Policy & Procedure Manual for Health Care Facilities, 2017 Course

Credits: 25
Course Expiration: September 6, 2020
Professional Approvals: CDR, CBDM
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Thorough in its design, this self-study manual will expand your knowledge of clinical documentation, menus, food production and safety, personnel training, sanitation, infection control, disaster planning, quality assurance/performance improvement, regulatory guidelines, and more.

2017 Manual Revisions Include:

  • Language changes to reflect changes in the CMS rules released November 2016. For example “dietary” department is replaced with “food and nutrition services” department and “qualified dietitian” is added in where appropriate.
  • Update in introductory section to include explanations of new language
  • Changes are incorporated throughout the book to reflect CMS’ new emphasis on resident/patient/representative input into care planning and focus on individual choice
  • New language that reflects physicians being able to delegate order-writing priveleges to RDNs is incorporated
  • QAPI policies/procedures have been strengthened/updated to reflect an increased emphasis on QAPI in the new CMS rules
  • Overall review/update of all policies and procedures with updates that include more emphasis on electronic record-keeping, electronic health records and electronic communication.
  • Review of all policies and procedures to assure that they are still pertinent, given the new CMS rules

New Policies and Procedures Include:

  • Menus and Therapeutic Diets: RDN order-writing, Resident’s right to refuse a diet, Resident’s choice meals
  • Food Production and Food Safety: Inventory and Cost control, Food Safety-Preventing burns
  • Sanitation and Infection Control: Foods brought in from outside the facility
  • Personnel Training: Facility-wide inservice training and Resource-Facilitation adult learning
  • Disaster Planning: Back-up for electronic files

Excellent for nursing homes or hospitals. New information on food code, food safety/sanitation, nutrition/unintended weight loss, person centered dining, Nutrition Care Process and more! A great time saver, includes step by step guidelines to ensure that regulatory, nutritional, dietary needs are met for optimal health of individuals in your care. 2017 Edition.

Customizable Bonus Materials on Flash Drive:

  • Policies and procedures
  • Job descriptions
  • More than 70 sample forms and resources

See “Product Samples” for the full table of contents.

Contact us for bulk purchases, corporate intranet, and other options.

IMPORTANT NOTE: This edition is based on the Advance Copy – Revisions to State Operations Manual (SOM), Appendix PP. Revised Regulations and Tags. November 9, 2016. Center for Medicare and Medicaid Services. Center for Clinical Standards and Quality/Survey & Certification Group. Ref: S&C 17-07-NH. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-07.pdf that was effective November 2016. There are a total of 3 phase ins for the CMS changes including November 28, 2016, November 28, 2017 and November 28, 2018. If needed, we will revise the book for each phase. Customers who purchase this 2017 edition will be provided a discount code to use on future 2 editions that include the revisions for the second and third phase ins.

Already have the book? Under “Product Options”, simply choose “Additional Certificate” to purchase the CPE self-study program.

“My nutrition consulting company (with over 50 RDNs) uses Becky Dorner & Associates nearly exclusively to meet our continuing education needs outside of our own in-person training. I trust that any continuing education provided by BDA is current, on-point and delivered in a professional and... Read More
- Sue Stillman Linja, RDN, LD, President of S&S Nutrition Network, Inc. Co-Founder, Officer, and Vice President of LTC Nutrition Counseling, LLC, Boise, Idaho

After completing this continuing education course, the learner should be able to:

