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Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities

      Abstract

      Intellectual and developmental disabilities (IDD) encompass both intellectual disabilities (ID) and developmental disabilities (DD). In 2016, 7.37 million people in the United States and 200 million worldwide were identified with an ID or DD. Approximately 1 in 6 (17.8%) children have been identified with a DD in the United States, which is up from 16.2% in 2009-2011. Globally, 52.9 million children from birth to 5 years of age have been identified with a DD. Registered dietitian nutritionists (RDNs) have an important role in the treatment of this population, as optimizing nutrition status improves cognition and quality of life. The Behavioral Health Nutrition Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs in Intellectual and Developmental Disabilities for 3 levels of practice—competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for care of individuals with an ID or DD. The SOPP describes 6 domains that focus on professionalism. Indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs caring for individuals with an ID or DD. The SOP and SOPP are intended to be used by RDNs for self-evaluation to assure competent practice and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.
      Editor’s note: Figures 1 and 2 that accompany this article are available online at www.jandonling.org.The Behavioral Health Nutrition (BHN) Dietetic Practice Group (DPG) of the Academy of Nutrition and Dietetics (Academy), under the guidance of the Academy Quality Management Committee, has revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians in Intellectual and Developmental Disabilities (IDD) originally published in 2012.
      • Cushing P.
      • Spear D.
      • Novak P.
      • et al.
      Academy of Nutrition and Dietetics: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities.
      The revised document, Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities, reflect advances in IDD practice during the past 8 years and replace the 2012 Standards. This document builds on the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      The Academy of Nutrition and Dietetics/Commission on Dietetic Registration’s (CDR) Code of Ethics for the Nutrition and Dietetics Profession,

      Academy of Nutrition and Dietetics/Commission on Dietetic Registration. 2018 Code of Ethics for the Nutrition and Dietetics Profession. Accessed May 23, 2018.https://www.eatrightpro.org/practice/code-of-ethics/what-is-the-code-of-ethics.

      along with the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and Revised 2017 Scope of Practice for the RDN,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      guide the practice and performance of RDNs in all settings.
      Scope of practice in nutrition and dietetics is composed of statutory and individual components; includes the code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employers codes of ethics); and encompasses the range of roles, activities, practice guidelines, and regulations within which RDNs perform. For credentialed practitioners, scope of practice is typically established within the practice act and interpreted and controlled by the agency or board that regulates the practice of the profession in a given state.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      An RDN’s statutory scope of practice can delineate the services an RDN is authorized to perform in a state where a practice act or certification exists. For more information, see https://www.eatrightpro.org/advocacy/licensure/licensure-map.
      The RDN’s individual scope of practice is determined by education, training, credentialing, experience, and demonstrating and documenting competence to practice. Individual scope of practice in nutrition and dietetics has flexible boundaries to capture the breadth of the individual’s professional practice. Professional advancement beyond the core education and supervised practice to qualify for the RDN credential provides RDNs practice opportunities, such as expanded roles within an organization based on training and certifications, if required; or additional credentials (eg, focus area CDR specialist certification, if applicable; Certified Nutrition Support Clinician [CNSC], Certified Diabetes Care and Education Specialist [CDCES]). The Scope of Practice Decision Algorithm (www.eatrightpro.org/scope) guides an RDN through a series of questions to determine whether a particular activity is within their scope of practice. The algorithm is designed to assist an RDN to critically evaluate their personal knowledge, skill, experience, judgment, and demonstrated competence using criteria resources.

      Scope of Practice Decision Algorithm. Academy of Nutrition and Dietetics. Accessed August 7, 2020. www.eatrightpro.org/scope.

      All registered dietitians are nutritionists—but not all nutritionists are registered dietitians. The Academy's Board of Directors and Commission on Dietetic Registration have determined that those who hold the credential Registered Dietitian (RD) may optionally use "Registered Dietitian Nutritionist” (RDN). The two credentials have identical meanings. In this document, the authors have chosen to use the term RDN to refer to both registered dietitians and registered dietitian nutritionists.
      Approved July 2020 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group of the Academy. Scheduled review date: September 2026. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Intellectual and Developmental Disabilities may be addressed to Academy Quality Management Staff: Dana Buelsing, MS, manager, Quality Standards Operations; and Carol J Gilmore, MS, RDN, LD, FADA, FAND scope/standards of practice specialist, Quality Management at [email protected].
      The Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services, Hospital

      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf.

      and Critical Access Hospital

      State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf.

      Conditions of Participation now allow a hospital and its medical staff the option of including RDNs or other clinically qualified nutrition professionals within the category of “nonphysician practitioners” eligible for ordering privileges for therapeutic diets and nutrition-related services if consistent with state law and health care regulations. RDNs in hospital settings interested in obtaining ordering privileges must review state laws (eg, licensure, certification, and title protection), if applicable, and health care regulations to determine whether there are any barriers or state-specific processes that must be addressed. For more information, review the Academy’s practice tips, which outline the regulations and implementation steps for obtaining ordering privileges (http://www.eatrightpro.org/dietorders/). For assistance, refer questions to the Academy’s State Affiliate organization.
      Medical staff oversight of an RDN(s) occurs in 1 of 2 ways. A hospital has the regulatory flexibility to appoint an RDN(s) to the medical staff and grant the RDN(s) specific nutrition ordering privileges or can authorize the ordering privileges without appointment to the medical staff. To comply with regulatory requirements, an RDN’s eligibility to be considered for ordering privileges must be through the hospital’s medical staff rules, regulations, and bylaws, or other facility-specific process.

      42 CFR Parts 413, 416, 440 et al. Medicare and Medicaid Programs; Regulatory provisions to promote program efficiency, transparency, and burden reduction; Part II; Final rule (FR DOC #2014-10687; pp 27106-27157). US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. http://www.gpo.gov/fdsys/pkg/FR-2014-05-12/pdf/2014-10687.pdf.

      The actual privileges granted will be based on the RDN’s knowledge, skills, experience, and specialist certification, if required, and demonstrated and documented competence.
      The Long-Term Care Final Rule published October 4, 2016 in the Federal Register, now “allows the attending physician to delegate to a qualified dietitian or other clinically qualified nutrition professional the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by State law” and permitted by the facility’s policies.

      Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872)—Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178). US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities.

      The qualified professional must be acting within the scope of practice as defined by state law and is under the supervision of the physician, which may include, for example, countersigning the orders written by the qualified RDN or clinically qualified nutrition professional. RDNs who work in long-term care facilities should review the Academy’s updates on CMS that outline the regulatory changes to §483.60 Food and Nutrition Services (https://www.eatrightpro.org/practice/quality-management/national-quality-accreditation-and-regulations/centers-for-medicare-and-medicaid-services). Review the state’s long-term care regulations to identify potential barriers to implementation and identify considerations for developing the facility’s processes with the medical director and for orientation of attending physicians. The CMS State Operations Manual, Appendix PP-Guidance for Surveyors for Long-Term Care Facilities contains the revised regulatory language (revisions are italicized and in red color).

      State Operations Manual. Appendix PP Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.

      CMS periodically revises the State Operations Manual Conditions of Participation; obtain the current information at https://cms.gov/files/document/appendices-table-content.pdf.

      Academy Quality and Practice Resources

      The Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      reflect the minimum competent level of nutrition and dietetics practice and professional performance. The core standards serve as blueprints for the development of focus area SOP and SOPP for RDNs in competent, proficient, and expert levels of practice. The SOP in Nutrition Care is composed of 4 standards consistent with the Nutrition Care Process and clinical workflow elements as applied to the care of patients/clients/populations in all settings.
      • Swan W.I.
      • Vivanti A.
      • Hakel-Smith N.A.
      • et al.
      Nutrition Care Process and Model update: Toward realizing people-centered care and outcomes management.
      The SOPP consist of standards representing the following 6 domains of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. The SOP and SOPP for RDNs are designed to promote the provision of safe, effective, efficient, equitable, and quality food and nutrition care and services; facilitate evidence-based practice; and serve as a professional evaluation resource.
      These focus area standards for RDNs in IDD provide a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering IDD nutrition and dietetic services. They are used by RDNs to assess their current level of practice and to determine the education and training required to maintain currency in their focus area and advancement to a higher level of practice. In addition, the standards can be used to assist RDNs in general clinical practice with maintaining minimum competence in the focus area and by RDNs transitioning their knowledge and skills to a new focus area of practice. Like the Academy’s core SOP in Nutrition Care and SOPP for RDNs,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      the indicators (ie, measurable action statements that illustrate how each standard can be applied in practice) (see Figures 1 and 2, available at www.jandonline.org) for the SOP and SOPP for RDNs in IDD were revised with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in IDD were reviewed and approved by the Executive Committee of the BHN DPG and the Academy Quality Management Committee.
      Figure 1Standards of Practice for Registered Dietitian Nutritionists (RDNs) in Intellectual and Developmental Disabilities. Note: The terms individual, person, group, and population are used interchangeably with the actual term used in a given situation depending on the setting and the population receiving care or services.
      Standards of Practice for Registered Dietitian Nutritionists in Intellectual and Developmental Disabilities

      Standard 1: Nutrition Assessment

      The registered dietitian nutritionist (RDN) uses accurate and relevant data and information to identify nutrition-related problems.

      Rationale:

      Nutrition screening is the preliminary step to identify individuals who require a nutrition assessment performed by an RDN. Nutrition assessment is a systematic process of obtaining and interpreting data in order to make decisions about the nature and cause of nutrition-related problems and provides the foundation for nutrition diagnosis. It is an ongoing, dynamic process that involves not only initial data collection, but also reassessment and analysis of person/individual or population needs. Nutrition assessment is conducted using validated tools based in evidence, the 5 domains of nutrition assessment, and comparative standards. Nutrition assessment may be performed via in-person, or facility/practitioner assessment application, or Health Insurance Portability and Accountability Act–compliant videoconferencing telehealth platform.
      Indicators for Standard 1: Nutrition Assessment
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Individual/person/population history: Assesses current and past information related to personal, medical, family, and psychosocial/social historyXXX
      1.1AListens and visually observes for the individual’s story, which provides background and the individual’s/family’s perspective on the individual’s lifestyle, health status, and factors related to their disease(s)/condition(s), disabilities, challenges and strengths, and goals; listens and observes for:
      • signs/symptoms of nutritional deficiency
      • reports of alteration of taste, smell
      • structural issues
      • needs not being provided
      • social skills impeding access to food
      • likes/dislikes and preferences
      • sitting issues impacting stability
      XXX
      1.1BAssesses medical, developmental, and family history (eg, socioeconomic status, family gatekeeper/decision maker, growth history, developmental milestones, nutritional status, diagnoses, medical conditions, treatments)XXX
      1.1B1Reviews screening data or screens for nutrition risk (eg, malnutrition, nutrient deficits, food security) using evidence-based screening tools for the setting and/or population (adult or pediatric)XXX
      1.1B2Reviews existing Individual Family Service Plan (IFSP), Individual Education Plan (IEP), Individual Service Plan (ISP), and/or Individual Program Plan (IPP), addressing nutrition, education, medical needs and progress towards those goals; and assesses team members’ level of understanding of nutrition concernsXXX
      1.1CEvaluates for age-related nutrition issues and comorbidities (Figure 6)XXX
      1.1DAnticipates potential problems related to chronic or acute medical conditionsXX
      1.2Anthropometric assessment: Assesses anthropometric indicators (eg, height, length, weight, body mass index [BMI], waist circumference, arm circumference), comparison to reference data (eg, percentile ranks/z-scores), and individual, family and disease historyXXX
      1.2AUses specialized techniques and/or equipment and trained personnel to obtain anthropometric measurements (Figure 5) and other measurements as appropriateXXX
      1.2BUses standardized measurements to determine desirable body weight based on most appropriate formulas (Figure 5)XXX
      1.2CEvaluates growth measurements (Figure 5) to determine growth progress, and trendsXXX
      1.2DAssesses accuracy and appropriateness of measurements considering differences in measurement protocols, type and placement/location of scale, individual’s cooperation, ethnicity of individual, muscle atrophy, differences in body habitus (eg, mid-upper arm circumference), impact of contractures or spinal differences (eg, kyphosis, scoliosis, congenital differences)XX
      1.2EUses information (eg, individual’s history, condition(s), congenital syndromes/differences, developmental milestones) to predict expectations for growth that are different than for the general populationXX
      1.2FUses experience and critical thinking in addition to multiple measurements/parameters in assessing complex health issues when standardized parameters do not applyX
      1.2F1Uses knowledge of body composition and nutritional physiologyX
      1.2F2Uses past experiences to critically evaluate data to develop an appropriate reference for growth parameters for an individual with intellectual and developmental disabilities (IDD) (Figure 6)X
      1.3Biochemical data, medical tests, and procedure assessment: Assesses laboratory profiles (eg, acid–base balance, renal function, endocrine function, inflammatory response, vitamin/mineral profile, lipid profile), and medical tests and procedures (eg, gastrointestinal study, metabolic rate, swallow study)XXX
      1.3AEvaluates nutritional implications of diagnostic tests (eg, glucose tolerance test, modified barium swallow, upper gastrointestinal, lower gastrointestinal, metabolic study, gastric emptying, micronutrient testing)XXX
      1.3BDevelops screening protocol in consultation with other interdisciplinary
      Interdisciplinary: The term interdisciplinary is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, social workers, occupational, physical, and speech therapists, oral motor therapist, Qualified Intellectual Disabilities Professional [QIDP], school administrators, teachers, school nurse, teacher’s aide, direct care professional, assistive technologist, applied behavior analysis [ABA] therapist, Adult Protective Services, Child Protective Services, regional center, state vocational rehabilitation agencies), depending on the needs of the individual. Interdisciplinary could also mean interprofessional or multidisciplinary.
      team (IDT) members to support diagnostic testing
      XX
      1.3CAssesses results of diagnostic tests, procedures, and evaluations; identifies appropriate laboratory testing for differentiating specific nutrition-related diseases and conditions; and interprets findingsXX
      1.3DDetermines need and appropriateness for further testing, based on findingsX
      1.4Nutrition-focused physical examination (NFPE) may include visual and physical examination: Obtains and assesses findings from NFPE (eg, indicators of vitamin/mineral deficiency/toxicity, edema, muscle wasting, subcutaneous fat loss, altered body composition, oral health, feeding ability [suck/swallow/breathe], appetite, and affect)XXX
      1.4AConducts NFPE that includes, but is not limited to:
      • evidence of and risk for malnutrition using multiple indicators (Figure 5)
      • dentition/chewing ability, health of teeth/missing teeth, sores in mouth, swollen and bleeding gums
      • ambulation changes
      • skin-related abnormalities, chronic sores/wounds on extremities
      • vital signs (blood pressure, temperature, and rate of respiration) as reported by others
      XXX
      1.4A1Evaluates clinical signs of fluid imbalance:
      • adults/adolescents/children: edema, ascites, pulmonary congestion, skin turgor with dehydration, fatigue, muscle cramps, dark urine, rapid weight changes with fluid overload or loss, constipation
      • small children/infant: signs of dehydration: dry mouth, few or no tears, sunken eyes, sunken-looking fontanelle, less than typical diapers, dry skin, irritability, unusually drowsy
      XXX
      1.4A2Evaluates clinical signs of undernutrition (eg, dry, brittle, or thinning hair and nails, irritability, inability to concentrate, muscle wasting, lanugo)XXX
      1.4A3Evaluates clinical signs and symptoms of malnutrition (eg, hypothermia, bradycardia, lanugo, muscle wasting, tooth erosion, bony protrusions, parotid gland enlargement, gastrointestinal distress, dry, brittle, or thinning hair or nails)XXX
      1.4BReviews physical findings that may indicate structural or functional abnormalities (eg, results of magnetic resonance imaging, ultrasound, x-rays, swallow studies); seeks assistance as neededXX
      1.5Food and nutrition-related history assessment (ie, dietary assessment)-Evaluates the following components:
      1.5AFood and nutrient intake including composition and adequacy, meal and snack patterns, and appropriateness related to food allergies and intolerancesXXX
      1.5A1Evaluates feeding history including intake patterns and method of nutrition delivery (eg, type/amount of food, number of types of food items, food groups, meal schedule, medical food/nutrition supplements, location and length of meals, foods used during therapies) to determine whether nutrients are adequately being provided and consumedXXX
      1.5A2Assesses existing and potential factors that may impact intake of a nutritionally adequate diet (Figure 5)XXX
      1.5A3Assesses effects of food preferences, macro- and micronutrient intake, food/texture aversions, person- centered meal plan, prescribed therapeutic diets, variety within food groups, and food allergies/intolerances on nutritional statusXXX
      1.5A4Assesses impact of specific IDD diagnosis(es) (Figure 6) on nutrient needs/intake, growth, and eating skills functionXX
      1.5A5Assesses impact of eating/chewing/swallowing ability on nutritional status and consults with IDT to assess dysphagia risk based on diagnostic tests, observation, and care provider reportsXX
      1.5A6Assesses impact of communication skills on nutrition intake (Figure 5)XX
      1.5BFood and nutrient administration, including current and previous diets and diet prescriptions and food modifications, eating environment, and enteral and parenteral nutrition administrationXXX
      1.5B1Assesses appropriateness of diet prescription based on meal-time observation(s), medical information, individual/care provider report(s), previous nutrition diagnosis (es), diet history, and food preferencesXXX
      1.5B2Assesses social environment (Figure 5)XXX
      1.5B3Evaluates impact of food habits and psychosocial behavior on nutrient intake (Figure 5)XXX
      1.5B4Evaluates need for collaboration with IDT, to address positioning concerns to minimize risks of aspirationXXX
      1.5B5Evaluates the potential for incorporating medical foods/nutritional supplements or enteral tube feedings to address the individual’s specific nutritional needs when necessary (eg, metabolic disorders, phenylketonuria)XX
      1.5B6Assesses nutritional adequacy and food safety concerns with individuals receiving enteral tube feeding formula (eg, cerebral palsy, gut disorders, enzyme deficiencies)XX
      1.5B7Collaborates with caretakers, service coordinators, oral motor therapist, and physician(s) to determine readiness progress along pathway to oral feeding for individuals receiving enteral or parenteral nutritionXX
      1.5CMedication and dietary supplement use, including prescription and over-the-counter medications, and integrative and functional medicine productsXXX
      1.5C1Considers the micro- and macronutrient completeness of the current diet prescription; and considers the effect of medications on micro-/macronutrientsXXX
      1.5C2Considers the safety and efficacy of over-the-counter medications, and dietary supplements; seeks additional information if needed (Office of Dietary Supplements https://ods.od.nih.gov/)XXX
      1.5C3Reviews and considers economic impact (eg, cost/budget, time) of medications and dietary supplements to the individual/familyXXX
      1.5C4Evaluates potential interactions between nutrients/ nutritional status and prescribed medications, over-the- counter and illicit drugs, dietary supplements, integrative and functional medicine products, bioactive substances, and caffeine used with/by IDD population; refer to database resources (eg, Natural Medicine Database: https://naturalmedicines.therapeuticresearch.com/)XXX
      1.5C5Assesses nutrition-related side effects, short or long term; absorption, metabolism, or excretion of nutrients; toxicity; and food and medication interactions for all medications (prescribed, over-the-counter, dietary supplements, integrative and functional medicine) considering symptoms of weight gain, fluid retention, dry mouth, excessive thirst, constipation, altered glucose and/or lipid metabolism, reduced calorie needs, gastrointestinal discomfort, anorexia, and increased appetite; seeks assistance if neededXXX
      1.5C6Assesses the nutrition implications of overall medication regimen, including adherence, side effects to consider need for adding, or discontinuing medications or adjusting the dose or timing as part of care planXX
      1.5C7Incorporates and applies in-depth knowledge of drug–food/nutrient and drug–dietary supplement interactions and associated pharmacokinetics and pharmacodynamicsX
      1.5DKnowledge, beliefs, and attitudes (eg, understanding of nutrition-related concepts, emotions about food/nutrition/health, body image, preoccupation with food and/or weight, readiness to change nutrition- or health-related behaviors, and activities and actions influencing achievement of nutrition-related goals)XXX
      1.5D1Assesses individual/care provider(s) understanding of nutrition diagnosis (es), if available, and need for nutrition care services/medical nutrition therapyXXX
      1.5D1iIdentifies and uses most effective communication methods to determine specific areas of understanding and learning needs and where information is being obtainedXX
      1.5D1iiListens for and notes eating beliefs and convictions (Figure 5)XX
      1.5D2Identifies individual’s/caregiver’s short and long-term goals for nutrition interventionXXX
      1.5D3Evaluates effectiveness of previously implemented nutrition interventions, strategies, methods, motivators, and barriers; seeks assistance as neededXXX
      1.5EFood security defined as factors affecting access to a sufficient quantity of safe, healthful food and water, as well as food/nutrition-related suppliesXXX
      1.5E1Assesses meal planning/cooking abilities/food acquisition issues to determine appropriateness of meals, nutritional adequacy, food safety, and resources for emergency/disaster/pandemic situations (eg, availability of appropriate food, water, and supply of medications)XXX
      1.5E2Assesses ability to provide for special diets and use of community resourcesXXX
      1.5E3Assesses any barriers or conflicts common in individuals with an IDD (Figure 5) that interfere with food access, selection, and preparationXX
      1.5FPhysical activity, cognitive and physical ability to engage in developmentally appropriate nutrition-related tasks (eg, self-feeding and other activities of daily living [ADLs]), instrumental activities of daily living [IADLs]) (eg, shopping, food preparation), and breastfeedingXXX
      1.5F1Uses validated tools to assess developmental, functional, mental, and intellectual status, and cultural, ethnic, and lifestyle factors or reviews reports of othersXXX
      1.5F2Consults and collaborates with IDT throughout assessment processXXX
      1.5F3Considers individual’s ability to feed self (when applicable), cognitive ability for providing self-care, and possible interaction with nutrition careXXX
      1.5F4Assesses physical ability to acquire and prepare food recommended by the RDNXXX
      1.5F5Assesses psychosocial, sensory aversion, and educational history to determine developmental, functional, and communication skillsXX
      1.5F6Uses individual-/person-centered processes and tools for evaluation to assess appropriateness of nutrition-related goals and educationXX
      1.5F7Assesses individual’s habits, self-care skills, and level of support needed for self-directed food selection, attainment, preparation, and intake, as applicable (eg, support of care providers, adaptive equipment, literacy tools, understanding and skills using cooking equipment); and individual’s/family’s/care provider’s:
      • understanding of support needed for the individual to select, prepare, and provide foods and beverages appropriate to the individual’s nutritional needs
      • ability to understand and make informed choices related to individual’s health condition(s)
      • access to instructional tools and methods needed to achieve maximum understanding and informed choices
      XX
      1.5F8Uses experience, clinical, and other supporting data in assessment when validated tools do not existX
      1.5GOther factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, lifestyle influencers, psychosocial, and social determinants of health)XXX
      1.5G1Considers risk of harm to self and possible nutritional implicationsXXX
      1.5G2Notes significant recent stressors and other considerations that may affect food intake (Figure 5)XXX
      1.5G3Evaluates other factors that may delay the individual’s/person’s progress toward nutritional independence when applicableXX
      1.5G4Assesses the risk/history of depression, anxiety, cognition difficulties, disordered eating, or addictions in relation to an individual’s disability or secondary conditions, and the impact on nutritional statusXX
      1.6Comparative standards: Uses reference data and standards to estimate nutrient needs and recommended body weight, body mass index, and desired growth patternsXXX
      1.6AIdentifies the most appropriate reference data and/or standards (eg, international, national, state, county, institutional, and regulatory) based on practice setting and individual-/person-specific factors (eg, disability, age, and disease state)XXX
      1.6BCompares individual’s data to established guidelines, given developmental age, functional status, and stage in life course; and consults with other appropriate health care practitionersXXX
      1.6CUses diagnosis(es) and age-appropriate standards (eg, evidenced-based growth chart) to complement (or augment) clinical assessmentXXX
      1.6DDetermines energy and nutrient requirements, using the Dietary Reference Intakes, and considering the individual’s medical status, food intake, level of activity, growth rate, growth history, mobility, degree of spasticity, medications, and other factors affecting energy requirementsXXX
      1.6EUse appropriate wellness guidelines developed for specific populations (Figure 4)XXX
      1.6FUses understanding of individual’s history, condition, or other issues to individualize expectations and deviate from established reference standards; seeks assistance as neededXXX
      1.7Physical activity habits and restrictions: Assesses physical activity, history of physical activity, and physical activity trainingXXX
      1.7AAssesses individual’s current ability/level of physical activity and effects on nutritional needs and intakeXXX
      1.7BEvaluates individual’s and/or care provider’s access to resources to facilitate physical activity regimenXXX
      1.7CRefers or consults with appropriate therapists for physical activity assessment when indicated (Figure 5)XXX
      1.7DEvaluates limitations of physical activities that provide movement and enjoyment that the individual is currently unable to do; uses information to develop future activity goalsXXX
      1.8Collects data and reviews data collected and/or documented by the nutrition and dietetics technician, registered (NDTR), other health care practitioner(s), individual/person/family or staff for factors that affect nutrition and health statusXXX
      1.8AConsiders multiple factors through interviews, observations, medical records, and IDT communications that contribute to identification of nutrition diagnosis(es):
      • potential impact of medical conditions and treatment, eating routine, and effect of disability history on current/future health status
      • general nutrition concerns, such as food allergies, intolerances, preferences/aversions; and issues of clinical significance, such as malnutrition, alterations in taste and smell, chewing and/or swallowing; and ability to be independent with dining
      • individual’s, family’s or advocate’s
        Advocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the individual/person. The person may be a family member or an individual not related to the individual/person (eg, friend, neighbor, religious leader) who is asked to support the individual/person with activities of daily living or is legally designated to act on behalf of the individual/person, particularly when the individual/person has lost decision making capacity. (Adapted from definitions within The Joint Commission Glossary of Terms12 and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation6).
        expressed wishes and preferences
      XXX
      1.9Uses collected data to identify possible problem areas for determining nutrition diagnosesXXX
      1.9ADiscusses test and nutrition assessment results with IDT to determine need for developing or revising nutrition diagnosis(es) (eg, vitamins D and C, and folate supplementation for individuals on seizure medications)XXX
      1.9BReviews evidence-based nutrition indicators of complications arising from various treatment modalities (eg, dysphagia resulting from medication use or low selenium from diet for phenylketonuria); seeks assistance as neededXXX
      1.9CIdentifies nutritional complications, such as food allergies, intolerances, and preferences and their impact on determining nutrition diagnosesXXX
      1.9DIdentifies underlying and potential problems (Figure 6) associated with the IDD diagnosisXX
      1.9EConsiders current issues and actual risk of developing chronic problems (eg, antipsychotics and development of metabolic syndrome)XX
      1.9FAssesses highly complex issues using an interdisciplinary approach to problem identification and determination of nutrition diagnoses (eg, medical, psychological, other therapies)X
      1.10Documents and communicates:XXX
      1.10ADate and time of assessmentXXX
      1.10BPertinent data (eg, medical, social, behavioral)XXX
      1.10B1Includes data used to determine current nutrition status (eg, laboratory results, height, weight history, food and fluid intake, medications, drug–nutrient interaction)XXX
      1.10CComparison to appropriate standards reflecting age and disabilityXXX
      1.10DDiscussion with individual, care provider(s), health care practitioners(s), and/or IDT throughout assessment processXXX
      1.10EIndividual/person/family/population perceptions, values, and motivation related to presenting problemsXXX
      1.10FChanges in individual/person/family/population perceptions, values and motivation related to presenting problemsXXX
      1.10GReason for discharge/discontinuation or referral, if appropriateXXX
      Examples of Outcomes for Standard 1: Nutrition Assessment
      • Appropriate assessment tools and procedures are used in valid and reliable ways
      • Appropriate and pertinent data are collected
      • Effective interviewing methods are used
      • Data are organized and in a meaningful framework that relates to nutrition problems
      • Use of assessment data leads to the determination that a nutrition diagnosis/problem does or does not exist
      • Problems that require consultation with or referral to another provider are recognized
      • Documentation and communication of assessment are complete, relevant, accurate, and timely
      Standard 2: Nutrition Diagnosis

      The registered dietitian nutritionist (RDN) identifies and labels specific nutrition problem(s)/diagnosis (es) that the RDN is responsible for treating.

      Rationale:

      Analysis of the assessment data leads to identification of nutrition problems and a nutrition diagnosis(es), if present. The nutrition diagnosis(es) is the basis for determining outcome goals, selecting appropriate interventions, and monitoring progress. Diagnosing nutrition problems is the responsibility of the RDN.
      Indicators for Standard 2: Nutrition Diagnosis
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Diagnoses nutrition problems based on evaluation of assessment data and identifies supporting concepts (ie, etiology, signs, and symptoms)XXX
      2.1AEvaluates and integrates assessment data, including pre-existing factors, comorbidities (Figure 6), and impact of other therapiesXXX
      2.1BOrganizes the defining characteristics of assessment data providing evidence that the nutrition diagnosis(es) existsXXX
      2.1CIdentifies factors/causes related to the nutrition problem(s) (Figure 5)XXX
      2.1DConsiders multiple complex factors (eg, pre-existing medical conditions, social skills, pharmacologic needs) in the determination of the etiologyXX
      2.1EApplies clinical knowledge and experience in compiling multiple signs and symptoms in individuals with complex nutrition problems to determine nutrition diagnosis(es)X
      2.2Prioritizes the nutrition problem(s)/diagnosis(es) based on severity, safety, individual/person needs and preferences, ethical considerations, likelihood that nutrition intervention/plan of care will influence the problem, discharge/transitions of care needs, and individual/person/advocate perception of importanceXXX
      2.2AUses evidence-based protocols and guidelines to prioritize nutrition diagnoses in order of urgency; seeks guidance as neededXXX
      2.2BCollaborates with focus area RDNs (Figure 5) and/or other health care practitioners/specialists when caring for individuals with complex needs (Figure 6)XXX
      2.2CUses experience, critical thinking skills, judgment, and information from other care providers to determine nutrition diagnosis hierarchy for individuals with complex needsXX
      2.3Communicates the nutrition diagnosis(es) to individual/person/family members/advocates, community, or other health care professionals when possible and appropriate (eg, through ISP)XXX
      2.3AUses the most appropriate communication method(s) (Figure 5) to share information with individual and support teamXXX
      2.3BParticipates in developing communication protocols and pathways to meet the organization’s/program’s standards and the workflow of the setting, when applicableXX
      2.4Documents the nutrition diagnosis(es) using standardized terminology and clear, concise written statement(s) (eg, using Problem [P], Etiology [E], and Signs and Symptoms [S] [PES statements] or Assessment [A], Diagnosis [D], Intervention [I], Monitoring [M], and Evaluation [E] [ADIME statements])XXX
      2.4AUses the electronic Nutrition Care Process Terminology (eNCPT) when possible (eg, PES statement) to document and explain the nutrition diagnosis(es) (eg, suboptimal/inadequate oral intake related to difficulty swallowing, as evidenced by significant weight loss over time using appropriate measures) in electronic health record, paper chart, and/or other locations in order of importance and in a manner that clearly describes the individual’s nutrition status and needsXXX
      2.5Re-evaluates and revises nutrition diagnosis(es) when additional assessment data become availableXXX
      2.5AUses most current information available/provided that may impact nutrition diagnoses and revises and reprioritizes if applicable, in a timely manner (eg, changes in living arrangements, changes in physical/medical and/or functional status, laboratory/diagnostic tests, evaluations)XXX
      2.5BCommunicates new information and nutrition implications with individual/family/care provider(s) and IDTXXX
      Examples of Outcomes for Standard 2: Nutrition Diagnosis
      • Nutrition diagnostic statements accurately describe the nutrition problem of the individual/person and/or community in a clear and concise way
      • Documentation of nutrition diagnosis(es) is relevant, accurate, and timely
      • Documentation of nutrition diagnosis(es) is revised as additional assessment data become available
      Standard 3: Nutrition Intervention/Plan of Care

      The registered dietitian nutritionist (RDN) identifies and implements appropriate, individual/person-centered interventions designed to address nutrition-related problems, behaviors, risk factors, environmental conditions, or aspects of health status for an individual, target group, or the community at large.

      Rationale:

