Dietary Services

Description of Federal Requirements  [TOP]

The Federal regulation, 483.35, holds that the nursing home must provide each resident with a nourishing, palatable, and well-balanced diet that meets dietary requirements and any special dietary needs.   Under (a), the facility must employ or contract with a qualified dietician.  If that dietician is not employed full-time, the facility must designate a food service director who “frequently receives consultation” from a qualified dietician.  A qualified dietician is either registered by the Commission on Dietetic Registration of the American Dietetic Association, or is qualified on the basis of education, training, or experience in identifying dietary needs, and planning and implementing dietary programs.  Under (b), the facility must employ sufficient staff to carry out the dietary service program.   

Under (c), the menus must meet the nutritional needs of residents, be based on menus prepared in advance, and be followed.  Under (d), the food must be prepared in away that preserves their nutritive value, appearance, and flavor, be palatable and attractive, served at the right temperature, and “prepared in a form designed to meet individual needs.”  Residents who refuse the food served must be offered substitutes “of similar nutritive value.”  Under (e) therapeutic diets must be ordered by the attending physician.  Under (f), the resident must be served at least 3 meals a day, “at times comparable to normal times in the community,” no more than 14 hours shall elapse from the last substantial meal of the evening to the first meal of the morning, the resident must be offered a bedtime snack, and if the resident is offered a “nourishing” snack at bedtime, 16 hours may elapse between the last evening meal and the first morning meal, if the residents agree to this meal schedule.  Under (g), the facility must provide special eating devices and utensils for residents who need them.

Under (i), sanitary conditions must be preserved.  Specifically, the  food must be obtained from sources approved as satisfactory by Federal , State, or local authorities; must be stored, prepared, distributed, and served under sanitary conditions, and the facility must dispose of garbage and refuse properly.

In 2003, a new section (h) was enacted that referred to paid feeding assistants.  This section clarified that the use of such feeding assistants who have received training in a State-approved course that is consistent with Federal law if: they are supervised by a registered nurse or licensed practical nurse; if they call a nurse for assistance in an emergency; if the facility assures that the residents selected for such assistance not have complicated feeding problems, such as difficulty swallowing, recurrent lung aspirations, and tube or parenteral/IV feedings; and if the selection is based on the resident’s assessment.   Another section of federal regulations, Subpart D- Requirements That Must be Met by States and State Agencies: Nurse Aide Training and Competency Evaluation, and Paid Feeding Assistants, specifies that the approved training must be at least 8 hours and must include specified content, including feeding techniques, assistance with feeding and hydration, communication and interpersonal skills, appropriate responses to resident behavior, safety and emergency techniques including the Heimlich maneuver, infection control, resident rights, and recognizing changes in residents inconsistent with their normal behavior and how to report those change.  The facility must maintain a record of those who successfully completed the course to be paid feeding assistants.

The dietary regulation, 483.35, is related in various ways to numerous other regulations.  The most salient are the regulations on Quality of Life, 483.15, because food and food service is related to dignity, self-determination, and choice; and the regulations on quality of care, 483.25, because (a) (1) (v) is related to assistance with eating, (g) is related to use of naso-gastric tubes, (i) is related to maintaining acceptable nutritional status, including weight and protein levels, (j) is related to maintaining hydration; and (K) (3) to parenteral and enteral fluids.  Section 483.35  (a) on dietician qualifications can be cross referenced to Administration 483.75 (a) that requires that all personnel are licensed as required by State law; sections on preparation and storage of food and sanitation are related to both 483.65 on infection control and 483.70 on physical environment.  Because licensed nurses oversee the work of paid feeding assistants and select the resident who may receive their help, some States include content under nursing services 483.30 to further elaborate those nursing roles.          

Comparison of State Requirements  [TOP]

A great deal of variation is found in State regulations pertinent to the larger Dietary regulation.  This section is organized into 8 subsections to describe that variation in greater detail, namely; dietician and dietary staff; menus, including therapeutic diets; food preparation and storage; frequency of meals (which also includes some variation in requirements on intervals between meals), assistive devices; paid feeding assistance, and the dining experience.  Most of these categories comprise one or more of the subsections of the federal regulation.  Our narrative on assistive devices extends to discuss various State rules related to residents who need substantial help in eating.  The Paid Feeding Assistant section reveals substantial variation in the way State have developed training programs and policies to address the newest federal regulation related in the dietary group. 

Food and beverages in general and meals in particular are highly related to the quality of life residents’ experience.  Although no federal rule speaks directly to the dining experience, States have enunciated various rules designed to make dining enjoyable; NHRegsPlus has assembled such State rules, many of which deal with ambiance, into a category called Dining Experience.

The Table below indicates for each State, which of these 8 sections contains content that goes beyond the Federal minimum specifications. 

[Summarized: March 2007]

Table Comparing States  [TOP]

Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Administration by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State regulation on Dietary Services at the bottom of the Table.

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Complete Transcript of State Regulations on Dietary Services