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Manual

Dining Assistant Programsin Nursing Homes:

Guidelines forImplementation



Contents

Chapter One ................................................................................................................ 1

Chapter Two ................................................................................................................ 3 Federal Regulations...............................................................................................4

State Regulations...................................................................................................5

Compliance with State Surveys .............................................................................6

Chapter Three .............................................................................................................7

Models of a Dining Assistant Program...................................................................9

Resident and Facility Assessment.......................................................................11

Chapter Four .............................................................................................................17

Immediate Program Goals ...................................................................................18

Long-Term Program Goals ..................................................................................22

Measuring Goal Progress .................................................................................... 25

Chapter Five..............................................................................................................27

Targeting Recruits................................................................................................28

Chapter Six ................................................................................................................33

Available Training Manuals.................................................................................. 34

Training Enhancements.......................................................................................36

Chapter Seven ..........................................................................................................41

Identifying Residents Appropriate for the Program..............................................42

When to Implement the Program.........................................................................44

How to Monitor Dining Assistant Care Quality.....................................................45

Chapter Eight ............................................................................................................49

Appendix ...................................................................................................................51

Appendix A .........................................53 Dining Assistant Program Worksheets

Appendix B ................................................................ 55 Federal Register Notice

Appendix C .............................................................................. 57 State Contacts

Appendix D

..................................59

CMS-Issued Guidance for State Surveyors

Appendix E .................61 Dining Assistant Observation Tool and Scoring Rules

Contents i Dining Assistant Program



Chapter One

Introduction

What nursing home administrator or director of nursing has not

cringed at the sight of half-eaten trays returned from the dining room,

untouched supplements dumped in the trash, and monthly logs

showing unintentional weight loss? Food and issues around dining

are usually the top complaint in every nursing home satisfaction

survey. A Dining Assistant (DA) program that could address and

mitigate just a portion of these issues with a minimal investment ofnursing home resources deserves consideration.

DA programs are flexible – they can involve only one or two

residents or only several staff, and be implemented on only one unit

or one shift. They can involve community volunteers or paid workers,

or in-house non-nursing staff looking for opportunities to advance to

direct care work. They can be scaled up or back depending on the

needs of the residents and resources of the nursing home (NH). If

the decision is made to train non-nursing staff, the DA program can

be the nursing home’s first step toward culture change.

While the Centers for Medicare & Medicaid Services (CMS) and themajority of states now allow the use of dining assistants in long-term

care facilities, relatively few nursing homes have implemented their

own programs. We believe this is due to the limited resources

currently available to educate decision-makers on designing and

implementing dining assistant programs and insufficient

understanding of the advantages to the resident and the NH overall

of a Dining Assistant Program.

Several stakeholder organizations—e.g., the American Health Care

Association (AHCA), the American Dietetic Association (ADA), and

the Colorado Department of Public Health and Environment— have

developed and published training manuals. These training manualsare discussed in Chapter 6 and provide staff developers with

complete lesson plans that prepare trainees to safely and effectively

assist residents during mealtimes. They do not, however, address

the decision-making process that nursing home management face as

they attempt to determine whether or not a DA Program is

appropriate for their NH.

Chapter One 1 Dining Assistant Program



Chapter One 2 Dining Assistant Program

Dining Assistant Programs in Nursing Homes: Guidelines for

Implementation is a manual intended to guide management staff

through a step-by-step process of assessment, goal identification,

program design, implementation, and planning for program

sustainability. It includes specific guidance to assist management

with:

Assessing their NH in terms of their strengths and weaknesses

around dining quality;

Determining if a DA program is an appropriate addition to current

programming;

Designing a DA program that meets the residents’ needs using

the NH’s resources; and

Successfully implementing a DA program that improves

residents’ quality of care, residents’ and families’ satisfaction

around dining, and encourages and promotes staff involvement

and advancement.

In addition to program descriptions and guidance throughout the

chapters of the manual, we provide DA Program Implementation

Worksheets (see Appendix A), designed to be copied from the

manual and used by nursing home staff developers and others to

assess and plan DA programs.

Developed by Abt Associates and Vanderbilt University with funding

and input from CMS and the Agency for Healthcare Research and

Quality (AHRQ), the manual is the culmination of three years of

research that involved an inventory of state programs in all 50 states,

site visits to DA programs in several states to observe the programs

and interview staff, and implementation of pilot programs in two sites

in two states. The research team consists of experienced long-term

care nurses, nationally- known nutrition experts and a gerontologist,

along with CMS and AHRQ staff.

The manual is further enhanced by the invaluable contributions of

nursing home staff developers who have implemented DA Programs

in their NHs. They generously shared with us lessons learned from

their experience with the program, recommended viable options for

recruitment and retention, and offered suggestions on how to

implement an optimal program. Additional contributions to this

manual come from other stakeholder groups such as long-term care

affiliate organizations (e.g., AHCA; American Association of Homes

and Services for the Aging (AAHSA)) and the ADA.

It is our hope that this manual will encourage nursing home

management to consider whether a DA Program could benefit their

NH, as well as provide a valuable resource for developing and

instituting a successful program.



Federal Regulations

The 2003 Federal Register notice includes a list of regulations that

serve as a minimum set of standards for nursing home

administrators to adhere to when they are interested in training

individuals to help feed residents during mealtimes. The Federal

Register notice is printed in its entirety in Appendix B and also can

be found at: http://www.gpoaccess.gov/nara/index.html. Following is

a list of the regulations that are included in the Federal Register

notice that should be considered when developing a program:

Dining Assistants must complete a state-approved training

course, that includes:

A minimum of eight hours of training.

Specific Training Topics:

– feeding techniques, – assistance with feeding and hydration,

– communication and interpersonal skills,

– appropriate responses to resident behavior,

– safety and emergency procedures including the Heimlich

maneuver,

– infection control,

– resident rights, and

– recognizing changes in residents that are inconsistent

with their normal behavior and the importance of

reporting those changes to the supervisory nurse.

State-specific training requirements.

Nursing homes must ensure their DA Program meets thefollowing requirements:

DAs work under the supervision of an RN or LPN.

DAs may not train other feeding assistants.

Resident selection must be based on the charge nurse’s

assessment, the resident’s latest assessment, and plan of

care.

DAs feed only residents who have no complicated feeding

problems such as difficulty swallowing, recurrent lung

aspirations, and tube or parenteral/IV feedings.

Management must maintain a record of individuals who have

been trained and are serving as DAs.

The program must follow state-specific programrequirements.

Chapter Two 4 Dining Assistant Program

http://www.gpoaccess.gov/nara/index.html

http://www.gpoaccess.gov/nara/index.html



State Regulations

As stated above, not all states allow DA programs, so NH

management interested in establishing a program should first make

sure that it is has been approved by the state. If the program does

not have state approval it cannot be implemented. If the DA

Program has been approved in the state, it is important to read and

understand the state-specific requirements. The state of interest

may have a unique approval process and/or require additional

program or training requirements beyond those published in the

Federal Register notice.

Additional state requirements may include:

More hours of training than the federally mandated eight

hours.

More training topics than the federally mandated topics. Competency testing with a skills demonstration, written

examination, or a combination of both skills and written

exam.

Training instructor qualifications.

State-specific curriculum.

Training requirements for Volunteers.