      Nutrition intervention consists of 2 interrelated components—planning and implementation.
      • Planning involves prioritizing the nutrition diagnoses, conferring with the individual/person and others, reviewing practice guidelines, protocols and policies, setting goals and defining the specific nutrition intervention strategy.
      • Implementation is the action phase that includes carrying out and communicating the intervention/plan of care, continuing data collection, and revising the nutrition intervention/plan of care strategy, as warranted, based on change in condition and/or the individual/person/population response.
      An RDN implements the interventions or assigns components of the nutrition intervention/plan of care to professional, technical, and support staff in accordance with knowledge/skills/judgment, applicable laws and regulations, and organization policies. The RDN collaborates with or refers to other health care professionals and resources. The nutrition intervention/plan of care is ultimately the responsibility of the RDN.
      Indicators for Standard 3: Nutrition Intervention/Plan of Care
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      Plans the Nutrition Intervention/Plan of Care:
      3.1Addresses the nutrition diagnosis(es) by determining and prioritizing appropriate interventions for the plan of careXXX
      Prioritization considerations may include:
      3.1APerception of importance based on discussion with IDT and individual’s choices and preferencesXXX
      3.1BCurrent acute and chronic health conditions, or risk of developing acute or chronic health conditionsXXX
      3.1CCognitive, physical, and developmental readiness to benefit from nutrition servicesXXX
      3.1DImmediacy of the problem and severity of nutrition risk or malnutrition, if presentXXX
      3.1ESafety risk or potential risk across current and planned interventions (eg, aspiration risk)XX
      3.1FIDD-specific disorders and other comorbidities (Figure 6)XX
      3.1GChallenges that impact nutrition status (Figure 5)XX
      3.1HAbility to improve health and nutrition status based on outcome(s) of preceding interventions, current supports, and likelihood for success based on evidence and practice experienceXX
      3.1IAbility to evaluate evidence and potential benefit from emerging therapiesXX
      3.2Bases intervention/plan of care on best available research/evidence and information, evidence-based guidelines, and best practicesXXX
      3.2AConsults and applies appropriate evidence-based practice guidelines for the individual’s diagnosis(es), nutritional needs, and other factors (Figure 4)XXX
      3.2A1Tailors plan of care based on the individual’s needs, preferences, and response to interventionXXX
      3.2BUses professional judgment that draws from scientific literature, practice experience, treatments for medical conditions, when applicable, and the nutrition status of the individual in developing an intervention plan; seeks assistance from experienced practitioner if neededXXX
      3.2CRecognizes when it is appropriate to use intervention guidelines based on physiological or other conditions (Figure 6) contraindicative of usual protocolXX
      3.3Refers to policies and procedures, protocols, and program standardsXXX
      3.3ARefers to policies, procedures, and protocols throughout the planning process to promote positive nutrition outcomes while considering individual’s preferences/choicesXXX
      3.3BAdapts nutrition protocols as appropriate to facilitate goal achievement consistent with individual’s choices and treatment planXX
      3.3CServes as a resource to other practitioners and the IDT on application of nutrition protocols and guidelines to an individual or populationXX
      3.4Collaborates with individual/person/advocate/population, caregivers, IDT, and other health care professionalsXXX
      3.4AConsiders individual’s and family’s/care provider’s knowledge, skills, and willingness to implement nutrition intervention to achieve goalsXXX
      3.4BCollaborates with the individual, including family, caregiver(s), IDT, and other health care practitioners as needed in all aspects of nutrition care and person-centered interventions and planningXXX
      3.4B1Recognizes specific knowledge and skills of other providers, and collaborates to provide comprehensive careXX
      3.4B2Develops collaborations with feeding teams for consultation and to facilitate referrals when indicatedXX
      3.4B3Facilitates the collaborative process with IDT members in planning the interventionX
      3.4CExplains to individual/family/care provider the risks and benefits of the nutrition care options; obtains guidance from an experienced practitioner, if neededXXX
      3.5Works with individual/person/advocate/population, and caregivers to identify goals, preferences, discharge/transitions of care needs, plan of care and expected outcomesXXX
      3.5ADevelops individual/person-centered goals and expected outcomes using S.M.A.R.T (Specific, Measurable, Attainable, Realistic, Timely) format; goal setting to consider:
      • nutrition and medical diagnoses identified in the assessment and seeks additional information when needed
      • health care and resource utilization (eg, service coordination, access, and delivery of care/services)
      • effects on individual and their family (eg, ADLs, participation in activities that are appropriate for age and developmental level)
      XXX
      3.5BDetermines and addresses when necessary, if foods/beverages are used as part of therapies (eg, swallowing evaluation/retraining) and if used as reward or punishment for positive/negative behaviorsXXX
      3.5CRefers individual to appropriate health care practitioner for problems outside scope of practiceXXX
      3.5DEngages with the individual/family/advocate to identify personal preferences and goals, help identify barriers and solutions while offering evidence-based nutrition information to support collaborative discussion through shared decision-making for achieving the desired outcomes (Figure 5)XXX
      3.5D1Takes into consideration social skills, processing of information (allowing time for individual to process and communicate needs), ability to communicate desired needs, and variety of ways needs are communicated, including nontraditional ways (Figure 5)XX
      3.5EAnticipates how nutrition intervention may minimize treatment- related side effects, treatment delays, and the need for hospital admissionXX
      3.6Develops the nutrition prescription and establishes measurable individual-/person-focused goals to be accomplishedXXX
      3.6ADevelops or adjusts the nutrition plan based on best-available evidence and individual-/person-centered goals and anticipated outcomes, taking into consideration factors affecting health status (Figure 6); seeks assistance from experienced resource if neededXXX
      3.6A1Determines intervention strategies/steps needed to address current and/or potential problems or barriersXXX
      3.6A2Considers energy requirements and hydration needs associated with changes in activity level, medications, and disease stateXXX
      3.6A3Considers impacts of nutrition and appetite on behavior and readiness to learnXX
      3.6A4Recommends adjusting diet prescription for increases or decreases in modified food textures, enteral/parenteral nutrition, and fluid needs as oral motor ability changes the degree of food texture modification and/or fluid thickness required for safe consumption of food/nutrient, and fluid needsXX
      3.6A5Integrates information, knowledge, and critical thinking to address more complex/subtle issues, such as complaints of stomach aches, headaches, insomnia, depressionX
      3.6A6Anticipates nutrient imbalances associated with altered mental status (eg, anxiety, depression), altered taste (zinc), and medicationsX
      3.6A7Considers emerging/alternative treatment strategies that are supported by evidence-based research, guidelines, and informationX
      3.7Defines time and frequency of care, including intensity, duration, and follow-upXXX
      3.7AIdentifies time and frequency of care based on individual’s needs, established goals and outcomes, and expected response to intervention(s) reflecting organization program policies and/or regulations, when applicableXXX
      3.7A1Considers expected changes in nutrition status, functional ability, and progress toward nutrition outcomesXX
      3.7A2Considers severity of nutrition issues, and/or pending medical interventions that are influenced by or may influence nutrition statusXX
      3.7BDetermines frequency and duration of care needed, including when recommended services are not consistent with reimbursement guidelines of funding source(s)XX
      3.7CDevelops guidelines for timing of intervention(s) and follow-up in population(s) served by setting based on outcomes data (Figure 4)X
      3.8Uses standardized terminology for describing interventionsXXX
      3.8AUses standardized terminology (eg, eNCPT, International Dysphagia Diet Standardization Initiative [IDDSI]) or adapts terminology to the facility/program system requirements and to facilitate understanding by the IDD populationXXX
      3.8BUses appropriate diagnostic and treatment language as per funding source or agencyXXX
      3.9Identifies resources and referrals neededXXX
      3.9AIdentifies resources/referrals/community programs with treatment approaches needed to meet individual’s nutrition needs and educational services in consultation with IDTXXX
      3.9A1Understands the roles of various disciplines (Figure 5) to facilitate appropriate referrals as neededXXX
      3.9A2Advocates for services needed for individual to support and achieve goals/outcomesXXX
      3.9A3Considers access to services needed to support adequate nutrition (Figure 5)XXX
      3.9A4Creates a list of nutrition and other resources specific to individual/family/care providers, in collaboration with IDT, to support accessing services, education, and transitions of careXX
      3.9BProvides guidance to individuals/families in response to request for integrative and functional medicine or nontraditional treatment approaches (eg, research, potential outcomes, and side effects); seeks assistance if neededXXX
      Implements the Nutrition Intervention/Plan of Care:
      3.10Collaborates with colleagues, IDT, and other health care professionalsXXX
      3.10AUses the individual-/person-centered plan of care and acknowledges the team approach in all aspects of plan implementationXXX
      3.10BSeeks and identifies opportunities for IDT to be involved with implementation of the individual’s nutrition plan (eg, determine appropriate form and method of administering medication[s] to individuals receiving enteral nutrition support, texture modified diets, or other medical or pediatric feeding disorder considerations)XX
      3.10CDevelops and/or monitors program-/agency-specific process to assess and continuously monitor an individual’s degree of nutrition risk considering health status, underlying morbidity, frequency, and duration of interventionsX
      3.10DSeeks opportunities to lead and direct IDT to discuss and resolve complex issues and/or implement changes to nutrition planX
      3.11Communicates and coordinates the nutrition intervention/plan of careXXX
      3.11AReviews nutrition goals, interventions, and referrals/resources needed to meet goals in nutrition plan of care and communicates with IDT, referring medical provider, other health care practitioners, medical care settings, and other involved professionals (Figure 5)XXX
      3.11BEnsures communication of nutrition plan of care and nutrition-related data between home, acute care, ambulatory care, vocational/educational team, and/or residential/long-term care facility as neededXXX
      3.11CCollaborates with IDT to facilitate coordination of care and awareness of potentially conflicting/problematic treatments (eg, medication-dietary supplement interaction)XX
      3.12Initiates the nutrition intervention/plan of careXXX
      3.12AUses approved clinical privileges, physician/nonphysician practitioner
      Nonphysician practitioner: A nonphysician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.6,7 The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.9,10
      -driven orders (ie, delegated orders), protocols, or other facility-specific processes for order writing or for provision of nutrition-related services consistent with applicable specialized training, competence, medical staff, and/or organizational policy
      XXX
      3.12A1Implements, initiates, or modifies orders for therapeutic diet, nutrition-related pharmacotherapy management, or nutrition-related services (eg, medical foods/nutrition/dietary supplements, food texture modifications, enteral and parenteral nutrition, intravenous fluid infusions, laboratory tests, medications, and education and counseling)XXX
      3.12A1iRecommends or initiates nutrition-related orders for diet, including food/fluid texture modifications, nutritional supplements, or enteral nutrition formula consistent with clinical privileges when applicable or physician-delegated orders or protocolXXX
      3.12A1iiProvides education and counseling on the use of prescribed or recommended over-the-counter dietary supplements for safety, to minimize food–nutrient–medication interactions and interactions with treatments; consults with pharmacist as neededXX
      3.12A2Manages nutrition support therapies (eg, formula selection, rate adjustments, addition of designated medications and vitamin/mineral supplements to parenteral nutrition solutions or supplemental water for enteral nutrition)XXX
      3.12A2iManages or oversees care for individuals receiving enteral or parenteral nutrition, consistent with privileging or physician-delegated orders, if applicable, or organization/program guidelines, regulations, in collaboration with physician or IDT; seeks assistance, if neededXXX
      3.12A3Initiates and performs nutrition-related services (eg, bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, and indirect calorimetry measurements or other permitted services)XXX
      3.12BConsiders literacy and numeracy levels and cultural/language differences and uses or adapts appropriate educational materials and tools that are understandable and culturally relevant to meet individual’s learning style and method of communication (Figure 5)XXX
      3.12CUses critical thinking skills to identify and combine multiple and/or complex intervention approaches as appropriate:
      • adapts general nutrition education tools to individual’s and family’s learning style and method(s) of communication
      • incorporates stages of behavior change as a guide to assess the individual’s readiness to learn and adjusts counseling style accordingly
      • uses appropriate behavior change theories (eg, motivational interviewing, positive habit formation, modeling) to facilitate self-management/self-care strategies
      • encourages greater independence in food choices and empowers the individual to take control of their health as they move toward a less structured environment
      XX
      3.12DUses critical thinking, synthesis skills, in-depth knowledge, and experience with IDD population to individualize the strategy for complex interventions, as appropriateX
      3.13Assigns activities to NDTR and other professional, technical, and support personnel in accordance with qualifications, organizational policies/ protocols, and applicable laws and regulationsXXX
      3.13ASupervises professional, technical, and support personnelXXX
      3.13BProvides professional, technical, and support personnel with information and guidance needed to complete assigned activitiesXXX
      3.14Continues data collectionXXX
      3.14AIdentifies and records specific data for individual, including weight change, biochemical, behavioral, and lifestyle factors using prescribed/standardized formatXXX
      3.14BCoordinates data and input from other IDT members to reflect on individual’s progress and potential need for change in nutrition care plan, meal plan, and/or discharge/transitions of care planXXX
      3.14CMaintains confidentiality of data records (eg, electronic, written)XXX
      3.15Documents:XXX
      3.15ADate and timeXXX
      3.15BSpecific and measurable treatment goals and expected outcomesXXX
      3.15CRecommended interventionsXXX
      3.15DIndividual/person/advocate/caregiver/community receptivenessXXX
      3.15D1Individual/care provider(s) changes in and/or acceptance of perceptions, values, and motivation related to presenting problems and designated interventionsXXX
      3.15EProgress meeting goals or expected outcomes, including evidence that intervention is or is not changing/maintaining the individual’s eating habits, satiety, or nutrition statusXXX
      3.15FReferrals made and resources usedXXX
      3.15GIndividual/person/advocate/caregiver/community comprehensionXXX
      3.15G1Understanding/comprehension of risks and benefitsXXX
      3.15HBarriers to changeXXX
      3.15H1Influencing factors or barriers affecting ability and/or willingness to follow nutrition care plan (Figure 5)XXX
      3.15IOther information relevant to providing care and monitoring progress over timeXXX
      3.15JPlans for follow-up and frequency of careXXX
      3.15KRationale for discharge or referral if applicable (eg, met goals/ outcomes, lack of progress, nonadherence, frequently missed appointments)XXX
      3.15LJustification for medical nutrition therapy continuation or follow-up (eg, frequency and duration of services, expected achievement with continued services, risks for discontinuation, supporting data)XXX
      Examples of Outcomes for Standard 3: Nutrition Intervention/Plan of Care
      • Goals and expected outcomes are appropriate and prioritized
      • IDT, including the individual/person (Figure 5), collaborate and is involved in developing nutrition intervention/plan of care
      • Appropriate individual-/person-centered nutrition intervention/plan of care, including nutrition prescription, is developed
      • Nutrition intervention/plan of care is delivered and actions are carried out as intended
      • Discharge planning/transitions of care needs are identified and addressed
      • Documentation of nutrition intervention/plan of care is:
        • o
          Specific
        • o
          Measurable
        • o
          Attainable
        • o
          Relevant
        • o
          Timely
        • o
          Comprehensive
        • o
          Accurate
        • o
          Dated and timed
      Standard 4: Nutrition Monitoring and Evaluation

      The registered dietitian nutritionist (RDN) monitors and evaluates indicators and outcomes data directly related to the nutrition diagnosis, goals, preferences, and intervention strategies to determine the progress made in achieving desired results of nutrition care and whether planned interventions should be continued or revised.

      Rationale:

      Nutrition monitoring and evaluation are essential components of an outcomes management system in order to assure quality, individual-/person-/population-centered care and to promote uniformity within the profession in evaluating the efficacy of nutrition interventions. Through monitoring and evaluation, the RDN identifies important measures of change or individual/person/population outcomes relevant to the nutrition diagnosis and nutrition intervention/plan of care; describes how best to measure these outcomes; and intervenes when intervention/plan of care requires revision.
      Indicators for Standard 4: Nutrition Monitoring and Evaluation
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Monitors progress:XXX
      4.1AAssesses individual/person/advocate/population understanding and compliance with nutrition intervention/plan of careXXX
      4.1A1Verifies understanding and adherence to nutrition intervention by having individual/caregiver/advocate verbalize and/or demonstrate understanding as evidenced by use of appropriate menus, meal planning, food choices, food-preparation techniques, and food-safety guidelines consistent with prescribed nutrition interventionXXX
      4.1A2Determines barriers to understanding that are present and impacting the individual’s/caregiver’s/advocate’s acceptance of the nutrition intervention/plan of careXX
      4.1A3Identifies, creates, or tailors tools and methods to improve understanding of and/or adherence to plan as needed based on the individual’s/caregiver’s/advocate’s specific needs and situationsXX
      4.1BDetermines whether the nutrition intervention/plan of care is being implemented as prescribedXXX
      4.1B1Verifies implementation of prescribed nutrition intervention (eg, reviews data collection records; conducts interviews and direct observations of nutrition intervention), and consults with IDT members, if neededXXX
      4.1B2Uses direct observation, interviews, and/or identifiers specific to the individual’s circumstances (eg, monitors physical, social, cognitive, environmental factors) that may influence response to nutrition interventionXXX
      4.1B3Identifies any barriers to implementation and adherence to interventionXXX
      4.1B4Evaluates nutrition intervention related to special situations (Figure 5) to determine additional resources neededXX
      4.2Measures outcomes:XXX
      4.2ASelects the standardized nutrition care measurable outcome indicator(s)XXX
      4.2A1Considers individual-/person-centered outcomes (eg, quality of life, physical well-being, anthropometric and laboratory data, and individual’s/advocate’s satisfaction)XXX
      4.2A2Uses multiple data sources to assess progress in meeting desired outcomes; examples include:
      • adequacy of food/nutrient intake from all sources
      • changes in body weight, composition
      • laboratory and other test results
      • positive/negative effects of pertinent medications and dietary supplements
      • changes in cognitive and functional status
      • changes in skin integrity
      • changes in physical activity level
      XXX
      4.2A3Uses critical thinking skills to adapt/create outcome measures when standardized measures do not apply to the individualXX
      4.2BIdentifies positive or negative outcomes, including impact on potential needs for discharge/transitions of careXXX
      4.2B1Assesses established nutrition goals to determine whether progress is being made to achieve desired clinical and lifestyle outcomesXXX
      4.2B2Monitors appropriateness of growth/maintenance of nutrition and fluid status while individual progresses along pathway to oral feeding (ie, transition off enteral/parenteral nutrition), when applicableXX
      4.2B3Anticipates potential for unintended consequences of a nutrition intervention/outcome (Figure 5)XX
      4.2B4Uses knowledge of the population, experience, and critical thinking in evaluating complex changes in condition, impact of interventions, and other factors on achievement of outcomesX
      4.3Evaluates outcomes:XXX
      4.3ACompares monitoring data with nutrition prescription and established goals or reference standard (Figure 4)XXX
      4.3A1Monitors and analyzes clinical data to improve individual’s outcomes; seeks assistance as neededXXX
      4.3A2Reviews and understands data based on experience, clinical judgment, and/or identifies criteria to which the data are comparedXX
      4.3BEvaluates impact of the sum of all interventions on overall individual/person/population health outcomes and goalsXXX
      4.3B1Evaluates the individual’s variance from planned outcomes and incorporates findings into future individualized treatment recommendationsXXX
      4.3B2Uses clinical judgment based on experience with IDD population to analyze the impact of all interventions on individual’s health outcomes and quality of lifeXX
      4.3CEvaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.3C1Uses data from individual and/or care provider/team members (Figure 5) to determine whether progress is being madeXXX
      4.3C2Uses multiple resources to assess progress (Figure 5) relative to effectiveness of care planXXX
      4.3C3Evaluates patterns, trends, and disparities related to problems and interventions (eg, complex medical problems, changes in mental health status, changes in social support needs)XX
      4.3C4Assesses underlying factors interfering with intervention outcomes and access to services (eg, lifestyle, prognosis, funding, resources) and analyzes their impact on future treatment recommendationsXX
      4.3C5Recognizes problems that are beyond the scope of nutrition that are interfering with interventions and achieving desired outcomes; makes referrals or consults with IDT to address issuesX
      4.3DEvaluates evidence that the nutrition intervention/plan of care is maintaining or influencing a desirable change in the individual/ person/population behavior or status; consults with IDT as applicableXXX
      4.3D1Accesses appropriate records for evidence of ability to follow plan (eg, mealtime observations, food available in home, food logs, activity logs, weight/growth charts, physical examination, laboratory results, medication changes)XXX
      4.3D2Evaluates individual’s outcomes in relation to nutrition plan and goals (eg, laboratory data, physical, social, cognitive, environmental factors, ADLs, and growth and development)XXX
      4.3ESupports conclusions with evidenceXXX
      4.3E1Clearly documents processes and outcomesXXX
      4.4Adjusts nutrition intervention/plan of care strategies, if needed, in collaboration with individual/person/family/population/advocate/caregiver and IDTXXX
      4.4AImproves or adjusts intervention/plan of care strategies based upon outcomes data, trends, best practices, and comparative standardsXXX
      4.4BModifies intervention strategies based on person-centered needs (Figure 5); seeks assistance as neededXXX
      4.4CModifies the diet or nutrition-related orders for improved comprehension and implementation consistent with approved clinical privileges for order writing or physician-delegated orders or protocol, as neededXXX
      4.4DIdentifies need for additional resources (eg, sources of equipment or nutrition products, avenues for therapy) to fulfill the nutrition prescriptionXX
      4.4EArranges for additional supportive services, as needed (eg, training of direct care providers, enrollment in supportive services) in collaboration with IDT membersXX
      4.4FIdentifies/develops tools/methods to tailor intervention to ensure desired outcomes based on individual’s/family’s/caregiver’s response to treatmentX
      4.4GMakes adjustments in unpredictable situations (eg, death of spouse/family member/close friend)X
      4.4HLeads in analysis of data and discussions with IDT when outcomes are not achieved to revise nutrition diagnosis and plan/interventionsX
      4.5Documents:XXX
      4.5ADate and timeXXX
      4.5BIndicators measured, results, and the method for obtaining measurementXXX
      4.5CCriteria to which the indicator is compared (eg, nutrition prescription/goal or a reference standard)XXX
      4.5DIndividual’s and/or family’s/care provider’s perspective on nutrition plan, problems, and progressXXX
      4.5EFactors facilitating or hampering progress

      Examples:
      • change in clinical, health status, or functional outcomes
      • change in individual’s level of understanding and food-related habits
      • self-determination decision by individual/family/advocate affecting acceptance of nutrition interventions
      • changes in family situation, advocate, caregiver, social supports, or living situation
      XXX
      4.5FInsufficient data or lack of data (eg, unavailable or incomplete medical records)XXX
      4.5GOther positive or negative outcomesXXX
      4.5HAdjustments to the nutrition intervention/plan of care, if indicatedXXX
      4.5IFuture plans for nutrition care, nutrition monitoring and evaluation, follow-up, referral, or dischargeXXX
      Examples of Outcomes for Standard 4: Nutrition Monitoring and Evaluation
      • The individual/person/community outcome(s) directly relate to the nutrition diagnosis and the goals established in the nutrition intervention/plan of care. Examples include, but are not limited to:
        • o
          Nutrition outcomes (eg, change in knowledge, habits, self-care, food, or nutrient intake)
        • o
          Clinical and health status outcomes (eg, change in laboratory values, body weight, blood pressure, risk factors, signs and symptoms, eating habits/preferences, clinical status, infections, complications, morbidity, and mortality)
        • o
          Individual-/person-/population-centered outcomes (eg, quality of life, satisfaction, self-efficacy, self-management, functional ability)
        • o
          Health care utilization and cost-effectiveness outcomes (eg, change in medication, special procedures, planned/unplanned clinic visits, preventable hospital admissions, length of hospitalizations, prevented or delayed nursing home admissions, morbidity, and mortality)
      • Nutrition intervention/plan of care and documentation is revised, if indicated
      • Documentation of nutrition monitoring and evaluation is:
        • o
          Specific
        • o
          Measurable
        • o
          Attainable
        • o
          Relevant
        • o
          Timely
        • o
          Comprehensive
        • o
          Accurate
        • o
          Dated and Timed
      a Interdisciplinary: The term interdisciplinary is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, social workers, occupational, physical, and speech therapists, oral motor therapist, Qualified Intellectual Disabilities Professional [QIDP], school administrators, teachers, school nurse, teacher’s aide, direct care professional, assistive technologist, applied behavior analysis [ABA] therapist, Adult Protective Services, Child Protective Services, regional center, state vocational rehabilitation agencies), depending on the needs of the individual. Interdisciplinary could also mean interprofessional or multidisciplinary.
      b Advocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the individual/person. The person may be a family member or an individual not related to the individual/person (eg, friend, neighbor, religious leader) who is asked to support the individual/person with activities of daily living or is legally designated to act on behalf of the individual/person, particularly when the individual/person has lost decision making capacity. (Adapted from definitions within The Joint Commission Glossary of Terms
      The Joint Commission
      Glossary of terms.
      and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation

      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf.

