Chapter 5 - Nutrition

3-5.1  INTRODUCTION

1. Purpose.  This chapter describes the mission, philosophy, policies, procedures, responsibilities, and guidelines for nutrition services and programs in the Indian Health Service (IHS). It states the goal and objectives, standards, scope, operating relationships, staffing criteria, and responsibilities to attain and maintain quality nutrition services for American Indian and Alaska Native (AI/AN) people.
2. Mission.  The goal of nutrition services and programs in the Indian Health System (federal, Tribal, and urban health programs) is to contribute to the attainment of the optimal health status of AI/AN adults, children, and youth by implementing evidence-based and culturally relevant nutrition strategies. These strategies are integrated into established programs within AI/AN communities to ensure sustainability for the long-term and to reduce chronic diseases through prevention and treatment efforts.
3. Philosophy.  The significance of nutrition throughout the life cycle is increasingly known and documented. Optimal nutrition ensures a sufficiency of all nutrients required for normal metabolic processes at all stages of human development and avoids excesses that can modify those metabolic processes and lead to pathologic changes. A state of poor nutrition contributes to or complicates a variety of diseases and disabilities. Many nutrition-related health problems among AI/AN people are associated with a number of factors related to poverty, food insecurity, access to nutritious foods, and historical trauma. Promotion of optimal nutrition and nutritional care is essential to a well-planned health program and is especially significant in quality health care for AI/AN people. Nutrition that is consistent with needs, resources, cultural acceptability, and educational level of AI/AN people are most effective when they are family-oriented and coordinated with other Indian Health System programs and services.
4. Policy.   It is the policy of the IHS for nutrition programs to:
   1. Provide comprehensive nutrition services that address preventive, therapeutic, and rehabilitative nutritional care of the highest possible quality, based on the availability of resources.
      
      Meet relevant accreditation standards of The Joint Commission (TJC), other accrediting organizations of the local facility, and the Centers for Medicare and Medicaid Services (CMS). In those program areas not guided by TJC and/or CMS standards or where more definitive professional standards do not exist, nutrition programs should:
      1. Adopt the standards of the Academy of Nutrition and Dietetics (the Academy);
      2. Ensure the consistency of IHS publications with the established U.S. Department of Health and Human Services (HHS) and U.S. Department of Agriculture (USDA) dietary guidance principles; and
      3. Provide dietary guidance publications that are scientifically accurate, culturally relevant, and meet the needs of the population served.
5. Purpose of Standards.  This chapter offers standards for the full range of nutrition services for AI/AN people to ensure that they receive the highest possible quality care. These standards provide a set of uniform practices for the operation of the nutrition programs within IHS. The standards do not preclude the use of additional or comparable standards by IHS or Tribal nutrition programs, especially in the interest of securing third-party revenue.
6. Professional Practice References:
   1. Academy of Nutrition and Dietetics Evidence Analysis Library. Evidence-based Nutrition Practice Guidelines. Available at http://www.andeal.org/.
   2. Academy of Nutrition and Dietetics Nutrition Care Process. Available at https://www.eatrightpro.org/practice/nutrition-care-process.
   3. Academy of Nutrition and Dietetics Nutrition Care Manuals. Available at http://www.nutritioncaremanual.org/.
      1. Adult Nutrition Care Manual
      2. Pediatric Nutrition Care Manual
      3. Sports Nutrition Care Manual
   4. Academy of Nutrition and Dietetics. RDNs in the New Primary Care: A Toolkit for Successful Integration. Available at https://www.eatrightpro.org/career/career-resources/rdns-in-the-new-primary-care-toolkit.
   5. Academy of Nutrition and Dietetics. Scope of Practice, Standards of Practice for professional reference. Available at https://www.jandonline.org/content/core
   6. Academy of Nutrition and Dietetics. Nutrition Screening Tools. Available at https://www.jandonline.org/article/S2212-2672(19)31366-8/fulltext.
