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Dietary Services

 

Description of Federal Requirements
Comparison of State Requirements
Table Comparing States

Complete Transcript of State Requirements on Dietary Services (PDF)


Federal Regulations & Related F-tags for 483.35 Applicable Federal Regulation
Dietary Services
(a)Staffing | F361
(b) Sufficient Staff | F362
(c) Menus and Nutritional Adequacy
(d) Food | F364
Food Preparation | F365-F366
(e) Therapeutic Diets | F367
(f) Frequency of meals | F368
(g) Assistive Devices
(1) - (2)Sanitary Conditions | F370-F371
(2) Disposal of Garbage and Refuse | F372
  • 483.35 Dietary Services
  • Subpart D - Requirements that Must be Met by States & State Agencies: Nurse Aide Training & Competency Evaluation, & Paid Feeding Assistants
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    Description of Federal Requirements    (TOP)    (NEXT)

    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)    (NEXT)

    NOTE:  The examples below may not list all States with similar language; always check your state for specifics

    A great deal of variation is found in State regulations pertinent to the larger Dietary regulation.  This topic is organized into 8 categories (each on its own sub-page; use links in right column) 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 category reveals substantial variation in the way States have developed training programs and policies to address the newest federal regulation related to the dietary group. 

    Food and beverages, in general, and meals, in particular, are closely 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; NH Regs Plus 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 categories contains content that goes beyond the Federal minimum specifications. 

    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 Dietary Services by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State requirements on Dietary Services.

