MICHAEL D. CREWS
SECRETARY
PROCEDURE NUMBER: 401.009
PROCEDURE TITLE:
PRESCRIBED THERAPEUTIC DIETS
RESPONSIBLE AUTHORITY: OFFICE OF HEALTH SERVICES
EFFECTIVE DATE:
SEPTEMBER 18, 2014
INITIAL ISSUE DATE:
JUNE 28, 2000
SUPERSEDES:
HSB 15.02.09 AND HCS 25.03.11
RELEVANT DC FORMS:
DC4-668, DC4-701, DC4-704B, DC4-711A, AND DC4-728
________________________________________________________________________________
ACA/CAC STANDARDS: 4-ACRS-4A-2 AND 4-4318
STATE/FEDERAL STATUTES: NONE
FLORIDA ADMINISTRATIVE CODE: RULES
204.003(5), F.A.C.
59A-3.2085,
33-204.002(2),
AND
33-
Procedure 401.009
PURPOSE: To provide guidance to medical personnel to ensure nutritionally adequate meals are
available to any inmate who has an identifiable disorder for which diet therapy is required.
These standards and responsibilities apply to both Department staff and Comprehensive Health
Care Contractor (CHCC) staff.
DEFINITIONS:
(1) Clinical Associate refers to a Physician’s Assistant or an Advanced Registered Nurse
Practitioner (ARNP).
(2) Comprehensive Health Care Contractor (CHCC) refers to contracted staff that has been
designated by the Department to provide medical, dental, and mental health services at
designated institutions within a particular region.
(3) Diet Compliance refers to picking up at least ninety percent (90%) of the prescribed diet meals
every month. An inmate who misses more than nine (9) diet meals per month is considered
non-compliant.
(4) Florida Department of Corrections’ Diet Manual refers to the food service technical manual
utilized primarily by health services. This manual describes selected common diseases
accompanied by an explanation of diet therapy recommended as part of the medical treatment
of the disease, including educational material handouts for inmates.
(5) Hora Somni (H.S.) Snack refers to a light feeding at the hour of sleep or otherwise as a
bedtime snack. The initials “H.S.” refer to “Hour of Sleep.” The H.S. snack is provided in the
2200, 2800, and 4000 calorie regulated diets.
(6) Public Health Nutrition Consultant refers to a Registered Dietitian as defined by the
Academy of Nutrition and Dietetics who is licensed as a Dietitian/Nutritionist in accordance
with chapter 468, F.S. These Florida Department of Corrections’ positions provide nutritional
consultative services on an as needed basis statewide.
(7) Therapeutic Diets refers to diets prescribed for medically necessary nutrition or for dental
reasons.
________________________________________________________________________________
SPECIFIC PROCEDURES:
(1) THERAPEUTIC DIETS:
(a) Therapeutic diets may be prescribed and provided by the Florida Department of Corrections
to those individuals whose needs are justified and documented, by a qualified medical
provider, in order to maintain optimum quality of health.
(b) Therapeutic diets are established by the Florida Department of Corrections’ Diet Manual.
The Florida Department of Corrections’ Diet Manual will be the basic source of information
when Physicians, Clinical Associates, and Dentists prescribe therapeutic diets.
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Procedure 401.009
(c) Therapeutic diets will comply with the guidelines established by the Florida Department of
Corrections’ Diet Manual. Written therapeutic diet menus will be analyzed and certified as to
the nutritional adequacy by a Licensed Registered Dietitian.
(d) Therapeutic diets may be prescribed by Physicians, Clinical Associates, and Dentists.
(e) Only therapeutic diet menus provided by the food services section will be used to prepare and
serve meals to those inmates who have been prescribed therapeutic diets. If a specialized diet
is needed which is not currently available in the current list of approved menus, a Public
Health Nutrition Consultant or the Public Health Nutrition Program Manager, who are
Registered and Licensed Dietitians employed by the Florida Department of Corrections,
should be contacted to assist in prescribing the appropriate medical nutrition therapy.
Documented or written approval (i.e., e-mail) must then be given by the Regional Medical
Director.
(f) The Florida Department of Corrections’ Diet Manual will be available in the health
services and food services areas for reference and information.
(g) A therapeutic diet is a component of medical treatment and is therefore confidential as
protected health information. Protected health information will only be disclosed to
medical staff and persons needing the information to comply with the prescription.
Licensed Registered Dietitians employed by the Department of Corrections are permitted
to review medical records for health information regarding therapeutic diets and may
document recommendations for medical nutrition therapy.
(2) APPROVED THERAPEUTIC DIETS:
(a) Prenatal Diet will be prescribed for pregnant women. This diet is based on the regular
diet (the Master Menu) and adjusted for the caloric value and nutritional recommendations
for pregnancy. The diet includes three (3) servings of fortified breakfast beverage per day.