   7. Centers for Medicare and Medicaid Services. CMS Manual System Memorandum, Jan. 30, 2015. §482.28 Condition of Participation: Food and Dietetic Services. Revised Guidance Related to New & Revised Regulations for Hospitals, Ambulatory Surgical Centers (ASCs), Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). Available at https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert- Letter-15-22.pdf
      1. IHS Nutrition. Available at www.ihs.gov/nutrition
      2. IHS Division of Diabetes Treatment and Prevention. Available at www.ihs.gov/diabetes
      3. Step-by-Step Guide to Medicare Diabetes Self-Management Training Reimbursement, 2011.
      4. Step-by-Step Guide to Medicare Medical Nutrition Therapy Reimbursement Addendum.
      5. IHS Nutrition “Dietitian Information Network” LISTSERV. Available at https://www.ihs.gov/listserv/index.cfm/topics/signup/?list_id=198/.
      6. The Joint Commission. Available at http://www.jointcommission.org/.
      7. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2020 – 2025 Dietary Guidelines for Americans. Available at www.dietaryguidelines.gov
      8. U.S. Food and Drug Administration (FDA). Food Code 2022. Available at https://www.fda.gov/food/retail-food-protection/fda-food-code

3-5.2  OBJECTIVES

1. The Nutrition Services and Programs.  These programs in the IHS are an integral part of the total Indian health care system. The objectives are:
   1. To promote and provide quality nutrition services with an emphasis on promoting health, preventing disease, restoring health, and maintaining health.
   2. To act as food advocates for AI/AN people/communities and address issues that affect the health status of AI/AN people, including food insecurity and food sovereignty.
   3. To understand and practice cultural sensitivity and competence.
   4. To provide encouragement and guidance to AI/AN students interested in nutrition careers.
   5. To integrate nutrition services into all applicable intervention programs and services in hospitals, residential substance abuse treatment centers, primary care clinics, health centers, and communities served by the IHS.
   6. To provide guidelines and standards as a basis for monitoring and evaluating nutrition services for quality improvement.
   7. To act as advocates for nutrition care by addressing issues that affect the health and nutritional status of AI/AN people.
   8. To promote efforts in gaining new knowledge to improve the nutritional status of AI/AN people through surveillance and research aimed at improving their health status.
2. Nutrition Functions.  Nutrition programs throughout the Indian Health System contain an interdependent system for the delivery of hospital inpatient and outpatient care, primary care, community nutrition services, and residential treatment center nutrition services. Generally, nutrition programs all address the mission, goal, and objectives through six standard functions:
   1. Program Planning. Program planning encompasses a range of activities for providing comprehensive nutrition services. This includes participation with various IHS and Tribal representatives to identify and assess community resources, evaluate problem areas, document areas of unmet need, and develop and carry out specific health plans. This planning also includes participation in national performance measure surveillance systems, such as Government Performance and Results Act (GPRA) and the IHS Diabetes Care and Outcomes Audit. In addition, planning also includes participation in government sponsored health initiatives (e.g., Million Hearts Initiative).
   2. Setting and Meeting Standards. Nutrition programs may choose to identify and implement relevant nutrition standards, such as those established by CMS or FDA, or by non-governmental organizations, such as TJC and the Academy. Programs may also choose to meet state standards, provided the program does not seek state licensure or permission.
   3. Program Operations.   Nutrition services are based on assessed needs and requested actions from Tribes. Program operations encompass a wide range of nutrition-related activities divided into three major subgroupings: patient services, community services, and administrative activities.
      1. Patient services are offered to individuals, groups, and families. These services include medical nutrition therapy (MNT), nutrition education, inpatient meal service, field contacts and follow-up, and referrals to the health care providers.
      2. Community services emphasize health promotion and disease prevention and strive to improve or maintain optimum nutritional health of the whole population or vulnerable subgroups within the population. Multiple coordinated strategies are used to reach and influence individuals, communities, and organizations.
      3. Administrative activities are related to resource management, quality improvement, maintenance of activities and cost records, and development and implementation of agreements with Tribal, state, and federal agencies/institutions.