      ).
      c Nonphysician practitioner: A nonphysician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.

      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf.

      ,

      State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf.

      The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.

      Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872)—Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178). US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities.

      ,

      State Operations Manual. Appendix PP Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.

      Figure 2Standards of Professional Performance for RDNs in Intellectual and Developmental Disabilities. Note: The term customer along with individual is used in this evaluation resource as a universal term. Individual could also mean person/customer, family, participant, consumer, or any individual. group, or organization to which the RDN provides service
      Standards of Professional Performance for Registered Dietitian Nutritionists in Intellectual and Developmental Disabilities

      Standard 1: Quality in Practice

      The registered dietitian nutritionist (RDN) provides quality services using a systematic process with identified ethics, leadership, accountability, and dedicated resources.

      Rationale:

      Quality practice in nutrition and dietetics is built on a solid foundation of education and supervised practice, credentialing, evidence-based practice, demonstrated competence, and adherence to established professional standards. Quality practice requires systematic measurement of outcomes, regular performance evaluations, and continuous improvement.
      Indicators for Standard 1: Quality in Practice
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Complies with applicable laws and regulations as related to their area(s) of practiceXXX
      1.1ARecognizes and complies with relevant local, state, and federal laws and regulations, and accreditation programs for people with intellectual and developmental disabilities (IDD)XXX
      1.1BComplies with state licensure or certification laws and regulations, if applicable, including telehealth and continuing education requirementsXXX
      1.2Performs within individual and statutory scope of practice and applicable laws and regulationsXXX
      1.2AAdheres to the practice boundaries related to nutrition and other areas of education and trainingXXX
      1.3Adheres to sound business and ethical billing practices applicable to the role and settingXXX
      1.3ADevelops an understanding and complies with appropriate payment and reimbursement requirements for payer (eg, Medicare, Medicaid) and type of nutrition visit applicable to IDD settingXXX
      1.3BFollows recognized and ethical business practices; complies with organization position description and processes or consultant contract (services, deliverables, fees, billing process) that contribute to accurate budgeting and data reporting, for example:
      • employee: hours and other required information
      • consultant: services provided and hours
      • documentation in the medical record (electronic or manual)
      • other processes used to report actions and recommendations
      XXX
      1.4Uses national quality and safety data (eg, National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division, National Quality Forum, Institute for Healthcare Improvement) to improve the quality of services provided and to enhance individual/person-centered servicesXXX
      1.4AEducates interdisciplinary
      Interdisciplinary: The term interdisciplinary is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, social workers, occupational, physical, and speech therapists, oral motor therapist, qualified intellectual disabilities professional, school administrators, teachers, school nurse, teacher’s aide, direct care professional, assistive technologist, applied behavior analysis therapist, Adult Protective Services, Child Protective Services, regional center, state vocational rehabilitation agencies), depending on the needs of the individual. Interdisciplinary could also mean interprofessional or multidisciplinary.
      PROMIS: Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient (or individual/person)-reported health status for physical, mental, and social well-being. PROMIS is a web-based resource and is publicly available.
      team (IDT) on pertinent quality and safety initiatives relevant to population served by setting (eg, food safety, International Dysphagia Diet Standardization Initiative [IDDSI])
      XXX
      1.4BResponds to changes to local, state, and national quality initiatives and advocates for positive-effect changes to support IDD nutrition care and related servicesXX
      1.4CLeads efforts to support and establish IDD nutrition benchmarks (eg, weight standards, nutrition care guidelines, and integrative and functional medicine practices)X
      1.4DLeads organization’s/program’s IDT review and application of national consensus-based standards and measures in performance monitoring processX
      1.5Uses a systematic performance improvement model that is based on practice knowledge, evidence, research, and science for delivery of the highest-quality servicesXXX
      1.5AIdentifies and participates in quality assurance and performance improvement (QAPI) activities per organization/agency quality review plan or processXXX
      1.5BObtains training and collaborates with members of the IDT on the organization performance improvement model(s) and leads performance improvement initiativesXX
      1.5CDevelops or collaborates on implementation strategies for quality management activities (eg, identification/adoption of evidence-based practice guidelines/protocols, skills training/reinforcement, organization support)X
      1.6Participates in or designs an outcomes-based management system to evaluate safety, effectiveness, quality, person-centeredness, equity, timeliness, and efficiency of practiceXXX
      1.6AInvolves colleagues and others, as applicable, in systematic outcomes managementXXX
      1.6A1Collaborates with IDT in promoting and measuring quality of IDD nutrition care and services using systemic outcomes managementXX
      1.6A2Leads interdisciplinary efforts to establish and/or improve IDD nutrition care interventions and outcomesX
      1.6BDefines expected outcomesXXX
      1.6B1Identifies evidenced-based nutrition-specific care and service outcomes and related processes to measureXXX
      1.6B2Identifies quality outcome indicators to measure (eg, Centers for Medicare and Medicaid Services [CMS], organization-specific measures)XX
      1.6B3Identifies and assesses factors influencing the achievement of expected outcomes through direct evaluation, benchmarking, and evaluation of environmental trends, such as:
      • individual/staff compliance to RDN/health care team guidance
      • insufficient care provider supports
      • need for individual and care provider training/education to improve knowledge and skills
      X
      1.6CUses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)XXX
      1.6C1Uses critical thinking skills to re-evaluate S.M.A.R.T. goals and update in a timely mannerXXX
      1.6C2Supports and/or serves in leadership role to evaluate benchmarks of IDD population-based indicators to improve outcomes (Figure 4)XX
      1.6DMeasures quality of services in terms of structure, process, and outcomesXXX
      1.6D1Seeks out and uses or adapts established systematic processes to collect and analyze data specific to individuals with IDD; seeks assistance as neededXXX
      1.6D2Selects criteria, participates in developing data-collection tools (eg, clinical, operational, and financial), and analyzes data to determine the success of action plans reaching individual and program outcome goalsXX
      1.6D3Leads in establishing a QAPI process to monitor and evaluate the effectiveness of IDD nutrition services providedX
      1.6EIncorporates electronic clinical quality measures to evaluate and improve care of individuals at risk for malnutrition or with malnutrition (www.eatrightpro.org/emeasures)XXX
      1.6E1Ensures that screening for nutrition risk is a component of program admission process or nutrition assessment using evidence-based screening tools for the setting and/or populationXXX
      1.6E2Uses applicable clinical quality measures to collect and report data on population risk factors, screening timeframes, number at risk or with malnutrition, and services providedXX
      1.6FDocuments outcomes and patient (individual) reported outcomes (eg, PROMIS
      PROMIS: Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient (or individual/person)-reported health status for physical, mental, and social well-being. PROMIS is a web-based resource and is publicly available.
      )
      XXX
      1.6F1Documents and reports outcomes to colleagues and groups; seeks assistance if neededXXX
      1.6F2Evaluates population and service outcomes using identified metrics to reinforce current practices or implement changes in practice(s)XX
      1.6GParticipates in, coordinates, or leads program participation in local, regional, or national registries and data warehouses used for tracking, benchmarking, and reporting service outcomesXXX
      1.6G1Collaborates with IDT to collect data for documenting and reporting outcomes of nutrition services and interventionsXX
      1.6G2Participates in population-based surveys and research for health and disease conditions for the IDD population (eg, data collection, policy development, and publications)XX
      1.6G3Actively promotes the inclusion of RDN-provided medical nutrition therapy and nutrition services for individuals with IDD in local, state, and/or national data registriesXX
      1.6HEvaluates nutrition-related issues from population-based surveys and studies and applies to practice (eg, Health and Nutrition Examination Survey, National Survey of Children with Special Healthcare Needs Chart Book 2009-2010; https://www.cdc.gov/nchs/slaits/cshcn.htm#anchor_1551498339279)XX
      1.7Identifies and addresses potential and actual errors and hazards in provision of services or brings to attention of supervisors and team members as appropriateXXX
      1.7AIdentifies and addresses errors and potential hazards as part of the evaluation process for quality care and alerts supervisors as appropriate (eg, drug–nutrient interactions, food safety, enteral feeding use)XXX
      1.7A1Keeps up to date on current findings regarding dietary supplements (eg, Natural Medicine Database; https://naturalmedicines.therapeuticresearch.com/), and food safety (https://www.foodsafety.gov)XXX
      1.7A2Collaborates with team to contribute to the awareness of potential drug–food/nutrient and drug–dietary supplement interactions; and to educate IDTXXX
      1.7A3Refers individuals/families to appropriate services when error/hazard is outside RDN’s scope of practiceXXX
      1.7A4Maintains awareness of problematic names and error prevention recommendations provided by Institute for Safe Medication Practices (www.ismp.org), US Food and Drug Administration (www.fda.gov), US Pharmacopeia (www.usp.org)XX
      1.7BAssesses and documents the potential for errors and hazards and implements corrective and/or preventative measures (eg, educational programs, system alerts) with monthly audits or according to organization policy; works with facility staff to reduce errors and hazardsXX
      1.7CLeads in the development of protocols to identify, address, and prevent errors and hazards; development of safety alert systems when needed; and in the implementation of revised processes in the delivery of food and nutrition servicesX
      1.8Compares actual performance to performance goals (ie, Gap Analysis, SWOT Analysis [Strengths, Weaknesses, Opportunities, and Threats], PDCA Cycle [Plan-Do-Check-Act], DMAIC [Define, Measure, Analyze, Improve, Control])XXX
      1.8AReports and documents action plan to address identified gaps in care and/or service performanceXXX
      1.8A1Develops or revises plan of action with IDT and staff to meet expected outcomesXX
      1.8BCompares department/organization performance to goals and expected outcomes to identify improvement recommendations/actions in collaboration with the IDT or other stakeholdersXX
      1.8CBenchmarks department/organization performance with national programs and standardsX
      1.9Evaluates interventions and workflow process(es) and identifies service and delivery improvementsXXX
      1.9AParticipates in testing interventions to improve nutrition processes and servicesXXX
      1.9BUses evaluation data and/or collaborates with IDT to identify facility/organization improvementsXX
      1.10Improves or enhances individual/person/population care and/or services working with others based on measured outcomes and established goalsXXX
      1.10AAdjusts services and programs based on data and review of current evidence-based information in collaboration with IDTXXX
      1.10BOversees, monitors, ensures consistency, and revises processes and outcomes evaluation efforts to improve servicesXX
      1.10CDevelops or investigates and shares systems, processes, and programs that support best practices in IDD nutrition care and services; publishes outcomes and best practicesX
      Examples of Outcomes for Standard 1: Quality in Practice
      • Actions are within scope of practice and applicable laws and regulations
      • National quality standards and best practices are evident in person-centered services
      • Performance improvement systems specific to program(s)/service(s) are established and updated as needed; are evaluated for effectiveness in providing desired outcomes data and striving for excellence in collaboration with other team members
      • Performance indicators are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)
      • Aggregate outcomes results meet pre-established criteria
      • Quality improvement results direct refinement and advancement of practice
      Standard 2: Competence and Accountability

      The registered dietitian nutritionist (RDN) demonstrates competence in and accepts accountability and responsibility for ensuring safe, quality practice and services.

      Rationale:

      Competence and accountability in practice includes continuous acquisition of knowledge, skills, experience, and judgment in the provision of safe, quality customer-centered service.
      Indicators for Standard 2: Competence and Accountability
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Adheres to the code(s) of ethics (eg, Academy/Commission on Dietetic Registration [CDR], other national organizations, and/or employer code of ethics)XXX
      2.1ADemonstrates understanding of, and practices in accordance with, the current Code of Ethics and other organization or local, and/or state policies applicable to those working with IDD populationsXXX
      2.1BIdentifies and seeks guidance through consultation with appropriate professionals (Figure 5)XXX
      2.2Integrates the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) into practice, self-evaluation, and professional developmentXXX
      2.2AIntegrates applicable focus area(s) SOP and/or SOPP into practice (eg, diabetes care, pediatric nutrition, mental health and addictions, eating disorders) (www.eatrightpro.org/sop)XXX
      2.2BUses the SOP and SOPP for RDNs in IDD to:
      • assess performance at the appropriate level of practice
      • develop and implement a professional development plan to enhance/advance practice and performance
      XXX
      2.2CDevelops department/organization policy, guidelines, human resource materials (eg, position description or agency nutrition service performance standards, career ladders, acceptable performance level) reflecting the SOP and SOPP for RDNs in IDD and evidence-based research and best practicesXX
      2.2DDevelops performance criteria for employment setting and for nutrition programs within local, state, and/or federal agencies, reflecting levels of practice described in the SOP and SOPP for RDNs in IDDX
      2.3Demonstrates and documents competence in practice and delivery of person-/customer-centered service(s)XXX
      2.4Assumes accountability and responsibility for actions and behaviorsXXX
      2.4AIdentifies, acknowledges, and corrects errorsXXX
      2.4BKnows and complies with policies, procedures, and other organization standards applicable to role and responsibilitiesXXX
      2.4CDemonstrates responsible behavior regarding scope of practice, supervision, referrals, collaboration, and self-disclosureXXX
      2.4DDemonstrates attributes, such as knowledge of the change process, assertiveness, enhanced listening, and conflict resolution skillsXXX
      2.4EDisplays professional integrity and performs as role model in nutrition services for individuals with IDDXX
      2.4FDevelops and implements policies and procedures that ensure staff accountability and responsibilityXX
      2.4GStrives for improvement in practice with self and others; is active in defining and positioning the RDN in IDD team or organizationXX
      2.4HLeads by example; exemplifies professional integrity as a leader in IDD nutritionX
      2.5Conducts self-evaluation at regular intervalsXXX
      2.5AIdentifies needs for professional developmentXXX
      2.5A1Uses self-assessment tools, employment performance reviews, and/or feedback from IDT to evaluate professional knowledge, skill, and practice consistent with best practices and research according to level of practice (eg, cultural sensitivity, communication methods, inclusivity in decision-making)XXX
      2.5A2Seeks to advance knowledge and skills from consultation with experienced IDD practitioners (Figure 5), publications, and various resourcesXXX
      2.5A3Identifies the need for development of IDD tools, guidelines, and other resources and works to develop in collaboration with nutrition and other health care professionals to increase knowledge and skillsXX
      2.5A4Evaluates role and responsibilities at the organization and/or systems level to identify areas for continuing education or qualifications for an expanded or new roleXX
      2.6Designs and implements plans for professional developmentXXX
      2.6ADevelops plan and documents professional development activities in career portfolio (eg, organization policies and procedures, credentialing agency[ies])XXX
      2.6A1Develops and implements a continuing education plan to:
      • address discrepancies that exist between actual performance and expected outcomes
      • maintain or advance practice consistent with level of practice and career goals
      XXX
      2.7Engages in evidence-based practice and uses best practicesXXX
      2.7AIntegrates evidence-based practices and research evidence in delivering quality care to IDD population using texts, websites, Academy Evidence Analysis Library (EAL), open-access journals, databases, position papers, and best practicesXXX
      2.7BDevelops skills in assessing and critically analyzing research; seeks assistance as neededXXX
      2.7CPromotes and advocates to integrate research and evidence-based knowledge into practice, policy/procedure development, presentations, and publicationsXX
      2.7DContributes expertise and critical thinking skills as a reviewer of original research and/or evidence-based guidelines relevant to IDD nutrition practiceX
      2.7EUses and guides others in applying planned change principles to integrate research into practiceX
      2.8Participates in peer review of others as applicable to role and responsibilitiesXXX
      2.8AEngages in peer-review activities consistent with setting and IDD population (eg, peer evaluation, peer supervision, clinical chart review, and performance evaluation)XX
      2.8BServes/leads on an editorial board/work group for scholarly review, including but not limited to, professional articles, systematic reviews, position papers, chapters, and booksX
      2.9Mentors and/or precepts othersXXX
      2.9APursues mentoring relationships and precepting opportunities with credentialed nutrition and dietetic practitioners, and nutrition and dietetics students/interns from underrepresented populationsXXX
      2.9BParticipates in precepting students/interns and mentoring entry-level health care professionals, and other interested individuals in the IDD practice area; seeks guidance as neededXXX
      2.9CProvides case consultation and supervises other credentialed nutrition and dietetics practitioners (eg, RDNs new to the IDD field, nutrition and dietetics technicians, registered)XX
      2.9DDevelops mentor/mentee programs for nutrition and dietetics practitioners and health professionals of other disciplinesXX
      2.9ETeaches clinical practice skills and rationales for nutrition interventions to students, colleagues, and IDT members in topics involving IDDX
      2.9FProvides expertise and counsel to education programs related to food and nutrition care services, practice guidelines, and practice roles for credentialed nutrition and dietetics practitioners in IDD settingsX
      2.10Pursues opportunities (education, training, credentials, certifications) to advance practice in accordance with laws and regulations, and requirements of practice setting (eg, cardiopulmonary resuscitation certification, other safety-related training)XXX
      2.10AAdvocates for a new position or opportunities within practice setting that reflect knowledge, experience, certifications when applicable, and demonstrated competenceXXX
      2.10BObtains and maintains specialty practice certification as applicable to practice setting (Figure 5)XX
      2.10CLeads efforts to pursue or advance education, training, and experience opportunities to provide support for creation of a specialist certification for RDNs in IDDX
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Practice reflects:
        • o
          Code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)
        • o
          Scope of Practice, Standards of Practice, and Standards of Professional Performance
        • o
          Evidence-based practice and best practices
        • o
          CDR Essential Practice Competencies and Performance Indicators
      • Practice incorporates successful strategies for interactions with individuals/groups from diverse cultures and backgrounds
      • Competence is demonstrated and documented
      • Services provided are safe and person-centered
      • Self-evaluations are conducted regularly to reflect commitment to lifelong learning and professional development and engagement
      • Professional development needs are identified and pursued
      • Directed learning is demonstrated
      • Relevant opportunities (education, training, credentials, certifications) are pursued to advance practice
      • CDR recertification requirements are met
      Standard 3: Provision of Services

      The registered dietitian nutritionist (RDN) provides safe, quality service based on customer expectations, and needs, and the mission, vision, principles, and values of the organization/business.

