Since 1989, federal regulations have required that diets, including therapeutic diets, be prescribed by the attending physician in long-term care.
In 2016, however, the Centers for Medicare and Medicaid Services (CMS) announced a final rule that changed this requirement, allowing the attending physician to delegate the task of prescribing a resident’s diet to a registered dietitian (1).
This article explains what dietitians need to know about writing diet orders in long-term care and offers tips to get your facility on board with the delegated order-writing rule.
Final rule for long-term care facilities
CMS released a final rule on October 4th, 2016 that made significant changes to the requirements for long-term care facilities that participate in Medicare and Medicaid (1).
The long-term care final rule became effective on November 28, 2016 and facilities were required to implement the changes by November 28, 2019.
The revised requirements aimed at aligning participation requirements with current and best practice clinical standards to improve resident safety and deliver services that enhance the quality and effectiveness of care.
The final rule retained the requirement that diets be prescribed by the attending physician, but established a new rule in §483.60(e)(2) that allows the resident’s physician to delegate to a dietitian the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by state law.
According to CMS, a therapeutic diet is ordered as part of treatment for a disease or clinical condition, to eliminate, decrease, or increase specific nutrients in the diet, or to provide foods the resident is able to eat, such as a mechanically altered diet.
Whether the physician chooses to delegate this responsibility to a dietitian is at his or her own discretion. In either case, the physician retains responsibility for the diet order, but co-signing is not required, except by state law.
CMS notes in the final rule that the terms “attending physician” or “physician” also include a non-physician provider, including a physician assistant or nurse practitioner, that is involved in the management of the resident’s care.
The intent of §483.60(e)(2) is to improve the responsiveness to a resident’s needs and provide physicians with flexibility, given the limited time that many spend in a facility (1).
There is no specific rule for ordering nutritional supplements, however, dietitians should be able to order them if the authority has been delegated by the attending physician and in accordance with state law.
Nutritional supplements, as defined by CMS, refer to products that are used to compliment a resident’s dietary needs, including calorie or nutrient-dense drinks, total parenteral products, enteral products, and meal replacement products.
State law and facility policy
Whether a dietitian can write diet orders in long-term care depends on the physician’s choice to delegate, but also on state law and facility policy.
Fortunately, few states prohibit the attending physician from delegating to a dietitian the task of writing diet orders.
That said, the primary limits are facility-based — the decision makers of a facility may not approve of the rule or the facility may not have an appropriate policy in place that allows for physician delegation.
In this case, a facility must first approve of the rule that allows this delegation and then develop a policy that is agreed upon by the dietitian, medical director, nursing director, administrator, and other decision makers at the facility.
How to obtain privileges to write diet orders in long-term care
Dietitians — based on their education and training — are qualified to prescribe diets, including therapeutic diets.
Due to differences in governing structures, current regulations don’t allow dietitians in long-term care to write diet orders independently without requiring supervision or approval of a physician as they allow in hospitals (2).
However, the final rule for long-term care facilities enables qualified dietitians to prescribe resident diets when delegated by the attending physician.
Still, many facilities have not adopted the new rule, representing an opportunity for dietitians like you to obtain order-writing privileges.
You can advocate for order-writing privileges through:
- Awareness: The leadership of a facility may be uninformed of this rule, in which case, you can increase awareness among the appropriate staff.
- Trust: Members of the interdisciplinary and leadership team must have trust in your clinical skills and knowledge before they can feel comfortable with granting you order-writing privileges. Earning and building this trust takes time, but it’s necessary.
- Presence: Simply being present can build rapport with leadership and medical staff, especially the attending physician, and make your pitch for order-writing privilege less intimidating. Increase your presence by regularly attending and participating in resident care plan meetings and quality assurance and performance improvement (QAPI) meetings.
Although order-writing privileges can provide a greater sense of participation in resident care, the rule comes with a significant amount of responsibility, especially if you are the sole provider for prescribing diets, in which case, you would need to be on call when you’re not present at the facility.
Consider whether you’re an employee of the facility or an independent contractor, the number of hours you’re at the facility, and the facility’s average number of short-term care residents when requesting order-writing privileges for your facility.
The bottom line
The attending physician may delegate to a dietitian the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by state law.
If your facilities has not adopted this rule, you can advocate for order-writing privileges by increasing awareness of the rule among the appropriate staff, establishing trust with members of the interdisciplinary and leadership team as well as increasing your presence and participation in meetings.