   4. Monitoring and Performance Improvement.   Performance improvement is a continuous activity that involves measuring the function of important processes and services, and when indicated, identifying changes that enhance performance. Monitoring programs helps to ensure that AI/AN people receive the highest possible quality of care, that requirements for IHS nutrition programs are met, and that the programs are in compliance with TJC, CMS, the Academy, Federal law, and IHS Standards.
   5. Program Evaluation.   Program evaluation ensures that the mission, goal, and objectives are achieved and that the services provided result in quality nutrition to AI/AN people. Program evaluation and reviews identify strengths, deficiencies, and unmet needs to enable corrective actions. Program reviews, through assessment of the nutrition services (using quality improvement processes, TJC and CMS surveys, peer review, achievement of national program standards, and benchmarks), are performed on an ongoing basis.
   6. Resource Management.   Resource management includes the utilization of personnel, money, and materials to achieve the desired outcomes in the most efficient and effective manner possible.
      1. All nutrition program professional staff delivering MNT services to AI/AN people must be Registered Dietitian Nutritionists (RDNs) or Registered Dietitians (RDs). RDNs and RDs are two credential designation options for one certification program. Practitioners may choose to use one or the other designation when listing their credentials.
      2. Paraprofessional staff providing nutrition services must have the qualifications and experiences required for their position and have supervision from an RDN or RD.
      3. Training. It will be the responsibility of the programs to identify training resources and to ensure that all nutrition program staff have completed the training. Training requirements include:
         1. RDN/RDs should conduct a regular learning needs assessment and self-evaluation that assesses their area of focus knowledge, skills, and competence. Review and use of the Academy’s Standards of Practice (SOP) and Standards of Professional Practice (SOPP) may aid self- assessment and enhance practice and professional performance.
         2. Updating knowledge and skills related to current trends in clinical, community, and administrative nutrition practice.
         3. Meeting continuing professional education requirements and personnel/program needs.
         4. An orientation to the foods local to their area (including traditional foods), local customs, and understanding the dynamics of the community served. This should include an orientation to the provision of culturally sensitive nutrition care.

3-5.3  ORGANIZATIONAL RESPONSIBILITY

These functions are designated to ensure program continuity.

1. Headquarters Functions.  A subject matter expert in nutrition, a Registered Dietitian, is designated by the Director of the Office of Clinical and Preventative Services. The Nutritionist is responsible for providing national leadership and professional guidance to strengthen and improve the quality and scope of nutrition services for clinical, community, and administrative services throughout the IHS.
   1. Program Planning.    Participates in Headquarters program planning activities and special planning projects.
   2. Setting and Meeting Standards.   Reviews and provides resources to the network of Indian health care providers regarding the national standards for nutrition services and professional practice [American Diabetes Association (ADA), American Association of Diabetes Educators (AADE), the Academy, CMS, and TJC].
      1. Participates in the development of IHS policies and procedures that affect nutrition services and programs.
      2. Participates in the development of national nutritional standards, guidelines, and objectives.
   3. Program Operations.
      1. Provides technical assistance, information, and support services to the IHS Director, Headquarters staff, and program staff. Provides coordination for consultation to nutrition services and programs on program planning, operations, standards of care, evaluation, and management of available resources.
      2. Provides information to nutrition staff on national and IHS policies that will impact Area and service unit operations. RDN/RDs are to participate in strategic planning, development, and use of programs and materials, peer program reviews, and networking activities.
      3. Maintains working relationships with national health and nutrition programs and collaborates in the development of interagency agreements.
      4. Disseminates pertinent legislation, policy, procedures, guidelines, and other information.
      5. Participates in the development of IHS policies that affect the health and well-being of AI/AN people, including, but not limited to those related to the provision of nutrition services.
      6. Explains the scope of nutrition services and programs to Indian health leaders, Tribal leaders, Tribal organizations, governmental agencies, and professional groups.
      7. Provides assistance to nutrition care providers and keeps them informed of national policies and legislation that impact the provision of services.
