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U.S. Department of Health and Human Services
Indian Health Manual

Chapter 5 - Nutrition

Part 3 - Professional Services

Title Section
Introduction 3-5.1
    Purpose 3.5.1A
    Mission. 3-5.1B
    Policy 3-5.1C
    Purpose of Standards 3-5.1D
    Professional Practice References 3-5.1E
    Definitions 3-5.1F
Objectives 3-5.2
    The Nutrition Services and Programs 3-5.2A
    Nutrition Functions 3-5.2B
Organizational Responsibility 3-5.3
    Headquarters Functions 3-5.3A
    Service Unit Functions 3-5.3B
Comprehensive Nutrition Services 3-5.4
    General 3-5.4A
    Program Planning 3-5.4B
    Setting and Meeting Standards 3-5.4C
    Program Operations 3-5.4D

3-5.1 INTRODUCTION

  1. Purpose. This revised 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. Optimal nutrition ensures 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. Many nutrition-related health issues among AI/AN people are associated with a number of factors related to poverty, food insecurity, limited access to nutritious foods, and historical trauma. Nutrition that is consistent with the needs, resources, and cultural acceptability of AI/AN people is most effective when it is family-oriented and coordinated with other Indian health system programs and services.
  2. Mission. The goal of nutrition services and programs in the Indian health system (Federal, Tribal, and Urban Indian 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 long-term sustainability and to reduce chronic diseases through prevention and treatment efforts.
  3. 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 to support Medicare and Medicaid participation; public trust and organizational credibility; contracts with commercial payors; and improvement efforts in internal controls and safety. In program areas without Centers for Medicare & Medicaid Service (CMS) guidance and established professional standards, 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 and U.S. Department of Agriculture dietary guidance principles; and
      3. Provide dietary guidance publications that are scientifically accurate, culturally relevant, and meet the needs of the population served.
  4. 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 the 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.
  5. Professional Practice References.
    1. Academy of Nutrition and Dietetics Evidence Analysis Library. Evidence-based Nutrition Practice Guidelines. 
    2. Academy of Nutrition and Dietetics Nutrition Care Process.
    3. Academy of Nutrition and Dietetics Nutrition Care Manuals. Available at https://www.nutritioncaremanual.org/.
      1. Adult Nutrition Care Manual
      2. Pediatric Nutrition Care Manual
      3. Sports Nutrition Care Manual
    4. Academy of Nutrition and Dietetics (AND). RDNs in the New Primary Care: A Toolkit for Successful Integration. Available only to AND members.
    5. Commission on Dietetic Registration. Scope and Standards of Practice.
    6. Academy of Nutrition and Dietetics. Malnutrition Screening Tools.
    7. Centers for Medicare and Medicaid Services. Medicare Enrollment for Providers & Suppliers
    8. IHS Nutrition.
    9. IHS Division of Diabetes Treatment and Prevention.
      1. IHS Nutrition “Dietitian Information Network” LISTSERV.
      2. IHS Nutrition “IHS Nutrition LISTSERV.
    10. Joint Commission.
    11. S. Department of Health and Human Services and U.S. Department of Agriculture. 2025 – 2030 Dietary Guidelines for Americans.
    12. S. Food and Drug Administration (FDA). Food Code 2022.
  6. Definitions.
    1. Registered Dietitian Nutritionist (RDN) or Registered Dietitian (RD). An individual who meets the education, supervised experience, testing, and continuing education requirements for dietetic registration with the Commission on Dietetic Registration. This person is a specialist educated for the profession that is responsible for the nutrition care of individuals and groups. This professional responsibility includes the application of science and art of human nutrition in helping people select and obtain food for the primary purpose of nourishing their bodies in health and disease throughout the life cycle. All nutrition professional positions funded by the IHS must be held by individuals who possess and maintain the RDN/RD credential.
    2. Administrative Dietitian, RDN/RD. The administrative dietitian, RDN/RD, is a member of the management team and affects the nutrition care of groups through the management of food service systems that provide optimal nutrition and quality food.
    3. Clinical Dietitian, RDN/RD. The clinical dietitian, RDN/RD, is a member of the health care team and affects the nutritional care of individuals and groups with emphasis on promoting health, preventing disease, restoring health, and maintaining health. The clinical dietitian assesses nutritional needs, develops and implements nutritional care plans, and evaluates and reports these results appropriately. When functioning in an organization that provides food service, the clinical dietitian cooperates and coordinates activities with the department's management team.