      Rationale:

      Quality programs and services are designed, executed, and promoted based on the RDN’s knowledge, skills, experience, judgment, and competence in addressing the needs and expectations of the organization/business and its customers.
      Indicators for Standard 3: Provision of Services
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      3.1Contributes to or leads in development and maintenance of programs/services that address needs of the customer or target population(s)XXX
      3.1AAligns program/service development with the mission, vision, principles, values, and service expectations and outputs of the organization/businessXXX
      3.1A1Participates in strategic and operational planning for the acquisition and use of internal and external organization/agency resources; and for collaboration with local and regional programs that support and optimize provision of IDD services (eg, Cooperative Extension, university programs, training facilities)XX
      3.1A2Designs and manages nutrition programs tailored to needs of organization and IDD population that are consistent will national guidelines and standards (Figure 4)XX
      3.1A3Designs, provides justification, promotes, and seeks executive commitment to new services that will meet organization and department/program goals for IDD populationX
      3.1BUses the needs, expectations, and desired outcomes of the customers/populations (eg, individuals/persons, families, community, decision makers, administrators, collaborating organization[s]) in program/service developmentXXX
      3.1B1Participate in program and service planning; actively seeks input from the population to improve program/service deliveryXXX
      3.1B2Integrates anticipated needs, identified goals, and objectives into program development and delivery; engages in long-term planningXX
      3.1B3Leads in strategic and operational planning, implementation, and monitoring of programs and servicesX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Shapes, modifies, and adapts program and service delivery in alignment with budget requirements, staffing, and organization/program prioritiesXX
      3.1C2Advocates for staffing and resources that support IDD population care and education needs, census/caseload, and services/goalsXX
      3.1DProposes programs and services that are person-centered, culturally appropriate, and minimize disparitiesXXX
      3.1D1Adapts practice to address or eliminate health disparities associated with culture, race, gender, socioeconomic status, age, and other factorsXXX
      3.2Promotes public access and referral to credentialed nutrition and dietetics practitioners for quality food and nutrition programs and servicesXXX
      3.2AContributes to or designs referral systems that promote access to qualified, credentialed nutrition and dietetics practitionersXXX
      3.2A1Leads team in managing and evaluating the effectiveness of IDD referral tools/systems and recommends modifications as needed to achieve desirable outcomesXX
      3.2A2Designs, directs, and coordinates referral process and systemsX
      3.2BRefers individuals to appropriate providers when requested services or identified needs exceed the RDN’s individual scope of practiceXXX
      3.2B1Builds relationships with other health care practitioners to facilitate collaboration and making referrals that meet individual/family needsXXX
      3.2B2Verifies potential referral practitioner’s care reflects evidence-based information/research and professional standards of practiceXXX
      3.2B3Supports referral sources with curriculum and training regarding nutritional needs of IDD populationXX
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomesXXX
      3.2C1Tracks data to evaluate efficiency and effectiveness of the nutrition referral processXXX
      3.2C2Collects and/or uses data to track effectiveness and revise referral process and systems when neededXX
      3.2C3Develops and implements pilot tests of nutrition risk screening indicators and/or referral systems and collaborates with regional/national data analysisX
      3.3Contributes to or designs person-centered servicesXXX
      3.3AAssesses needs, beliefs/values, goals, resources of the individuals/families, and social determinants of healthXXX
      3.3A1Recognizes the influences that culture, health literacy, and socioeconomic status have on health/illness experiences and the IDD population’s use of and access to health care services; assesses resources available to specific target populationXXX
      3.3A2Participates in or conducts needs assessment in collaboration with IDT and community stakeholders to identify needs of the IDD population and services that are availableXX
      3.3BUses knowledge of the IDD/target population’s health conditions, cultural beliefs, and business objectives/services to guide design and delivery of person-centered servicesXXX
      3.3B1Participates in the design and maintenance of programs/ services to meet the needs of diverse IDD populationsXXX
      3.3B2Adapts practice and tailors interventions and services to meet the needs of an ethnically and culturally diverse IDD populationXXX
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the individuals with IDD or target populationXXX
      3.3C1Identifies risks for developing health problems and determines most effective methods for promoting positive behavioral change for the individuals with IDD, with the care providers, and their environmentsXX
      3.3C2Develops and shares methods of behavioral change for individuals with IDD in collaboration with other IDT members (Figure 5)X
      3.3DCollaborates with the individuals/families and others to set priorities, establish goals, and create person-centered action plans to achieve desirable outcomesXXX
      3.3D1Seeks guidance regarding the behavioral change and counseling theories effective with individuals with IDD to use when providing servicesXXX
      3.3D2Adapts practice to address IDD population’s barriers to changes and/or use of health care services, including community and educational resourcesXX
      3.3D3Leads efforts with IDD service providers to recognize the value of including nutrition goals in interdisciplinary treatment/service plans (eg, medical, social, educational)X
      3.3D4Creates systematic approaches to improve population-centered action plansX
      3.3EInvolves individuals/families/stakeholders in decision-makingXXX
      3.3E1Uses appropriate communication skills/tools to involve individuals/families in directing their nutrition care (Figure 5); seeks assistance if neededXXX
      3.3E2Develops process for IDT collaboration on design of medical nutrition therapy plans to address complex needsXXX
      3.4Executes programs/services in an organized, collaborative, cost-effective, and person-centered mannerXXX
      3.4ACollaborates and coordinates with peers, colleagues, stakeholders, and within IDTsXXX
      3.4A1Works within the IDT for education/skills development and to demonstrate role of RDN and nutrition in care of individuals with IDDXXX
      3.4A2Serves in consultant role for medical nutrition management of IDD and comorbiditiesXX
      3.4A3Directs, leads, and facilitates efforts to improve collaboration with IDT and other care or service providers and uses input/feedback in execution of program/servicesX
      3.4A4Develops and implements provision of IDD nutrition care and services within health care systemsX
      3.4BUses and participates in, or leads in the selection, design, execution, and evaluation of programs and services for individuals with IDD (eg, nutrition screening system, medical and retail foodservice, electronic health records, interdisciplinary programs, community education, grant management)XXX
      3.4B1Incorporates standards for nutrition and IDD nutrition care based on evidence-based guidelines and recommendations in design of programs and services; seeks assistance as neededXXX
      3.4B2Participates in or develops age-specific nutrition screening process (eg, who, when, form[s], guidelines, screening parameters to use [eg, anthropometrics, medications/dietary supplements used]), documentation and follow-up stepsXXX
      3.4B3Assures program(s) is compliant with federal, state, and local laws and regulations; implements corrective action as necessaryXX
      3.4B4Evaluates the effectiveness of IDD nutrition screening tools using established guidelines, indicators, and recommendationsXX
      3.4B5Plans, develops, and/or collaborates on IDD community-based health promotion/prevention programs to encourage inclusivity and support for services that meet the varied needs of the IDD populationX
      3.4CUses and develops or contributes to selection, design, and maintenance of policies, procedures (eg, discharge planning/ transitions of care, emergency planning), protocols, standards of care, technology resources (eg, Health Insurance Portability and Accountability Act [HIPAA]–compliant telehealth platforms), and training materials that reflect evidence-based practice in accordance with applicable laws and regulationsXXX
      3.4C1Uses evidence-based guidelines (eg, Academy EAL), practice guidelines, federal and/or state regulations, accreditation standards (eg, Joint Commission) for setting and populations served to create and/or update policies, procedures, and nutrition care protocols applicable to settingXXX
      3.4C2Develops policies, procedures, protocols, educational and clinical pathways tailored to the needs of the organization and population served by setting(s) (eg, use of Nutrition Care Process and electronic Nutrition Care Process Terminology, identification and/or adaptation of practice guidelines, skills training, nutrition screening or intervention protocols, use of telehealth)XX
      3.4C3Leads in the identification or development of IDD nutrition intervention protocols and policies based on research; evidence-based guidelines; consensus best practices; and trends in state, regional, national, and international guidelinesX
      3.4DUses and participates in or develops processes for order writing and other nutrition-related privileges, in collaboration with the medical staff,
      Medical staff: A medical staff is composed of doctors of medicine or osteopathy and may, in accordance with state law including scope of practice laws, include other categories of physicians and nonphysician practitioners who are determined to be eligible for appointment by the governing body.6
      or medical director (eg, post-acute care settings, intermediate care facilities, dialysis center, public health, community, free-standing clinic settings, corrections facilities), consistent with state practice acts; federal and state regulations; organization policies; and medical staff rules, regulations, and bylaws
      XXX
      3.4D1Uses and participates in or leads development of processes for privileges or other facility-specific processes related to (but not limited to) implementing physician/non-physician practitioner
      Nonphysician practitioner: A nonphysician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.6,7 The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.9,10
      –driven delegated orders or protocols, initiating or modifying orders for therapeutic diets, medical foods/nutrition supplements, dietary supplements, enteral and parenteral nutrition, laboratory tests, medications, and adjustments to fluid therapies or electrolyte replacements
      XXX
      3.4D1iAdheres to organization-approved provider protocols/delegated orders for including in scope of work: ordering or revising diet, ordering laboratory testing, ordering or revising medical food/nutrition and dietary supplements, or other nutrition-related ordersXXX
      3.4D1iiContributes to organization/medical staff or medical director process for identifying RDN privileges to support IDD care and servicesXX
      3.4D1iiiNegotiates for and gains privileges at a systems level for new advances in practiceX
      3.4D2Uses and participates in or leads development of processes for privileging for provision of nutrition-related services, including (but not limited to) initiating and performing bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, providing home enteral nutrition or infusion management services (eg, ordering formula and supplies), and indirect calorimetry measurementsXXX
      3.4EComplies with established billing regulations, organization policies, grant funder guidelines, if applicable to role and setting, and adheres to ethical and transparent financial management and billing practicesXXX
      3.4E1Develops tools to monitor adherence to billing regulations and ethical billing practicesXX
      3.4FCommunicates with the interprofessional team and referring party consistent with HIPAA rules for use and disclosure of individual’s personal health information (PHI)XXX
      3.4F1Obtains consent to communicate PHI and transfer pertinent records to other health and education professionals, adhering to HIPAA and other confidentiality guidelinesXXX
      3.4F2Follows regulations and organization/program policies for accessing, transporting, and storing information containing PHI when working in multiple sites; seeks assistance if neededXXX
      3.5Uses professional, technical, and support personnel appropriately in the delivery of person-centered care or services in accordance with laws, regulations, and organization policies and proceduresXXX
      3.5AAssigns activities, including direct care to individuals/persons, consistent with the qualifications, experience, and competence of professional, technical, and support personnelXXX
      3.5A1Identifies capabilities/expertise of support staff to determine tasks that may be delegatedXXX
      3.5BSupervises profession, technical, and support personnelXXX
      3.5B1Trains professional, technical, and support personnel and evaluates and documents their skills/competence following organization/program guidelinesXX
      3.6Designs and implements food delivery systems to meet the needs of individualsXXX
      3.6ACollaborates in or leads the design of food delivery systems to address health care needs and outcomes (including nutrition status), ecological sustainability, and to meet the culture and related needs and preferences of target populations (ie, individuals/persons in health care settings, employee groups, schools, child and adult day-care centers, community feeding sites, local food banks)XXX
      3.6A1Collects data and provides feedback on current food delivery systems serving IDD population in health care and community settingsXXX
      3.6A2Collaborates in foodservice planning, delivery, training, and assuring compliance with regulations and accreditation standards when applicable for health care and community settings that provide IDD population care and servicesXXX
      3.6A3Develops IDD nutrition-related guidelines for foodservice system planning and delivery that support meeting the population’s needs and preferencesXX
      3.6A4Serves as consultant to organization leadership in determining services to be provided to meet the nutritional needs of the population served by the settingX
      3.6BParticipates in, consults/collaborates with, or leads the development of menus to address health, nutritional, and cultural needs of target population(s) consistent with federal, state, or funding source regulations or guidelinesXXX
      3.6B1Reviews or develops and approves menus and snack options reflecting national nutrition standards and applicable regulations as required by setting; modifies or approves cycle menu offerings for IDD population with special needs to accommodate preferences within therapeutic diet guidelinesXXX
      3.6B2Directs or contributes to the development of menus, recipes, and foodservice operations consistent with role, setting, and regional and cultural preferencesXX
      3.6CParticipates in, consults/collaborates with, or leads interprofessional process for determining medical foods/ nutritional supplements, dietary supplements, enteral and parenteral nutrition formularies, and delivery systems for target population(s)XXX
      3.6C1Provides nutrition expertise in the selection of enteral formulary products, nutritional supplements, and enhanced foodsXXX
      3.6C2Leads the IDT process for determining nutrition formularies and delivery systemsXX
      3.7Maintains records of services providedXXX
      3.7ADocuments according to organization policies, procedures, standards, and systems, including electronic health recordsXXX
      3.7A1Uses and participates in the development/revision of electronic health records applicable to settingXXX
      3.7A2Maintains records of services provided and completes reports following organization/agency policiesXXX
      3.7A3Develops or revises organization/agency policies and procedures related to maintenance of nutrition service recordsXX
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilizationXXX
      3.7B1Develops or collaborates with the IDT to capture IDD-specific data through electronic health records or other data collection toolsXX
      3.7B2Seeks opportunities to contribute expertise to national bioinformatics/medical informatics projects as applicable/requiredX
      3.7CUses data to document outcomes of services (ie, staff productivity, cost/benefit, budget compliance, outcomes, quality of services) and provide justification for maintenance or expansion of servicesXXX
      3.7C1Shares program outcomes and impact with organization, IDT, or community participantsXXX
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulationsXXX
      3.7D1Analyzes and uses data to communicate value of nutrition services in relation to IDD population and organization outcomes/goalsXX
      3.8Advocates for provision of quality food and nutrition services as part of public policyXXX
      3.8ACommunicates with policymakers regarding the benefit/cost of quality food and nutrition servicesXXX
      3.8A1Considers organization policies related to participating in advocacy activitiesXXX
      3.8A2Advocates with state and federal legislators regarding needs of IDD population and benefit of nutrition services on health care costs (eg, responds to Academy Action Alerts and other calls to action)XXX
      3.8A3Interacts and serves as a resource with legislators, payors, and policymakers to contribute and influence IDD care and services (eg, providing testimony at legislative and regulatory hearings and meetings)XX
      3.8A4Serves as an expert resource to policymakers and lawmakers and contributes to development/review of comments/recommendations on policy, statutes, administrative rules, and regulationsX
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditionsXXX
      3.8B1Identifies and participates in advocacy opportunities for nutrition services for individuals with IDD in health care and community programs (Figure 4)XXX
      3.8B2Assesses individuals/families for situations where IDD advocacy is needed and participates in efforts to address issues(s) (eg, local, state, and national IDD coalitions or collaborations)XX
      3.8B3Provides support and/or advocacy resources to assist individuals/families/care providers with having a voice in advocating for IDD servicesXX
      3.8B4Leads advocacy activities (eg, authors article(s), delivers presentations on topics, networks)XX
      3.8CAdvocates for protection of the public through multiple avenues of engagement (eg, legislative action, establishing effective relationships with elected leaders and regulatory officials, participation in various Academy committees, workgroups and task forces, Dietetic Practice Groups, Member Interest Groups, and State Affiliates)XXX
      Examples of Outcomes for Standard 3: Provision of Services
      • Program/service design and systems reflect organization/business mission, vision, principles, values, and IDD population’s needs and expectations
      • Individuals/families and other stakeholders participate in establishing program/service goals and person-focused action plans and/or nutrition interventions (eg, in-person or via telehealth)
      • Person-centered needs and preferences are met
      • Individuals/families are satisfied with services and products
      • Individuals/families have access to food assistance and to food and nutrition services
      • Foodservice system incorporates sustainability practices addressing energy and water use and waste management
      • Menus reflect the cultural, health, and/or nutritional needs of target population(s) and consideration of ecological sustainability
      • Evaluations reflect expected outcomes and established goals
      • Effective screening and referral services are established or implemented as designed
      • Professional, technical, and support personnel are supervised when providing nutrition care to individuals/families
      • Ethical and transparent financial management and billing practices are used per role and setting
      Standard 4: Application of Research

      The registered dietitian nutritionist (RDN) applies, participates in, and/or generates research to enhance practice. Evidence-based practice incorporates the best available research/evidence and information in the delivery of nutrition and dietetics services.