      8. Provides guidance for the IHS Nutrition and Dietetics Training Program in the provision of continuing education hours for RDN/RDs.
      9. Represents the IHS and advocates for AI/AN people at governmental meetings and serves on IHS and other pertinent committees.
      10. Encourages, coordinates, and conducts research aimed at improving the health of AI/AN people within the Indian Health System. Such research efforts are coordinated to gain relevant knowledge, while at the same time protecting the rights and well- being of research project participants and resources when appropriate collaboration with other governmental agencies and interested parties is encouraged.
   4. Monitoring and Performance Improvement.
      1. Remains apprised of national standards (TJC, CMS, the Academy, ADA, AADE) for nutrition care services and programs. Makes resources regarding these national standards accessible to the network of Indian health nutrition care providers.
      2. Establishes and maintains a national network of nutrition care providers through an RDN/RD listserv and other activities. Encourages RDN/RD participation in a national network of nutrition care providers.
      3. Encourages RDN/RD peer support and peer review locally and regionally.
   5. Program Evaluation.
      1. Participates in management reviews of IHS nutrition services and programs, as requested and recommends a change when necessary.
      2. Analyzes, interprets, and reports data from objectives established in program plans and nutrition data from the annual IHS Diabetes Care and Outcomes Audit and other data sources.
   6. Resource Management.
      1. Participates in preparing budget proposals to ensure that adequate resources are available to meet established program objectives.
      2. Assists in the recruitment and retention of qualified nutrition program staff.
      3. Works with the nutrition network in identifying training needs and training priorities. Works with the Division of Diabetes Treatment and Prevention and the Nutrition and Dietetics Training Program in planning and conducting training to meet the needs of staff and service population. Assists in the orientation of new staff in nutrition programs.
      4. Seeks and encourages interested AI/AN students to enter the field of nutrition. Where possible, provides assistance in connecting students to dietitians in the field. Nutrition programs are permitted to offer field experience and mentorship to graduate and undergraduate nutrition students from accredited programs as time, staff, and meaningful experience opportunities are available. When student training is provided, a collaborative agreement or contract is developed between the educational institution and the program.
2. Service Unit Functions.    Qualified RDN/RDs are responsible for the service unit nutrition services and programs. RDN/RDs serve as the consultants and technical advisors to the service unit/Tribal health director and staff regarding the scope of the service unit program, its operations and quality of services, priorities, and identification of unmet needs.
   1. Program Planning.
      1. Collects, analyzes, and interprets service unit/Tribal nutrition data.
      2. Encourages community members to participate in program planning.
      3. Prepares a nutrition program plan that is consistent with expressed needs of the local service population and with national, Area, and service unit priorities and objectives.
   2. Setting and Meeting Standards.
      1. Reviews national and IHS standards, operational procedures, program guidelines from IHS and non-IHS health and nutrition agencies/institutes, and assesses applicability for use locally. If the IHS standards are not applicable, Tribal specific standards are utilized. Develops local policy and procedure issuances and nutrition care standards and guidance.
      2. Reviews and updates the service unit nutrition program policy and procedure manual for administrative, community, inpatient, and outpatient services annually.
   3. Program Operation.
      1. Provides comprehensive nutrition services to AI/AN patients, families, and communities through a variety of methods, including nutrition education, medical nutrition therapy, hospital/treatment center food services, community services, in-service consultation, and applied research.
      2. Provides technical assistance and support to the service unit director and administrative and program staff.
      3. Supervises service unit nutrition professional and paraprofessional staff.
      4. Describes the scope of the service unit nutrition program to local Tribal leaders, program managers, and community agencies.
      5. Maintains working relationships with local health and nutrition agencies to coordinate services.
      6. Maintains familiarity with changes in legislation, IHS and Tribal policies, and regulations that impact service delivery and patient care.
      7. Implements policies, procedures, and nutrition guidelines.
      8. Participates in the development of IHS procedures at the service unit level to improve the management and delivery of health care.