    4. Consultant Dietitian, RDN/RD. The consultant dietitian, RDN/RD, with experience in administrative and clinical dietetic practice affects the management of human effort and facilitates resources by advice or services in nutritional care.
    5. Director, RDN/RD. An RDN/RD with an advanced academic degree and successful experience, who assumes full responsibility for the management of a department and serves as a member of the organization's management team. The Director, RDN/RD, reports to the designated administrator.
    6. Research Dietitian, RDN/RD. The research dietitian, RDN/RD, with advanced preparation in dietetics and research techniques, plans, investigates, interprets, evaluates, applies, and expands knowledge in one or more phases of dietetics and communicates findings through reports and publications.
    7. Public Health Nutritionist, RDN/RD. The position title used for the nutrition professional with academic preparation in public health who is employed in a local public health agency to assess community nutrition needs and plans, directs, and evaluates population-based nutrition programs to meet those needs. If the ambulatory care clinic nutrition professional staffing levels are insufficient to meet service needs or are not justified based on population size, patient care is provided by hospital dietitians, community nutritionists, and public health nutritionists as specified in a written plan.
    8. Dietitian, RDN/RD. An individual who is professionally trained to be responsible for the nutritional care of individuals and groups through food service management, teaching food and nutrition principles to groups, or in providing individual dietary counseling.
    9. Nutritionist, RDN/RD. Position title used for the entry-level nutrition professional employed in a public health agency to provide nutrition services to clients and the public.
    10. Dietetic Manager. A person who is a graduate of an approved dietetic manager program and who manages food operations in institutions, such as hospitals, nursing homes, and other educational and community feeding centers. Uses the services of a dietitian (consultant) as required for development of special diets and menus.
    11. Nutrition and Dietetics Technicians, Registered (NDTR). A person who is a graduate of an Associate Degree Program approved by the Accreditation Council for Education in Nutrition and Dietetics and who has passed the Commission on Dietetic Registration’s Examination for Dietetic Technicians. The program may emphasize either food service management or nutritional care. The NDTRs work under the clinical supervision of the RDN when engaged in direct patient/client nutrition care activities in any setting.
    12. Nutrition Assistant. Position title used for the auxiliary nutrition worker who is trained on-the-job to assist nutrition professionals in the delivery of nutrition services.
    13. Therapeutic Diet. A nutrition intervention prescribed by a physician or other authorized non-physician practitioner that provides food, fluid, or nutrients via oral, enteral, and/or parenteral routes as part of the treatment of disease or clinical conditions to modify, eliminate, decrease, or increase identified micro- and macro-nutrients in the diet. Therapeutic diets provide nutrition intervention based on nutrition assessment that addresses an identified disease, clinical condition, or nutrition diagnosis by providing the specific nutritional requirements.
    14. Nutrition. The science of food, the nutrients and other substances therein, their action, interaction, and balance in relation to health and disease, and the process by which the organism ingests, absorbs, transports, utilizes, and excretes food substances. (Commission on Dietetic Registration, 2024)
    15. Nutrition Assessment. As part of the Nutrition Care Process, Nutrition Assessment (and reassessment) is a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status-related nutritional problems, and their causes. It is an ongoing, dynamic process that involves not only initial data collection, but also reassessment and analysis of client or community needs and provides the foundation for Nutrition Diagnosis and nutritional recommendations, including enteral and parenteral nutrition. (Commission on Dietetic Registration, 2024)
    16. Nutrition Care Process. The Nutrition Care Process (NCP) is a systematic problem-solving method that credentialed nutrition and dietetics practitioners use to think critically and make decisions when providing medical nutrition therapy or to address nutrition-related problems and provide safe and effective quality nutrition care. The NCP consists of four distinct, interrelated steps: Nutrition Assessment and Reassessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation. (Commission on Dietetic Registration, 2024)
    17. Nutrition Screen. A limited nutrition assessment of factors pertinent to the feeding of a hospitalized patient. Pertinent information includes but is not limited to appetite, food allergies or intolerance, diet prior to admission, eating or feeding problems, personal and cultural food preferences, and diet order.

