We frequently receive questions about meal times and the Center for Medicare & Medicaid Services (CMS) 14 hour rule for nursing facilities. The concerns are related primarily to the requirements for spacing of the evening meal and the next day’s breakfast especially in the context of person-centered dining. Facilities are trying to balance regulations with personal choice, and this is fairly easy to achieve.
CMS State Operations Manual
The CMS State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, tag F809 Frequency of meals states that each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community. The surveyor probes for F809 includes this question: “Are snacks and meals available for residents at non-traditional times or outside of scheduled meal service times, or upon request?”
The facility should make snacks available at bedtime daily. There must be no more than 14 hours between a substantial evening meal and breakfast the following day except when a nourishing snack is provided at bedtime, in which case, up to 16 hours may elapse between a substantial evening meal and breakfast the next day if a resident group agrees to this meal span and a nourishing snack is served. A nourishing snack is defined as a verbal offering of items, single or in combination from the basic food groups. Adequacy of the nourishing snack will be determined both by resident interviews and by evaluation of the overall nutritional status of residents in the facility. It is also wise to check your state’s nursing home regulations. Some states have more specific regulations on the expectations regarding what type and how much food is to be offered at HS.
Policies and Procedures
Based on the CMS regulation, a best practice is to offer an HS snack from at least two food groups including one group that provides some protein. (For example, a half turkey sandwich with juice or milk, cereal with milk, a milkshake or milk with graham crackers, etc.). It comes down to what your residents want and whether or not they are satisfied with what you offer. It’s always best to ask the individual resident what they would like at HS snack – and to offer a variety of options for residents to choose from. This helps to incorporate personal choice while meeting the intent of the regulation. If residents complain to a surveyor or if a surveyor finds that your facility has issues with unintended weight loss or other nutrition related problems then they may investigate further.
In addition, be sure that you have a written policy to explain what you will do if your meal times do not meet the 14 hour rule – and what you are providing as the “nourishing HS snack” to show you are complying with the regulation. Our Policy & Procedure Manual has a specific “Meal Times and Frequency” policy and procedure that covers this (see Chapter 2). We use the explanation that a “substantial evening meal” is defined as offering of three or more menu items at one time, one of which includes a high quality protein. The meal should represent no less than 20% of the daily total nutritional requirement. “Nourishing snack” is defined as verbal offering of items, single or in combination, from the basic food groups. Adequacy of the snack will be determined both by individuals in the group and evaluating the overall nutritional status of those in the facility.
Call to Action
- Assess the timeframe between the evening meal and breakfast at your facility. If it is more than 14 hours, ensure that a substantial evening snack is provided.
- Have a written policy to explain what you will do if your meal times do not meet the 14-hour rule – and what you are providing as the “nourishing HS snack” to show you are comply with the regulation.
- Promote personal choice by discussing snack preferences with the resident to enhance resident satisfaction and potentially avoid unintended weight loss or other nutrition-related concerns.
- Assess intake of snack quarterly or as needed to ensure that preferences haven’t changed.
- Regularly review state nursing home regulations to help ensure compliance and optimal resident care.
- Learn more from our Policy & Procedure Manual.
Reference:
Centers for Medicare & Medicaid Services. State Operations Manual. Appendix PP – Guidance to Surveyors for Long Term Care Facilities. Rev. 225 Updated August 8, 2024. Accessed October 15, 2024.
Originally published 8/6/14. Revised 1/3/22, 10/15/24.
CMS State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities Course
This course is based on the Centers for Medicare and Medicaid Services (CMS) State Operation Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities 11-22-17 revision, which is the document used for conducting nursing home surveys in accordance with survey protocols and Federal requirements to determine whether a citation of non-compliance is appropriate.
Minimum Data Set (MDS) 3.0 RAI Manual v1.17 Course
This course is based on The Centers for Medicare and Medicaid Services’ (CMS) Minimum Data Set (MDS) 3.0 Resident Assessment Instruments (RAI) Manual (v1.17 October 1, 2019 revision) which is a document used for implementing standardized assessment for facility care management in nursing homes and non-critical access hospital swing beds.
Policy & Procedure Manual: For Nutrition and Food Service in Healthcare Facilities, 2023 Course
This self-study course will expand your knowledge of policies and procedures related to clinical documentation, menus, food production and safety, personnel training, sanitation, infection control, disaster planning, quality assurance/performance improvement, regulatory guidelines, and more.
Diet and Nutrition Care Manual, Course
This self-study course is based on a comprehensive resource that includes guidelines for evidence-based practice, including the 2020-2025 Dietary Guidelines for Americans and MyPlate, updated information on cardiovascular disease, hypertension, pressure injuries, and more!
Hi, my husband is in long term care due to a stroke he suffered in August of 2020. He is currently 65 y/o, paralyzed right arm and leg, aphasia, kidney failure and recently had all his teeth removed. He will likely be in a facility the rest of his life. He is the same guy I married, and I visit almost daily as we work on having a marriage and he finds quality of life that includes his limitations. He has been unable to eat the regular mealtime options, either because it isn’t soft enough, or because he finds it unappealing. Recently he asked me to bring in some Ramen noodle pkgs, and a nurse assisted me in preparing them in a microwave. I have an auto immune illness, and recently was advised by my m.d. to rest more, so I couldn’t visit today. The staff refused to make the ramen noodles for him, saying that the dietary manager could not prepare or reheat foods from residents family members saying it was against regulations. I’ve seen this done numerous times in the past year that he has been there, though kitchen staff has a large turnover. I was also told that the RN who helped me yesterday was in non compliance using the break room microwave to boil water for me. I was told the nurse may make the food too hot, she wasn’t trained as a cook.
I have been given misinformation from employees in the past, so I’m trying to find regulations to back their claims.
I’m also concerned that my husband is being treated like a child, told he cannot have his favorite foods, though he is on a regular, soft diet. He lives at this facility. He is willing to wait until the kitchen is not so busy, and he does not intend to ask for this food every day. I tried calling the facility social worker, and the executive director but haven’t received a callback. There is currently no Director of Nursing.
I hope you can give me some insight and information on this issue.
My sister is in a nursing home and is being served some form of pressed chicken meat 3 times per week. Her as well as several residents have asked for cereal just so they have something to eat and are being told they don’t have cereal. They’ve had cereal up until now. So my sister is eating nothing. I need help!
Our facility just dropped their long term nursing in lew of Rehab nursing. How does the CMS/ACHC regulate the meal times for a facility like this type in Ohio. Dinner to Bfast with and without a snack program?
I would like to know about water being available my mother is only getting fluids with meals
Are there guidelines on amount of each individual item on plate per meal? It just doesn’t seem like much.
Hello,
Does the 14-hour rule apply to inpatient hospitals or exclusively to LTC facilities? Does Joint Commission have a similar standard with a noted time frame? Or do inpatient facilities just need to establish meal frequency in their policies and procedures?
What is the regulation for alternate foods, requested by a resident that are not otherwise on menu