Annual in-service for Dining Assistants.

To locate information on state requirements, see Appendix C that

provides state contact information. The appendix, current as of

September 2008, includes web-based links and/or other contact

information to assist nursing homes to locate state-specific DAProgram regulations.





Compliance with State Surveys

In 2005, the Abt Associates and Vanderbilt research teams

conducted telephone interviews with state agency representatives

engaged in the regulation of long-term care facilities to explore the

extent to which NHs across the nation were implementing the DA

Program and to understand the reasons why many NHs had not

chosen to implement it. We also visited a small sample of NHs that

had implemented a DA Program.

Some NH administrators expressed concerns that the presence of

DAs during a state survey would be a “red flag” and result in greater

scrutiny of nutrition- and dining-related compliance issues. However,

a program that is implemented according to federal and state

guidelines should not risk a compliance violation.

During the state survey, the objectives of the investigative protocol

for state surveyors are to determine, for a nursing home that uses

paid feeding assistants (or DAs):

If individuals used as DAs successfully completed a state

approved training course.

If sampled residents who were selected to receive assistance

from Dining Assistants were assessed by the charge nurse and

determined to be eligible to receive these services based on the

latest assessment and plan of care.

If the DAs are supervised by an RN or LPN.

The complete CMS-issued guidance for surveyors in assessing

compliance with the regulations concerning DAs is presented in

Appendix D.



Chapter Three

Deciding on a Dining AssistantProgram: Program Fit

The DA Program is a viable solution for increasing staffing during

mealtime. It can serve as a preventive measure against

unintentional weight loss and dehydration, and it can directly

contribute to improving the quality of residents’ lives. This isbecause DAs are likely to have more time to spend interacting with

residents than CNAs who are often pulled away from the dining room

to provide more “hands on” resident care. As a result, DAs are in a

position not only to ensure better nutrition and hydration, but also to

engage residents in social interactions and improve the overall

quality of their dining experience. Congregate meals are intended to

encourage social interaction; yet all too often residents eat meals

isolated in their rooms, or sit alone and disengaged in the dining

room. The use of trained DAs can help to alleviate this problem.

Some nursing homes may not need to implement a full DA Program

because they do not have a history of nutrition problems such as

unintentional weight loss and/or dehydration. Other NHs may not

have the physical space or staffing resources to accommodate such

a program. For example, DAs are often recruited from the Laundry

and Housekeeping departments. If a NH subcontracts these workers

through an outside agency, it is unlikely that their contract will allow

them to perform duties beyond those for which they are

subcontracted.

Nonetheless, with the exception of unusual cases, some type or

model of the DA Program will prove beneficial to residents and staff

in most NHs. This chapter presents options and assessment ideas

for how to create a facility-specific DA Program.

Addressing Concerns about a Dining Assistant Program

During our visits to NHs that have implemented DA programs, we

obtained feedback from upper-level staff regarding concerns they

may have had prior to program implementation. In addition to the

concerns about state survey noted above, some staff expressed

concerns about the implications of the DA Program for resident care

Chapter Three 7 Dining Assistant Program

F rom the F i e l d :

Because Joe is available and has been

trained as a Dining Assistant, we are

able to bring Mary to the dining room

for the noon-time meal. Joe is

outgoing and willing to chat with the

residents. Although Mary does not

communicate well verbally, she smilesand laughs throughout the meal when

she is assisted by Joe. It has made a

big difference in the quality of her

meal-time experience (Staff Developer,

Massachusetts, 2008).

Note. Names used in these field notes arenot the actual names of the Dining Assistantand resident.



and safety. These included that dining assistant training and

supervision would not be adequate, that assignment of residents to

dining assistants may not be appropriate (i.e. residents with

complicated feeding assistance needs such as swallowing difficulties

would be selected), and that training non-nursing staff in dining

assistance could increase the likelihood that they will be used to

provide other aspects of daily care (e.g., transferring, toileting,dressing).

We understand that many administrators who are contemplating the

implementation of a DA Program may have some of these concerns.

However, evidence from early studies indicates these concerns can

be mitigated by a well-designed program that adheres to state and

federal guidelines and incorporates the guidance in this manual

which was compiled from field experience and input from staff

developers who have implemented the program in other NHs.

For example, some administrators or other NH management may be

concerned that the minimum federal requirement of eight hours oftraining is not enough. Most of the authors of the published training

manuals that we reviewed seem to agree with this concern; the

training manuals that are referenced in Chapter 6, Training Dining

Assistants, present curricula that are longer than the minimum eight

hours. Further, Chapter 6 offers some ideas for supplementing the

basic eight hours of training.

Proper training will set parameters within which DAs can work. For

example, they will be taught that they cannot assist residents with

daily living tasks that are unrelated to dining. They will also be

trained to recognize and appropriately respond if a resident is

observed having difficulty swallowing. It is very important to alsotrain the nursing staff who will be involved with the program in the

proper supervision of DAs, and to require that a supervisor be

available whenever a DA is assisting residents.




Models of a Dining Assistant Program

Although the DA Program has the potential to be beneficial to all

residents and staff, one type or model of program may be more

appropriate than another for a specific NH. Through onsite

observations during mealtimes, the Abt Associates and Vanderbilt

University research teams observed several DA Program models. In

some homes, DAs’ roles were restricted to delivering and setting up

resident trays, whereas in other NHs they engaged in all meal-

related tasks including physical assistance with eating.

By selecting one or some combination of the following meal-

related tasks, a facility-specific model of the DA Program can be

tailored to meet the dining needs of nearly all NHs:

Transport residents to and from the dining room.

Deliver and set up trays for residents in the dining room and

in their rooms.

Circulate around the dining room and in and out of resident

rooms to provide social stimulation.

Circulate around the dining room and in and out of resident

rooms to identify residents who are not eating and to offer

them, and obtain, substitute food items.


We have included a hydration

component to the Dining Assistant

Program. I methodically identifyresidents who require regular

hydration and assign a Dining

Assistant to offer them 8 ounces of

fluids periodically throughout the day

(Staff Developer, Tennessee, 2008).

Provide physical guidance to residents in the dining room

and in resident rooms who are able to eat on their own but

need some level of physical guidance (e.g., hand them a fork

with food on it; guide their hand to scoop food). Provide full physical assistance to residents in the dining

room or in resident rooms who are unable to eat on their

own.

Offer residents between-meal snacks and fluids.

Obviously, not all of the meal-related tasks identified above require

formal DA training. However, participating in the minimal eight hours

of training will prepare entry-level staff and/or volunteers to provide

better service to residents across all of these tasks. Furthermore, it

will prepare staff to engage in more-direct resident care such as full

physical assistance with eating, if emergency staff shortages occur.In addition, a DA Program can be expanded beyond regularly

scheduled meals to include offering residents additional foods and

fluids (snacks, supplements) between meals to increase oral intake.

Basic DA Training Programs include modules on communication/

interpersonal skills, dealing with resident behaviors, and emergency

procedures, among others (see Chapter 6, Training Dining

Assistants). As an example of how DA training can improve resident




service, consider a non-nursing, untrained dining room helper who

delivers and sets up trays during the lunch-time meal. This helper

may routinely salt, pepper, and/or sweeten a resident’s food as well

as mix together various food items on the tray without soliciting the

resident’s preferences. The skills obtained during DA training will

provide the staff member with information on how to approach the

resident, communicate with the resident, and set up the trayaccording to the resident’s preferences.





