other

benets of team care include enhanced communication among healthcare providers, greater

patient safety, better care of common chronic illnesses, better medication adherence, fewer

adverse drug reactions, preservation of function, and fewer hospital readmissions." Specically,

the position statement found that, "(i)nterdisciplinary care has...been demonstrated to be useful

in...skilled nursing facilities."

Thus, the Academy strongly supports CMS's proposal to explicitly require "an appropriate

member of the food and nutrition services sta... be a part of the (interdisciplinary team, or)

IDT."As CMS concluded, "(i)ncluding these critical team members in the IDT and the care

planning process would ensure that the individual needs of a particular resident are being

assessed and appropriately addressed." We agree that, "nutrition is a fundamental part of a

resident's overall health and well-being, (and thus,) it is important that a member of the food and

nutrition services sta be knowledgeable of the resident's needs and preferences to achieve their

maximum practicable well-being."

In many facilities, RDNs are already improving the quality of care by serving as members of the

IDT. The RDN is the most experienced and eective member of the food and nutrition services

sta with the ability to provide a comprehensive scope of nutrition services using the Nutrition

Care Process in an eort to meet residents' goals and prevent hospital readmissions, and would

thus provide the most value as a member of the IDT. RDNs conduct nutrition assessments

obtaining residents' food and uid intake, food preferences, weight status, skin integrity, lab

status, and other measures. Although other members of the food and nutrition services sta may

be able to observe residents and refer those at risk, RDNs are able to monitor the overall nutrition

care of each resident as the clinical expert trained in nutrition and are thus the appropriate

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choice for the IDT if resources are available to ensure they can spend the needed time doing so. It

is critical, however, that CMS provide greater clarity as to the qualications and competencies that

would make an individual "an appropriate member of the food and nutrition services sta" to join

the IDT when an RDN is not available.

A Nutrition and Dietetics Technician, Registered (NDTR) working under the guidance and direction

of an RDN can eectively participate in the care process of the IDT when the RDN is not present.

In LTC facilities where an RDN or NDTR is not present on a daily basis, a Certied Dietary Manager

(CDM) can play an integral role in relaying information to the RDN and supporting the IDT if the

CDM is familiar with residents and competent at obtaining residents' preferences and making

sure the facility kitchen can accommodate the preferences. Any food and nutrition services sta

member on the IDT should be familiar with the facility's food availability and the food service

operations and capabil ities. The importance of the sta member's personal knowledge of clients

and their needs (including any refusal of therapeutic diets and repeated requests for alternative

or substitute menu items) cannot be overstated. CDMs are likely able to represent stable residents

who are eating well and are at low nutritional risk. Our members report, however, that uncertied

dietary managers without concomitant educational requirements are unlikely to have the

necessary competencies to prevent unnecessary dehydration and weight loss.

D. Baseline Care Plan ( 483.21)

The Academy encourages the Baseline Care Plan to include as many of the data elements in

Section II(A) above ("Required Data Elements Should Include Nutrition Care Components") as is

practicable within 48 hours of admission. At a minimum, the Baseline Care Plan should list the

diet (including texture needs and aspiration risks) ordered, the ability to tolerate and self-feed

said diet, any advance directives related to feeding, and any food allergies the resident may have.

A member of the food and nutrition services sta should also see the patient within 24-48 hours,

recognizing that care plans are frequently modied as residents adjust to new levels of care and

nutrition needs change. CDMs may be able to develop some low-risk Baseline Care Plans until theRDN can review and modify when present in the facility. We note that development of a Baseline

Care Plan as envisioned and proposed by CMS is likely to require a stang adjustment and

additional clinical coverage, particularly on weekends. Some residents who are admitted on

Fridays may be nutritionally compromised until an RDN is present in the facility to order an

appropriate nutrition intervention, which may not be possible within the mandated 48-hour

window without stang adjustments.