  1. Summarize a basic understanding of policies and procedures for the food and nutrition services department which are based on the current evidence based research, federal skilled nursing facility regulations and current version of the U.S. Department of Health and Human Services Food Code.
  2. Implement procedures that meet regulations and current standards of practice to ensure that nutritional and dietary needs are met to promote optimal health of all individuals in a facility’s care.
  3. Describe at least 3 policies and procedures to enable the facility to provide nutritious, palatable and attractive meals to meet and satisfy individual needs.
  4. Discuss at least 5 things that facilities can do to meet established standards for planning nutritionally well-balanced menus and preparing and serving foods.
  5. Describe the menu substitution procedure and list at least 3 correct substitutions for foods in at least 3 of each of the major food groups.
  6. Summarize the resident’s right to refuse a diet and or food choices that do not meet the guidelines for the resident’s diet order.
  7. Identify at least 3 types of meal service that can be implemented for person centered dining service.
  8. Apply at least 3 policies and procedures that allow the facility to provide the highest quality, safest food possible.
  9. Explain at least 3 food hazards and how they could occur.
  10. List at least 3 food hazards and how they could be prevented.
  11. Report at least 5 guidelines for a personal hygiene training policy.
  12. Summarize at least 3 ways to assure safety in the kitchen (safe lifting, preventing/controlling fire, knife safety, etc.).
  13. Discuss at least 5 guidelines for evaluating food and nutrition services and clinical nutrition personnel.
  14. List at least 5 topics for periodic in-services including mandatory in-services.
  15. Explain an appropriate nutrition screening system for older adults.
  16. List at least 5 diseases/conditions that should be referred to the registered dietitian nutritionist (RDN).
  17. Summarize role delineation for documentation of nutrition assessment, care plans and progress notes.
  18. Explain at least 3 systems to evaluate when practicing nutrition focused physical assessment.
  19. Report at least 3 ways to promote optimal nutritional status of each individual through medical nutrition therapy (MNT) in accordance with the written diet orders and consistent with each individual’s needs.
  20. Describe at least 3 appropriate interventions for unintended weight loss.
  21. Name 4 things that can be monitored to promote quality assurance and performance improvement for the food and nutrition services department.
  22. Restate 3 things a facility should do in advance to prepare for a potential disaster or emergency.
  23. Calculate the drinking water requirements per person for disaster planning purposes.
  24. Demonstrate at least one way to purify water during an emergency or disaster.
  25. Summarize how to use foods in order of perishability during an emergency or disaster.

This course is intended for: RDNs, NDTRs, and CBDMs

CDR Activity Number: 136048     Self Study Activity Type: 720 Printed
CPE Level: 2

Suggested CDR Learning Needs Codes:

  • 1070 Leadership, critical and strategic thinking
  • 5000 Medical Nutrition Therapy
  • 7000 Business and management
  • 8000 Food Service Systems and Culinary Arts

Additional Learning Needs Codes that may apply (including but not limited to): 3000, 5010, 5040, 5050, 5090, 5100, 5390, 5410, 7060, 7090, 7100, 7160, 7180, 7190, 8020, 8040, 8050, 8070, 8090

Suggested CDR Performance Indicators:

  • 4.1.1 Demonstrates effective problem solving and professional judgment to address a need
  • 8.3.6 Keeps abreast of current nutrition and dietetics knowledge and trends.
  • 6.1.3 Establishes goals for improving quality of services provided.
  • 8.4.3 Uses a variety of cooking techniques, food preparation and production and delivery systems.

Additional Performance Indicators may apply (including but not limited to): 1.6.1, 2.3.2, 3.1.4, 4.1.3, 7.1.1, 7.1.2, 7.1.3, 7.2.5, 7.2.7, 7.2.8, 7.2.9, 7.2.10, 7.2.11, 8.1.5, 8.2.2, 8.4.1, 8.4.4, 10.1.3, 10,.2.8, 10.2.9, 10.2.11,  13.2.8

Additional Learning Need Codes and Performance Indicators may apply (full list included in the course e-book).


This course is also approved by the Certifying Board of Dietary Managers (CBDM).

Hours: 25 General CE

Approval Number: 163877

Each CDM in attendance will be required to report their CE hours by logging into their online account at www.ANFPonline.org.
CDMs are to retain a copy of the certificate of completion in the event they are audited.


Becky Dorner, RDN, LD, FAND is widely-known as one of the nation’s leading experts on nutrition, aging, and long-term care. An experienced speaker and extensively published author, Becky is Founder/ President of Nutrition Consulting Services, Inc., whose dedicated team of RDNs and NDTRs have served health care facilities in Ohio since 1983; and Becky Dorner & Associates, Inc., which provides a broad library of credible continuing education (CE) programs and nutrition resources. Her free email magazine keeps 35,000 health care professionals up to date on the latest news in the field.

Honors: Academy of Nutrition and Dietetics Medallion Award, Fellow of the Academy of Nutrition and Dietetics, and the Academy Award of Excellence in Business and Consultation.

Contributing Editor:

Liz Friedrich, MPH, RD, CSG, LDN, FAND is a Registered Dietitian and president of Friedrich Nutrition Consulting in Salisbury, NC. The company provides a variety of nutrition consulting services with a focus on gerontological nutrition. She has co-authored numerous articles in journals and magazines, including the Academy of Nutrition and Dietetics. Liz was also the Associate Director of Nutrition411.com, a respected website for dietitians, and is an evidence analyst for the Academy of Nutrition and Dietetics’ Evidence Analysis Library. In 2009 Liz became Board Certified as a Specialist in Gerontological Nutrition.

Honors: She is the recipient of two North Carolina Dietetic Association awards, the Recognized Young Dietitian of the Year (1991) and the Member of the Year (2000).

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