      Rationale:

      Application, participation, and generation of research promote improved safety and quality of nutrition and dietetics practice and services.
      Indicators for Standard 4: Application of Research
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Reviews best available research/evidence and information for application to practiceXXX
      4.1AUnderstands basic research design and methodology (eg, data collection, interpretation of results, and application to practice)XXX
      4.1BReads major peer-reviewed publications in IDD and nutrition; uses evidence-based guidelines, practice guidelines, and related resources to guide practiceXXX
      4.1CDemonstrate the experience and critical thinking skills required to evaluate strength of original research, including limitations and potential bias, and evidence-based guidelines relevant to IDDXX
      4.1DIdentifies and addresses IDD-related questions and uses a systematic approach for applying research and evidence-based guidelines (eg, EAL); guides others in making informed decisions for IDD careX
      4.2Uses best available research/evidence and information as the foundation for evidence-based practiceXXX
      4.2AShares available scientific literature and evidence-based practice guidelines with the IDTXXX
      4.2BApplies evidence-based practice guidelines to provide consistent, safe, effective quality care for individuals with IDD (Figure 4); consults with more experienced practitioner for guidance as neededXXX
      4.2CCritically evaluates the available scientific literature in situations where evidence-based practice guidelines for nutrition in IDD do not existXX
      4.2DEvaluates and uses the best-available research/evidence for development and implementation of complex nutrition interventions in IDD nutrition practiceX
      4.3Integrates best available research/evidence and information with best practices, clinical and managerial expertise, and customer valuesXXX
      4.3AAccesses and uses commonly used sources of evidence in identifying applicable courses of action in person-centered care and services (Figure 4)XXX
      4.3BMonitors and evaluates delivery of IDD population care over time to adapt nutrition interventions/plans of care as indicated according to IDD best practices and expertiseXX
      4.3CMentors others in identifying and applying best available research/ evidence and integrating best practicesX
      4.4Contributes to the development of new knowledge and research in nutrition and dieteticsXXX
      4.4AParticipates in efforts to extend research to practice through journal clubs, professional discussion groups, and the Academy’s Research workgroups (eg, EAL)XXX
      4.4BInitiates research relevant to IDD nutrition practice and reports practice data to collaborative research projects and/or practice-based research networks (Figure 4)XX
      4.4CParticipates in quantitative and qualitative scientific investigation of new and emerging nutrition practices in IDDXX
      4.4EAuthors original research papers to identify and advance quality and outcomes of IDD practiceX
      4.4FServes as an advisor, preceptor, and/or committee member for graduate-level researchX
      4.5Promotes application of research in practice through alliances or collaboration with food and nutrition and other professionals and organizationsXXX
      4.5AParticipates in identifying research issues/questions and facilitates or participates in studies related to IDD careXXX
      4.5BDisseminates the results and emphasizes the significance and value of IDD-related research findingsXXX
      4.5CParticipates in interdisciplinary and/or interorganization research teams to develop, perform, and/or disseminate IDD nutrition researchXX
      4.5DAdvocates to stakeholder organizations, groups, and/or agencies for prioritizing and funding of IDD nutrition research projectsX
      Examples of Outcomes for Standard 4: Application of Research
      • Evidence-based practice, best practices, clinical and managerial expertise, and individual values are integrated in the delivery of nutrition and dietetics services
      • Individuals with IDD receive appropriate services based on the effective application of best available research/evidence and information
      • Best available research/evidence and information is used as the foundation of evidence-based practice
      Standard 5: Communication and Application of Knowledge

      The registered dietitian nutritionist (RDN) effectively applies knowledge and expertise in communications.

      Rationale:

      The RDN works with others to achieve common goals by effectively sharing and applying unique knowledge, skills, and expertise in food, nutrition, dietetics, and management services.
      Indicators for Standard 5: Communication and Application of Knowledge
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      5.1Communicates and applies current knowledge and information based on evidenceXXX
      5.1ADemonstrates critical thinking and problem-solving skills when communicating with othersXXX
      5.1A1Seeks/studies scientific principles, research, and theory in order to communicate and apply accurate/current informationXX
      5.1A2Demonstrates the ability to review and apply evidence-based guidelines when communicating and disseminating informationXX
      5.1A3Demonstrates the ability to convey complex concepts to other health care practitioners, IDT, and the publicX
      5.1BCommunicates evidence-based information, best practices, and related resources (eg, CMS, Joint Commission) in collaboration with colleagues in all areas of IDD practiceXXX
      5.1CInterprets regulatory, accreditation, and reimbursement programs and standards for organizations and providers that are specific to IDD care and education (Figure 4); seeks assistance if neededXXX
      5.1DAuthors and/or presents evidence-based IDD nutrition information at the local or regional level (Figure 4)XX
      5.1EConsults on complex IDD service issues with other health care professionals, organizations, and the communityX
      5.2Selects appropriate information and the most effective communication method or format that considers person-centered care and the needs of the individual/group/populationXXX
      5.2AUses communication methods (ie, oral, print, one-on-one, group, visual, electronic, and social media) targeted to various audiencesXXX
      5.2A1Determines and develops methods and tools to communicate nutrition information, using the most appropriate format (eg, presentation, publication, demonstration, electronic)XX
      5.2A2Leads in the design of population-specific and systematic approaches to effectively communicate nutrition information to varied audiences addressing a variety of IDD-specific conditionsX
      5.2BUses information technology to communicate, disseminate, manage knowledge, and support decision-makingXXX
      5.2B1Identifies and uses information technologies including telehealth to organize data, complete assessments and reports, and communicate with individuals, care providers, colleagues, and/or health care practitionersXXX
      5.2B2Leads professional networking groups in using various media (eg, online learning, face-to-face, social media) to share information and stay current on nutrition practice for IDD populationXX
      5.2B3Maintains or develops up-to-date web-based/electronic IDD nutrition education tools, resources, and delivery methods (eg, telehealth) for individuals/families/care providers and/or health care professionalsXX
      5.2B4Leads technology/informatics advancement in IDD nutrition management and educationX
      5.3Integrates knowledge of food and nutrition with knowledge of health, culture, social sciences, communication, informatics, sustainability, and managementXXX
      5.3AApplies current and emerging knowledge of IDD nutrition when considering the health issues, behaviors, communication skills, and IDT involvement with the population with IDD served by setting; seeks guidance as neededXXX
      5.3BIntegrates pertinent research and professional judgment, case consultation, and professional supervision within IDD practiceXX
      5.3CIntegrates current and emerging knowledge based on research findings, and experience, consultation, and professional supervision in the management of complex and exceptional problems/situations in IDDX
      5.4Shares current, evidence-based knowledge, and information with various audiencesXXX
      5.4AGuides individuals/persons, families, students, and interns in the application of knowledge and skillsXXX
      5.4A1Presents information to individuals, families/care providers, and other health care practitioners (eg, shares relevant articles, follows up on inquiries)XXX
      5.4A2Participates in or initiates development of guidelines and tools to guide individuals and/or their support networks in health-related shared decision making and goal setting for maximizing outcomesXX
      5.4A3Fulfills teaching or faculty role as an expert in IDD nutrition for education programs for nutrition and dietetics (undergraduate or graduate), physicians, and other health care professionalsX
      5.4BAssists individuals and groups to identify and secure appropriate and available educational and other resources and servicesXXX
      5.4B1Participates in securing appropriate resources and services necessary to the specific needs of individuals with IDDXXX
      5.4B2Refers individuals and groups to culturally appropriate programs and services with documented desirable outcomes (Figure 5)XX
      5.4B3Identifies additional IDD resources and support systems within the community (Figure 4) and collaborates as appropriate to assist with health-related decisions, resources for emergencies or crisis (such as natural disasters and illness outbreak/pandemic)XX
      5.4B4Leads in the development and expansion of resources and services necessary to meet person-centered outcomes and nutrition and health needs of individuals with IDDX
      5.4CUses professional writing and verbal skills in all types of communicationsXXX
      5.4C1Demonstrates professional writing and oral communication skills with the ability to translate complex scientific and policy information to the publicXX
      5.4DReflects knowledge of population characteristics in communication methods (eg, literacy, numeracy levels, need for translation of written materials and/or a translator, communication skills, physical ability, and learning, hearing, or vision disabilities)XXX
      5.4D1Determines and uses the most appropriate methods for the individuals and family/care providers to understand and apply nutrition knowledge and skills for communication; incorporates tools that support person-centered care and education (Figure 5); seeks assistance if neededXXX
      5.5Establishes credibility and contributes as a food and nutrition resource within the interprofessional health care and management team, organization, and communityXXX
      5.5ASeeks to become primary IDD nutrition resource to interdisciplinary health care and management team by increasing knowledge, skills, and experience in IDDXXX
      5.5BParticipates in and leads interdisciplinary collaborations at the organization and systems levelXX
      5.5CEstablishes credibility in the work environment by providing leadership and expertise for collaboration in national projects and professional organizations (Figure 4)X
      5.6Communicates performance improvement and research results through publications and presentationsXXX
      5.6AContributes to publications and presentations by assembling and reporting research data and documenting outcomesXXX
      5.6BPresents evidence-based IDD research, guidelines, and information within organization, community, and professional meetingsXX
      5.6CAuthors IDD-related articles, and develops webinars, and social media messagesXX
      5.6DParticipates in or leads planning committees/task forces to develop continuing education programs and resources (eg, curriculums, guidelines, education materials) to share current and emerging knowledge and best practices in IDDXX
      5.6EDevelops and presents curriculums, guidelines, and programs, based on current and emerging knowledge related to IDDXX
      5.6FServes in a leadership role for IDD nutrition-related publications (eg, editor or editorial board member of peer-reviewed journal[s]) and program planning at regional and national levelsX
      5.6GLeads collation of research data into publications (eg, systematic reviews, practice and position papers) and presentationsX
      5.7Seeks opportunities to participate in and assume leadership roles with local, state, and national professional and community-based organizations (eg, government-appointed advisory boards, community coalitions, schools, foundations or nonprofit organizations serving the food insecure) providing food and nutrition expertiseXXX
      5.7ACollaborates with health care professionals and others who work in the IDD field regarding IDD nutrition-related evidence-based health and nutrition strategies that optimize outcomesXXX
      5.7BParticipates in professional and employment-related leadership activitiesXXX
      5.7CCollaborates at a systems level to incorporate IDD nutrition strategies aimed at optimizing health and quality of life outcomes balanced with person-centered outcomes planning (eg, involvement in community health and wellness programs, enteral nutrition vs oral intake, meal-time assistance)XX
      5.7DSeeks leadership roles within local, regional, national, international organizations (eg, Special Olympics) (Figure 4)XX
      5.7ESeeks opportunities to be identified as an expert on IDD nutrition-related issues and educational needs of consumers and health care professionals (eg, consultant to industry, national IDD organizations, and/or media spokesperson)X
      5.7FIdentifies new opportunities for leadership and cross-discipline dialogue to promote nutrition and dietetics in a broader contextX
      Examples of Outcomes for Standard 5: Communication and Application of Knowledge
      • Expertise in food, nutrition, dietetics, and management is demonstrated and shared
      • Interoperable information technology is used to support practice
      • Effective and efficient communications occur through appropriate and professional use of e-mail, texting, and social media tools
      • Individuals/families, groups, and stakeholders:
        • o
          Receive current and appropriate information and person-centered service
        • o
          Demonstrate understanding of information and behavioral strategies received
        • o
          Know how to obtain additional guidance from the RDN or other RDN-recommended resources
      • Leadership is demonstrated through active professional and community involvement
      Standard 6: Utilization and Management of Resources

      The registered dietitian nutritionist (RDN) uses resources effectively and efficiently.

      Rationale:

      The RDN demonstrates leadership through strategic management of time, finances, facilities, supplies, technology, natural, and human resources.
      Indicators for Standard 6: Utilization and Management of Resources
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      6.1Uses a systematic approach to manage resources and improve outcomesXXX
      6.1ARecognizes and uses existing resources (eg, educational/training tools and materials) as needed in the provision of IDD nutrition servicesXXX
      6.1BParticipates in, provides consultation, or leads operational planning and delivery of food and nutrition programs and services applicable to setting (eg, nutrition care, food/dining services, budgeting, staffing, menu planning, purchasing processes, education program/services)XXX
      6.1CManages effective delivery of IDD nutrition programs and servicesXX
      6.1DLeads strategic and operational planning, implementation, and monitoring for maintaining and managing services and resourcesX
      6.2Evaluates management of resources with the use of standardized performance measures and benchmarking as applicableXXX
      6.2AUses the Standards of Excellence Metric Tool to self-assess quality in leadership, organization, practice, and outcomes for an organization (www.eatrightpro.org/excellencetool)XXX
      6.2BParticipates in collecting and analyzing IDD population and outcomes data, program participation, and expense/revenue/reimbursement data to evaluate and adjust programs and servicesXXX
      6.2CMonitors, documents, and evaluates program and service resource usage against budget or other metrics (eg, staff hours, staff to individual/family ratio, referral requests, program participation rates, revenue/insurance reimbursement data, and other costs as applicable)XX
      6.2DDirects operational review reflecting evaluation of performance and benchmarking data to manage resources and modifications for design and delivery of IDD programs and servicesX
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and productsXXX
      6.3AParticipates in evaluation, selection, and implementation (when applicable) of new products, equipment, and services to ensure safe, optimal, and cost-effective delivery of IDD nutrition care and servicesXXX
      6.3BEvaluates and articulates care and service needs when justifying the types of products and services to have available for meeting population’s desired nutrition outcomes (eg, published practice guidelines, mortality reviews, effectiveness of service delivery and training, cost and safety of nutritional supplements/formulas)XX
      6.3CEvaluates safety, effectiveness, and value of programs and services in meeting the needs of the IDD population served by settingX
      6.4Participates in QAPI and documents outcomes and best practices relative to resource managementXXX
      6.4AParticipates actively in QAPI, including developing/adapting tools, collecting, documenting, and analyzing data to document resource use and resulting outcomes (eg, staff time, types of services, supply use, expenses)XXX
      6.4BAnalyzes use of resources; makes needed modifications; and implements, assesses, and documents outcomes to determine the effectiveness of change(s) and to assure appropriate/responsible resource use; shares with organization/program leadersXX
      6.4CShares QAPI or other quality assurance results via professional presentations and publishingX
      6.5Measures and tracks trends regarding internal and external population outcomes (eg, satisfaction, key performance indicators)XXX
      6.5AGathers and evaluates population/caregiver satisfaction data related to IDD care, education, and related services; seek assistance as neededXXX
      6.5BDevelops or modifies IDD nutrition programs or services to improve stakeholder (eg, individuals/families, caregivers, employees, administration) satisfactionXX
      6.5CResolves internal and external problems that may affect delivery of IDD servicesXX
      6.5DImplements, monitors, and evaluates changes based on data collection and analysisX
      Examples of Outcomes for Standard 6: Utilization and Management of Resources
      • Resources are effectively and efficiently managed
      • Documentation of resource use is consistent with operational and sustainability goals
      • Data are used to promote, improve, and validate services, organization practices, and public policy
      • Desired outcomes are achieved, documented, and disseminated
      • Key performance indicators are identified and tracked in alignment with organization mission, vision, principles, and values
      a Interdisciplinary: The term interdisciplinary is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, social workers, occupational, physical, and speech therapists, oral motor therapist, qualified intellectual disabilities professional, school administrators, teachers, school nurse, teacher’s aide, direct care professional, assistive technologist, applied behavior analysis therapist, Adult Protective Services, Child Protective Services, regional center, state vocational rehabilitation agencies), depending on the needs of the individual. Interdisciplinary could also mean interprofessional or multidisciplinary.
      b PROMIS: Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient (or individual/person)-reported health status for physical, mental, and social well-being. PROMIS is a web-based resource and is publicly available.
      c Medical staff: A medical staff is composed of doctors of medicine or osteopathy and may, in accordance with state law including scope of practice laws, include other categories of physicians and nonphysician practitioners who are determined to be eligible for appointment by the governing body.

      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf.

      d Nonphysician practitioner: A nonphysician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.

      State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf.

      ,

      State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf.

      The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.

      Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872)—Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178). US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities.

      ,

      State Operations Manual. Appendix PP Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.

      Three Levels of Practice

      The Dreyfus model
      • Dreyfus H.L.
      • Dreyfus S.E.
      Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer.
      identifies levels of proficiency (novice, advanced beginner, competent, proficient, and expert) (refer to Figure 3) during the acquisition and development of knowledge and skills. The first 2 levels are components of the required didactic education (novice) and supervised practice experience (advanced beginner) that precede credentialing for nutrition and dietetics practitioners. Upon successfully attaining the RDN credential, a practitioner enters professional practice at the competent level and manages their professional development to achieve individual professional goals. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDNs in IDD. In Academy focus areas, the 3 levels of practice are represented as competent, proficient, and expert.
      With safety and evidence-based practice

      Definition of terms. Academy of Nutrition and Dietetics. Accessed August 7, 2020. https://www.eatrightpro.org/practice/quality-management/definition-of-terms.

      as guiding factors when working with individuals/populations, the RDN identifies the level of evidence, clearly states research limitations, provides safety information from reputable sources, and describes the risk of the intervention(s), when applicable.
      The Academy offers a webinar, “Evidence-Based Nutrition Using Scientific Evidence to Inform Clinical Practice” (www.eatrightstore.org/cpe-opportunities/recorded-webinars) that presents the 5-step evidence-based process as a mechanism to acquire and critique evidence for practicing evidence-based nutrition care. The RDN is responsible for searching literature and assessing the level of evidence to select the best available evidence to inform recommendations. RDNs must evaluate and understand the best available evidence in order to converse authoritatively with the interprofessional team and adequately involve the patient/client/customer/population in shared decision making.
      Figure 3Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities (IDD).
      Standards of Practice (SOP) are authoritative statements that describe practice demonstrated through nutrition assessment, nutrition diagnosis (problem identification), nutrition intervention (planning, implementation), and outcomes monitoring and evaluation (4 separate standards) and the responsibilities for which registered dietitian nutritionists (RDNs) are accountable. The SOP for RDNs in Intellectual and Developmental Disabilities (IDD) presuppose that the RDN uses critical thinking skills; analytical abilities; theories; best-available research findings; current accepted nutrition, dietetics, and medical knowledge; and the systematic holistic approach of the nutrition care process as they relate to the application of the standards. Standards of Professional Performance (SOPP) for RDNs in IDD are authoritative statements that describe behavior in the professional role, including activities related to Quality in Practice; Competence and Accountability; Provision of Services; Application of Research; Communication and Application of Knowledge; and Utilization and Management of Resources (6 separate standards).
      SOP and SOPP are evaluation resources with complementary sets of standards—both serve to describe the practice and professional performance of RDNs. All indicators may not be applicable to all RDNs’ practice or to all practice settings and situations. RDNs operate within the directives of applicable federal and state laws and regulations, as well as policies and procedures established by the organization in which they are employed. To determine whether an activity is within the scope of practice of the RDN, the practitioner compares their knowledge, skill, experience, judgment, and demonstrated competence with the criteria necessary to perform the activity safely, ethically, legally, and appropriately. The Academy’s Scope of Practice Decision Algorithm is specifically designed to assist practitioners with this process.
      The term individual is used in the SOP as a universal term as these Standards relate to direct provision of nutrition care and services. Individual is the preferred term to emphasize thinking of the person or the individual and not the disability. Individual could also mean person, client, patient, resident, participant, consumer, or any group who receives IDD care and/or services. Customer along with individual is a term used in the SOPP as a universal term to encompass those who interact with the individuals with IDD. Customer may refer to program/service directors, community members, government officials, organization representatives, while individual refers to the person being served. These services are provided to individuals of all ages. The SOP and SOPP are not limited to the clinical setting. In addition, it is recognized that the family and caregiver(s) of individuals of all ages, including individuals with special health care needs, play critical roles in overall health and are important members of the team throughout the assessment and intervention process. The term appropriate is used in the standards to mean: Selecting from a range of best practice or evidence-based possibilities, one or more of which would give an acceptable result in circumstances.
      Each standard is equal in relevance and importance and includes a definition, a rationale statement, indicators, and examples of desired outcomes. A standard is a collection of specific outcome-focused statements against which a practitioner’s performance can be assessed. The rationale statement describes the intent of the standard and defines its purpose and importance in greater detail. Indicators are measurable action statements that illustrate how each specific standard can be applied in practice. Indicators serve to identify the level of performance of competent practitioners and to encourage and recognize professional growth.
      Standard definitions, rationale statements, core indicators, and examples of outcomes found in the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs have been adapted to reflect 3 levels of practice (competent, proficient, and expert) for RDNs in IDD (see image below). In addition, the core indicators have been expanded to reflect the unique competence expectations for the RDN providing nutrition care and services for individuals with IDD.