Resident and Facility Assessment

To implement the best DA Program model for the NH, residents’

nutritional status and quality of life should be assessed, as well as

NH policies and procedures. Following are quality of care and NH

staffing issues that should be considered when determining the

overall suitability of a DA Program, and used as a guide for

constructing an appropriate facility-specific model for the Program.

This section is organized by identification of the issue that may be

problematic for the nursing home, followed by specific guidance for

how to assess and address that issue. Appendix A includes a series

of six worksheets designed to assist the NH in designing and

implementing a DA program. Worksheet # 1 covers “Conducting the

NH Dining Assessment” and may be used to “score” the nursing

home’s dining program.

Resident Quality of Care Issues

Problem: Unintentional Weight Loss

One of the most salient long-term goals that management identify as

a reason for implementing a DA Program is to reduce the incidence

of unintentional weight loss. This goal will be expanded upon in

Chapter 4, Creating Dining Assistant Program Goals, but is

mentioned here because it should be used as a primary determining

factor for whether or not to implement a DA Program.

Sources of information from which to determine the prevalenceof residents with unintentional weight loss at your NH include:

Monthly resident weight documentation.

Quality Measure score for significant weight loss for long-

stay residents.

Care plans.

Interviews with charge nurses.

Interviews with dietary staff.

Most recent state survey results to check for nutrition-related

deficiencies.

Minimum Data Set (MDS) item K3a for problematic weight

change (5 percent weight loss in the last 30 days, or 10

percent weight loss in the last 180 days).2

2 All references to the Minimum Data Set (MDS) throughout this Manual are to the 2.0

Version.



Problem: Poor Meal Consumption

Although poor meal consumption is directly related to unintentional

weight loss, we list it separately because using a DA in a NH that

has a high number of residents with poor meal consumption can

potentially preempt a weight-loss problem.

Not eating one’s meal can be caused by a number of issues such as:

the food is room temperature when it should be hot (or warm when it

should be cold) and no longer palatable to the resident due to the

length of time it took for the tray to be delivered from the cart to the

resident; the food is not palatable to the resident because s/he does

not receive adequate tray set-up such as adding salt, pepper, and

sugar to food and beverages, or cutting up hard-to-eat items; the

resident does not like the food that is being served, but is not offered

a substitute meal; the resident is a very slow eater but is not given

adequate time to finish the meal; the resident is bored and lonely and

lacks the motivation to eat; or the resident requires some level of

physical assistance, but does not receive it because on occasion this

resident can self-feed.

Sources of information from which to determine the prevalence

of residents with poor meal consumption include:

Interviews with dietary staff to determine whether or not trays

are coming back to the kitchen with uneaten food.

CNA documentation of food and fluid intake.

Interviews with CNAs to determine if there have been

complaints about the food.

Facility dietary policy regarding when dietary supplementsare routinely administered.

Dining room observations.

MDS items K4a, K4b, and K4c for complaints about the food,

complaints of hunger, and leaving more than 25 percent of

food uneaten at most meals, respectively.

How a Dining Assistant Program can help: Unintentional weight loss

and poor meal consumption can be improved with the

implementation of a DA Program. First, the DA Program places

more designated staff in the dining room during meals to helpfacilitate tray delivery and set-up. As a result, the food is more likely

to be served at the temperature it was intended. In addition,

increased staff availability during mealtimes makes it more likely that

residents’ preferences will be accommodated. Second, DAs have

designated time in the dining room so they are more likely to identify

residents who are not eating and are available to offer and obtain

substitute food items or provide verbal cueing to encourage meal

consumption. Also, keeping in mind standard infection control





procedures, DAs can be seated at a table with one or two residents

who require full physical assistance or physical guidance as they eat.

Finally, DAs can help to deliver between- meal foods and fluids and

dietary supplements as a way to improve residents’ caloric intake.

Problem: Quality of Life

The clinical impact of residents’ quality of life cannot be

underestimated. Poor quality of life including the perception of

loneliness and isolation can lead to depression and poor nutritional

intake. Research has demonstrated that social stimulation during

meals can improve the overall quality of life for nursing home

residents as well as improve their oral intake and nutritional status.3

4 A positive dining experience that includes social interactions

results in more food eaten, fewer digestive disturbances, better

absorption of nutrients, and more positive resident5

attitudes.

Competing demands for CNA time both limit the amount of physical

assistance residents receive during meals, as well as the CNA’s time

for social conversations with residents. Further, restricted CNA time

often impedes their ability to dress and transport all appropriate

residents under their care to the dining room. This leaves many

residents to eat alone and isolated in their rooms who might have

benefited from the social environment of the dining room.

Sources of information from which to determine quality of life

problems include:

Social Services notes and interviews with social service staff

to identify residents with potential problems.

Activities notes and interviews with activities staff to identify

residents with potential problems.

MDS Section E1 for indicators of depression, anxiety, and

sad mood.

Resident observations.

How a Dining Assistant Program can help: Fundamentally,

implementing a DA Program will increase the number of staff

available in the dining room and circulating in and out of resident

rooms during mealtimes to communicate with residents. As

mentioned previously, a component of the DA training includes a

3 De Castro JM. Age-related changes in the social, psychological, and temporal

influences on food intake in free-living, healthy, adult humans. J Gerontol:MEDSCI 2002,57A(6):M368-M377.

4 Simmons SF & Schnelle JF. (2004). Individualized feeding assistance care for

nursing home residents: Staffing requirements to implement two interventions.Journal of Gerontology: Medical Sciences, 59A(9):966-973.

5 Morton K. (Ed.). (2003). Eating Matters: A Training Manual for Feeding

Assistants. West Hartford, CT: Consultant Dietitians in Health Care Facilities. ADietetic Practice Group of American Dietetic Association.



module on resident communication. Staff who participate in a DA

Training Program are taught the significance of engaging residents in

social interactions as well as the nuances of communicating with

them. They learn how to approach residents, how to listen to

residents, and how to read resident cues. With the addition of DAs

to a nursing home’s staff, CNAs will also have more time available to

provide care and interact with residents during mealtimes. They willalso have more time to groom and dress residents and to encourage

them to eat all three meals in the congregate setting of the dining

room.

Nursing Home Staffing Issues

Availabi li ty and Appropriateness of Staf f

Several issues related to nursing home staff can be motivating

factors for implementing a DA Program. These factors include the

interest of entry-level staff to gain more direct resident contact, andthe use of the program as a stepping-stone toward CNA and

eventual LPN or RN licensure. On the other hand, there are also

some NH factors that might impede the implementation of a viable

program. These factors include entry-level staff who are not

interested in direct resident contact, entry-level staff who are

subcontracted and therefore not available to perform tasks beyond

those for which they were hired, and lack of interest in the program

from nursing staff.


At this facility, staff cannot work more

than 40 hours per week and it is

difficult for them to complete their

work in 40 hours. They are not going

to be willing to give up their lunch

time or work overtime without

compensation so that they can assist atmealtimes (Staff Developer,


Information to be gathered to determine staff interest and

availability to participate in a DA Program:

Determine whether or not contracted non-nursing staff areavailable to participate in the program.