    483.35 Dietary Services

    State Goes beyond Federal Regulations? Subjects Addressed: How State Differs From or Expands On Federal Regulations
    Alabama Yes Same as Federal Categories.
    Alaska Yes Administration; Staff Credentials; Diet Manual; dietetic services.
    Arizona Yes Staff Credentials; Nutrition Specifics.
    Arkansas Yes Staff Credentials; Staff Hygiene; Minimum Daily Food Requirements; Diet Manual; Meal Service; Menus; Preparation and Storage; Dishwashing.
    California Yes Administration; Diet Manual; Menu Details; Food Storage; Cleaning and Disinfecting; Equipment and Supplies; Dietetic service supervisor; therapeutic diets; menus; food storage; sanitation; equipment and supplies; staff and care policies and procedures.
    Colorado Yes Organization, Personnel; Policies, Assessments & Progress Notes; Space; Safety; Diet Manual; Equipment and Storage; Staff Hygiene; Dairy; resident socialization; Dietary Services; nail polish and false nails; dining and recreational facilities.
    Connecticut Yes Diet Manual, Portion Sizes, Minimum Supplies on Hand.
    Delaware Yes Diet Manual; Minimum Supplies on Hand; Dining Area; Food Storage; Menus.
    District of Columbia Yes Dietary Supervision, Services and General Requirements; infection control committee.
    Florida Yes Florida is silent on Dietary Services under its nursing home regulations; exception for Dining and Hospitality Assistant under "Administration."  Guidance through standards recommended by nationally recognized professional groups.
    Georgia Yes Diet Manual; Minimum Supplies on Hand.
    Hawaii Yes Diet Manual; Storage and Handling.
    Idaho Yes Supervision and Administration; Staff Hours and Schedules; Nutrition Specifics; Diet Manual; Menu Planning; Recordkeeping; Dairy; Food Preparation and Service.
    Illinois Yes Staff Credentials; Staff Hygiene; Meal Planning; Nutrition Specifics; Menus and Food Records; Diet Manual; Food Preparation and Service; Food Handling; Scheduling Meals; Scheduling meals.
    Indiana Yes Staff Credentials; Nutrition Assessments; Diet Manual; Dining Assistants; Training; Dining Assistant.
    Iowa Yes Organization, Staffing; Inspections and Appeals; Ordering, Receiving and Storage; Diet Manual; Nutritional Assistants; Training
    Kansas Yes Staff Credentials (including Education and Experience, Continuing Education, Examination Requirements, Licensing and Fees); Dietary Areas; Staffing; Food Safety; Licensure; Adoptions by reference 2005 Dietary guidelines.
    Kentucky Yes Same as Federal Categories.
    Louisiana Yes Staff Credentials; Diet Manual; Equipment and Supplies; Detailed Sanitary Conditions; Staff Health and Hygiene; Feeding Assistants.
    Maine Yes Policies and Procedures; Health and Hygiene; Staff Credentials; Recordkeeping; Diet Manual; Nutrition Specifics; Food Storage and Protection; Food Preparation; Cleaning, Sanitization and Storage of Equipment and Utensils; Disposal; Dietary Area.
    Maryland Yes Supervision; Consultation; Staffing Schedules; Diet Manual; Menus; Preparation of Food; Dietetic Service Area; New Construction Requirements; Storage.
    Massachusetts Yes Staff Credentials; Staff Hours; Staff Health and Hygiene; Diet Manual; Nutrition Specifics; Menu Planning; Records; Preparation and Serving; Storage; Main Meal of the Day requirements.
    Michigan Yes Statement regarding Recommended Dietary Allowances; Policies and Procedures: Nutritional Needs of Patients; Menus, posting and filing; Food Acceptance Record.
    Minnesota Yes Nursing/Dietary Staff Interaction; Volunteers; Nutritional Assessment; Diet Manuals; Staff Health, Grooming and Hygiene; Staff Credentials; Dishes and Utensils Requirements; Dishwashing; Floor Cleaning and Trash; Poison and Disease Reporting, Food Supplies; Cleaning and Sanitizing; Menus; Dairy.
    Mississippi Yes Direction and Supervision; Food Handling Procedures; Diet Manual; Meal Service; Nutrition Specifics; Food Preparation and Serving; Personnel; Physical Facilities; Equipment and Utensils; Dishwashing; Food Storage.
    Missouri Yes Minimum Supplies on Hand; Dietary Requirements; Extensive Sanitary Requirements.
    Montana Yes Definitions; Purpose; Minimum; Standards; Billable Items; Food Storage, Preparation and Display; Food Equipment and Utensils.
    Nebraska Yes Staff Credentials; Minimum Supplies on Hand; Physical Requirements; Training.
    Nevada Yes Staff Credentials; Administration; Physical Space; Food Service.
    New Hampshire Yes Menu Administration; Meal Service; food Services to meet the 2005 Dietary Guidelines for Americans; Sanitation.
    New Jersey Yes Organization; Staff Credentials; Diet Manual; Nutrition Specifics.
    New Mexico Yes Staffing Hours; Staff Hygiene; Nutrition Specifics; Food Supplies and Preparation; Equipment and Utensils; Dietary Records.
    New York Yes Staff Credentials; Diet Manual; Kosher Food; Feeding Assistant Training Course.
    North Carolina Yes Staff Credentials; Resident Assessment; Diet Manual; Sanitation Rules.
    North Dakota Yes Staff Credentials; Staff Health and Hygiene; Feeding Assistants (Qualifications, Training, Continuing Education).
    Ohio Yes Dining Assistants (Training and Education), Resident Assessment and Monitoring; Minimum Supplies on Hand; Dining and Recreation Rooms; Dining Assistants; qualification.
    Oklahoma Yes Facilities; Assessment and Recordkeeping; Storage, Supply and Sanitation; Nutrition Specifics; Food Service: Sanitation: Feeding Assistants.
    Oregon Yes Sanitation; Preparation Areas; Receiving, Storage and Other Work Areas; Organization; Staff Credentials; Diet Manual; Documentation; Dining Assistants (Training and Education).
    Pennsylvania Yes Diet Manual; Ice Containers and Storage; Dining Room.
    Rhode Island Yes Administration; Policies and Procedures; Diet Manual.
    South Carolina Yes Inspection and Approval; Personnel; Diet Manual; Health and Disease Controls; Supplies; Protection; Storage; Preparation and Serving; Equipment and Utensils; Sanitation; Physical Space; Linens and Clothes Storage; Refrigeration; Tests and Inspections; Meal Service; Menus.
    South Dakota Yes Organization; Minimum Supplies on Hand; Policies; Preparation of Food; Staff Credentials; Diet Manual; Dining Arrangements; Nutritional Assessments; Required In-service Training; Dining Assistance Program.
    Tennessee Yes Organization and Administration; Ongoing Education and Training; Resident Assessment; Diet Manual; Protection.
    Texas Yes Dining Areas; Staff Credentials; Ongoing Education; Diet Manual; Minimum Supplies on Hand; Food Intake; Feeding Assistants; Training.
    Utah Yes Nutrition Specifics; Dining Assistants; Minimum Supplies on Hand; Survey Compliance.
    Vermont Yes Same as Federal Categories.
    Virginia Yes Staff Credentials; Staffing Schedules; Diet Manual; Food Service; Dining Space and Facilities; Dietician Duties.
    Washington Yes Meal Provision; Individual Needs; Personnel; Orders; Tube Feeding.
    West Virginia Yes Staff Credentials; Recordkeeping; Diet Manual; Emergency Supplies.
    Wisconsin Yes Staff Credentials; Hygiene of Staff; Nutrition Specifics; Meal Service; Supplies and Preparation; Sanitation; Dishwashing.
    Wyoming Yes Supervision and Consultation; Diet Manual; Hygiene; Non-dietary Personnel excluded from dietary area.

    Complete Transcript of State Requirements on Dietary Services    (TOP)