III. Quality of Care

Consequences of undernutrition include increased mortality, loss of strength, depression,

lethargy, immune dysfunction, pressure ulcers, delayed recovery from illness, increased chance of

hospital admission, and poor wound healing. Older adults are at higher risk for pressure ulcer

development due to age, skin frailty, unintended weight loss, and other factors. Although pressure

ulcers have multiple causes, poor nutritional status is a contributing factor and is an important

aspect of prevention. RDNs are skilled and eective at preventing and resolving these

complications.

A. Nasogastric Tubes and Assisted Nutrition and Hydration 483.25(d)(8)

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"RDNs and NDTRs may work in collaboration with therapy providers (e.g., speech language

pathologists and occupational therapists) and caregivers to implement the plan of care. Texture

modications, thickening liquids, oral nutritional supplements, or self feeding equipment may all

be included in a plan of care to help an individual maximize feeding independence when safe to

do so. RDNs determine appropriate food choices that follow the dysphagia recommendations and

educate the individual and/or caregivers to implement the plan."

The Academy thus supports the proposed regulatory revisions and encourages ongoing

collaboration between speech language pathologists (SLPs) and RDNs to document oral intake and

evaluate data and the need for enteral feeding adjustment. SLPs should be involved from day one

of a resident's stay to assess capabilities of tolerating foods orally. Adequate caregiver time is

essential to encourage restoration of eating skills, and we support weaning residents o enteral

feeding as soon as possible. For patients with dementia, familiar, individualized nutrition plans

are more likely to promote a better long-term outcome. If possible, the use of hand feeding should

be encouraged, as it is one of the few pleasures available to individuals with dementia.

B. Pressure Ulcers ( 483.25(d)(4))The role of nutrition and hydration in the development and

impaired healing is well-documented, and the National Pressure Ulcer Advisory Panel has

established nutritional guidelines for nutrition and hydration for pressure ulcer prevention andtreatment in adults. A comprehensive nutrition assessment is the most cost-eective and

impactful initial intervention for preventing and treating pressure ulcers, including the amount of

food and protein consumed, the extent to which residents require assistance eating, and whether

uids are oered and consumed at meals and between meals. Nursing sta and other sta

members noting the presence of pressure ulcers should immediately communicate with the RDN

to initiate a care plan. Potential challenges will arise if residents exercise their rights to refuse

adequate nutrition and hydration or adopt advance directives related to end of life status.

Ensuring sucient exibility to enable incorporation of new theories and emerging research is

also important as regulations and guidance are nalized.

IV. Quality Assurance and Performance Improvement ( 483.75)

CMS details at length the new Quality Assurance and Performance Improvement (QAPI)

requirements and includes recommendations for the utilization of electronic health records,

common clinical data sets, and other health IT components to improve care and transitions of care

throughout assessments and care plans. The Academy has long been a strong supporter of CMS's

QAPI initiatives and we are committed to eliminating burdensome red tape that prioritizes

documentation of care over actual provision of care. Performance improvement is critical,

because ultimately residents' quality of life is at stake.

Audits and systematized assessments that include collecting and assessing relevant nutritional

status parameters (e.g., lab values, weights and weight trends, skin integrity, dysphagia

interventions, therapeutic diets, use of nutritional supplements, and meal/uids intake and

tolerance) enable facili ties to determine opportunities for improvement. Members report that

existing QAPI teams have been both educational for the sta and benecial for residents, because

they require a facility to act in a collaborative and interdisciplinary manner to make necessary

improvements.

V. Food and Nutrition Services ( 483.60)

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The Academy strongly supports the improvements in the proposed rule that underscore the

importance of nutrition in residents' quality of life and health status.

A. Denition of "Qualied Dietitian" ( 483.60(a))

The Academy is highly concerned about the proposed changes to the denition of "qualied

dietitian," which will weaken professional standards and enable unqualied practitioners

without necessary training or skills to oversee LTC facilities' food and nutrition services.

Without explaining its rationale, CMS proposes to replace the requirement that one must be eitheran RDN credentialed with the Commission on Dietetic Registration or be qualied "on the basis of

education, training, or experience in identication of dietary needs, planning, and implementation

of dietary programs" with a mere requirement that one need onlymeet state standards for

licensure. This proposal expands the ability to become a "clinically qualied nutrition

professional" by removing the only consistent government standard dening what it actually

means to be "clinically qualied" in LTC facilities.