      9. Represents the service unit and/or nutrition program at state or local meetings.
      10. Serves on IHS and other pertinent committees and care teams.
      11. Collaborates with other service unit RDN/RDs activities, including strategic planning, cooperative development and use of programs and materials, peer program reviews, quality improvement, training, and networking.
   4. Monitoring Performance Improvement.
      1. Identifies areas for improvement, develops proposals, and plans and submits them to the leadership team at the service unit.
      2. Monitors departmental operations and quality controls to ensure conformance with program requirements, operational guidelines, IHS requirements, CMS, TJC, federal law, and professional standards.
      3. Maintains, reviews, and audits activity data, nutrition files, and entries in medical/health records.
      4. Actively participates in service unit quality improvement processes.
      5. Completes nutrition audits as required by TJC and IHS standards.
   5. Program Evaluation.
      1. Develops a nutrition performance improvement program that will comply with IHS, CMS, TJC, and professional standards and requirements.
      2. Conducts an evaluation of the service unit nutrition program using the results of nutrition and dietetics audits, TJC survey team findings, and service population surveys/audits. Results of evaluations are reflected in future program plans.
      3. Participates in peer reviews following the CMS and TJC standards.
   6. Resource Management.
      1. Assesses and establishes personnel needs and identifies resources according to the IHS staffing standards for nutrition services. IHS, Resource Requirement Methodology (RRM).
      2. Participates in staff recruitment, placement, and retention.
      3. Identifies training needs and deficiencies and develops a plan to meet those needs.
      4. Seeks and encourages interested AI/AN students to enter the field of nutrition. Offers field experience and mentorship to graduate and undergraduate nutrition students from accredited programs as time, staff, and meaningful experience opportunities are available. When student training is provided, a collaborative agreement or contract is developed between the educational institution and the program.

3-5-4  COMPREHENSIVE NUTRITION SERVICES

1. General.  The nutrition program provides comprehensive food and nutrition services. These services include nutrition education, medical nutrition therapy, hospital/treatment center food service, community services, and in-service consultation. Nutrition services are organized and directed by a qualified RDN/RD. Nutrition services contribute to the attainment of the optimal health status of the population by reducing the risk of chronic diseases by bridging the gap between nutritional sciences and applying sound nutritional practices by community members. Nutrition services comply with IHS regulations and TJC and CMS standards.
2. Program Planning.  . Nutrition activities are conducted according to a written plan that is based on identified needs and available resources and is consistent with local traditions and culture. The plan is reviewed and updated as necessary, but at least annually, and approved by appropriate administrative personnel. Program planning includes, but is not limited to, the following:
   1. External Needs Assessment.   An external needs assessment includes:
      1. Perceived needs of the community, including food security.
      2. Nutritional status of the service population, including major disease prevalence and incidence.
      3. Profile of the service population, including demographics, socioeconomic conditions, and health risk factors.
      4. Description of health care and nutrition services currently available to the population, including service and location.
      5. Cultural and traditional practices, including food habits.
      6. Referral hospitals and ambulatory care centers.
   2. Internal Needs Assessment.   An internal needs assessment includes:
      1. Service unit and nutrition program mission statements.
      2. Nutrition services scope of work.
      3. Agency, service unit, and nutrition program organizational charts and facility committee structures.
      4. Staffing resources (RDN/RDs, dietetic technicians, food service personnel, nutrition assistants, and others).
      5. Average daily inpatient census, daily patron and non-patron ratios, and outpatient and health center care visits.
      6. Level and type of service including diagnoses prevalence.
      7. Food service facility including equipment type and age.
      8. Budget and procurement processes.
   3. Nutrition Services Plan.   The plan includes at a minimum:
      1. A program mission, goals, objectives, priorities, and resources available.
      2. Long-range objectives with measurable outcomes consistent with local program priorities, health and nutritional status of populations, national health objectives, Area and service unit strategic plans, and applicable legislation.
      3. Intermediate and short-range objectives with measurable outcomes that are practical in scope and will lead to the achievement of long- term objectives over time.
