A. Schedule and Availability
A Registered Dietitian (RD) is available to evaluate the nutritional requirements of students as referred by the nursing staff or the pediatrician. The Dietitian works with the Director of Food Services and the Nursing Department; he/she is available for consultation when needed.
The Dietitian covers all campuses and accommodates the needs of all students. The Dietitian reports to the Nursing Office on each campus to address all nutritional consultation issues.
The Dietitian also helps to insure that Nutrition Services meet or exceed applicable state regulations and JCAHO standards.

B. Levels of Care

1. Using data obtained during the nutrition assessment, a nutrition level of care (LOC) is assigned. The LOC may be changed after meeting with the student; meeting with clinical and medical staff; guardian; or at the discretions of the RD. In all situations, the RD needs to use his/her professional judgment to provide the appropriate and highest of quality nutritional care. In all situations this must take into consideration the medical, social, and environmental needs of the student and be consistent with the services provided at Hillcrest Educational Centers.
2. Students will receive ongoing nutritional care consistent with the standards specified for the assigned level of care.

C. Criteria for Levels:
a. Level of Care 1
Any student in need of a specialized or modified diet due to a chronic nutrition-related condition or acute malnutrition will be classified as Level of Care 1: (LOC 1)
a. Including but not limited to the following diagnoses:
1) active eating disorder
2) uncontrolled diabetes
3) malnutrition
4) malabsorption
5) enzyme deficiency (excluding lactose intolerance)

Level 1 Nutritional Care Standard:
1. When referred, the Registered Dietitian will complete a nutrition assessment. The assessment is documented in the student’s master medical file under Nutrition. The Dietitian will use his/her professional judgment as to whether a specific nutrition care plan is needed at this time and a treatment plan will be documented in the student’s medical record.
2. Follow-up nutrition care and documentation will be completed at least monthly thereafter for as long as the RD working in conjunction with the Medical team determines it necessary. Follow-up nutrition care will include re-evaluation of LOC.

2. Level of Care 2
Any student with one or more of the following criteria will be classified as Level 2:
a. Abnormal Growth- including but not limited to the following:
1) Obesity
2) Weight for Length >95% or Body Mass Index (BMI) = >95%
3) Growth Failure – also known as Failure to Thrive (FTT)
• Weight for Length <5%
• Unexpected weight loss or inability to maintain an appropriate weight
b. Fasting blood cholesterol on admission exceeding 199
Policy: Hypercholesterolemia (I. – below)
c. Abnormal Nutrition related lab values on admission- including but not limited to the following:
1) Albumin less than 3.2
2) Anemia related lab values: Hct, Hgb, MCV
d. Documented food allergies/intolerance that may put a student at risk for malnutrition or require a significantly modified diet (other than sick day diet)
e. Non-insulin dependent Diabetes
f. Anorexia (Vs. Anorexia Nervosa)
g. Unmanaged lactose intolerance
h. Any diagnosed condition in which the RD and Medical team deem it necessary for close nutrition follow-up.

Level 2 Nutritional Care Standard
1. When referred, the registered dietitian will complete a nutrition assessment. The assessment is documented in the student’s Electronic Progress Notes under Nutrition. The dietitian will use his/her professional judgment as to whether a specific nutrition care plan is needed at this time and a treatment plan will be documented in the student’s medical record.
2. Follow-up nutrition care and documentation will be completed at least quarterly thereafter for as long as the RD working in conjunction with the Medical team determines it necessary. Follow-up nutrition care will include re-evaluation of LOC.

The dietitian and nurse will develop a Treatment Plans for students with a level of care of 1 or 2, as deemed necessary. The treatment plan will be part of the student’s medical chart.
Treatment Plans are designed to satisfy the student’s special diet requirement and may include exercise goals as well. These plans must also take into consideration the medical, social, and environmental needs of the student and be consistent with the services provided at the Hillcrest Educational Centers. These plans are updated and reevaluated quarterly to coincide with each student’s quarterly reviews.

3. Level of Care 3

Students considered to be at minimal nutritional risk upon admission are classified as Level 3 (LOC 3). (Regular Diet)

Level 3 Nutritional Care Standard
Screening will be provided only at RN or MD’s request. Staff should be encouraged to write down their concerns and submit them to the Nursing Department for review, as they are the campus’s link to medical/clinical providers.

D. Assessment of Students
Nutritional assessment is done by nursing on every student upon admission and will be reviewed by the pediatrician with referral to the RD as indicated.

E. Dietitian Role and Responsibility
1. The Registered Dietitian assists the Director of Food Services in providing students with safe and nutritionally adequate meals. He/she provides nutritional assessment, and evaluations of student as needed, and consults with the medical, clinical, educational, and administrative community at Hillcrest Educational Centers to help foster the highest quality of healthcare to our students.