Interview non-nursing staff (e.g., laundry, housekeeping,

dietary) to determine if they are interested in more resident

contact.

Interview non-nursing staff (e.g., laundry, housekeeping,

dietary) to determine their interest in moving toward

becoming a CNA and possibly an LPN or RN.

Post a sign-up sheet with a flyer announcing the program

and emphasizing that this may be an opportunity for

advancement to becoming a CNA.

Interview nurses to determine their availability to be trained

on the program and to supervise the DAs.

How a Dining Assistant Program can help: The Abt Associates and

Vanderbilt research teams received positive feedback during

interviews with non-nursing staff (e.g., housekeeping and laundry)

who had been trained and were serving as DAs. The majority of




these staff felt proud to have earned the certification necessary and

to be providing direct resident care. Often the DA Program has the

indirect effect of boosting the self-esteem of entry-level workers who

believe, correctly, that they are fulfilling an important aspect of

resident care. As a result, these workers tend to spend more one-

on-one time with residents and engage in more positive social

interactions with them than CNAs. One caveat to the use of entry-level staff as DAs is the manner in which staff are approached to

participate. For example, during our study, negative feedback about

the program was received from a DA who worked under a mandatory

rather than voluntary DA Program. The issue of mandatory versus

voluntary recruitment of DAs is discussed further in Chapter 5,

Recruiting Dining Assistants.

Feedback obtained by the research team during interviews with

charge nurses and directors of nursing about the DA Program was

generally positive. However, taking on another responsibility – that

of supervising DAs – is not always welcome. Our field experience

indicates that once NH management endorse the program andnursing staff are able to observe the ease of implementation as well

as the positive results that the program has for residents and staff,

nursing staff are more interested in assuming the responsibility of

program supervision. The topic of program supervision will be

covered in detail in Chapter 7, Implementing a Dining Assistant

Program.

Whether the Nursing Home is Suited to a Dining Assistant

Program

The appropriateness and/or model of the DA Program hinges on

several factors related to the NH’s physical plant and/or policies.

Appendix A contains a series of six worksheets designed to assist

NHs in designing and implementing a DA program. Worksheet # 2,

“Assessing Nursing Home Resources,” may be useful in evaluating

the resources needed to implement a DA program.

Information to be gathered to determine whether the NH is

appropriately suited to a DA Program includes:


Dining space is a challenge for full

Program implementation in our

facility due to State regulations that

prohibit feeding physically dependent

residents in the presence of

independent residents (Staff

Developer, Tennessee, 2008).

Is there corporate support?

Is there space in the NH to conduct the DA training?

Is there currently an active volunteer program, or an initiativeto begin one?

Does the NH have a quality improvement initiative for

nutritional status/outcomes?

What is the dining room environment like; is there space to

implement a full DA Program?





How a Dining Assistant Program can help: Without corporate

support, subsidiary NHs are restricted in their ability to implement a

program. However, more and more corporate offices are embracing

the DA Program and encouraging their affiliates to implement the

program. If corporate management has not yet endorsed the

program, but the NH administrator is committed to implementing the

DA Program, the administrator and NH staff developer can use thisImplementation Manual and other supporting materials mentioned

here to try to obtain corporate interest and approval.

Space restrictions should not entirely rule out the possibility of

implementing a DA Program; creative training locations and/or an

abbreviated model of the program can be considered. First, program

training can take place in an office or in any space where other

onsite training takes place. The number of trainees per session

should be based on the size of the space available for training. If the

NH is part of a corporation, it is possible that training can take place

at corporate headquarters with or without trainees from other

corporate locations.

If space restrictions are such that the dining room cannot

accommodate a DA to sit and help residents eat, a family room or a

resident’s room could be a possible setting. Finally, a DA who helps

deliver and set up trays, interacts with residents, and retrieves

substitutions from the kitchen plays a very valuable role that can be

beneficial to residents and staff regardless of the size of the NH.



Chapter Four

Creating Dining Assistant ProgramGoals

Upper-level nursing home staff may have a number of different goals

in mind when considering the implementation of a DA Program.

These may reflect both immediate and long-term program goals.

The two most common immediate goals of a DA Program include:

Improving care during dining, and

Improving the overall quality of the dining experience for all

residents.

Some longer-term program goals include:

Fostering a team approach to care among both nursing and non-

nursing staff.

Supporting community involvement in the daily lives of residents.

Promoting career advancement.

Reducing the prevalence of unintentional weight loss among

residents throughout the NH or residents on a particular unit

(e.g., Dementia Care).

Reducing the prevalence of pressure ulcers.

Regardless of the specific goal(s) selected, a well-coordinated DA

Program has the potential to help a NH achieve one or all of these

aforementioned goals. Incorporating the knowledge gained in the

field during our CMS- and AHRQ-funded project, we offer insight and

helpful guidelines for achieving seven common program goals.

Chapter Four 17 Dining Assistant Program



Immediate Program Goals

Goal: To Improve Provision of Dining Assistance Care

What you need to know: Improvement in providing dining assistance

care should be among the primary goals of a DA Program, because

it represents a key daily care process that affects residents’ body

weight and nutritional status over time (see long-term goals, below).

Two main aspects of dining assistance care provision should be the

focus of a DA Program: (1) amount of assistance, and (2) quality of

assistance.

Amount of assistance: Most residents in need of assistance require

at least 20 to 30 minutes (per resident per meal) during meals to

promote adequate food and fluid intake. Federal guidelines define

“adequate” food and fluid intake as consuming 75 percent or more ofserved food and fluid items during meals, although some residents

may be able to maintain a healthy body weight by consuming slightly

less than this amount (e.g., 60 to 70 percent). Staff should evaluate

a resident’s oral intake, weight loss history, and current nutrition and

hydration status to determine if s/he is eating enough to maintain

nutritional health.

Quality of assistance: The enhancement of independence in eating

defines the second important aspect of dining assistance care.

Residents should be encouraged and allowed to be as independent

as possible while eating. Studies have shown that staff often provide

unnecessary or excessive physical assistance (spoon to mouthfeeding assistance) to residents capable of eating on their own with

verbal cueing (e.g., “Try a bite of eggs”), encouragement (e.g., “What

are you having for breakfast this morning?”), or physical guidance

(e.g., staff member guides resident’s hand to utensil, helps resident

hold utensil or cup). Residents in need of these types of assistance,

however, require just as much staff time (20 to 30 minutes, on

average) as residents who are totally dependent on staff for eating.

How a Dining Assistant Program can help: Residents in need of staff

attention during meals can be grouped together such that one DA

can be seated at a table with three residents, one or two of whom

might require physical help to eat while the remaining resident(s)might need only verbal cueing and encouragement. This seating

arrangement is time-efficient for staff and allows up to three

residents to be assisted simultaneously in a manner that promotes

adequate food and fluid intake and independence in eating during

approximately 45 minutes per meal per group of three. Beyond the

quality of dining assistance care provision, there are other aspects of

the overall dining experience that can be improved for all residents,

regardless of their individual dining assistance care needs.




Goal: To Improve the Overall Quality o f the Dining Experience

This goal applies to all residents within the NH, regardless of their

dining assistance care needs, and represents a goal directly related

to residents’ daily quality of life. This goal can be defined in a

number of different ways, depending upon the dining service within a

NH.