It is critical that CMS understand that there are multiple states where one can become licensed as

either a "dietitian" or a "nutrition professional" without ever having attended an accredited

dietetics or nutrition program (as required to provide MNT pursuant to the Social Security Act 1861(vv)(2)) and without having received any training in food service management, food safety, or

other competencies that this proposed rule declares are necessary in a LTC facility. Thus, this

proposed change would allow unqualied and incompetent (albeit licensed) practitioners to be

able to be "qualied dietitians" simply because some state licensure laws have been weakened

to the point where they no longer reect any "education, training, or experience in

identication of dietary needs, planning, and implementation of dietary programs."This is a

troubling development the Academy has been working to proactively solve, but which presently

present creates signicant problems in a number of states. As an example, pending regulations in

Florida will not require any food service management training, and one can be licensed in Illinois

as a licensed dietitian nutritionist without any relevant clinical nutrition or food servicemanagement training.

Anticipated benets to patient care and associated cost savings can only be realized if CMS

retains high standards and qualications of competency and training for qualied dietitians. State

licensure laws in some states set minimum qualications for licensed dietitians substantially

below that calculated to achieve the improved patient outcomes anticipated under this rule,

making it necessary that CMS better dene "qualied dietitian" to ensure patients' health and

safety. Because state licensure merely sets the minimum standard to engage in the practice of

dietetics and nutrition (as a "licensed dietitian," "licensed dietitian nutritionist," "licensed

nutritionist," or a similar such title), it cannot, by itself, be assumed to indicate the licensee has thetraining and competencies required to be a "qualied dietitian" under existing federal law and

regulation.

Thus, the Academy urges CMS to denitively adopt the denition of "qualied dietitian" in

482.94(e) ("A qualied dietitian is an individual who meets practice requirements in the State in

which he or she practices and is a registered dietitian with the Commission on Dietetic

Registration."). Alternatively, the Academy recommends that CMS either retain the existing

denition for qualied dietitians in LTC facilities or dene "qualied dietitian" consistent with the

denition of "registered dietitian or nutrition professional" in 1861(vv)(2) of the Social Security Act


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(42 U.S.C. 1395(x)(vv)(2)). The Social Security Act denition rightly requires third-party objective

accreditation of dietetics and nutrition programs and curricula, recognizing that the mere

accreditation of a college or university in no way ensures that graduates have obtained the skills,

education, and training necessary to protect the public and achieve the benecial patient

outcomes as a qualied provider. Notably, the Social Security Act properly recognizes that

unlicensed RDNs in states that choose not to license "registered dietitians or nutrition

professionals" are still qualied providers under federal law and should be eligible to order

resident diets under the proposed rule absent specic, directly countervailing state law.

Unfortunately, much like some state licensure laws, the Social Security Act denition provides no

guarantee that the nutrition and dietetics practitioner has any training or education in food

service, clinical nutrition, food safety, or management of food systems.

In addition, we note that no federal provision specically requires a registered dietitian to become

licensed to be a "qualied dietitian" unless state law not just a state agency's conicting

interpretation of federal regulations or guidance requires state licensure or certication. The

Academy requests that the Survey and Certication Group issue a guidance memorandum

conrming there is no controlling federal law, regulation, or Survey and Certication Group

interpretive memorandum that would either (1) preclude a LTC facility from authorizing a

competent, qualied registered dietitian from ordering patient diets in a state that does not

license dietitians or (2) require an additional federal or state oversight entity other than a

physician delegating his or her ordering authority absent a specic, directly countervailing state

law. In the minority of states without any relevant regulatory boundaries (such as the six states

that choose not to license or certify dietitians), federal law controls to enable long term care

facilities to exercise the exibility CMS arms they need to meet the needs of their residents most

eciently and eectively.

