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What are the CMS LTC Regulations?

The Centers for Medicare & Medicaid Services (CMS) is the federal agency responsible for administering requirements governing long-term care facilities. In October 2016, CMS released a comprehensive update of the regulations to reflect advances in theory and practice of service, delivery, and safety for LTC residents, including a section newly defined as Food and Nutrition Services.

CMS Regulations Timeline


Phase I

On September 28, 2016, the Centers for Medicare & Medicaid Services (CMS) issued its final regulations of Part 483 to Title 42 of the Code of Federal Regulations, the requirements for states and long-term care facilities.

Why is this important and how does it impact CDM, CFPPs?

Phase I of the revised nursing home regulations went into effect November 28, 2016. Five regulatory sections were fully implemented in this phase. They include:

  1. Resident Assessment
  2. Quality of Life
  3. Physician Services
  4. Laboratory, radiology, and other diagnostic services, and
  5. Specialized Rehabilitation.

Additions to §483.60 Food and Nutrition Services Include:

  • Continues food and nutrition protections - food safety
  • Qualified food and nutrition services staff - sufficient and competent
  • Reasonable efforts to address religious, cultural, and ethnic needs
  • Frequency of meals - snacks
  • Policy regarding use and storage of foods
  • Updated educational requirements (dietitian and food service manager)

In Section §483.60 Food and Nutrition Services, several highlights are significant to the CDM, CFPP credential.

How do the New Regulations Impact Food and Nutrition Services?

In Section §483.60 Food and Nutrition Services, the following highlights are significant:

• The Certified Dietary Manager, Certified Food Protection Professional (CDM, CFPP) credential is now listed as the primary qualification for the Director of Food and Nutrition Services in the absence of a full-time dietitian.

• A representative from the Food and Nutrition Services department must be included on the Interdisciplinary Team (IDT). The CDM, CFPP is the only credential listed in addition to the Registered Dietitian Nutritionist that is qualified to participate as defined by scopes of practice. A scope of practice is a critical component in defining the role of any credentialed professional. View the CDM, CFPP Scope of Practice HERE.

• While CMS lists the CDM, CFPP credential as the primary qualification for the Director of Food and Nutrition Services, the regulations also acknowledge state requirements for staffing qualifications. Currently, the CDM, CFPP meets requirements in 18 states. View the list of states HERE.

• CMS also posted two additional documents that are important to CDM, CFPPs.

•Updated List: Federal Regulatory Groups for Long Term Care Facilities (click HERE to view)
•Phase II Tag Crosswalk – Click HERE to see which F-Tag changes are relevant to CDM, CFPPS
•For the full list of F-Tag changes, click HERE.

How do the New Requirements Impact Staffing?

According to the requirements, individuals who are currently employed as the designated Director of Food and Nutrition Services prior to November 28, 2016 will have five years to meet the staffing requirements outlined by CMS. Individuals hired after November 28, 2016 will have no later than one year to meet these staffing requirements.

Current foodservice managers may already be eligible to sit for the CDM, CFPP Credentialing Exam. Learn about exam eligibility HERE.



Phase II

What's Here and Now? Phase II: November 28, 2017

Phase II went into effect November 28, 2017, and includes revised F-Tags, interpretive guidance for existing requirements and a new computer-based, annual LTC survey process. This new survey process is nationwide, blending both elements of the traditional survey and Quality Indicator Survey processes. Nursing facilities are responsible for demonstrating compliance with the Phase I requirements during their 2017 annual surveys and need to focus on both the Phase I and II requirements in order to avoid the potential for survey deficiencies and negative outcomes. It is important that facilities have a plan to address all the changes outlined in both phases including processes to review current practices to secure effective and efficient adherence to the new standards.

Additional Phase II Focus Areas Include:

  • Behavioral Health Services
  • Quality Assurance and Performance Improvement - QAPI
  • Infection Control - Facility Assessment & Antibiotic Stewardship
  • Compliance & Ethics
  • Physical Environment - Smoking Policies

CDM, CFPPs need to review these new focus areas to see where food and nutrition services plays a role in helping their facility's team safeguard residents and be compliant with the new regulations.



Phase III

What's Yet to Come? Phase III: November 28, 2019

The CMS-phased approach for the rollout, spreading out implementation of the various requirements over three years, ends with the implementation of Phase III on November 28, 2019. The three phases were categorized based on CMS's assessment of each revision's complexity and the extent to which interpretive guidance and survey processes will need to be revised.

Phase III has requirements that need more time to implement (personnel hiring and training, implementation of systems, approaches to quality), so it was set for three years after November 28, 2016 and requires all areas from Phases I and II to be compliant.

Proposed Phase III Areas of Compliance

§483.85 Compliance and Ethics/Ethics Committee/Facility Compliance & Ethics Designee
§483.21 Comprehensive Person - Centered Care Planning/Trauma informed care
§483.40 Behavioral Health Services/Residents with history of trauma/PTSD
§483.75 QAPI - Quality Assurance and Performance Improvement/Full Implementation of QAPI and integration of Infection Preventionist
§483.90 Physical Environment/Resident call light next to the bed
§483.95 Training Requirements/Training requirements for all staff, contractors, volunteers

A Work in Progress: Preparing for Phase III Implementation

§483.85(c)(1) Compliance and Ethics
The operating organization for each facility must develop, implement, and maintain an effective compliance and ethics program that contains, among other elements, established written compliance and ethics standards, policies, and procedures to follow that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under the Act and promote quality of care, which include, but are not limited to

  • The designation of an appropriate compliance and ethics program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution; and
  • Disciplinary standards that set out the consequences for committing violations for the operating organization’s entire staff; individuals providing services under a contractual arrangement; and volunteers, consistent with the volunteers’ expected roles.

§483.75(c) QAPI feedback, data collection, and monitoring
Facility must establish and implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse events monitoring. The policies and procedures must include, at a minimum, the following:  Facility maintenance of systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

  • Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at § 483.70(e) and including how such information will be used to develop and monitor performance indicators.
  • Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.
  • Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d)(2) QAPI systematic approach for quality improvement
The facility will develop and implement policies addressing

  • How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
  • How they will develop corrective action that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
  • How the facility will monitor the effectiveness of its performance improvement activities to ensure improvements are sustained.