A summary is provided below of just a few aspects of the quality of

dining service salient to all residents, including ensuring timely meal

delivery, offering alternatives and additional food helpings,

encouraging more residents to eat in the dining room, and enhancing

social interactions.


My goals for the Program are to create

a calm ambiance in the dining room

and to increase the efficiency of tray

delivery (Director of Nursing,


Timely Meal Delivery Service

What you need to know: Studies have shown that a commoncomplaint among residents is that they have to wait a long time for

meal service and food items are often served at inappropriate

temperatures (i.e. hot items are served cold). This goal requires

communication and coordination with the dietary and kitchen staff

responsible for meal preparation along with the staff responsible for

meal delivery, if different from dietary (e.g., CNA or DA). The lack of

coordination between the kitchen and floor staff related to meal

delivery time(s) can pose a significant barrier to program

implementation (see Chapter 7, Implementing a Dining Assistant

Program).

How a Dining Assistant Program can help: The availability of extrastaff during mealtimes can improve the timeliness of the meal

delivery service for all residents because DAs can help with tray

delivery and set-up (e.g., opening containers, cutting up meat,

buttering bread) for their assigned residents or a larger group of

residents. In addition, to the extent that DAs take responsibility for

providing dining assistance to individual residents, this alleviates

some of the care responsibility of the CNA who, in turn, has more

time available to ensure timely meal tray delivery and set up for all

residents to whom the aide is assigned. Meal tray “set-up” is

included with delivery because it is time-efficient to deliver and set up

simultaneously, and can greatly enhance a resident’s independence

in eating. Meal tray set-up consists of simple preparations that makeit easier for the resident to eat independently, orient the resident to

the meal, and engage the resident. (“Good morning, Betty. It’s time

for breakfast. Are you hungry this morning? Would you like salt or

pepper on your eggs? How about cream or sugar in your coffee?

May I butter your toast for you?” Let me open your carton of milk for

you for your cereal.”)


Having a focused person assures that

residents receive their food quickly

when it is palatable (Administrator,





Offer Alternatives to the Served Meal and Allow Second

Servings of Preferred Items

What you need to know: The availability of choices during mealtime

enhances a resident’s quality of life, and federal care regulations

require that meal alternatives be available to the resident. In

practice, there are often barriers to offering residents choices during

mealtimes, such as direct care staff being unaware that other options

are available to the resident, or the additional staff time required to

go to the kitchen and get something else for the resident.

How a Dining Assistant Program can help: Similar to improving the

meal delivery and set-up service for all residents, the availability of

additional staff during mealtime allows for more staff time to be spent

ensuring that residents actually have food and fluid items served that

are appealing to them. In addition to offering alternatives to the

served meal, making second servings available for preferred foods

and fluids (as requested by residents or as evidenced by residents

consuming 100 percent of one item and 0 percent of something else)

is an effective way to increase the amount residents eat. Another

strategy beyond increasing overall staffing during mealtimes through

a DA Program is to coordinate with the dietary and kitchen staff such

that an extra smaller cart is sent to the unit with “alternatives” to the

main dish and/or second servings of popular items. This creates

“easy access” for staff, thus increasing the likelihood that residents

will be offered alternatives and second servings.

Allow More Residents to Eat More Meals in the Dining

Room

What you need to know: This goal appears simple, but in daily

nursing home practice it is quite complex. Studies have shown that it

is common for many residents to eat their morning and evening

meals in their own rooms, and often while in bed, and only be served

their mid-day meal in a dining room. There are many different

reasons for this common care practice. First and foremost, many

NHs do not have enough dining room space to accommodate all, or

even most, of their resident population. The availability of two

seatings per meal (early/late service for each meal) and the creative

use of other space (activities room, family meeting rooms) can help

address space limitations within a NH while also accommodating

resident preferences and the potential need to feed some residentsin different locations. For example, if meal service in the main dining

room is reserved for higher-functioning residents, smaller spaces

(activities room, family meeting rooms) can be used to provide dining

assistance to residents with higher care needs. A second reason

commonly given for this practice is that residents prefer to eat most

meals in their own rooms, but research evidence suggests that it is





more often the staff care routine – not residents’ preferences – that

determine a resident’s dining location for meals.6

Why does it matter where residents dine? Research studies have

shown that residents who eat their meals in a common area, such as

a dining room, receive more staff assistance to eat and more social

interaction with staff and other residents during meals, resulting inhigher food and fluid intake.

7 In addition, these residents also have

more accurate medical record documentation (e.g., percent eaten

estimates) compared to residents who eat in their rooms.

How a Dining Assistant Program can help: Minimally, residents who

require staff assistance to eat should be encouraged to eat most of

their meals in the dining room to allow CNA or DA staff to provide

assistance in a time-efficient manner (grouping residents together for

care delivery, as described above). This also allows for easier

supervision and management of a DA Program. The impact of a DA

Program on residents’ dining location is that additional staff are

available to assist with other mealtime tasks that might includetransporting residents to and from the dining room. This extra help

allows CNA staff more time to provide other aspects of care (transfer

out of bed, dressing assistance) to prepare the resident for mealtime

in the dining room.

Enhancement of Social Interaction Among Residents

and Staff

What you need to know: Social interaction among residents and

staff during mealtime enhances residents’ food and fluid intake and

quality of life. Thus, it is beneficial to all residents, and almost

anyone on the staff (nursing and non-nursing) can provide social

interaction without any required training. As mentioned above, the

dining room is more conducive to the enhancement of social

interaction because residents and staff are all in the same location.

How a Dining Assistant Program can help: Studies have shown that

residents allowed to dine in their rooms are usually capable of eating

independently, but if they have a problem with low intake, it tends to

go unnoticed by staff until weight loss occurs. Thus, an extremely

valuable role for a DA might be to visit residents who are dining in

their own rooms to socially interact with them, see if they are happy

with the served meal or if they would like something else, and offer to

provide simple tray set-up. A designated staff member toperiodically check on residents allowed to eat most meals in their

own rooms would help identify residents who are eating poorly on

their own and may be socially isolated during mealtime.

6 Simmons SF & Levy-Storms L. (2006). The effect of staff care practices on

nursing home residents’ preferences: Implications for individualizing care.Journal of Nutrition, Health & Aging, 10(3): 216-221.

7 Simmons SF & Levy-Storms L. (2006). The effect of dining location on nutritional

care quality in nursing homes. Journal of Nutrition, Health & Aging, 9(6): 434-439.



Long-Term Program Goals

Goal: To Promote a “ Team” Approach to Care

What you need to know: As part of an earlier study, this research

team visited a number of NHs with active DA Programs. Several of

these NHs reported they already had been using non-nursing staff

from a variety of departments (e.g., activities, housekeeping,

administrative) to assist during mealtimes prior to the federal

regulation. The federal regulation simply made this arrangement

more structured and formal. Many NHs might be similar in that they

already are aware of non-nursing staff in other departments who

desire to play a role in resident care provision.

How a Dining Assistant Program can help: A DA Program offers a

constructive, meaningful avenue to offer non-nursing staff additionaltraining that will directly benefit the residents as well as nursing staff.