B. Food Service Director and Other Sta Qualications ( 483.60(a)(2) et seq.)

CMS proposes to "add to the requirement for the designation of a director of food and nutritionservice that the person serving in this position be a certied dietary manager, certied food

service manager, or have a certication for food service management and safety from a national

certifying body or have an associate's or higher degree in food service management or hospitality

from an accredited institution of higher learning." The Academy supports rening the proposed

rule to require that the director of food and nutrition service has obtained, at minimum, the

designation as a Certied Dietary Manager and the ServSafe certication.

The Director of Food Service should conduct and provide training on various aspects of dietary

operations for the food and nutrition services sta to ensure they develop and retain skills

necessary to eectively provide mandated services. CMS should work with stakeholders to set aminimum number of documented training hours specic to food and nutrition services for elderly

populations and specify the content necessary to demonstrate competency for the Director of

Food Service. Competencies should include diet rationale and restrictions, feeding skills, balancing

of client rights and diet limitation, policies and procedures, food safety, food service management,

and familiarity with residents' needs and preferences.

More broadly, continuing education, including regular in-service education, is necessary for all

food and nutrition sta members.


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C. Menus and Nutritional Adequacy ( 483.60(c))

The Academy's Nutrition Care Manual promotes cultural competence and will assist facilities in

meeting the proposed requirement for menus to reect the cultural and ethnic needs of

residents. CMS notes that this proposal would "require that menus be updated by a qualied

dietitian or other clinically qualied nutrition professional in the course of routine reviews and

updates," which is a task for which RDNs and NDTRs are highly qualied. We note rst that unlike

a number of other purported "nutrition professionals," RDNs and DTRs are bound by a Code of

Ethics providing that, "The dietetics practitioner provides services in a manner that is sensitive to

cultural dierences." Secondly, we note that the Academy's Nutrition Care Manual has cultural

food practices resources for African American, Asian, Indian, Caribbean, Chinese, Ecuadorean,

Filipino, Hispanic, Jewish, Korean, Mormon, Muslim, and Native American populations.

RDNs and NDTRs are fully committed to respecting residents' cultural preferences by meeting

specic needs when available from facilities' regular food purveyors. We appreciate CMS's

recognition that there are reasonable limits to these proposed requirements. The Academy

understands the nancial and operational realities of long term care facilities, specically that

certain patient preferences for more extravagant or non-medically indicated preferences may

result in unreasonable costs. In addition, meeting residents' food preferences for foods not in thefacility's formularies may require revamping of food preparation areas (to prevent cross

contamination), stang, and service and are often signicantly more expensive when not bought

in bulk. Members at some facilities have had success having residents phone the kitchen if they

are unable to be satised to speak with either the cook or dietary personnel to ensure their

preferences and needs are being met.

The Academy interprets the proposed requirement in 483.11(d)(6)(iii) providing that "(t)he facility

can only charge a resident for any noncovered item or service if such item or service is specically

requested by the resident" to mean that a facility is able to charge a resident for preferred foods

when ordered only upon resident preference. We encourage CMS to further clarify thisrequirement to ensure compliance.

CMS proposes to change 483.60(c)(1) to require that menus must "(m)eet the nutritional needs of

residents in accordance with established national guidelines or industry standards." The Academy

conrms that the Academy's Nutrition Care Manual is the recognized benchmark industry

standard applicable to this proposed revision. Established national guidelines, such as specic

dietary recommendations for energy and several essential nutrients and food components, such

as dietary ber, have been delineated in the Dietary Reference Intakes (DRIs). The DRIs include

the age categories 51 to 70 years and 70 years and older, and although chronological age is used

as an indicator, actual nutrient requirements may be wide-ranging in this population.Chronological age categories may be useful for many purposes such as assessing current and

planning future nutrient intakes related to both the diet of an individual and of groups. The

precise nutrition needs of an older adult at any age are multi-factorial because of the high

diversity within this population. The MyPlate for Older Adults icon illustrates the

recommendations of the 2010 Dietary Guidelines for Americans (DGA) and MyPlate specially

tailored to older adults by emphasizing topics such as adequate uid; convenient, aordable, and

readily available foods; and physical activity.