      Competent Practitioner

      In nutrition and dietetics, a competent practitioner is an RDN who is either just starting practice after having obtained RDN registration by CDR or an experienced RDN recently transitioning their practice to a new focus area of nutrition and dietetics. A focus area of nutrition and dietetics practice is a defined area of practice that requires focused knowledge, skills, and experience that applies to all levels of practice.

      Definition of terms. Academy of Nutrition and Dietetics. Accessed August 7, 2020. https://www.eatrightpro.org/practice/quality-management/definition-of-terms.

      A competent practitioner who has achieved credentialing as an RDN and is starting in professional employment consistently provides safe and reliable services by employing appropriate knowledge, skills, behavior, and values in accordance with accepted standards of the profession; acquires additional on-the-job skills; and engages in tailored continuing education to further enhance knowledge, skills, and judgment obtained in formal education.

      Definition of terms. Academy of Nutrition and Dietetics. Accessed August 7, 2020. https://www.eatrightpro.org/practice/quality-management/definition-of-terms.

      A general practice RDN can include responsibilities across several areas of practice, including, but not limited to, community, clinical, consultation and business, research, education, and food and nutrition management.
      An RDN new to providing care and services to individuals with IDD, even those with considerable experience in other practice areas, must begin at the competent level. RDNs may use resources (see Figure 4) and seek out more experienced practitioners to add depth and breadth to their knowledge, skills, and responsibilities in IDD nutrition and dietetics. In addition, the RDN may discover new modes of communication and learn to speak with each individual who presents in unique ways based on their needs. Competent-level RDNs need to build knowledge regarding the types of IDD and the characteristics and behaviors of individuals experiencing these conditions. Additional training may come from a facility or course specific to IDD, including potential coexisting mental health diagnoses. It is important for RDNs to identify the side effects of prescribed medications, dietary supplements, and integrative and functional medicine products used with or by the IDD population. The potential impact may lead to deficiencies or excess of nutrients.
      Figure 4Resources for registered dietitian nutritionists in intellectual and developmental disabilities (IDD) (not all inclusive).
      ResourceURL or ReferenceDescription
      Academy of Nutrition and Dietetics (Academy)
      Academy Nutrition Care Manuals, Adult Nutrition and Pediatric Nutritionhttps://www.nutritioncaremanual.org/The Nutrition Care Manuals are Internet-based practice manuals with resources for registered dietitian nutritionists (RDNs) and interdisciplinary team that contains an education library with evidence-based nutrition recommendations for adults and children.
      Academy Pediatric Nutrition Focused Physical Exam Pocket Guidehttps://www.eatrightstore.org/product-type/pocket-guides/pediatric-nutrition-focused-physical-exam-pocket-guideThis pocket guide provides the RDN with tools for nutrition assessment, documentation, and coding. A nutrition focused physical examination covers the fundamental skills needed for the early identification and prevention of pediatric malnutrition.
      Behavioral Health Nutrition (BHN) Dietetic Practice Group (DPG)https://www.bhndpg.org/The BHN DPG provides various resources in IDD, such as self-directed, interactive training modules (some using the pediatric growth charts), webinars, fact sheets, and a newsletter. BHN DPG’s newsletter, BHN in the kNOW, provides BHN DPG members with a monthly resource containing articles, case studies, and continuing professional education articles and is a platform to share news within the practice group. Past article titles include, but are not limited to, “Autism and Nutrition,” “Feeding Aversion in Intellectual and Developmental Disability: Identifying and Treating the Root Cause,” and “Sensory Processing Disorder, Autism and Food Challenges.”
      Pocket Guide to Children with Special Health Care and Nutritional Needs (eBook)https://www.eatrightstore.org/product-type/ebooks/pocket-guide-to-children-with-special-health-care-and-nutritional-needs-ebookThis pocket guide provides RDNs with information on managing the nutrition care of children with special health care needs, such as Down syndrome, autism, or cerebral palsy. This guide contains current interdisciplinary research and evidence-based information and includes nutrition assessment methods and tools, feeding problems and menu modifications, considerations for non-oral enteral feeding and limited oral feeding, and community services, among others.
      Other Resources
      American Academy of Developmental Medicine and Dentistryhttps://www.aadmd.org/The American Academy of Developmental Medicine and Dentistry works “to improve the quality of health care for individuals with neurodevelopmental disorders and intellectual disabilities.” They provide various resources, such as a forum for health care professionals to exchange experiences and ideas regarding caring for the IDD population, research articles, and an IDD training program curriculum.
      American Association on Intellectual and Developmental Disabilities (AAIDD)https://www.aaidd.org/The AAIDD is a professional organization that provides sound research, effective practices, and advocates for universal human rights for people with IDD.
      Association of Diabetes Care & Education Specialistshttps://www.diabeteseducator.org/The Association of Diabetes Care & Education Specialists (formerly the American Association of Diabetes Educators) provides resources related to prediabetes and diabetes. Resources include the 2017 Diabetes and Disabilities American Association of Diabetes Educators Practice Paper. This statement provides recommendations for the general approach to care and goals and strategies for glycemic control for diabetes.
      Autism Society of Americahttps://www.autism-society.org/Autism Society's vision is to increase the quality of life of everyone living with autism spectrum disorder by building autism-friendly, inclusive communities. The Autism Society provides reliable information about autism and leads advocacy efforts related to autism, among other efforts to support autism awareness.
      Centers for Disease Control and Prevention (CDC): Developmental disabilitieshttps://www.cdc.gov/ncbddd/developmentaldisabilities/index.htmlThe CDC Developmental Disabilities webpage provides resources for developmental disabilities, including facts, growth charts, research, a resource center, articles, and multimedia.
      Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)https://chadd.orgCHADD provides advocacy, education, support, and public awareness related to attention-deficit/hyperactivity disorder (ADHD). Professional resources include clinical practice guidelines, ADHD Diagnostic Process (children, adults, co-existing conditions), clinical practice tools, and treatment strategies.
      National Down Syndrome Society (NDSS)https://www.ndss.org/NDSS empowers individuals, educates families and communities, and celebrates the extraordinary lives of people with Down syndrome. Resources they provide include, but are not limited to, an overview of Down syndrome, health and well-being guidebooks, and lesson plans.
      International Association for the Scientific Study of Intellectual and Developmental Disabilities (IASSIDD)https://www.iassidd.org/IASSIDD promotes the development of new knowledge, research, and other scholarly activities, as well as the application of knowledge, to improve the lives of people with IDD, their families, and those who support them.
      National Alliance on Mental Illness (NAMI)https://www.nami.org/NAMI provides advocacy, education, support, and public awareness so that all individuals and families affected by mental illness can build better lives.
      Pediatric Feeding Disorder: Consensus Definition and Conceptual FrameworkGoday and colleagues
      • Goday P.S.
      • Hus S.Y.
      • Silverman A.
      • et al.
      Pediatric feeding disorder: Consensus definition and conceptual framework.
      This article defines pediatric feeding disorder, as impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.
      The Arcwww.thearc.orgThe Arc is a national community-based organization that promotes and protects the human rights of people with IDD and actively supports their full inclusion and participation in the community throughout their lifetimes.
      The Association for Persons with Severe Handicaps (TASH)https://tash.org/TASH promotes the full inclusion and participation of children and adults with significant disabilities in every aspect of their community, and to eliminate the social injustices that diminish human rights. TASH provides advocacy efforts, education to the public, and research.
      The Individuals with Disabilities Education Act (IDEA)https://sites.ed.gov/idea/IDEA ensures students with a disability are provided with free appropriate public education that is tailored to their individual needs. This website provides information on IDEA updates, and links to the US Department of Education, the Office of Special Education and Rehabilitative Services, and others.
      The International Dysphagia Diet Standardization Initiative (IDDSI)https://iddsi.org/IDDSI developed a standardized common language that can be used for technical, cultural, professional, and nonprofessional uses to describe texture-modified foods and thickened liquids for individuals with dysphagia.
      The National Center on Birth Defects and Developmental Disabilities (NCBDDD)https://www.cdc.gov/ncbddd/index.htmlNCBDDD identifies the causes of birth defects and developmental disabilities. The website promotes health and well-being among people of all ages with disabilities and blood disorders and provides information, research, and tools.
      United Cerebral Palsy (UCP)https://www.cerebralpalsyguidance.com/cerebral-palsy/united-cerebral-palsy-association/UCP is a nonprofit organization that provides services to children and adults with cerebral palsy. Services include, but are not limited to, health and wellness awareness, support groups, public advocacy, and assistive technology.

      Proficient Practitioner

      A proficient practitioner is an RDN who is generally 3 or more years beyond credentialing and entry into the profession and consistently provides safe and reliable service; has obtained operational job performance skills; and is successful in the RDN's chosen focus area of practice. The proficient practitioner demonstrates additional knowledge, skills, judgment, and experience in a focus area of nutrition and dietetics practice. An RDN may acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice.

      Definition of terms. Academy of Nutrition and Dietetics. Accessed August 7, 2020. https://www.eatrightpro.org/practice/quality-management/definition-of-terms.

      Proficient practitioners have developed a deeper understanding of IDD care and are better equipped to apply evidence-based guidelines and best practices than the competent-level RDN. RDNs working with individuals with IDD have gained additional knowledge in person-centered planning and working with the interdisciplinary team (see Figure 5). RDNs have obtained work experience in delivering medical nutrition therapy, feeding, and complex medical issues (see Figure 6), and a further understanding of the side effects of prescribed medications, dietary supplements, and integrative and functional medicine products and their influence on altered mental state, toxicity, or deficiencies. In addition, RDNs have developed an understanding of communication methods used by individuals with IDD and communication tool options, as well as learned techniques for providing education to this population with complex needs. These RDNs may have obtained additional focused skill development in working with a variety of disabilities.
      Figure thumbnail gr1
      Figure 5Considerations for person-centered goal-setting for individuals with intellectual and developmental disabilities (not all inclusive). aBMI = body mass index (calculated as kg/m2). bADL = activity of daily living.
      Figure 6Examples of comorbidities and challenges in individuals with intellectual and developmental disabilities.
      Abnormal growth trendsAltered gastrointestinal functionAnxietyAsthmaAttention-deficit hyperactivity disorder
      Avoidance/ restrictive food intake disorderAutism spectrum disorderCeliac diseaseCerebral palsyCleft pallet
      DementiaDepressionDown syndromeDyslipidemiaDysphagia
      Food aversionFood/ environmental allergiesFood intolerancesGenetic disordersHypertonia/hypotonia
      Inborn errors of metabolismInsomniaKidney diseaseLimited food acceptanceMalnutrition
      Overweight/obesityPediatric feeding disorderPoor dental healthPrader-Will syndromePrediabetes/diabetes
      Pressure ulcerSeizuresSensory intoleranceUndernutritionUrinary tract infection

      Expert Practitioner

      An expert practitioner is an RDN who is recognized within the profession and has mastered the highest degree of skill in, and knowledge of, nutrition and dietetics. Expert-level achievement is acquired through ongoing critical evaluation of practice and feedback from others. The individual at this level strives for additional knowledge, experience, and training. An expert has the ability to quickly identify "what" is happening and "how" to approach the situation. Experts easily use nutrition and dietetics skills to become successful through demonstrating quality practice and leadership, and to consider new opportunities that build upon nutrition and dietetics.

      Definition of terms. Academy of Nutrition and Dietetics. Accessed August 7, 2020. https://www.eatrightpro.org/practice/quality-management/definition-of-terms.

      An expert practitioner may have an expanded or specialist role or both and may possess an advanced credential(s), such as the CDR Advanced Practitioner Certification in Clinical Nutrition or focus area credential. Generally, the practice is more complex and the practitioner has a high degree of professional autonomy and responsibility.
      Expert RDNs in IDD have mastered the highest degree of skill in, and knowledge of, nutrition. Expert-level achievement is acquired through ongoing critical evaluation of practice and feedback from others. Experts easily use their intuitive nutrition and dietetics skills acquired through a combination of experience and education. Expert RDNs are successful in demonstrating quality practice and leadership and consider new opportunities that build upon nutrition and dietetics. Expert RDNs formulate judgments to identify needs and develop and provide educational resources for individuals with intellectual disabilities and other professionals to support the expansion of knowledge of the complexity and the diversity of conditions/disabilities and comorbidities in this population. Expert RDNs also make credentialed nutrition and dietetics practitioners and other care providers aware of developments in the field and their applicability in the workplace. They develop resources, records, and data systems to contribute scientific research and knowledge to the facility/program or to the broader field. Expert RDNs may have obtained certifications that can be adapted and applied to individuals with disabilities. Lastly, expert RDNs not only implement IDD nutrition practice, they also drive and direct clinical practice, conduct and collaborate in research and advocacy, contribute to interdisciplinary teams, and lead the advancement of IDD nutrition practice.
      These Standards, along with the Academy/CDR Code of Ethics,

      Academy of Nutrition and Dietetics/Commission on Dietetic Registration. 2018 Code of Ethics for the Nutrition and Dietetics Profession. Accessed May 23, 2018.https://www.eatrightpro.org/practice/code-of-ethics/what-is-the-code-of-ethics.

      answer the questions: Why is an RDN uniquely qualified to provide IDD nutrition and dietetics care and services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, and quality person-centered IDD care and service at the competent, proficient, and expert levels?

      Overview

      Intellectual and Developmental Disabilities (IDD) encompass both intellectual disabilities (ID) and developmental disabilities (DD). ID are defined by significant limitations both in intellectual functioning and adaptive behavior as expressed in conceptual, social, and practical adaptive skills, and originate before age 18 years.
      • Schalock R.L.
      • Borthwick-Duffy S.A.
      • Bradley V.J.
      • et al.
      Intellectual Disability: Definition, Classification, and Systems of Supports.
      ,
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders.
      The disability is classified according to the severity of the limitation of daily functions, ability to perform developmental milestones, and/or live independently as an adult. In addition, most states require that people with ID have intelligence quotient scores at or below 70 to qualify for public services.
      • Livermore G.A.
      • Bardos M.
      • Katz K.
      Perspectives: Supplemental Security Income and Social Security Disability Insurance Beneficiaries with Intellectual Disability. Soc Secur Bull. 2017;77(1). Accessed September 24, 2020.
      ,

      Individuals with Disabilities Act (IDEA), Public Law 101-476, 2004. US Department of Education. Accessed August 7, 2020. https://sites.ed.gov/idea/.

      DD are diagnosed before age 18 years and are disabilities that cause delays in meeting developmental milestones and are frequently life-long. This includes a group of conditions that affect the functioning in day-to-day life. Areas of significant deficit can include physical, behavioral, language, both expressive and receptive, learning, self-care activities, and/or movement.

      National Center on Birth Defects and Developmental Disabilities. Facts about developmental disabilities. Centers for Disease Control and Prevention. Accessed August 7, 2020. www.cdc.gov/ncbddd/developmentaldisabilities/facts.html.

      ,
      • Friedman C.
      • Spassiani N.A.
      Community-based dietician services for people with intellectual and developmental disabilities.
      Both DD and ID can be the result of chromosomal abnormalities, premature birth, injury during or after birth, or metabolic disorders, such as phenylketonuria.
      • Van Karnebeek C.D.
      • Stockler S.
      Treatable inborn errors of metabolism causing intellectual disability: A systematic literature review.
      Disabilities, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders.
      and the American Association of Intellectual and Developmental Disabilities, can change with regular updates and as new research arises. RDNs need to be proactive in staying abreast of current information.
      Individual is the preferred term when referring to those with an IDD. Referring to individuals who are identified with an IDD as residents, patients, clients, or customers is considered inappropriate, except when in a medical or applicable setting. Although there is debate on the use of person-first language, many use the practice that places the person before the disability (eg, individual who has autism), emphasizing the person is not defined by their disability. Communications by the individual on their nutrition needs and preferences may be verbal or nonverbal, for example, mood, behavior changes, facial expression, and body language (Figure 5). The importance of speaking with the individual directly cannot be overemphasized.
      In 2016, the prevalence of IDD for all ages in the United States was 7.37 million people, up from 4.7 million in 2013, and was 200 million worldwide.
      • Kraus L.
      • Lauer E.
      • Coleman R.
      • Houtenville A.
      2017 Disability Statistics Annual Report.
      ,

      What is an intellectual disability? Special Olympics. Accessed August 7, 2020. https://www.specialolympics.org/about/intellectual-disabilities/what-is-intellectual-disability.

      Youth ages 3 to 17 years, increased from 16.2% to 17.8% from 2009 to 2017, respectively. This equates to 1 in 6 children diagnosed with a DD.
      • Zablotsky B.
      • Black L.I.
      • Blumberg S.J.
      Estimated Prevalence of Children with Diagnosed Developmental Disabilities in the United States, 2014–2016. NCHS Data Brief, No. 291.
      Globally, 52.9 million children birth to 5 years of age have been identified with a DD.
      • Olusanya B.O.
      • Davis A.C.
      • Wertlieb D.
      • et al.
      Developmental disabilities among children younger than 5 years in 195 countries and territories, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016.
      In addition, 20% of prisoners and 30% of jail inmates have a cognitive disability.

      Bronson J, Maruschak LM, Berzofsky M. Disabilities Among Prison and Jail Inmates, 2011-12. US Department of Justice, Bureau of Justice Statistics. Published December 14, 2015. Accessed August 7, 2020. https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5500.

      These increasing numbers indicate the continuing need for RDN services.
      • Ptomey L.T.
      • Wittenbrook W.
      Position of the Academy of Nutrition and Dietetics: Nutrition services for individuals with intellectual and developmental disabilities and special health care needs.
      The role of the RDN in providing services to this population covers a broad range, infants to elderly, in almost every aspect of life. RDNs may work in hospitals or other facilities, which may range from schools to intermediate and long-term care facilities. RDNs may provide services in homes via Early Intervention programs, schools, state or federal programs, jails or prisons, and/or therapy companies. An individual’s living environment may include their family’s home, group home, or congregate living situation. The requirement for provision of nutrition services is usually designated in regulations by the state of residence according to the individual’s age, degree of disability, and residence placement (Figure 4). Working with an interdisciplinary team (Figure 5), the RDN may address medical issues and dual diagnosis(es), recommended diet and modifications, meal planning, diet orders, and fluid intake. The RDN is part of an interdisciplinary team that develops a plan (eg, Individual Family Service Plan [IFSP], Individual Education Plan [IEP], Individual Service Plan [ISP], or Individual Program Plan [IPP]

      State Operations Manual. Appendix J-Guidance to surveyors: Intermediate care facilities for individuals with intellectual disabilities. (Rev. 178, 04-13-18); §483.480 Conditions of participation: Dietetics services. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed August 7, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_j_intermcare.pdf.