      4. Strategies, interventions, and methods designed to achieve objectives.
      5. Description of resources needed to achieve program mission and objectives.
      6. Evaluation plans describing what indicators of change will be evaluated and measured, what data will be collected, how data will be collected and analyzed, who is responsible, and how information will be used.
      7. Evidence that nutrition program staff, community members, and collaborating organizations participate in the planning process.
3. Setting and Meeting Standards.  Written nutrition service policies and procedures are developed in cooperation with the hospital and/or clinic staff. Nutrition programs may choose to identify and implement relevant nutrition standards, such as those established by CMS or FDA, or by non-governmental organizations, such as the TJC and the Academy. Programs may also choose to meet state standards, provided the program does not seek state licensure or permission.
   
   Policies and procedures are available to appropriate staff, reviewed and updated at least annually, and maintained for nutrition and food service administration in the following areas:
   1. Nutrition Program Administration.   The administrative policies and procedures include, at a minimum:
      1. The scope of work adequate for accreditation and contracting services.
      2. Responsibilities and authority of the director of nutrition services.
      3. Employee management.
         1. Performance appraisals.
         2. Staffing patterns and scheduling.
         3. Union agreements.
         4. Orientation, in-service education, and training.
      4. Performance improvement.
      5. Food service administration.
         1. Meal hours, tray service, cafeteria service, and vending machine(s).
         2. Therapeutic diet orders.
         3. Menu planning.
         4. Inventory and food procurement.
         5. Food preparation.
         6. Storage of food and non-food items.
         7. Nutrition and food cost accounting.
         8. Schedule of staff training.
         9. Collaborative agreements, liaison, or cooperative activities with other organizations or agencies.
      6. Disaster plan - internal and external.
      7. Fire, safety, sanitation, and infection control.
   2. Clinical Nutrition Care Standards.
      1. Scope of nutrition services and patient priorities, including therapeutic diet order-writing privileges by the RDN/RD, as approved by the medical staff in the hospital setting.
      2. Use of the Academy of Nutrition and Dietetics (AND) Nutrition Care Manual(s) or other approved diet manuals and other reliable references.
      3. Use of AND Nutrition Care Guidelines or other approved nutritional care guidelines.
4. Program Operations.  
   1. Medical Nutrition Therapy (MNT).   MNT is the development and provision of specific nutrition procedures in the treatment of a disease or condition or to prevent or delay disease or complications and optimize health and performance.
      1. The RDN/RD is an integral team member in the hospital – both inpatient and outpatient, primary care and health care centers, and community health programs.
      2. MNT is provided using the Nutrition Care Process (NCP) and includes performing a comprehensive nutrition assessment to determine a nutrition diagnosis, planning and implementing a nutrition intervention using evidence-based nutrition practice guidelines, and monitoring and evaluating an individual’s progress over subsequent visits. The level, content, and frequency of nutrition services that are appropriate for optimal care and nutrition outcomes are individualized by the RDN/RD providing the MNT.
         1. Nutrition Screen. The nutrition program will develop a nutrition screening process to determine the nutritional risks for patients. Inpatient nutrition screening is completed within 24 hours of admission through the Nursing Admissions Assessment (according to TJC and CMS standards). Information pertinent to the feeding of the patient is collected and transmitted to the Nutrition Services food preparation area.
         2. Inpatient Therapeutic Diet Order. All patients have a diet order written by the provider responsible for the care of the patient or by the RDN/RD, if authorized by the organization. The diet order is communicated to the nutrition program. A system must be in place for notifying nutrition services of the diet order in a timely manner.
         3. Nutrition Assessment. The RDN/RD collects and documents information, such as food or nutrition-related history, biochemical data, medical tests and procedures, anthropometric measurements, nutrition-focused physical findings, and client history.
         4. Nutrition Diagnosis. Data collected during the nutrition assessment guides the RDN/RD in selection of the appropriate nutrition diagnosis (i.e., naming the specific problem).