D. Frequency of Meals ( 483.60(f))

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The Academy supports CMS's proposed change "to require facilities to have available suitable and

nourishing alternative meals and snacks for residents who want to eat at non-traditional times or

outside of scheduled meal times in accordance with the resident's plan of care." Specically, the

Academy supports CMS's proposal "to modify the requirement that facilities provide and residents

receive 3 meals per day at regular times by adding language to clarify that meals should be

served at times in accordance with resident needs, preferences, requests and the plan of care ...

(and CMS's proposal) to eliminate the requirement that there be no more than 14 hours between

a substantial evening meal and breakfast the following day, except when a substantial bedtime

snack is provided, and focus instead on when residents prefer to eat and on ensuring that meal

service is provided to meet residents' clinical and nutritional needs."

E. Procuring Safe, Local Food ( 483.60(i)(1)(i))

The Academy is pleased to see CMS's commitment to culture change by supporting the ability of

LTC facilities to utilize facility gardens ("subject to compliance with applicable safe growing and

handling practices") and procure food from local producers farmers and growers. We note that

although CMS has declined to require the detailed HACCP process, many of our members would

support such a requirement, even as they recognize the inherent cost implications.

F. Denition of "Licensed Health Professional" ( 483.5)

The Academy is concerned that RDNs have been inexplicably omitted from the denition of

"licensed health professional" in 483.5. CMS proposes to dene "licensed health professional

(as) a physician; physician assistant; nurse practitioner; physical, speech, or occupational

therapist; physical or occupational therapy assistant; registered professional nurse; licensed

practical nurse; or licensed or certied social worker." Given the role of the RDN on the IDT and

the critical importance of nutrition in improving residents' quality of life and health status, we

urge CMS to correct this oversight in the nal rule.

G. Ordering of Therapeutic Diets ( 483.30(f)(2); 483.60(e)(2))

Enabling RDNs in LTC facilities to order patient diets is particularly important, because they are

frequently the only regularly available practitioners competent to modify diets in changed

circumstances. Most nursing homes have limited physicians or mid-level practitioners on-site, and

current practice requires diet order changes to be delayed until the physician can be reached for

approval. The delay in care in LTC facilities is particularly problematic; necessary diet

modications may not happen in a timely manner, the risk of malnutrition increases, and costly

hospital readmissions become more likely. RDNs recognize that the benets and risks associated

with dietary restrictions and therapeutic diets for older adults should be considered. Less-restrictive diets that are tailored to each person's needs, desires, and medical conditions can lead

to enhanced quality of life and improved nutritional status for older adults living in health care

communities.

RDNs' training and education best qualies them to order patient diets both initially upon

admission and after a nutrition assessment that considers the connection between patients'

complex medical problems, nutrition status, and actual nutrition risk. RDNs authorized to order

patient diets are more likely to conform the wording of their diet orders to the formulary,

eliminating confusion that has frequently resulted in food service workers serving the wrong diet.

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The Academy appreciates the opportunity to comment and serve as a resource to CMS as you

nalize the proposed rule and develop resources to implement the revised LTC standards. We are

happy to discuss these recommendations in greater detail in the near future. Please contact

either Jeanne Blankenship at 202-775-8277 ext. 6004 or by email [email protected]

Pepin Tuma at 202-775-8277 ext. 6001 or by email at [email protected] with any questions or

requests for additional information.

Sincerely,

Jeanne Blankenship, MS RDN

Vice President, Policy Initiatives and Advocacy

Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.

Senior Director, Regulatory Aairs

Academy of Nutrition and Dietetics

The Academy recently approved the optional use of the credential "registered dietitiannutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and

what they do as the nation's food and nutrition experts. The RD and RDN credentials have

identical meanings and legal trademark denitions.

NDTRs are educated and trained at the technical level of nutrition and dietetics practice for the

delivery of safe, culturally competent, quality food and nutrition services. They are nationally

credentialed and are an integral part of health care and foodservice management teams. They

work under the supervision of a registered dietitian nutritionist when in direct patient/client

nutrition care; and often work independently in providing general nutrition education to healthy

populations.

Dorner B, Friedrich EK, Posthauer ME. Position of the American Dietetic Association:

individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc.

