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CMS Clarifies Dining Requirements

July 20, 2012

The Pioneer Network, a national non-profit serving the culture change movement, requested and received the following clarification from the Centers for Medicare & Medicaid Services (CMS) regarding dining requirements. Cathy Lieblich, Pioneer Network’s Director of Network Relations, posed six questions to CMS that surfaced via providers engaged in the transformation of dining systems. In a message dated May 6, 2012, and sent directly to Cathy Lieblich, CMS offered the following responses:

Thank you for your six inquiries regarding food and dining requirements.

After careful review, we are providing answers to each question you have listed below.

Q: Surveyors focus on the scoop sizes in the kitchen instead of what portions a resident wants. Does CMS want providers to focus on generic RDA menu portions and generalized scoop sizes in the kitchen or on assessing what a person prefers on a daily basis and serving them that? Can the survey process support comprehensive assessment and comprehensive care plan in this area?

A: Our regulations and interpretive guidelines stress resident individual assessment, participation in care planning, and resident choice.

It is true that in the Traditional Survey, the survey team will check on sizes of scoops used to dish food onto trays if they discover a nutrition or weight loss issue that they are investigating. The purpose of this check is to determine whether the facility is routinely providing sufficient food to all residents. The requirement for facilities to provide adequate nutrition is not intended to interfere with any resident’s rights or preferences. If a specific resident requests to have a smaller amount of food because larger portions feel overwhelming, the facility should accommodate this request.

If that resident is losing weight unintentionally due to this choice, the surveyors will investigate the resident’s preferences to determine what alternatives the facility is offering to accommodate the resident.

Q: Many homes changing institutional culture to self-directed living are offering many non-institutional dining styles. One such style is restaurant dining in which the resident can place their order according to their preference and choice. Is it considered deficient practice if residents are served at various times according to when they come to the dining room, including sitting at a table where other residents have already been served? Also, is it considered deficient practice where a resident may have to wait just as a customer does in a restaurant?

A: There has been a problem in many nursing homes over the years with having some residents seated with others to wait long periods for their meals while others received theirs. Therefore, surveyors have been attuned to checking how long residents were waiting for service while seated with others who were already eating.

The issue of restaurant style dining is a new concept and is one which we encourage, as it has the potential to provide additional enjoyment and quality of life to residents, when they are able to place an order from a menu with a variety of choices and have the meal of their choice prepared and delivered to them according to their preferences. In an actual restaurant, it would be very unusual for a person to sit with others who were engaged in dining, and then to order their meal. But we realize that this may indeed happen in a restaurant style dining presentation in a culture changing nursing home. If a resident comes in at the time of their choice and discovers friends already there and eating, and the resident wishes to dine with these friends, we see no problem with the resident ordering her/his meal and waiting for it, as would occur when placing an order in an actual restaurant. As in an actual restaurant, we would expect to see presentation of a menu and taking of the order, followed by the usual practice of delivering silverware, a drink, and perhaps an offering of bread and butter while the meal was being prepared. This would make it more pleasant for residents arriving at different times, and would be more like actual restaurant service. Surveyors would consider whether the resident in question made the choice as to when she/he wished to come to the dining room and whether the resident then chose to sit with friends who were already dining.

Q: Is the buffet style dining where buffet steam tables are located in a dining room viewed as potential for harm? We’re hearing that surveyors are citing this as an accident hazard viewing the heating element as dangerous.

A: We encourage buffet style dining, as we believe the sight and smell of foods encourages residents to eat and also encourages them to make choices of foods and amounts they prefer. The presence of the buffet steam table in the dining room is not considered an accident hazard as the heating element is located below the food trays and is not directly accessible to the residents in the dining room who pass by the steam table.

Staff who are in the dining room should monitor resident use of steam tables to prevent accidental burns.

Q: Will CMS guide surveyors to accept a person’s preference not to follow recommended medical advice (i.e., not to accept a tube feeding, altered consistency diet or restricted diet among others) in writing or verbally if they do not want it? Providers want to acknowledge appropriately a person’s choice while not forcing the person to follow recommended medical advice and in so doing honor their choice and right to refuse medical treatment.

A: We encourage nursing homes to honor resident choices and preferences, and we also want to ensure that residents become aware of the consequences of their choices to accept or refuse tube feedings or diet restrictions. This is a complex issue that must be decided individually, depending on the specific choice/refusal, the level of resident (or representative) understanding of the health consequences of the choice, the work of the interdisciplinary team to attempt to uncover the root cause behind the choice and their attempts to provide a satisfactory alternative, etc. For example, one resident might refuse a medication because the pill is too large and hard to swallow, another because the drug causes stomach upset, another because of disturbing side effects, etc. A resident might make another choice to refuse some aspect of treatment for a variety of reasons. In any case, the team is responsible to make sure the resident (or representative if the resident is unable to make decisions) understands the issue, and to offer alternatives if any are available.

We are working on this issue and invite further dialog with the Pioneer Network and other stakeholders on this key concept of resident care planning and quality of care/quality of life.

Q: Is it permissible for a resident to work in a household kitchen, in their home, as long as good infection control practices are followed?

A: Yes, this is permissible for a resident to assist with food preparation. We would consider this to be an activity the resident has chosen to do, as long as the resident is not being required to perform these tasks and all kitchen safety practices are followed.

Q: Some homes are getting the message from surveyors that staff must wear hairnets for all interactions with food on a household. Must staff members wear hairnets for all interactions with food in the household? People do not wear hairnets in their own homes nor do servers when waiting tables.

A: According to the Food Code of the Food and Drug Administration, dietary staff should be wearing hairnets during the cooking or preparation of food, such as stirring pots or assembling the ingredients of a salad. If staff are assembling food trays in a tray line they should wear hairnets. However, staff do not need to wear hairnets when conveying foods to the dining table(s) or when assisting residents to dine. We are aware that in a small house or household setting, the customary roles of staff who are cooking/preparing and those same staff when they are serving food to a dining table are blurred and sometimes occur in quick succession as a staff member moves from a kitchenette to a dining table. Residents will also be entering the kitchenette to do preparation or serve themselves if they are able. As for Question 4, we welcome further dialogue with Pioneer Network and other stakeholders on this issue.

If you have any additional questions or concerns please forward them to the following email:


Karen Schoeneman Technical Director Centers for Medicare & Medicaid Services Survey & Certification Division of Nursing Homes

The information provided in this email is only intended to be general summary information. It is not intended to take the place of statute, regulations, or official CMS policy.

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