A DA Program can facilitate a “team” approach to care provision

wherein every member of the staff (nursing and non-nursing) can

play a vital role in the daily lives of the residents. The involvement of

upper-level staff in the program further supports this effort. Finally,

NHs should consider that a dining program offers a way to reward

and advance exemplary CNA staff through involvement in the

training and ongoing monitoring of the program.

Goal: To Increase Community Involvement

What you need to know: The involvement of various communitygroups in a DA Program, in whatever capacity, requires additional

staff time, resources (e.g., advertisement, interview and screening)

and coordination (e.g., scheduling) but can be as effective as using

non-nursing staff within the NH.

How a Dining Assistant Program can help: A DA Program offers an

avenue through which to increase the involvement of the surrounding

community in the daily lives of residents. An active volunteer

program as well as family members and friends who visit often

during mealtime might be an excellent resource for improving the

mealtime experience of all residents. Volunteers, family, and friends

represent groups who might be interested in receiving formal trainingto become a DA. Other potential outreach groups include

community service programs through local high schools and senior

centers.




Goal: To Promote Career Advancement

What you need to know: Many nursing homes provide career

building programs that facilitate the process through which CNAs

become licensed nurses. A successful DA Program can serve as a

first step in this process by providing advancement opportunities to

non-nursing staff.

How a Dining Assistant Program can help: A DA Program offers an

excellent opportunity for non-nursing staff to gain experience and

exposure to providing direct care to residents. The positive

experience gained by being trained as a DA as well as the

satisfaction of providing hands-on care to residents may inspire

some DAs to pursue nurse aide certification. A DA Program is a

viable option as a first step in a series of skilled certifications.


I think that the Dining Assistant

Program can promote growth to a new

level. For example, we have a CNA

career program that takes CNAs

through steps that eventually lead to

nursing. Using the Dining Assistant

Program as an incentive, we can train

non-nursing staff as Dining Assistants

and eventually step them up to the

CNA program if appropriate (Staff

Developer, Massachusetts, 2008).

Goal: To Decrease the Prevalence of Unintentional Weight Loss

What you need to know: It is likely that decreasing the overall

“prevalence of unintentional weight loss” in a NH represents a goal

most salient to nursing homes because it is an MDS quality

measure. However, the key daily care process that affects residents’

weight status is the amount and quality of dining assistance care, so

improvements in dining assistance care represent the most effective

solutions to reducing weight loss among nursing home residents. It

should be noted that according to the literature, a small percentage

of residents (

10 percent) will continue to lose weight, despite quality

dining assistance care.

How a Dining Assistant Program can help: A DA Program canprovide additional staff to help residents to eat and ensure that

optimal dining assistance is provided consistently (i.e. daily), thus

reducing weight loss over time among most residents.

Goal: To Decrease the Prevalence of Pressure Ulcers

What you need to know: Similar to weight loss, the “prevalence of

pressure sores” is an MDS quality measure. While adequate

nutrition and hydration are vital to prevention and treatment efforts

for pressure ulcers, a decrease in pressure ulcer prevalence

represents a long-term program goal and one that requires a multi-

faceted approach to care (e.g., nutrition and hydration, routine skinhealth assessments, repositioning programs).

How a Dining Assistant Program can help: A resident who has a low

body mass index indicative of under-nutrition and/or a history of

unintentional weight loss is likely to be at higher risk for pressure

ulcer development, and inadequate nutrition and hydration can delay

wound healing. A DA Program can improve the daily food and fluid

intake of at-risk residents through dining assistance care and other




improvements to the overall dining experience of the resident, as

discussed above. Trained DAs also can be used to promote

hydration for residents throughout the day (between regularly

scheduled meals) by being responsible for offering fluids multiple

times per day between meals to residents. Thus, a DA Program

need not be limited to scheduled mealtime periods to improve

nutrition, hydration, weight loss, and skin health among residents.




Measuring Goal Progress

Strategies for measuring progress toward a goal depends on the

goal itself. However, most of the goals described in this section can

be measured with an observational tool that was designed for

nursing home staff to use to monitor program implementation. This

tool will be described in greater detail in Chapter 7, Implementing a

Dining Assistant Program. The observational tool is easy to use and

can be modified to reflect the specific goals of a given NH (e.g.,

increase the proportion of residents who eat most of their meals in

the dining room). Worksheet # 3 in Appendix A may be used to

record and track DA program goals.




Chapter Five

Recruiting Dining Assistants

Trainee recruitment can be one of the most challenging aspects of

implementing a successful DA Program. This chapter helps prepare

management for recruitment of potential DAs by presenting some of

the hurdles that NHs may face during this process, and offering

some suggestions to facilitate a successful recruitment process.

Appendix A, Worksheet # 4, “Designing the DA Program” and

Worksheet # 5, “Implementing the DA Program” may be useful tools

for evaluating various recruitment strategies.

Chapter Five 27 Dining Assistant Program



Targeting Recruits

Once the decision to implement a DA Program has been made, the

administration needs to determine the most appropriate population to

target for trainee recruitment. Trainees can be recruited from non-

nursing staff or residents’ families or other volunteers within the NH,

or from the outside community.

A first step in the recruitment process is to determine or review the

DA Program goals (see Chapter 4, Creating Dining Assistant

Program Goals) so that the population that will best facilitate the

achievement of these goals can be targeted. For example, if the NH

management has a goal of creating an active volunteer program by

increasing community involvement, then the target population should

be volunteers from the community. If, on the other hand, the goal is

supporting non-nursing staff in their advancement to direct care work

such as nursing, then the recruitment target should be existing non-

nursing staff.

Family and Community Volunteers

Federa l Regis ter Not i ce

(68 FR 55528):

While we believe that it is a good idea

for family members and volunteers to

take the training, and we encourage it,

we are not making this a requirement.

Many volunteers in facilities are

family members who are only there to

feed a relative. Often, family members

have been feeding the ailing resident

for years, both at home and in the

facility. We are leaving it to each

facility to determine whether or not to

require volunteers and family

members to complete feeding

assistance training. Ultimately,

facilities are responsible for the care

and safety of residents, even if the

resident is fed by a relative or friend

(2003).

Although DAs can be family or community volunteers or they can be

drawn from existing non-nursing staff, only non-nursing staff are

required by the federal regulation to participate in a Training

Program. According to the federal rule, training volunteers is left to

the discretion of the individual NH, as the NH is ultimately

responsible for the care and safety of its residents. Specific statesmay have requirements regarding the training of non-staff

volunteers. Nursing homes are encouraged to check the approval

process and requirements for their specific state (see Appendix C for

state contact information).

As noted, the federal rule does not require training for family or

community volunteers; however, the lessons regarding the quality of

resident care that are included in basic training modules provide

invaluable education to non-medically trained individuals. Formal

training teaches individuals about the importance of residents’

independence, nutritional needs, safety, and communication styles

with the outcome of improved overall quality of life for the residents(see Chapter 6, Training Dining Assistants).

Recruiting Family Volunteers

Targeting potential family volunteers to participate in the DA Program

is relatively straightforward. Family volunteers, especially those who

already assist relatives in the dining room, demonstrate an




unsolicited interest in improving the quality of their loved ones’ lives

and are therefore, likely candidates.

Following are a few suggestions that might be useful when

recruiting family volunteers for participation in the DA Program:

Approach individuals who already provide regular diningassistance.

