If you are a dietitian who is new to practicing in long-term care or a seasoned RD who wishes to learn more about what it means to work in this type of healthcare setting, you have come to the right place to get a consolidated and updated review of long-term care regulations.
Types of Long-Term Care Facilities
Let’s start off by examining the different types of long-term care settings.
Nursing Homes: Designed to assist patients who are not appropriate for acute care hospitalization following an illness, injury or surgery, but cannot care for themselves independently at home. Often patients are discharged from a hospital into a nursing home and may stay for several weeks all the way through the end of life.
Skilled Nursing Facilities (SNF): Considered to be transitional care. A patient receives a similar level of medical care that they would in a hospital setting with the addition of three specific types of therapy – speech, physical, and occupational therapy. The goal is for the patient to recover and return to their home environment.
Assisted Living Facilities (ALF): House several different levels of care under one roof. These facilities are typically designed for a patient who is relatively independent and does not need as much help as a patient in a nursing home. Medical staff are present but only needed on a minimal basis such as for assistance with medication management and activities of daily living (ADL). Other staff provide assistance with laundry, housekeeping, meals, and transportation. There is a social engagement component to ALFs as well as an emphasis on an overall healthy lifestyle.
Hospice Care: A service offered to a patient who is approaching the end of life while living in a healthcare facility such as a nursing home or assisted living facility. Hospice care offers support, comfort and dignity when a physician feels that a person’s life expectancy is within its final six months.
Long-Term Care Requirements
The implementation of CMS guidelines for Long-Term Care Facility Requirements was originally published in 2016. There were three phases, including Phase 1 in 2016, Phase 2 in 2017, and Phase 3 in 2019. The staggered implementation of guidelines was designed to allow time for facilities to become familiar with the regulations and participate in surveys that evaluated the new information.
Phase 1 emphasized the education level of the registered dietitian, dietary manager, and staff. CMS expanded the title of Dietary Services (483.85) to Food and Nutrition Services (483.60). Facilities are now required to employ a full-time, licensed RD or a certified dietary manager with a consulting dietitian. A section that includes support staff was added to ensure facilities provide adequate staff to safely and efficiently complete all the duties of the Food and Nutrition Services department.
In Phase 2, CMS revised the nursing facility F-tags to comply with new regulations. In some cases, tags were combined or split into multiple subsections depending on how the tag was revised. At this time, the survey process transitioned to a computer-based process, which combined the traditional survey and Quality Indicator Survey (QIS). The goals for this new survey process were for improved efficiency and effectiveness.
Phase 3 includes updated MDS 3.0 quality measures user manual, which has been posted to the CMS.gov site. The final version of MDS Items Sets is projected to be effective October 1, 2023. Phase 3 holds requirements such as trauma informed care, compliance and ethics, and quality assurance performance improvement (QAPI). Also included are revisions to quality of life and quality of care, food and nutrition services, and physical environment. President Joe Biden’s first State of the Union Address in March 2022 released an outline of significant changes, which can be found here.
Additional considerations and review of regularity requirements for dietitians working in long-term care mostly apply to documentation. Long-term care facilities that receive payments from Medicare, Medicaid, or both must comply with strict regulations established by the Centers for Medicare and Medicaid (CMS). To avoid tags (which can carry a fine) and deficiencies, ensure your nutrition documentation is accurate, clear, comprehensive, and continuous.
Charting and Documentation
A new admission assessment should be completed on every new patient within 72 hours of them entering the facility. This note is a comprehensive assessment that includes pertinent information such as anthropometrics, diet order, diet history, medications, labs, diagnosis, and medical history. Nutritional needs are calculated in this assessment and a care plan is established addressing nutritional concerns. The data from this assessment will be used to complete Section K of the admission MDS and the care area assessment (CAA) that accompanies it.
Monthly or quarterly documentation is completed depending on the patient’s level of nutritional risk. If high risk, a monthly nutrition review is warranted. If low risk, a quarterly review is sufficient corresponding to their MDS assessment reference date (ARD). Diet, weight trends, appetite, PO tolerance, and skin condition should be addressed in this note.
A high-risk patient is defined as a patient having one or more of the following nutrition risk factors:
- Tube feeding or TPN
- Significant weight gain or loss – notification of physician and responsible party required
Annual notes and significant change in condition documentation are completed for different purposes but include the same comprehensive review. Like a new admission assessment, this note addresses the patient as a whole and includes any new medical concerns or changes that have occurred since their last nutrition note. A CAA is required for both annual and significant change MDS assessment.
Discharge documentation is required to be given to the patient upon discharge including discharge diet order and other recommendations determined by the dietitian and/or physician.
Care plans should be established on admission and updated regularly or when changes are made to the plan of care. It is important that the information in the patient’s care plan matches the information found in your notes and the medication administration record and treatment administration record (MAR/TAR).
It’s important to be survey ready at all times as the inspection is unannounced, and although conducted annually, there is a window of time before and after the last survey that the team may enter your building. Nutrition documentation will be audited as far back as needed so be sure that you keep up to date on your documentation daily so that nothing is missed or out of compliance.
For further information on updated guidelines, FAQs and useful training resources, review CMS’s available training resources.
Revised as of March 2023
Sarah Hammaker, RDN is a clinical dietitian working primarily in long term care and acute rehabilitation hospital settings in PA. She holds certificate of trainings in the areas of Adult Weight Management as well as Integrative and Functional Nutrition. Outside of work, Sarah enjoys spending time with her husband and their four children. She loves running and being outdoors. Her hobbies include reading, planting and shopping.
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Robinson GE, Cryst S. Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Post-Acute and Long-Term Care Nutrition. JAND. 2018;118(9):1747-60.E53.
Van De Walle, G. Dietitian charting guidelines for long-term care. Dakota Dietitians website. Updated November 5, 2022. Accessed from https://dakotadietitians.com/dietitian-charting-guidelines-ltc/