         5. Nutrition Intervention. The RDN/RD then selects a nutrition intervention that will, (1) address the root cause (or etiology) of the nutrition problem and (2) alleviate the signs and symptoms associated with the nutrition diagnosis.
         6. Monitoring/Evaluation. The RDN/RD determines if the patient/client has achieved or is making progress toward the planned goals.
         7. Nutrition Care Plans. Care plans are completed and include a summary of the dietary history, nutritional assessment, patient education and patient goals, description of education materials given, and assessment of a patient's understanding of diet.
         8. Documentation. MNT is documented in the electronic health record (EHR) or an equivalent patient record.
         9. Discharge Planning and Referrals. Discharge planning and appropriate referrals are made for follow-up.
         10. Equipment. Clinical equipment used for nutrition assessment is adequate, well maintained, and calibrated at least annually or according to manufacturer instructions for use.
      3. MNT can be provided in-person or via telehealth. Telehealth is “the use of electronic information and telecommunications to support long-distance clinical health care, and patient and professional health-related education.” Telenutrition refers to the use of electronic information and tele-communications for the provision of nutrition care. Telenutrition has significantly facilitated access to nutrition care which is especially challenging in remote AI/AN communities. Establishment of a service unit-wide telenutrition policy/procedure that will include licensure requirements, privacy and security requirements, workflows, an adverse event reporting plan, billing and documentation requirements is recommended. https://www.eatrightpro.org/practice/practice-resources/telehealth
   2. Community Nutrition Service. Community nutrition services are planned, implemented, and evaluated in a manner consistent with standards of professional practice.
      
      Community nutrition staff:
      1. Promotes community awareness of nutrition-related health problems and issues through screening and educational activities.
      2. Participates as a leader, liaison, or technical advisor in organized community partnerships using educational, environmental, and social change strategies to improve nutritional status.
      3. Participates in interdisciplinary and interagency networks, committees, and task forces that promote or facilitate achievement of nutrition program objectives and contribute to the improvement of health and the nutritional status of the AI/AN community.
      4. Develops and implements community-based interventions designed to reduce the risk of chronic diseases, reduce food insecurity, and improve the nutritional status of the community members.
      5. Depending on staff availability, collaborates and participates in development, implementation, and publication of local, Area, and national nutrition program research (including data collection, analysis, and use) to determine disease prevalence, measure changes in health status, and evaluate programs.
      6. Establishes and maintains referral systems. Coordinates with and promotes federal nutrition programs, such as: Women, Infants and Children; Supplemental Nutrition Assistance Program; Food Distribution Program on Indian Reservations; Summer Food Programs; Summer Electronic Benefits Transfer for Children; and others.
      7. Develops or adapts community-specific public information and educational materials, and campaigns through social media and other communication media (print, radio, etc.).
      8. Advocates for resources needed to maintain or improve community nutrition practices.
      9. Advocates for and monitors ordinances or legislation pertinent to nutritional problems of the service population.
      10. Provides MNT and nutrition education to individuals, families, and groups in the community.
      11. The scope of the community nutrition service includes participating in health promotion and disease prevention activities and maintaining a liaison relationship with appropriate groups. If sufficiently staffed, the RDN/RD will provide technical assistance and consultation services to organizations outside the IHS, according to a written agreement that details objectives to be achieved, resources to be used, and timeframes for completing activities, projects, or services.
   3. Patient Food Service. The characteristics of the food served are often what the patient remembers most about their hospitalization. Food is important to the healing process and provides a sense of comfort, nurturance, and well-being to the patient. Meals served should be in compliance with the individual’s cultural and traditional beliefs and be appropriate for their medical diagnosis.
      1. Patient Meals.   Patient meals include all meals, infant formulas, and tube feedings served to patients.
         1. Patients on oral intake receive at least three meals daily with not more than a 14-hour (CMS 14 hours, TJC 15 hours) span between a substantial evening meal and the first substantial meal of the next day.
         2. Systems should be in place that ensure each patient receives the correct tray and diet.
         3. Nutrition personnel are responsible for delivering trays to the nursing units.
         4. Nursing or nutrition service personnel may be responsible for serving trays to patients; hospital policy will determine this responsibility.