(b) Liquid Diets:
1. Clear Liquid Diet provides clear fluids that are easily absorbed with a minimum of
digestive activity and which leave limited residue. No milk products are included.
The foods are liquid or will become liquid at body temperature. This diet is only used
for short periods of time; no more than three (3) to five (5) days. Justification must be
provided in the record if this time is extended. If this diet is used for longer than three
(3) to five (5) days, an appropriate low-residue liquid dietary supplement should be
ordered for supplementary nutrition.
2. Cold Liquid Diet provides cold fluids that are liquid or semi-liquid foods with a
smooth, soft texture. No red, orange, or chocolate foods are included. This diet is
used for short periods of time, no more than three (3) to five (5) days. Justification
must be provided in the record if this time is extended. If this diet is prescribed for
more than three (3) to five (5) days, appropriate low-residue liquid dietary
supplements may be ordered for supplementary nutrition on a cold liquid diet.
3. Full Liquid Diet includes a variety of foods that require no chewing. All foods are
liquid or will become liquid at body temperature. Milk products are included. This
diet can be used up to eight (8) weeks only. Liquid dietary supplements should be
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Procedure 401.009
ordered three (3) times a day between meals to meet nutrient needs on a full liquid
diet.
(c) Puree Diet is based on the regular diet; however, the food has been mechanically altered
to a liquid or semisolid form. Pureed diets can only be made with a blender.
(d) Mechanical Dental Diet is based on the regular diet and requires some ability to chew.
Foods that may be difficult to chew will be chopped.
(e) Mental Health Diet is to be used when an inmate is placed on Self-Harm Observation
Status (SHOS).
1. The food and drinks will be served using styrofoam containers with safety utensils
that have been approved by the Regional Mental Health Director.
2. As an alternative to regular meals and as an added safety precaution, finger foods are
available. Accordingly, the attending clinician may order the Mental Health Diet
stipulating “finger foods” on the prescription if the inmate’s clinical and behavioral
presentation warrants it.
3. Bones will be removed from all meats.
4. This diet is based on modifications to the regular diet.
(f) Low Residue Diet includes foods that are low in indigestible carbohydrates and
connective tissues which reduce intestinal motility.
(g) Fat Intolerance Diet is limited to 40 - 50 gm total fat per day with no distinction made as
to type of fat. This diet is not appropriate for cardiac disease or to reduce lipid levels such
as cholesterol or borderline triglycerides. This diet is appropriate for plasma triglycerides
greater than 500 mg/dl
(h) Calorie Regulated Diets:
1. The 2200 calorie regulated diet is written with three (3) meals and one (1) H.S. snack.
The 2800 calorie regulated diet is written with three (3) meals and three (3) snacks.
All have minimal simple sugars, and are low in cholesterol (<300 mg/day) and sodium
(<2300 mg/day). Inmates must be permitted to consume snacks between meals in
order to attain the prescribed caloric intake and nutritional needs. Calorie regulated
diets should not be prescribed for inmates who are overweight or obese and have no
other chronic disease state.
2. The 4000 calorie diet is a modified regular menu with some portions slightly
increased and with three (3) snacks daily. This diet can be prescribed for significant
weight loss and a Body Mass Index (BMI) of 18.5 or less. Inmates must be permitted
to consume snacks between meals at mid-morning, mid-afternoon, and at bedtime in
order to attain their prescribed caloric intake and nutritional needs.
(i) Renal Diets: There are two (2) diets that may be prescribed for inmates with renal
problems:
1. The pre-dialysis diet contains 60-65 gm protein, 2.0-3.0 gm sodium, 3.0-3.2 gm
(75-80 mEq) of potassium and 1.0-1.2 gm phosphorus. This diet contains three (3)
meals and three (3) snacks daily.
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Procedure 401.009
2.
3.
The dialysis diet contains 95-105 gm protein, 2.0-3.0 gm sodium, and 3.0-3.2 gm (7580 mEq of potassium) and 1.0-1.2 gm phosphorus. This diet is for inmates receiving
dialysis. This diet contains three (3) meals and three (3) snacks daily.
Inmates prescribed pre-dialysis and dialysis diets must be permitted to consume
snacks between meals at mid-morning, mid-afternoon, and at bedtime in order to
attain their prescribed caloric intake and nutritional needs.
(3) Diets written for allergies or food intolerances (i.e., gluten or lactose intolerance) require full
documentation in the medical record, to include the method used to determine authenticity of
problem (e.g., food challenge, allergy test). This testing, especially when the inmate has
several medical folders, will be brought forward to the current medical folder in use in order to
maintain currency of medical documentation. Food preferences are not to be addressed in this
category.
