IDDSI Is Being Enforced Now — Is Your Facility Ready?
- John Holahan
- 9 hours ago
- 5 min read
I've been saying for years that IDDSI was coming whether facilities were ready or not. Well — it's here.
California surveyors started enforcing IDDSI as the standard of care on January 1, 2026. Wisconsin surveyors have known about IDDSI for years and are now citing choking incidents as immediate jeopardy deficiencies. And the organization that wrote the National Dysphagia Diet — the Academy of Nutrition and Dietetics — no longer publishes it, no longer updates it, and no longer supports it. They moved to IDDSI.
That's not me editorializing. That's the regulatory reality on the ground right now.
I had the chance to sit down with Dr. Shellie Sonnentag for a recent episode of SimplyThick John + Friends, and I want to share some of what she told me — because she's not just an IDDSI advocate. She's a Chief Nursing Officer who led full IDDSI implementation across multiple skilled nursing facilities starting back in 2019. She's already been where the rest of the industry is heading.
The NDD Is No Longer the Standard of Care
Here's the thing I want every facility administrator, DON, and dietary manager to understand clearly:
The NDD does not have an organization behind it anymore. The body that created it has moved on. If a surveyor walks into your building today and asks what standard of care you're following for dysphagia diets — and your answer is the NDD — you are on shaky ground. Not because IDDSI is being pushed as a preference, but because current federal regulations (CMS Appendix PP) require facilities to follow current recognized professional standards of practice.
Shellie put it plainly: "If IDDSI is the only nationally and internationally recognized standard of care for dysphagia diets, I don't see how any provider can say they're not going to do it."
And she's right. I've spent time in Appendix PP, and the phrase "current recognized professional standards" appears more than 30 times. It's written that way intentionally — so the regulation doesn't need to be rewritten every time standards evolve. The standard has evolved. IDDSI is it.
The Legal Reality Nobody Wants to Talk About
Shellie's facility has had two residents die from choking incidents over her 31-year career. One from a peanut butter and jelly sandwich. One from a grilled cheese. Both are foods that fall under IDDSI's bread restrictions — restrictions that exist because researchers went back through coroner's reports and found bread appearing over and over again as a contributing factor.
I know bread restrictions are the most contentious part of IDDSI adoption. Facilities push back on them constantly. But as Shellie said, "IDDSI didn't just decide to pick on bread. They looked at the data."
Now here's the question that keeps me up at night: if a resident in your facility chokes and passes away, and your facility was not following the only recognized standard of care for dysphagia diets — how do you defend that in a lawsuit?
The answer is: you probably can't.
Implementation Is More Doable Than You Think
I don't say any of this to scare people into paralysis. I say it because Shellie's story is genuinely encouraging for any facility that hasn't started yet.
She heard about IDDSI for the first time in November 2017 at a conference in Wisconsin. By April 2019 — 18 months later — her organization went live with full IDDSI implementation across multiple facilities. And she did it using the resources on IDDSI.org, her food vendor's support, and a lot of determination.
"Using just 2017 and 2018 resources," I said to her during our conversation. She confirmed: that's all she had. Nowadays there is so much more — training materials, vendor support, apps, symposiums, YouTube channels (hi). A facility starting today could have an implementation plan in three months and complete staff training not long after.
The framework is logical. When Shellie walks new dietary hires through the IDDSI levels and explains why a Level 6 piece is 15mm — because that's the size that won't block your esophagus — something clicks. "A light bulb goes on," she said. "That makes sense."
The Training Turnover Problem — And How to Solve It
The part of the conversation I think deserves more attention is what Shellie called the "Groundhog Day" problem.
You get everyone trained. Your kitchen staff knows the levels. Your visual aids are up. Then someone turns over — and you start all over again. This is real, and it's especially acute for facilities that went through COVID-related staffing upheaval.
Shellie's answer: front-load the onboarding. Start every new hire with IDDSI basics from day one. Use the free training materials at IDDSI.org. Use vendor resources. Put the IDDSI app on a kitchen iPad. When a surveyor walks in and asks a brand-new dietary aide what size she's cutting a Level 6 portion — she should be able to point to the cutting board image on the wall, not freeze.
That's not luck. That's infrastructure.
Where Things Are Headed
California is the leading edge. Wisconsin is close behind. States where IDDSI is less known — Indiana, Montana — are starting to pick it up partly because staff and residents are moving from states where it's already the norm.
This is not a coastal thing. It's not a large-facility thing. It's coming everywhere.
If you've been waiting to start your IDDSI implementation — or if you've been doing it "a little differently" — now is the time to take it seriously. The resources exist. The framework is solid. The science is clear. And the regulatory environment is catching up.
Knowing better means doing better. That's how Shellie put it. I couldn't say it better myself.
Go Deeper with Shellie: Live Webinar — May 28, 2026
If this conversation resonated with you, Shellie is taking it further in a formal CEU webinar hosted by SimplyThick on Thursday, May 28, 2026.
The topic: Implementation of IDDSI in Assisted Living and Skilled Nursing Facilities. It's a 1.5-hour intermediate-level session designed specifically for SNF and AL staff — covering the IDDSI framework, the implementation process, common challenges, and practical lessons learned. Exactly what we talked about, but with structured learning objectives and time for Q&A.
Professional credits available:
1.5 AND CEUs for RDs and DTRs
1.5 ANFP CEUs for CDMs
0.15 ASHA CEUs for SLPs
Cost is $25. Registration is open through May 15, 2026, and spots are limited to the first 500 registrants (USA and Canada only). Testing kits ship ahead of the webinar, which is why the registration deadline is earlier than the event date.
If you're reading this after May 28, 2026 and the registration link has closed, check simplythick.com for upcoming webinars and continuing education opportunities.
Want to hear the full conversation? Watch Episode 9 of SimplyThick John + Friends on YouTube.