Post flyers in the lobby and hallways announcing the

program and asking for volunteers.

Post a notice in the monthly newsletter.

Discuss the program at facility gatherings to which residents’

families are invited, e.g., family council meetings.

Recruiting Community Volunteers

Experience in the field has shown us that recruiting communityvolunteers is not an easy task. Our research team posted flyers

announcing the program and soliciting volunteers in four senior

centers local to the target nursing home; we received no responses.

However, if the NH has an active volunteer program and/or outreach

staff, recruiting community volunteers is a viable option for the DA

Program.

Following are some suggestions to help facilitate community

volunteer recruitment:

Post flyers in area Senior Centers.

Attend area Senior Center meetings to make a brief

presentation about the program.

Contact local colleges that offer a certificate or degree in a

related discipline (e.g., Home Health Aide, Gerontology) to

discuss the possibility of setting up an internship program.

Contact local high schools that may have internship or

community volunteer requirements.

Advertise the program in community newspapers.

Post announcements in local church newsletters.

Recruiting Non-Nursing Staff

To recruit trainees from existing non-nursing staff from within a

facility, many different departments can be targeted.


It makes me feel good to help people

(Dining Assistant, Wisconsin, 2005).

Following is a list of staff who may be the best fit for the program:

Activity aides and social services staff as they already do

an excellent job of providing social stimulation and verbal




encouragement to residents. Providing these aspects of

care in the context of feeding seems like a natural extension

of their current job tasks.

Speech and occupational therapy departments take

some responsibility for feeding residents as part of

assessments and “Restorative Dining Programs” to teach

residents self-feeding skills.

Dietary staff may not be the best choice for training due to

competing kitchen responsibilities that might prevent them

from having adequate time available to feed residents.

However, dietary staff could take responsibility for meal tray

delivery, set up (opening containers, buttering bread, cutting

up meat), pick-up, and providing an extra cart with available

meal alternatives and/or second servings of popular items to

make it easier for both CNAs and DAs to provide optimal

care quality.

Housekeeping and laundry staff usually can assist only

during the mid-day (lunch) meal due to their work schedules

that typically have them starting their work day after the

morning meal and ending their work day prior to the evening

meal.

Staff from any department who are interested in becoming

CNAs.

Any staff interested in obtaining personal satisfaction by

helping residents in a greater capacity than their daily work

tasks require.

Mandatory Versus Voluntary Participation of Non- Nursing Staff

In-house trainees can participate on a voluntary or mandatory basis.

The Abt Associates and Vanderbilt research teams observed that

some nursing home administrators require that all non-nursing staff

complete the DA training. Most of those who institute this

requirement do so to preempt a potential crisis situation where the

NH is drastically short-handed and residents are left without

adequate assistance during meals. By training all non-nursing staff

in dining assistance, the NH can rely on an “all-hands-on-deck”

model to fill this need during an emergency. One New Hampshire

nursing home adopted this model because of the harsh winter

weather and rural nature of the area. During the winter months, it is

not unheard of for many staff members to have difficulty getting to

work due to blizzards or ice storms. The “all-hands-on-deck” model

works well in this situation.


To have everyone do it – during snow

times it’s a big help (Dining Assistant,

New Hampshire, 2005).

Often trainees who participate in a mandatory program are employed

as DAs on an as-needed basis. Further, their assistance is used




only for resident transport, tray delivery, and tray set-up. However,

observations the research team made during visits to nursing homes

where DA Programs had been implemented revealed that in some

instances hands-on dining assistance is mandatory. Unless the NH

is instituting “all-hands-on-deck” policy, this is not a recommended

model to ensure optimal Program implementation or sustainability.

Placing a mandatory requirement on dining assistance will likelycause workers to become disgruntled and could lead to poorer

quality care to residents. In interviews with Trained DAs, our

research team learned that when staff are required to help feed

residents, they are often dissatisfied.

Recruitment of volunteers from among existing staff may be difficult if

they perceive that becoming a DA will force them to give up their

own time, lengthen their day, or in other ways create more work for

them. When using non-nursing staff, it is important to ensure that

staff have reasonable daily work schedules that allow their existing

job tasks to be completed along with adequate breaks, and their new

responsibilities as a DA. In other words, staff should not have tosacrifice their own lunch break or work overtime to complete their

other job tasks to fulfill their responsibilities as a DA, as this will

decrease interest in the program (see Chapter 8, Sustaining the

Dining Assistant Program).


Dining Assistants who perceived that

they had no choice when management

proposed Dining Assistant training

were less satisfied than those whose

participation was voluntary: When Itook the job in laundry, no one said

that I would have to feed residents,

and I don’t like it ( Dining Assistant,

Colorado, 2005).

Volunteerism can be encouraged with incentives. For some non-

nursing staff, stressing the fact that they will obtain a Trained DA

Certificate upon completion of the Training Program is an incentive.

For others, an enticement is knowing that once they have

successfully passed the Training Program, they will be able to

provide direct care to residents and personally help to improve the

quality of their lives. Both of these concepts should be stressedduring recruitment, especially with non-nursing staff.


When they graduate from Dining

Assistant Training, they get a raise

and get more hours because they are

part-time employees (Administrator,

Colorado 2005). Other non-nursing staff may need more tangible incentives such as a

monetary award. For example, one NH with which the team has

worked in Tennessee offers a 50-cent per hour raise to all staff that

successfully complete the training program and commit to a routine

of regular dining assistance.




Available Training Manuals

Multiple training manuals have been published and are available for

staff developers/educators to use when conducting DA training. The

manuals meet the federal requirements, but the NH may be required

(due to state requirements) or may choose (due to facility culture and

procedures) to supplement these materials with additional topics or

activities. Following, we provide a list of training manuals that are

readily available online to download or for purchase. Please note

that this list is not exhaustive; there may be other training manuals

developed by states or Associations that are not listed here.

Available through Associations and other publishers:

American Health Care Association, Assisted Dining: The

Role And Skills Of Feeding Assistants.

– Available for Purchase on the AHCA website:

http://web1.pmds.com/AHCA_eBiz/Default.aspx?tabid=4

4&action=ShowProductDetails&args=248

The Consultant Dietitians in Health Care Facilities American

Dietetic Association Practice Group, Eating Matters – A

Training Manual for Feeding Assistants

– Available for Purchase on the Consultant Dietitian in

Health Care Facilities website:

http://www.cdhcf.org/products/training/details.asp?id=50

28

Richardson, B. (Ed) The Consultant Dietitians in Health Care

Facilities American Dietetic Association Practice Group

Pocket Resource for Management, 2006 Revision

– Available for Purchase on the Consultant Dietitian in

Health Care Facilities website:


28

Hartman Publishing, Assisting with Nutrition and Hydration in

Long Term Care

– Available for Purchase on the Hartman Publishing

website: http://www.hartmanonline.com/fab/index.html

Available through state websites:

Colorado Department of Public Health and Environment,

Feeding Assistant Curriculum Specifications and Program

Requirements

http://www.cdphe.state.co.us/hf/download/FEEDING%20AS

ST%20Curriculum%20(Jan%2005).pdf

Chapter Six 34 Dining Assistant Program

http://web1.pmds.com/AHCA_eBiz/Default.aspx?tabid=44&action=ShowProductDetails&args=248









http://www.hartmanonline.com/fab/index.html


http://www.cdphe.state.co.us/hf/download/FEEDING%20ASST%20Curriculum%20(Jan%2005).pdf














