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Provision of Dietary Services from Hospital Off-site Location

PDF Version of BQA 99-047 (PDF, 11 KB) - includes attachment

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Date: August 18, 1999 DSL-BQA 99-047

To: Hospitals HOSP 17

From: Susan Schroeder, Director, Bureau of Quality Assurance

The purpose of this memorandum is to provide you with information we received [see below] from the federal Health Care Financing Administration. This information clarifies the provision of dietary services from off-site locations. Though dietary services may be provided by a contracted service, the hospital is responsible for meeting the food and dietetic services condition of participation at 42 CFR 482.28 and the dietary services regulations in Wisconsin Administrative Code, Chapter DHS 124 (exit DHS) Hospitals Rules.

Please share this information with appropriate staff. If you have questions, please contact Jean Kollasch, Dietary Services Consultant, Bureau of Quality Assurance, at (608) 267-0466.


DATE: [Undated memo received electronically in the RO on 7-14-99.]
FROM: Director, Clinical Standards Group, Office of Clinical Standards and Quality
SUBJECT: Provision of Dietary Services from Off-site Locations

TO: Associate Regional Administrators
Division of Medicaid and State Operations
Regions I-X

We recently learned of some inconsistencies in applying the hospital condition of participation (CoP)--Food and Dietetic services when dietary services are provided from off-site locations. The purpose of this memorandum is to provide guidance regarding interpretation of 42 CFR 482.28, food and dietetic services for hospitals.

The food and dietetic services CoP at 42 CFR 482.28 states:

The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this condition of participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment.

There are several ways by which hospitals may provide dietary services: 1) hospitals may provide the service in the traditional configuration where the kitchen is located on the hospital premise; 2) hospitals may provide the service directly, but may prepare the bulk of the meals in a kitchen owned by the hospital, located off-site; and 3) hospitals may contract out for dietary services through an off-site vendor. The hospital dietary services CoP does not specifically require a hospital to have dietary services/food preparation on the hospital premise. When foods are prepared off-site, modern technology makes it possible to transport foods without compromising quality. If the hospital provides dietary services through an off-site vendor, the vendor is under contract with the hospital. In such instances, the standard for contracted services (42 CFR 482.12(f)), under the Governing Body CoP, is applicable. However, regardless of how the hospital provides the service, the hospital is ultimately responsible for meeting the dietary services CoP.

To determine compliance when dietary services are provided from an off-site location, surveyors can monitor compliance by reviewing such things as:

  • integration into the quality assurance program,

  • integration into the infection control program,

  • integration into the dietetic policies and procedures in regards to meal service for off hours’ admissions, late trays, food substitutions, reasonable meal schedules, posting of current menus in the hospital as well as in the off-site kitchen, tray accuracy, food handling safety practices, emergency food supplies and deliveries, staffing and patient satisfaction,

  • a current therapeutic diet manual approved by the dietitian and medical staff,

  • nutritional assessment indicating nutritional needs are met in accordance with recognized dietary practices as well as with orders of the practitioners responsible for the care of the patients.

/s/ Mary R.Vienna

 cc: Joan Simmons, CMSO

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