(4) Therapeutic diets will not be prescribed with double portions or extra items (i.e., fruit at all
meals, etc.). All diets must be served according to the therapeutic diet menus without additions
or deletions. No salt or pepper packets will be provided on therapeutic diet trays.
(5) NUTRITIONAL SUPPLEMENTS:
(a) Nutritional supplements will be furnished after a Physician, Clinical Associate, or Dentist
writes an order.
1. The order will be written as a single-dose prescription and require a DER (Drug
Exception Request).
2. The product will be single-dosed and issued to the inmate by the nursing staff.
3. The supplement will be consumed in a cup in the presence of nursing staff.
4. The Health Services Administrator or health services designee at each institution will
do the ordering and stocking of nutritional supplements.
5. In general, the BMI will need to be ≤18 to qualify for a supplement and/or a 4000
calorie regulated diet has not provided an improvement in the inmate’s BMI.
(b) The supplements will be available in two (2) types:
1. A hyper-caloric, high-protein, lactose-free product (such as Boost Plus by Nestle
Nutrition or Ensure Plus by Abbott Nutrition or similarly constituted products sold by
manufacturers, such as Equate) will be used for a patient:
a. prescribed a full liquid diet (see Florida Department of Corrections’ Diet Manual);
b. with a demonstrated hyper-metabolic state (i.e., hyperthyroidism, etc.) if there is
continued demonstrated significant weight loss despite adequate dietary intake
(demonstrated adherence to a 4000-calorie therapeutic diet) for a period of not
less than four (4) weeks;
c. who needs dietary supplementation because of malnutrition resulting from AIDS
or advanced malignancies;
d. who is unable to maintain an adequate dietary intake such as a patient undergoing
complex dental procedures or a patient undergoing head and neck radiation; or
e. who is prescribed a clear liquid diet for an extended period of time.
2. A hyper-caloric, high-protein, low residue product with MCT (medium-chain
triglyceride) oil as a significant part of the fat source (such as Vital 1.5 Cal , by Abbott
Nutrition or Peptamen 1.5 by Nestle Nutrition) will be used only when there is
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Procedure 401.009
demonstrated continued significant weight loss and prolonged malabsorption and GI
dysfunction.
(6) THERAPEUTIC DIETS FOR INMATES WITH CHRONIC DISEASES:
(a) A therapeutic diet for an inmate with a chronic disease must be prescribed by a Physician,
Clinical Associate, or Dentist for a period not to exceed ninety (90) days. Prior to
prescribing the diet, the clinician must counsel the inmate regarding the need for the diet
and that adherence is required. Inmates should be permitted to sign a “Refusal of Health
Care Services,” DC4-711A, if the inmate is not willing to comply with a written diet order.
If the inmate chooses to accept her/his prescribed therapeutic diet, non-compliance with
the written diet prescriptions may cause the diet to be discontinued. Inmates who are not
compliant with their prescribed therapeutic diet will be subject to disciplinary action for
not following a written or verbal order.
(b) The appropriate diet prescription must be forwarded to the Food Service Director within
twenty-four (24) hours to ensure appropriate diet foods are available. If any diet is ordered
that is not on the approved list of therapeutic diets (this includes food
allergies/intolerances), the Food Service Director or designee must contact the Regional
Public Health Nutrition Consultant or Nutrition Program Manager for guidance in
providing the appropriate meals.
(c) The prescribed therapeutic diet meal will be served at the meal following the receipt of the
white copy of the diet prescription in food services.
(d) Renewals for diet prescriptions should be scheduled as appointments so that diet
prescriptions can be reissued and forwarded to the Food Service Director prior to
expiration of the original diet order so there is no disruption in continuity of care.
(e) The “Diet Prescription/Order,” DC4-728, must be signed by a Physician, Clinical
Associate, or Dentist to be valid and acknowledged.
(f) An inmate who is on a therapeutic diet and is received from another institution or outside
hospital over the weekend will continue to be on the diet until the Physician, Clinical
Associate, or Dentist reviews the inmate diet prescription which should be done within
five (5) days of transfer. Diet prescriptions of inmates who arrive during the week must be
reviewed within twenty-four (24) hours. Once the diet prescription is reviewed for
medical necessity, the diet prescription will be re-written and the white copy will be
forwarded to food services. Food services must have a copy of the original prescription.
Labels will not be used on diet prescriptions from another facility.
(g) The DC4-728 will be used for all therapeutic diet prescriptions/orders with the following
distribution by health services:
1. White - food service,
2. Canary - inmate copy, and
3. Pink - medical record.
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Procedure 401.009
(h) The white copy of the DC4-728 is to be given directly to food services from health
services. It must never be sent to food services via the inmate.
(i) The pink DC4-728 copy is to be attached to the “Dietary Prescription Display Sheet,”
DC4-704B, in the inmate’s health record.
