Recently we have had a few questions about meal times and the 14 hour rule from CMS 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.

The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, tag F368 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 facility must offer snacks 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, 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. 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.

Based on the CMS regulation, my personal recommendation would be to offer an HS snack from at least 2 food groups and preferably one that provides some protein. For example: half turkey sandwich with juice or milk, cereal with milk, a milkshake or milk with graham crackers, etc. It really comes down to what your residents want and whether or not they are satisfied with what you offer. So it's always best to ask the individual resident what they would like at HS snack - and providing a variety of HS snacks for residents to choose from is ideal. 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. 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 day's 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.