      ) using a person-centered approach that prioritizes the individual’s preferences and needs. Nutrition care and services for individuals or people with IDD must balance nutrition needs with the individual’s desires, abilities, and supports (necessary services and adaptations) to achieve quality of life. There is a need for RDNs who specialize in providing nutrition care or services to individuals with IDD in a variety of organizations, including but not limited to federal, state, and county agencies; nonprofit; research; and in the private sector.
      Nutrition services and protocols vary by program, the organizations overseeing the program, and state and federal regulations. Early intervention referrals may be submitted by anyone with legitimate medical knowledge of the child (eg, educators, parent, physician, and Child Protective Services). School-aged children may be referred via the IEP process, and those in group or congregate living situations are generally required to be assessed annually; regulation requirements vary by state. Typically, adult referrals are made through primary physicians or county programs. There is a need for continuation of services from childhood to adulthood. The availability of services varies by state.
      Progress toward goals may be tracked via growth charts, developmental milestones met, infant mortality rates, and eating and ability to transition off enteral or parenteral nutrition support. Tracking of growth is unique to each individual due to the wide variety of comorbidities in this population (Figure 6). The impact of the RDN is important to track using quality metrics in order to show the need for and value of nutrition services. Research-based screening tools for this population need to be developed for the community to improve referrals and support value of including RDNs as core IDD team members. Knowledge and understanding of the unique aspects of providing services to individuals with an IDD are essential for the RDN to effectively deliver nutrition care through a person-centered approach. RDNs have an important role in the treatment of this population, as optimizing nutrition status improves cognition and quality of life.
      • Ptomey L.T.
      • Wittenbrook W.
      Position of the Academy of Nutrition and Dietetics: Nutrition services for individuals with intellectual and developmental disabilities and special health care needs.
      The BHN DPG (https://www.bhndpg.org/) is the Academy DPG that provides networking, education (Figure 4), and resources for RDNs working with the IDD population throughout the lifespan. BHN DPG resources include peer-reviewed articles in topics such as attention-deficit hyperactivity disorder (ADHD), autism, and feeding children with DD, in addition to case studies and other resources, such as books, articles, and webinars. Due to the increasing number of people with an IDD, there is a continuous need for mentorship of RDNs new to IDD regarding the focus area and the DPG resources available to support working with this population.

      Academy Revised 2020 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in IDD

      An RDN can use the Academy Revised 2020 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in IDD (see Figures 1 and 2, available at www.jandonline.org, and Figure 3) to:
      • identify the competencies needed to provide IDD nutrition and dietetics care and services;
      • self-evaluate whether they have the appropriate knowledge, skills, and judgment to provide safe, effective, and quality IDD nutrition and dietetics care and service for their level of practice;
      • identify the areas in which additional knowledge, skills, and experience are needed to practice at the competent, proficient, or expert level of IDD nutrition and dietetics practice;
      • provide a foundation for public and professional accountability in IDD nutrition and dietetics care and services;
      • support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of IDD nutrition and dietetics services and resources;
      • enhance professional identity and skill in communicating the nature of IDD nutrition and dietetics care and services;
      • guide the development of IDD nutrition and dietetics–related education and continuing education programs, job descriptions, practice guidelines, protocols, clinical models, competence evaluation tools, and career pathways; and
      • assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in IDD nutrition and dietetics, and the understanding of the full scope of this focus area of practice.

      Application to Practice

      All RDNs, even those with significant experience in other practice areas, must begin at the competent level when practicing in a new setting or new focus area of practice. At the competent level, an RDN in IDD is learning the principles that underpin this focus area and is developing knowledge, skills, judgment, and gaining experience for safe and effective IDD practice. This RDN, who may be new to the profession or may be an experienced RDN, has a breadth of knowledge in nutrition and dietetics and may have proficient or expert knowledge/practice in another focus area. However, the RDN new to the focus area of IDD must accept the challenge of becoming familiar with the body of knowledge, practice guidelines, communication methods for individuals with IDD, and available resources to support and ensure quality IDD-related nutrition and dietetics practice.
      At the proficient level, an RDN has developed a more in-depth understanding of IDD practice and is more skilled at adapting and applying evidence-based guidelines and best practices than at the competent level. This RDN is able to modify practice according to unique situations, including developing setting-specific evidence-based nutrition care guidelines or protocols for working with individuals with IDD. Proficient-level RDNs understand the complexities with the comorbidities, feeding challenges, management of chronic diseases, skin integrity/pressure injury/ulcer, weight management. The RDN has acquired specialized knowledge, enhanced decision making skills, experience, and clinical competence supporting individuals with physical, developmental, and intellectual disabilities. The RDN at the proficient level may possess a specialist credential(s) (eg, Certified Specialist in Pediatrics [CSP], CDCES, and/or CNSC) or advanced credentials(s).
      At the expert level, the RDN thinks critically about IDD nutrition and dietetics, demonstrates a more intuitive understanding of the practice area, displays a range of highly developed clinical and technical skills, and formulates judgments acquired through a combination of education, experience, and critical thinking. Essentially, practice at the expert level requires the application of composite nutrition and dietetics knowledge, with practitioners drawing not only on their practice experience, but also on the experience of the IDD RDNs in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of IDD nutrition and dietetics within a contextual whole, are fluid and flexible and have considerable autonomy in practice. The expert RDN in IDD not only develops and implements IDD nutrition care and services, they also manage, drive, and direct clinical care; conduct and collaborate in research; participate in advocacy; accept organization leadership roles; engage in scholarly work; guide interdisciplinary teams; and are leaders in the advancement of IDD nutrition and dietetics practice.
      Indicators for the SOP and SOPP for RDNs in IDD are measurable action statements that illustrate how each standard can be applied in practice (Figures 1 SOP and 2 SOPP, available at www.jandonline.org ). Within the SOP and SOPP for RDNs in IDD, an "X” in the competent column indicates that an RDN who is caring for patients/clients is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A competent RDN in IDD could be an RDN starting practice after registration or an experienced RDN who has recently assumed responsibility to provide care for individuals with IDD. This could also include individuals with pediatric feeding disorder (Figure 4), low self-care skills, dysphagia, low cognition skills, auditory or receptive processing disorders, diabetes, or other comorbidities (Figure 6).
      An "X” in the proficient column indicates that an RDN who performs at this level has a deeper understanding of IDD nutrition and dietetics and has the ability to modify or guide therapy to meet the needs of individuals with an IDD in various situations (eg, more in-depth understanding and use of communication methods for individuals with ID and/or DD, and current research on nutritional needs that may exist due to disability).
      An "X” in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of IDD nutrition and dietetics and a highly developed range of skills and judgments acquired through a combination of experience and education. The expert RDN builds and maintains the highest level of knowledge, skills, and behaviors, including leadership, vision, and credentials.
      Standards and indicators presented in Figure 1 and Figure 2 (available at www.jandonline.org) in boldface type originate from the Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and should apply to RDNs in all 3 levels. Additional indicators not in boldface type developed for this focus area are identified as applicable to all levels of practice. Where an "X” is placed in all 3 levels of practice, it is understood that all RDNs in IDD are accountable for practice within each of these indicators. However, the depth with which an RDN performs each activity will increase as the individual moves beyond the competent level. Several levels of practice are considered in this document; thus, taking a holistic view of the SOP and SOPP for RDNs in IDD is warranted. It is the totality of individual practice that defines a practitioner’s level of practice and not any one indicator or standard.
      RDNs should review the SOP and SOPP in IDD at determined intervals to evaluate their individual focus area knowledge, skill, and competence. Consistent self-evaluation is important because it helps identify opportunities to improve and enhance practice and professional performance and set goals for professional development. This self-appraisal also enables IDD RDNs to better utilize these Standards as part of the Professional Development Portfolio recertification process,
      • Weddle D.O.
      • Himburg S.P.
      • Collins N.
      • Lewis R.
      The professional development portfolio process: Setting goals for credentialing.
      which encourages CDR-credentialed nutrition and dietetics practitioners to incorporate self-reflection and learning needs assessment for development of a learning plan for improvement and commitment to lifelong learning. CDR’s 5-year recertification cycle incorporates the use of essential practice competencies for determining professional development needs.
      • Worsfold L.
      • Grant B.L.
      • Barnhill C.
      The essential practice competencies for the Commission on Dietetic Registration’s credentialed nutrition and dietetics practitioners.
      In the 3-step process, the credentialed practitioner accesses an online Goal Wizard (step 1), which uses a decision algorithm to identify essential practice competency goals and performance indicators relevant to the RDN’s area(s) of practice (essential practice competencies and performance indicators replace the learning need codes of the previous process). The Activity Log (step 2) is used to log and document continuing professional education during the 5-year period. The Professional Development Evaluation (step 3) guides self-reflection and assessment of learning and how it is applied. The outcome is a completed evaluation of the effectiveness of the practitioner’s learning plan and continuing professional education. The self-assessment information can then be used in developing the plan for the practitioner’s next 5-year recertification cycle. For more information, see https://www.cdrnet.org/competencies-for-practitioners.
      RDNs are encouraged to pursue additional knowledge, skills, and training, regardless of practice setting, to maintain currency and to expand individual scope of practice within the limitations of the legal scope of practice, as defined by state law. RDNs are expected to practice only at the level at which they are competent, and this will vary depending on education, training, and experience.
      • Gates G.R.
      • Amaya L.
      Ethics opinion: Registered dietitian nutritionists and nutrition and dietetics technicians, registered are ethically obligated to maintain personal competence in practice.
      RDNs should collaborate with other RDNs in IDD as learning opportunities and to promote consistency in practice and performance and continuous quality improvement. See Figure 7 for examples of how RDNs in different roles, at different levels of practice, may use the SOP and SOPP in IDD.
      Figure 7Role Examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities (IDD).
      RoleExamples of use of SOP and SOPP documents by RDNs in different practice roles
      For each role, the RDN updates the professional development plan to include applicable essential practice competencies for IDD care and services.
      Clinical practitioner (including hospital, clinic, private practice, group home, residential care or long-term care)An RDN working in the community hospital’s outpatient clinic is receiving more referrals for individuals with medical conditions who have an intellectual or developmental disability (IDD). To strengthen knowledge, the RDN reviews the SOP SOPP in IDD and the recommended published practice guidelines and nutrition resources to guide assessment and plan of care. The RDN meets with an RDN colleague who works with the IDD population for guidance, to identify continuing education options, and to identify where to refer individuals or the family/caregiver in order to recommend to the referring physician if a higher level of care is indicated.
      Nutrition program managerA nutrition program manager refers to the SOP and SOPP in IDD to increase knowledge of potential service needs when an individual with IDD participates in programs or services offered by the agency/program. The RDN manager and the RDNs who provide direct services to the individual consult the SOP SOPP for information and resources for skills training. The RDNs and the manager review resources and current agency/program nutrition care guidelines to identify continuing education options that would address the nutrition and social needs of the IDD population.
      Food and nutrition services manager/directorA new food and nutrition services manager in a residential care facility uses the resources identified in the SOP and SOPP in IDD and other applicable focus area SOP and/or SOPP (eg, pediatric nutrition, post-acute long-term care) to identify practice expectations when working with individuals with disabilities. The resources and consultation with an RDN manager in another facility assists the RDN with tailoring the menu, meal service, and snack offerings to better support the nutritional needs and food preferences of the residents.
      Community nutrition/early intervention practitionerAn RDN working in a community-based flexible support program provides consultations for participants with IDD and other medical diagnoses who present with nutrition-related problems. The RDN reviews the SOP and SOPP in IDD and other applicable focus area SOP SOPP periodically to evaluate knowledge, skills, and competence level for providing care to program participants. The SOP and SOPP are used as a resource for developing approaches in early intervention, nutrition care, and guiding quality improvement projects to maximize participant and program outcomes.
      Research/education practitionerAn RDN working in research/education is awarded a grant or contract to demonstrate the role of the RDN and the impact of nutrition interventions provided by an RDN on health outcomes of individuals with IDD. The RDN uses the SOP and SOPP in IDD in consultation with proficient- and expert-level IDD RDNs among other resources to design the research protocol and develop education materials, books, journal articles, fact sheets, handouts, presentations, social networking tools. The SOP and SOPP also serve as a resource for identifying areas for staff development and/or collaboration with a colleague more experienced in research, education, or writing focused on IDD.
      Home health practitionerAn RDN working for a home care agency oversees several individuals with IDD who require nutrition services. The RDN reviews the SOP and SOPP in IDD and for Nutrition Support, and the Academy of Nutrition and Dietetics/Commission on Dietetic Registration Code of Ethics. The RDN gains knowledge to educate and support individuals, families/caregivers, and interdisciplinary team (IDT) members in understanding the overriding principle of respecting the individual’s unique personal values and decisions that affirm their right to self-determination. The RDN consults with experienced RDN colleagues and IDT members for advice and continuing education options to meet professional development goals in early intervention, pediatric and older adult feeding approaches, and palliative and end-of-life care.
      School district practitionerAn RDN employed by a school district participating in the federal Child Nutrition Program reviews required documented medical requests for special foods for students with IDD because schools must provide special meals requested for medical reasons. The RDN reviews the SOP and SOPP as a resource to better understand the needs of the IDD population. The RDN uses self-assessment results to pursue additional knowledge and training, which includes working with school nutrition directors or RDNs who have experience with the IDD population. The RDN uses the information gained to expand resources to assist school nutrition directors, school administrators, teachers, school nurses, and early intervention teachers in understanding regulations pertaining to accommodating students with special needs.
      Prison system practitionerAn experienced RDN is employed by a prison system with a growing population of inmates with IDD. The RDN provides nutrition care through a screening process; educates and counsels inmates with physiological, functional, cognitive, or sensory problems; collaborates with the IDT to ensure optimal inmate care; and oversees the menu adjustments and meal service managing within the system's safety and budgetary constraints. Striving for additional training, the RDN uses the SOP and SOPP in IDD to evaluate personal knowledge and skills for identifying performance goals.
      a For each role, the RDN updates the professional development plan to include applicable essential practice competencies for IDD care and services.
      In some instances, components of the SOP and SOPP for RDNs in IDD do not specifically differentiate between proficient-level and expert-level practice. In these areas, it remains the consensus of the content experts that the distinctions are subtle and captured in the knowledge, experience, and intuition demonstrated in the context of practice at the expert level, which combines dimensions of understanding, performance, and value as an integrated whole.
      • Chambers D.W.
      • Gilmore C.J.
      • Maillet J.O.
      • Mitchell B.E.
      Another look at competency-based education in dietetics.
      A wealth of knowledge is embedded in the experience, discernment, and practice of expert-level RDN practitioners. The experienced practitioner observes events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. The knowledge and skills acquired through practice will continually expand and mature. The SOP and SOPP indicators are refined with each review of these Standards as expert-level RDNs systematically record and document their experiences, often through use of exemplars. Exemplary actions of individual IDD RDNs in practice settings and professional activities that enhance individual/person/population care and/or services, can be used to illustrate outstanding practice models.

      Future Directions

      The SOP and SOPP for RDNs in IDD are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, changes to dietetics education standards, regulatory changes, and outcomes of practice audits. Continued clarity and differentiation of the 3 practice levels in support of safe, effective, equitable, and quality practice in IDD remains an expectation of each revision to serve tomorrow's practitioners and individuals with IDD. Development of a certificate of training in nutrition in IDD by the Academy and BHN DPG will be beneficial and is forthcoming. In addition, more research and resources addressing care and services for the IDD population need to be developed and/or pursued.

      Summary

      RDNs face complex situations every day. Addressing the unique needs of each situation and applying standards appropriately is essential to providing safe, timely, person-centered quality care and service. All RDNs are advised to conduct their practice based on the most recent edition of the Code of Ethics for the Nutrition and Dietetics Profession, the Scope of Practice for RDNs, and the SOP in Nutrition Care and SOPP for RDNs, along with applicable federal and state regulations and facility accreditation standards. The SOP and SOPP for RDNs in IDD are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by RDNs in daily practice who provide care to individuals with IDD to consistently improve and appropriately demonstrate competence and value as providers of safe, effective, and quality nutrition and dietetics care and services. These standards also serve as a professional resource for self-evaluation and professional development for RDNs specializing in IDD practice. Just as a professional’s self-evaluation and continuing education process is an ongoing cycle, these standards are also a work in progress and will be reviewed and updated every 7 years.
      Current and future initiatives of the Academy, as well as advances in IDD care and services, will provide information to use in future updates and in further clarifying and documenting the specific roles and responsibilities of RDNs at each level of practice. As a quality initiative of the Academy and the BHN DPG, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.
      These standards have been formulated for use by individuals in self-evaluation, practice advancement, development of practice guidelines and specialist credentials, and as indicators of quality. These standards do not constitute medical or other professional advice, and should not be taken as such. The information presented in the standards is not a substitute for the exercise of professional judgment by the credentialed nutrition and dietetics practitioner. These standards are not intended for disciplinary actions or determinations of negligence or misconduct. The use of the standards for any other purpose than that for which they were formulated must be undertaken within the sole authority and discretion of the user.

      Acknowledgements

      Special acknowledgement and thanks to Jaimie Winkler, RD, LDN, who willingly gave her time to review these standards, and to the Behavioral Health Nutrition Dietetic Practice Group’s Executive Committee. The authors also extend thanks to all who were instrumental in the process for the revisions of the article. Finally, the authors thank Academy staff, in particular, Carol Gilmore, MS, RDN, LD, FADA, FAND; Dana Buelsing, MS, CAPM; Karen Hui, RDN, LDN; and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, who supported and facilitated the development of these SOP and SOPPs.

      Author Contributions

      Each author contributed to drafting and editing the components of the article (eg, article text and figures) and reviewed all drafts of the manuscript.

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      Biography

      C. Conway is the chief of nutritional services, Young Adult Institute/National Institute for People with Disabilities, New York, NY.
      S. Lemons is a senior dietitian, My Health My Resources of Tarrant County, and owner, Lemons Nutrition, LLC, Saginaw, TX.
      L. Terrazas is a registered dietitian, Valley Convalescent and Rehab, Watsonville, CAg