2010;110(10):1549-53.

Ibid

O'Sullivan Maillet J, Baird Schwartz D, Posthauer ME. Position of the Academy of Nutrition and

Dietetics: Ethical and Legal Issues in Feeding and Hydration.J Acad Nutr Diet.2013;113(6):828-33.

Ibid.

Hoyt RE, Bowling LS. Reducing readmissions for congestive heart failure. Am Fam Physician. Apr

15 2001;63(8):1593-1598.

Paterna S, Parrinello G, Cannizzaro S, et al. Medium term eects of dierent dosage of diuretic,

sodium, and uid administration on neurohormonal and clinical outcome in patients with recently

compensated heart failure.Am J Cardiol.Jan 1 2009;103(1):93-102

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Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N

Engl J Med.2013;368(2):100-2.

Position statement on interdisciplinary team training in geriatrics: an essential component of

quality health care for older adults. J Am Geriatr Soc.2014;62(5):961-5.

Mion L, Odegard PS,Resnick B et al.Interdisciplinary care for older adults with complex needs:

American Geriatrics Society position statement.J Am Geriatr Soc2006;54:849852.

Rask K, Parmelee PA,Taylor JA et al.Implementation and evaluation of a nursing home fall

management program.J Am Geriatr Soc2007;55:342349.

Swaord KL, Miller LL, Tsai PF et al. Improving the process of pain care in nursing homes: A

literature synthesis.J Am Geriatr Soc2009;57:10801087.

Challa S, Sharkey JR, Chen M, Phillips CD. Association of resident, facility, and geographic

characteristics with chronic undernutrition in a nationally represented sample of older residents

in U.S. nursing homes.J Nutr Health Aging. 2007;11:179-184.

Dorner B, Posthauer ME, Thomas D. The role of nutrition in pressure ulcer prevention and

treatment: National Pressure Ulcer Advisory Panel white paper.Advance Skin Wound Care.

2009;22:212-221.

Ptomey LT, Wittenbrook W. Position of the Academy of Nutrition and Dietetics: nutrition services

for individuals with intellectual and developmental disabilities and special health care needs. J

Acad Nutr Diet .2015;115(4):593-608.

Cherno R. Tube feeding patients with dementia. Nutr Clin Pract.2006;21(2):142- 145.

Dorner B, Posthauer ME, Thomas D. The role of nutrition in pressure ulcer prevention and

treatment: National Pressure Ulcer Advisory Panel white paper.Advance Skin Wound Care.

2009;22:212-221.

Academy of Nutrition and Dietetics Nutrition Care Manual. NCM website. Accessed September

5, 2015.

American Dietetic Association/Commission on Dietetic Registration code of ethics for the

profession of dietetics and process for consideration of ethics issues.J Am Diet Assoc.

2009;109(8):1461-7.

title="Dietary Guidance DRI Table">Dietary Guidance DRI Tables. US Department of Agriculture

Food and Nutrition Information Center website. Accessed September 12, 2015.

MyPlate for Older Adults. Jean Mayer USDA Human Nutrition Research Center on Aging

website. Accessed September 10, 2015.

Position of the American Dietetic Association: Individualized nutrition approaches for older

adults in health care communities.J Am Diet Assoc.2010; 110(10):1549-1553.

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MDS 3.0 RAI Manual, Chapter 3, Section K: Swallowing/ Nutritional Status. Accessed

September 5, 2015.

Ibid., Dening "mechanically altered diet" as "(a) diet specically prepared to alter the texture or

consistency of food to facilitate oral intake. Examples include soft solids, pured foods, ground

meat, and thickened liquids. A mechanically altered diet should not automatically be considered a

therapeutic diet."

Ibdi

CITE My Plate for Older Adults. Jean Mayer USDA Human Nutrition Research Center on Aging at

Tufts. University website.

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2016 eatright.org. Academy of Nutrition and Dietetics, All Rights Reserved.
http://hnrca.tufts.edu/wp-content/uploads/MyPlateforOlderAdults_Handout.pdfhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

academy comments to cms re revised long term care regulations

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