         5. Tray service for patients in isolation is carried out in accordance with the Service Unit Infection Control Committee policies.
         6. In hospitals with inpatient dining room facility areas, all inpatients, both wheelchair and ambulatory, are encouraged to eat in these areas.
      2. Non-patient Food Service. The provisions regarding subsistence to IHS employees and guests at AI/AN hospitals and residential treatment centers include:
         1. When adequate hospital meal service facilities and food service staff are available, each IHS Area Director (or Service Unit Director if so designated) may authorize the sale of meals to hospital employees and guests and must approve Area/service unit rates for meals. Food portion costs will be reviewed and adjusted at least annually.
         2. Internal controls are established to ensure that only authorized personnel are served.
         3. Authorized guest meals are served only where the food service staff is sufficient and dining room space is adequate to provide this service.
      3. Non-patient Special Events. No food or beverage for coffee breaks and special occasions are provided from hospital subsistence.
   4. Meal Planning and Preparation.
      1. Culturally appropriate menus are planned for all age groups in accordance with AND Diet Manual requirements, other IHS approved diet manual requirements, current Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, and the Dietary Guidelines for Americans. Meals provided to patients are therapeutically correct, prepared under safe and sanitary conditions, attractively served, palatable, nutritionally adequate, and culturally appropriate.
      2. Cycle menus are planned, posted, and followed. Menu substitutions are appropriate, documented, initialed, dated on the menu form or calendar, and kept on file for six months.
      3. Patients on oral intake receive at least three meals daily with not more than a 14-hour span between a substantial evening meal and the first substantial meal of the next day.
      4. Patients not receiving oral intake are identified and monitored.
      5. Only authorized persons are served meals.
      6. No food or beverage for coffee breaks or other occasions are provided from hospital subsistence.
      7. Food sanitation and safety practices are in accordance with the latest edition of the FDA Food Code and applicable laws, regulations, and codes.
      8. Food, disposable products, and cleaning supplies are prepared and stored in accordance with the latest edition of the FDA Food Code and the Occupational Safety and Health Administration. Only food service subsistence items are stored in refrigerators, freezers, and areas assigned to the Nutrition Program. All items are properly stored, wrapped, and labeled.
      9. Employee health policies for the nutrition program personnel are in compliance with Federal, State, and local laws and regulations.
      10. Approved equipment is used for keeping perishable foods at safe temperatures during preparation, holding, delivery, and service to patients or clients.
   5. Procurement.
      1. All foods are procured from sources considered satisfactory by a qualified food inspector.
      2. Spoiled, adulterated, misbranded, or outdated food is reported to the RDN/RD and/or sanitarian for appropriate credit and disposal.
   6. Safety and Sanitation.
      1. Food service sanitation surveys are conducted at least semiannually by the IHS Division of Environmental Health Services (Indian Health Manual, Part 3, Chapter 11, Environmental Health). The RDN/RD or designee receives a written report of each inspection and submits a written reply to the hospital administrative officer stating corrective actions taken. Unsatisfactory reports require a follow-up within the next 10 weeks. The dietitian or designee will conduct regularly scheduled sanitation inspections.
      2. Safety and sanitation control measures are maintained. Facilities and equipment are in compliance with the latest edition of the FDA Food Code and applicable regulations. Aim to prevent food safety problems from occurring. Recommend the implementation and maintenance of a Hazard Analysis Critical Control Points (HACCP) Plan.
      3. Only authorized personnel enter receiving, storage, preparation, and service areas.
      4. No food or beverage is consumed in the receiving, storage, preparation, and service area.
      5. Comply with the IHS tobacco-free policy (Indian Health Manual, Part 3, Chapter 5, Tobacco-Free Policy). In non-IHS facilities, tobacco use should be prohibited in receiving, storage, preparation, and service areas.
      6. Cleaning schedules are developed, posted, and followed.
      7. Equipment is adequate and appropriate and meets existing National Sanitation Foundation standards.