3-5.2 OBJECTIVES

  1. The Nutrition Services and Programs. These programs within 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 implement specific health plans. This process involves participating in national performance surveillance systems, such as the Government Performance and Results Act and the IHS Diabetes Care and Outcomes Audit, as well as other 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 Joint Commission (JC) and the Academy. Programs may also choose to meet state standards, provided the program does not seek state licensure or permission. Nutrition programs must comply with their identified standards.
    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 subgroups: 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 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. They use multiple coordinated strategies 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 help 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 comply with JC, CMS, the Academy, Federal law, and IHS standards.
    5. Program Evaluation. Program evaluation ensures that the mission, goals, and objectives are achieved and that the services provided result in quality nutrition for AI/AN people. Program evaluation and reviews identify strengths, deficiencies, and unmet needs to enable corrective actions. Program reviews are performed on an ongoing basis through assessment of nutrition services (using quality improvement processes, accreditation agency surveys, peer review, achievement of national program standards, and benchmarks).
    6. Resource Management. Resource management includes the use 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). The two credentialed designation options, RDNs and RDs, are from 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 is 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. All RDN/RDs will conduct regular learning needs assessments and self-evaluations that assess their area of focus, knowledge, skills, and competence. Review and use of the Commission on Dietetic Registration Scope and Standards of Practice may aid self-assessment and enhance practice and professional performance.
        2. Update staff knowledge and skills related to current trends in clinical, community, and administrative nutrition practice.
        3. Meet the continuing professional education requirements and personnel/program needs.
        4. Provide an orientation on the foods that are local to their area (including traditional foods), local customs, and understanding the dynamics of the community served. This should include an orientation on the provision of culturally sensitive nutrition care.

3-5.3 ORGANIZATIONAL RESPONSIBILITY

These functions are designated to ensure program continuity.

  1. Headquarters Functions. As a subject matter expert in nutrition, a Registered Dietitian is designated by the Director of the Office of Clinical and Preventive Services. The National Nutrition Consultant, Public Health 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. The National Nutrition Consultant 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 JC).
      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. The 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, and when appropriate, collaboration with other governmental agencies and interested parties is encouraged.
    4. Monitoring and Performance Improvement.
      1. Remains apprised of national standards (JC, CMS, the Academy, ADA, AADE) for nutrition care services and programs. Makes resources on 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. The RDN/RDs serve as 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 used. Develops local policy and procedure issuances, as well as 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, MNT, 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, JC, Federal law, and professional standards.
      3. Maintains, reviews, and audits activity data, nutrition files, and medical/health records entries.
      4. Actively participates in Service Unit quality improvement processes.
      5. Completes nutrition audits as required by JC and IHS standards.
    5. Program Evaluation.
      1. Develops a nutrition performance improvement program that will comply with IHS, CMS, JC, and professional standards and requirements.
      2. Conducts an evaluation of the Service Unit nutrition program using the results of nutrition and dietetics audits, JC 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 JC standards.
    6. Resource Management.
      1. Assesses and establishes personnel needs and identifies resources according to the IHS staffing standards for nutrition services. (See Resource Requirement Methodology).
      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, MNT, hospital/treatment center food service, community services, and in-service consultation. A qualified RDN/RD will direct and organize nutrition services. Nutrition services contribute to the attainment of the optimal health status of the population by reducing the risk of chronic diseases, bridging the gap between nutritional sciences, and applying sound nutritional practices by community members. Nutrition services comply with IHS regulations and JC and CMS standards.
  2. Program Planning. Nutrition activities are conducted according to a written plan based on identified needs and available resources, and 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 JC 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). Medical Nutrition Therapy is the development and provision of specific nutrition procedures for 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. Medical Nutrition Therapy is provided using the Nutrition Care Process 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 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 JC and CMS standards). Information pertinent to the patient’s feeding 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 patient’s care 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 the 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: (a) address the root cause (or etiology) of the nutrition problem and (b) 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 the patient's understanding of diet.
        8. Documentation. Medical Nutrition Therapy 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. Medical Nutrition Therapy 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. 
        (See Practice Tips: Delivery of Nutrition-Related Services Using 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; as well as State nutrition programs, Tribal nutrition programs, 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, in accordance with 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 comply 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, JC 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 2025-2030 Dietary Guidelines for Americans. Meals provided to patients are therapeutically correct, prepared in 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 6 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 who do not receive oral intake are identified and monitored.
      5. Only authorized people 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. (See Indian Health Manual (IHM), 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 will comply 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 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. (See IHM Part 5, Chapter 3, 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.