Susan LaGrange

CMS Memo on F-Tag 322 (Feeding Tubes)On September 27, 2012, the Centers for Medicare & Medicaid Services published a Memo: Ref: S&C 12-46-NH, to the State Survey Agency Directors on F tag 322—Feeding Tubes. These revisions were to be implemented no later than November 30, 2012.

This memo says, “CMS made changes to the surveyor guidance for Feeding Tubes in Appendix PP of the SOM to provide clarification to nursing home surveyors when determining compliance with the regulatory requirements for Feeding Tubes. The regulatory language remains unchanged.” The full memo can be downloaded via the above link.

Upon review, there may be a few questions we ask ourselves:

  1. Are our systems consistent with F-322 and current standards of practices?
  2. Does our documentation include clinical conditions that demonstrate the use of the feeding tube is   unavoidable (documentation rules out viable alternatives, assessments and appropriate clinical objective)?
  3. Have we included the resident choice and/or any Advance Directives in the plans?
  4. Do we need to update our policies and procedures?
  5. Do we need to educate our interdisciplinary teams?

A decision to use a feeding tube has a major impact on a resident and his or her quality of life. Therefore, we want to rule out any other alternatives during the assessment process with the Interdisciplinary Team to make sure the use of the tube is unavoidable.


Let’s take a look at the facility policies and procedures to see that the facility will make sure the necessary care and services are consistent with current standards of practice. This means going through an assessment process, looking at tube related complications/incidents, assessing resident choice, verifying tube placement, noting the administration of product, in addition to site care, staff education, preventative maintenance of equipment, documentation, etc.



Next, we will want to educate the facility staff in the policies and procedures, clinical considerations, skills necessary and management of complications as well as a system to evaluate staff compliance with the policies and procedures. This can include sign-in sheets, return demonstrations and/or skills check sheets.



Documentation can include:

  1. Comprehensive assessment outlining  reason for tube feeding, alternative attempted prior to use of the tube (or reasons why alternatives are not an option)
  2. Assessed nutritional needs
  3. Care planning of individualized goals and interventions
  4. Ongoing reassessment for the need of the tube
  5. Administration of product and medications
  6. Any psychosocial concerns
  7. Complications
  8. Evaluation-Evidence of monitoring




If we find that there are any areas that need improvement, we can develop an action plan outlining the identified concern, recommended action, who will be responsible and date of completion.  The Action Plan can then be discussed and worked on by the Interdisciplinary Team during the next Quality Assurance Committee for review and recommendations.


Once our system is in place, we can audit on a regular basis to ensure that we are in compliance with F322!