(j) Any therapeutic diet deviating from the list in section (2)(a)-(i) of this procedure must be
discussed by the Chief Health Officer/Institutional Medical Director and central office
Public Health Nutrition Program Manager prior to its prescription, and written approval
must be obtained from the Regional Medical Director or the Assistant Secretary of Health
Services.
(7) RECEPTION AND MEDICAL CENTER (RMC):
(a) The RMC Hospital is exempt from the requirement to follow this procedure due to the
severity of illness or condition of inmate patients at this facility.
1. Any Physician, Clinical Associate, or Dentist at the RMC Hospital prescribing a diet
order other than those identified in this procedure must utilize the RMC Hospital
Dietitians to provide menu deviations required for any diets ordered that are not
included on the DC4-728.
2. The menu and diet order must be submitted to the Public Health Nutrition Program
Manager for approval to ensure food availability.
(b) Additional food and/or snack items that are considered medically necessary beyond those
included on therapeutic diet meals itemized in this procedure and on the DC4-728 will be
furnished by the hospital at its expense. Non-perishable snack food items may be
purchased directly by the RMC Hospital.
(c) Inmates prescribed therapeutic diets not on the Florida Department of Corrections’ list of
approved diets will be housed at the RMC Hospital until a standard diet order from the
approved list can be written. If such an inmate must be transferred to another facility for
security reasons, the diet not on the list of approved diets will require:
1. written approval from the Regional Medical Director or the Assistant Secretary of
Health Services; and
2. review by the Public Health Nutrition Program Manager.
a. The RMC Hospital Dietitian will forward to the Public Health Nutrition Program
Manager all menus and other appropriate information for review.
b. The Public Health Nutrition Program Manager will review, approve if
appropriate, and transmit the response to the respective facility.
(d) Any food service provider at the RMC Hospital will comply with the requirements of Rule
59A-3.2085(1), F.A.C.
(8) THERAPEUTIC DIET COMPLIANCE:
(a) The “Diet Attendance Roster,” DC4-668, will be used to record each inmate’s adherence
to the prescribed therapeutic diet. This form is to be completed by food service staff and
sent to the Chief Health Officer/Institutional Medical Director and the Regional Public
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Procedure 401.009
Health Nutrition Consultant responsible for the institution at the end of each month for
follow-up on inmate diet compliance.
(b) At the time a diet prescription is written, the inmate will be informed that failure to pick-up
the prescribed meals in compliance with the written diet order will result in a disciplinary
report.
(c) The inmate will receive a disciplinary report with the charge 6-1, disobeying a verbal or
written order, when the inmate misses nine (9) meals in any calendar month and is
considered non-compliant.
(d) A review of the inmate’s canteen records may be conducted at any time to additionally
ensure that the inmate is compliant with her/his therapeutic diet. If there is significant
noncompliance as evidenced by canteen purchases, the diet may be discontinued at the
clinician’s discretion.
(e) Inmates will have their identification badges and diet prescriptions available at all times
when picking up their therapeutic diet meals. This will enable food services to verify the
correct therapeutic diet tray is being served to an inmate.
(f) The Chief Health Officer/Institutional Medical Director, or her/his health services
designee, will review the DC4-668 concurrently with medical charts when considering
renewal of a therapeutic diet. As a result of the review, the following action will be taken:
1. Any inmate, following the orientation, who misses ten percent (10%) or more of
her/his meals during any month will be called to sign a DC4-711A and the diet will be
discontinued accordingly. If the inmate will not sign a refusal, continued noncompliance with her/his prescribed therapeutic diet will be handled in accordance with
section (8)(c) above.
2. If the inmate refuses a special diet in the food service facility (or is found consuming a
regular tray when known to be on a therapeutic diet), s/he will be directed by the
Correctional Officer to return to the health services unit to sign a DC4-711A for the
therapeutic diet.
3. Therapeutic diet counseling will be documented on the “Chronological Record of
Health Care,” DC4-701.
(g) Unless unusual medical circumstances exist, the Chief Health Officer/Institutional Medical
Director or health services designee may refuse to re-prescribe a therapeutic diet for an
inmate who has been non-compliant. Food services should be notified of any inmate who
has been removed from her/his therapeutic diet. This can be done by email or writing a
new diet prescription that indicates the therapeutic diet was discontinued.
(9) Inmates who have concerns or inquiries regarding therapeutic diets should address these
inquiries/concerns initially to the Chief Health Officer/Institutional Medical Director at her/his
institution.
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Procedure 401.009
(10) HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA):
Prescription diet forms, records of compliance, and related documentation, will be safeguarded
in accordance with “HIPAA Privacy Policy,” Procedure 102.006, and not left out where
unauthorized persons, including staff and inmates can view them. These forms will be
maintained in a secure cabinet when not in use.
__/S/_________________________
Secretary
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