CMS Gives Hospitals Food for Thought

Key Takeaways

• The Centers for Medicare & Medicaid Services (CMS) has asked hospitals to align their food and nutrition service policies, standard menus, therapeutic diet protocols and food procurement practices with the 2025–2030 (DGAs), consistent with the Conditions of Participation (CoPs) at 42 C.F.R. § 482.28.
• Whether and how CMS, state survey agencies, and accrediting organizations plan to enforce the guidelines remains unclear—regardless, improving food quality for patients may offer benefits beyond compliance, including improved patient experience and better health outcomes.
• Hospitals can take practical steps to integrate the Dietary Guidelines for Americans (DGAs) into their nutrition services, set themselves up for long-term success and build on learnings from other institutional settings that have incorporated the DGAs.

Background

On March 30, CMS issued a advising hospitals to align with the recently updated Dietary Guidelines for Americans (DGAs) when carrying out their existing food and nutrition obligations under the Conditions of Participation (CoPs)—the core set of federal regulatory requirements that hospitals must meet to participate in the Medicare program.  

The food and nutrition CoPs at 42 C.F.R. § 482.28 require hospitals to provide diets that meet individual patient nutritional needs and maintain adequate staffing and qualified dietetic oversight. Guidance interpreting these CoPs has historically focused on hospitals’ staff qualifications, operational readiness to meet specialized nutritional needs and alignment with more general dietary standards like the Dietary Reference Intakes. Now, CMS is asking hospitals to make fundamental changes to their food service operations and to educate patients on healthy food.

Potential Enforcement, and Genuine Motivation?

Enforcement mechanisms for CoPs remain the same, and we anticipate that any potential oversight of DGA incorporation will be folded into standard processes by CMS, state survey agencies and The Joint Commission. For the Food & Dietetics CoPs, citations have historically involved immediate jeopardy of patient safety—such as giving a patient a food that —or ignoring clearly defined required processes. It remains to be seen what level of compliance with the DGAs will trigger enforcement action, but CMS has outlined in the memorandum the changes that it expects to see. These are among the most consensus-based recommendations from the DGAs, rather than those recommendations that were the subject of greater debate.

Practical Suggestions for Hospitals

Even without formal enforcement guidance, hospitals can take steps toward overall improved nutrition services that will support compliance and improve patient care.

(1) Compliance in a Clinical Setting

Hospitals with clearly defined and consistently implemented nutrition processes are better positioned to deliver reliable, individualized care at scale. For example, hospitals may consider:

• Integrating nutrition into clinical workflows. Hospitals may benefit from better aligning food and nutrition services with existing clinical processes (e.g., malnutrition screening, nutrition assessment, and care planning). Ensuring that menu systems reliably incorporate therapeutic diet considerations (including allergies and texture-modified diets), and that diet changes trigger timely kitchen updates, are central to supporting individualized care. Breakdowns in these processes can adversely affect nutritional intake, prolong recovery and increase length of stay, ultimately worsening clinical outcomes.
• Measuring outcomes (not just menu compliance). Another strategy is incorporating a small dashboard into the QAPI system that links nutrition to clinical outcomes. Being able to quickly visualize metrics such as nutrition consult timeliness, therapeutic diet adherence indicators, and readmissions where nutrition is a known driver can facilitate effective pivots towards what works for the hospital’s patient population, and away from what does not. After implementing major menu changes, hospitals might also consider auditing for downstream outcomes such as hypoglycemia events, unintended weight loss, and inadequate protein intake in wound and healing populations. These results can also help guide phased implementation rather than one-time menu swaps that are less likely to lead to meaningful progress.

(2) Menu Planning and Procurement

In addition to clinical considerations, hospitals will need to decide how to ensure DGA-compliant offerings are available to patients. Through navigating their own , offer relevant lessons, such as:

• Menu planning. First, hospitals can assess current menus against the standards identified in the memorandum and standardize menu planning using DGA-based parameters. Menu-planning allow schools to ensure system-wide compliance with the program-specific DGA standards. Next, define institutional metrics for “[e]mphasizing” and “[p]rioritizing” the categories highlighted in the guidance. Developing internal standards will not only help with compliance but also with monitoring costs, product acceptance and other necessary considerations for a successful nutrition program.
• Procurement. Full compliance will impact procurement; immediate challenges include the lack of a clear federal definition for ultra-processed foods and sourcing replacement products. For example, requiring 100% whole-grain products in schools was so burdensome that the federal government eventually relaxed the standard. One strategy is to start with a reduction target, such as moving towards serving 50% of grains in whole-grain form. These changes may be effected through more local procurement, which can be an excellent source of fresh, less processed food with added benefits to the local community. Distributors and food management companies that have already invested in building supply chains around nutrition goals can also provide important support.

(3) Patient Tailoring and Education to Enhance Success

Strict DGA compliance may not be possible or recommended for all patients and is not limited to the memorandum’s standard diets. To improve patient outcomes, hospital nutrition guidance needs to extend beyond discharge. Hospitals can pursue several strategies to support patients’ dietary needs both during and after their stay:

• Centering equity, culture, and accessibility. DGA-based menus should ensure concordance with different cultural, religious, health literacy, language, and disability-related needs. Rather than broadly banning less-healthy options, hospitals may improve uptake of DGA-aligned selections by designing defaults for patient-choice menus, while being intentional about preserving clinically necessary options and highlighting culturally appropriate choices. 
• Planning for exceptions to DGA adherence. Hospitals will need to anticipate when DGA-driven menu changes could undermine clinically indicated diets, such as high-fiber options that are contra-indicated for certain digestive conditions. Exception-approval processes should establish documentation expectations and communication channels with dietary operations.
• Focusing on patient education and discharge planning. Developing short, diagnosis-relevant nutrition education that aligns with what patients see on their trays will support long-term nutrition benefits. Clinical teams can link education to measurable goals, incorporate nutrition into care transitions, strengthen referrals to outpatient registered dietitians, align with payer and benefit resources where applicable, screen for food insecurity, and refer to community-based resources such as SNAP and local food access programs.
• Training and stakeholder engagement. Lasting impact is impossible without patient acceptance. Meals not consumed do not support clinical goals, contribute to waste, and can undermine patients’ confidence in their care. Attention to patient and staff feedback will play an important role in ensuring that DGA‑aligned changes are effective in practice.

Taking Nutrition a Step Further

While implementing new requirements is always a challenge, the CMS memorandum is an opportunity to strengthen the role of nutrition in patient care. Regardless of the level of oversight, these steps are an attainable and effective avenue for improving patient health.

In making required changes, hospitals should also consider the role that nutrition can play outside of the hospital in enhancing patient outcomes. Several states and commercial payers have Food is Medicine programs available to patients that provide the kind of additional at-home medical nutrition support that leads to long-term patient success. In addition, this administration is considering steps to advance payment mechanisms for dietitians and other supporting roles that may supplement physician input. Some hospitals have found that including such services helps keep repeat patients out of the ER for non-acute conditions. Hospital executives should take this opportunity to rethink their overall approach to nutrition and other services.

The CoPs at 42 CFR Part 482 apply to several types of hospitals, including short-term acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, children’s hospitals, cancer hospitals, and other specialty care hospitals.  

For example, each hospital must have a full-time director of food and dietetic services, full- or part-time dietician (or consulting dietician), and administrative and technical personnel, each competent and qualified based on education, experience, and specialized training. Hospitals must also ensure patients’ nutritional needs are met and monitored through patient weight, intake and output, and/or lab values, including when patients require therapeutic diets or other “non-routine” nutritional interventions. The contains additional enforcement guidance.