CMS' New Dining Practice Standards Memorandum

Talking Points for ASHA Members

On March 1, 2013, CMS released a Memorandum (Ref: S&C: 13-13-NH) [PDF] on New Dining Practice Standards to increase focus on nursing home resident's food choices.


  • The New Dining Practice Standards came from a 2010 project in which the Pioneer Network convened stakeholders from a variety of organizations and agencies, including the Centers for Medicare and Medicaid Services, to address food and dining issues in long-term care. ASHA, as the representative for speech-language pathologists-the primary service providers in the area of swallowing-was invited to participate in the informational symposium and subsequent stakeholder meeting. The purpose of the meeting was to develop food and dining practice standards that move away from diagnosis-focused treatment toward more self-directed living-while at the same time supporting safety and quality care.
    • The standards addressed many types of therapeutic diets, including tube feedings and diabetic, low sodium, and cardiac diets in addition to altered consistency diets due to swallowing problems.
    • ASHA provided significant comments to the draft document. ASHA accepted the standards and disseminated the information to support culture change regarding food and dining in nursing homes.

Information about the Memorandum

  • ASHA was not consulted or notified in advance about the CMS Memorandum or the linked surveyor training video. ASHA contacted CMS to express concerns.
  • In the video, the Frazier Water Protocol is mentioned as an "excellent guide." However, the video does not discuss broader considerations in implementing a free water protocol.
  • The New Dining Standards are not CMS requirements. Surveyors should not issue deficiency citations simply because a facility is not following the dining standards referenced by the memo.

Considerations for SLPs

  • The Memorandum does not prescribe or imply any changes in the role of speech-language pathologists with respect to evaluating and treating swallowing and feeding disorders. The role of speech-language pathologists goes beyond recommending diet modification to include other compensatory strategies such as postural changes as well as teaching the patient habilitative/rehabilitative techniques to improve swallowing physiology (ASHA, 2001). Examples include tongue strengthening, super superglottic swallow, Mendelsohn maneuver, etc.
  • SLPs should work within an interdisciplinary team including physicians, nurses, dietitians, physical, occupational and recreation therapists, social workers, and others who provide care to the residents of a health care facility.
  • Documentation should reflect that patients and families have been counseled on diet modifications, and are in agreement with recommendations. The recommendations should be individualized based on information such as the patient's medical history, bedside and instrumental assessment results, trial treatment, patient preferences, and family input.
  • Although research has shown positive outcomes with appropriate changes in food texture and liquids in decreasing aspiration pneumonia, other studies have found mixed reviews.
  • Dysphagia treatment (both diet texture modification and neuromuscular strength training) has been found to:
  • Reduce risk/incidence of pneumonia (e.g., Carnaby, Hankey & Pizzi, 2006; Foley, Teasell, Salter, Kruger & Tegner, 2008),
  • Improve nutritional status of patients (e.g., Elmståhl, Bülow, Ekberg, Petersson & Tegner, 1999; Sura, Madhavan, Carnaby & Crary, 2012).


American Speech-Language-Hearing Association. (2001). Roles of speech-language pathologists in swallowing and feeding disorders: technical report [Technical Report]. Available from

Carnaby, G., Hankey, G. J., Pizzi, J. (2006). Behavioral intervention for dysphagia in acute stroke: A randomized controlled trial. The Lancet Neurology, 5, 31–37.

Elmstahl, S., Bulow, M., Ekberg, O., Petersson, M. & Tegner, H. (1999).Treatment of dysphagia improves nutritional conditions in stroke patients. Dysphagia,14, 61–66.

Foley, N., Teasell, R., Salter, K., Kruger, E. & Martino, R. (2008). Dysphagia treatment post-stroke: a systematic review of randomized controlled trials. Age and Ageing, 37, 258–264.

Sura, L., Madhavan, A.,  Carnaby, G. & Crary, M. (2012). Dysphagia in the elderly: management and nutritional considerations. Clinical Interventions in Aging, 7, 287–298.

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