The responsibilities of the R.D. include but are not limited to:
a. To serve as a consultant to the Food Service Director, Nursing Dept., and other involved staff.
b. To approve all menus in accordance with the diet manual.
c. To participate in the development and ongoing monitoring and evaluation of departmental Quality Improvement indicators.
d. To periodically observe the serving of meals.
e. To review special diets and provide nutritional counseling as needed.
f. To review food acceptance survey results and aid in determining the response to students’ requests for menu changes.
g. To act as a resource for the Education Dept., to support health teachers in their role as nutrition educators.
h. To review student medications for drug nutrient interaction, implications and providing nutrition information and counseling where needed.

2. Nutrition Counseling/Education
The R.D. is responsible for nutrition counseling and diet instruction for students that are in need of this type and degree of instruction. All staff are encouraged and expected to support each student’s nutritional goals. The goal for the diet instruction is to involve the student in learning simple concepts about the diet and to become responsible, to some extent, for self-care of the component of his/her treatment. The degree to which each student can participate in his or her nutritional care plan is dictated by the stage of his or her treatment and may vary greatly from student to student.
a. Upon receipt of a physician’s request for a consultation or diet modification, the R.D. will review the medical record, access the patient’s nutritional status, consult with the physician and other treatment team members, and develop a nutrition care plan which includes appropriate nutrition counseling.
b. Appropriate written instructions should accompany a verbal instruction. Where indicated, other staff (i.e., teachers, Youth Development Professionals) shall become involved in student education and/or implementation of special diet.
c. Follow-up visits should be made to each student receiving instruction in order to evaluate the effectiveness of the instruction.
d. All diet instructions should be documented in the medical record, including a description of the diet instructions and materials given to the student, a summary of the diet history, an assessment of their diet knowledge, and a recommendation for post-discharge follow-up, as appropriate.

F. Diet Orders
1. The attending physician orders a regular or special diet upon admission or at any other time during a student’s placement that is deemed necessary by the medical team. The Food Service Dept. receives the order from Nursing. The R.D. acknowledges implementation of the diet in the student’s chart in the nutrition assessment and progress note section. Any change in the diet order is documented by the nursing staff and forwarded to the Dietary Department.
2. The dietitian will meet with all students on special diets. Special diets are identified in the student’s medical record chart and in his/her Treatment Plan.
3. Food service staff are informed of students’ dietary needs, and direct care staff are notified as well.
4. At the time of discharge the student’s current diet plan is included in the student’s discharge summary.

G. Consumer Satisfaction Surveys
Food will be prepared in an environment suitable for safe food production and served in an atmosphere suitable for the students. To monitor quality and overall food service acceptance, at least annually a consumer satisfaction survey will be utilized to address food service and nutrition issues. The Food Service Director will oversee the monitoring; the Registered Dietitian will consult when necessary.
1. Approved CSQ forms are used. (See Attachment 7 – B)
2. All students are given the opportunity to complete the CSQ annually.
3. Results are reviewed. Corrective Action reports are discussed, and menus are revised and circulated through the Dietitian, FSD, Program Director and Cooks as needed.

H. Off Campus Meal Policy
The following policy applies to all students and all meals when it is deemed necessary to provided meals in the community, away from a Hillcrest campus.

Hillcrest Educational Centers
Off-Campus Meal Policy

Students under 10 years:
1 burger or sandwich 1 small fry
1 medium non-caffeinated beverage

Students over 10 years:
2 burgers or 2 sandwiches 1 medium fry
1 large non-caffeinated beverage

Points to remember:
Foods and/or beverages may have an effect on medication utilization in the body.

No Caffeinated Beverages, which may include:
 Soda
 Coffee
 Sports Drinks that contain:
 Caffeine  Mau Hung
 Ephedrine

Excessive amounts of high fat foods, high calorie foods are not appropriate for anyone. No super-size meals.

High sugar items should be kept to a minimum.

All foods are acceptable in moderate amounts.

Please contact student’s Clinician and Nursing if you note any of the following:
 Individuals hoarding food
 Consuming excessive amounts  Consuming food in an abnormally rapid fashion
 Refusal to eat at multiple or consecutive meals

I. Hypercholesterolemia Policy

Goal: The reduction of elevated cholesterol levels in our students.

Definition: hypercholesterolemia will be defined by a fasting cholesterol level greater than 199.

Procedure: all students will have a fasting cholesterol test upon admission and follow up testing annually. If an elevated level (greater than 199) is found the level will be repeated in three-month intervals and assessment for referral to endocrinologist will take place.

Evaluation Process:

1. Fasting cholesterol will be ordered and completed as part of admission process.

2. Medical Director, Registered Dietitian, and Registered Nurse will review all Cholesterol studies.

3. An elevated (over 199) cholesterol level will be repeated in three months.

4. In the case of hypercholesterolemia the Medical Director will review and consult with RD and Nurse. The following considerations shall be made:
• R/T medication
• Family history, if possible
• Dietary intervention
• Lipid profile
• Cholesterol lowering medication

5. After careful review and consideration for the student’s age, independence, maturity, diagnosis, current medications, history, and the effects of additional medication a treatment plan will be established.
• There will be documentation in progress note of the plan regarding hypercholesterolemia.
• Reviews for students with hypercholesterolemia will take place quarterly.

6. When the cholesterol level has returned to less than 200 or when deemed appropriate by the RN, RD, or MD the time between testing will be modified.