CMS revisions regarding therapeutic diet orders may give MSPs plenty to chew on

The revised Conditions of Participation (CoP) allow certain nonphysician practitioners, when determined to be eligible for appointment by the governing body, to have privileges like other medical staff members. These nonphysician practitioners may be advanced practice registered nurses, physician assistants (PA), registered dietitians (RD), and doctors of pharmacy. In addition, CMS' final rule now allows qualified dietitians or qualified nutrition professionals to order patient diets—as authorized by the medical staff and state law—under the hospital CoPs.

CMS amended the former requirement that a therapeutic diet be prescribed only by the practitioner or practitioners responsible for the patient's care. CMS' Interpretive Guidelines addressing this prior requirement had stated that a dietitian could assess a patient's nutritional needs and provide recommendations, but only the practitioner responsible for the patient's care could actually prescribe the patient's diet. This resulted in hospitals not granting dietitians ordering privileges.

To allow hospitals flexibility regarding the granting of such privileges, CMS amended the CoPs to state that therapeutic diets must be ordered by:

• The practitioner responsible for the patient's care
• A qualified dietitian
• Other clinically qualified nutrition professionals as authorized by the medical staff and in accordance with state law

In comments to CMS in 2013, National Association Medical Staff Services (NAMSS) requested clarification to affirm that the CMS proposal would only provide hospitals the option to credential and privilege dietitians. NAMSS pointed out, "Many hospitals use contractors to supply dietitians." In such situations, there is not a consistent roster of dietitians on staff. If CMS required such hospitals to credential dietitians, MSPs in such settings would need to constantly credential new dietitians, and the high turnover rate would generate additional expenditures. In its statement, NAMSS encouraged CMS to consider the potential for added costs and to keep flexibility in the final rule by not requiring hospitals to credential and privilege dietitians. ("CMS Issues Final Rules on Hospital Medical Staff Conditions of Participation," NAMSS, May 12, 2014)

CMS' response to NAMSS in 2014 was: "We are permitting registered dietitians (RDs) and other clinically qualified nutrition professionals to be privileged to order patient diets under the hospital Conditions of Participation (CoPs)."

For patients to have access to the timely nutritional care that can be provided by RDs, hospitals must have the regulatory flexibility either to appoint RDs to the medical staff and grant them specific nutritional ordering privileges or to authorize the ordering privileges without appointment to the medical staff, all through the appropriate hospital medical staff rules, regulations, and bylaws, CMS stated.

Hospital credentialing and privileging processes, therefore, must be compliant with medical staff rules and regulations as well as medical staff bylaws. "In many cases, this may require revisions to bylaws and/or rules and regulations before any changes to the privileging and credentialing processes can be implemented," NAMSS stated.

Source: Medical Staff Briefing