Minnesota Department of Health, Paid Feeding Assistant

Training Program

http://www.health.state.mn.us/divs/fpc/profinfo/lic/pfa/pfacou

rse1_4.pdf

North Carolina Department of Health and Human Services,

Division of Health Service Regulation, North Carolina State- Approved Curriculum for Feeding Assistant

http://www.dhhs.state.nc.us/dhsr/hcpr/pdf/approved_fed_cur

r.pdf

Texas Department of Aging and Disability Services, Feeding

Assistant Training

http://www.dads.state.tx.us/providers/NF/credentialing/NAT

CEP/feedingassistant.pdf


http://www.health.state.mn.us/divs/fpc/profinfo/lic/pfa/pfacourse1_4.pdf



http://www.dhhs.state.nc.us/dhsr/hcpr/pdf/approved_fed_curr.pdf



http://www.dads.state.tx.us/providers/NF/credentialing/NATCEP/feedingassistant.pdf











Training Enhancements

The federal regulations and some state’s rules are specific about

training topics that should be included in DA training. In addition,

some instructors may want to enhance the training modules beyond

the federal and state regulations and thereby fully engage the DA

trainees in the overall DA Program. Ideas to incorporate in an

enhanced training program include the following:


I liked the training materials, overall;

however, in the future I will add more

hands-on observations and training

(Staff Developer, Massachusetts, 2008).

Emphasize the importance of quality dining assistance and the

DA’s role.

Incorporate hands-on dining room observations and training.

Present the CMS-sponsored webcast, “How to Enhance the

Quality of Dining Assistance in Nursing Homes.”

Conduct a DA skills evaluation.

Emphasize the Importance of the Dining Assistant’s

Role

DA training can begin with an overview of the philosophy of the DA

Program and the goals that the nursing home management have set

for implementation of the DA Program. Instructors should

emphasize that through this program, trainees can directly affect the

quality of residents’ lives. Introducing DA trainees to the importance

of their role in improving the residents’ quality of life can help

promote the DAs’ accountability, ownership, and investment in theprogram.

Incorporate Hands-On Dining Room Observations and

Training

Regular monitoring of meal-time activities can help to identify future

quality improvement opportunities (see Chapter 7, Implementing a

Dining Assistant Program). Used in training, instructors can model

appropriate DA behavior and assistance through hands-on practice

in the dining room.

CMS Webcast

The CMS-sponsored webcast “How to Enhance the Quality of Dining

Assistance in Nursing Homes” was developed based on research

conducted by Dr. Sandra Simmons and Dr. John Schnelle of

Vanderbilt University, and presents step-by-step instructions for

conducting observations of staff behaviors that characterize optimal




dining assistance.8

9 The goal of the webcast is to provide nursing

homes with a tool to assess and identify areas for improvement in

dining assistance.

After viewing the program, participants will:

Be familiar with the federal DA regulation. Understand the importance of direct observation in

assessing dining assistance care quality.

Be able to use a standardized observational tool to assess

dining assistance care quality.

Be able to use a standardized observational tool to identify

areas for improvement.F rom the F i e l d :

The CMS webcast on Dining

Assistance was helpful. I will

continue to use the whole video as

part of the syllabus. It was useful in

illustrating to the Dining Assistantswhy the Program is valuable

(Tennessee NH Staff Developer, 2008).

I found the webcast very helpful – I

want to show it to current CNAs.

However, in the future, I will probably

just show the vignettes and some of

the history and philosophy that are

important for trainees to understand

(Staff Developer, Massachusetts, 2008).

This free webcast is available at

http://www.cms.internetstreaming.com. The original webcast airdate

was March 16, 2007. The entire webcast is about one hour, with

about 10 minutes of vignettes of proper dining assistance care.

While the entire webcast is beneficial for DA training, time

constraints may not allow instructors to air it in its entirety.

Interviews with staff developers suggest that the following are the

most helpful sections of the webcast for training:

The introduction to the regulations and study in the

beginning of the webcast. This will help introduce trainees to

the DA requirements and the importance of quality dining

assistance.

The vignettes of proper dining assistance care are half-way

through the webcast. These vignettes can be used to

provide trainees with examples of quality dining assistance

techniques, including:

– Social stimulation

– Tray-set up

– Verbal queuing

– Offering a substitution or offering choices to residents

– Physical assistance with verbal queuing

– Allowing residents enough time for eating

The CMS Dining Assistant webcast is also useful to nursing homemanagement as an introduction to the DA regulations, DA Programs,

and quality dining assistance techniques. In addition, it can be used

8 Simmons, SF, Babinou S, Garcia E, Schnelle JF. (2002). Quality assessment in

nursing homes by systematic direct observations: Feeding assistance. Journal ofGerontology: Medical Sciences, 57A (10), M665-671.

9 Simmons SF, Garcia EF, Cadogan MP, Al-Samarrai NR, Levy-Storms LF, Osterweil

D, Schnelle JF (2003). The Minimum Data Set weight loss quality indicator:Does it reflect differences in care processes related to weight loss? Journal of the

American Geriatrics Society, 51(10), 1410-1418.


http://www.cms.internetstreaming.com/

http://www.cms.internetstreaming.com/



as a tool for training DA supervisors on the observation tool (see

Chapter 7, Implementing a Dining Assistant Program).

Additionally, Appendix A, Worksheets # 4 “Designing the DA

Program” and # 5, “Implementing the DA Program” may be helpful

for recording and tracking issues around training.





Dining Assistant Skills Evaluation

Many states require evaluation of the DA through a skills

demonstration, written examination, or combination of both. Even if

a state does not require a skills demonstration or written

examination, nursing homes may want to use these tools to ensure

that the trained DAs have mastered the skills and concepts. States

that do require competency testing may have specific requirements

such as a standardized multiple-choice written exam and/or a skills

demonstration test where DAs must successfully feed a resident in a

clinical setting. Nursing homes in states without standardized exams

can find written exams included in many of the available Training

Manuals. Following is an example of a skills demonstration

evaluation, “Assessing the Competency of the DA,” that the

instructor can use to observe DA trainees while they assist residents.

This example is a photo-ready version of the skills evaluation. This

checklist should be added to the DA’s personnel file, as record of

successful completion of the Dining Assistant Skills Evaluation.



Dining Assistant Skills Evaluation

Date:_____/______/_____ Meal: _____Breakfast _____Lunch _____Dinner

Observer:__________________________ Trainee observed:__________________________

Number of Residents Assisted ____________

DID THE TRAINEE… Yes No Not App licabl e

1. Greet the resident(s) by name?

2. Introduce self?

3. Orient the resident(s) to the meal (breakfast, lunch, dinner)?

4. Orient resident(s) to items on the tray (list what is being served)?

5. Seat themselves either beside or across from the resident(s) toprovide assistance?

6. Ensure that the served meal is in accordance with resident’sprescribed diet?

7. Ensure that the resident(s) are sitting upright, to the greatest extentpossible?

8. Provide social stimulation intermittently throughout the meal period?

9. Provide verbal instruction or orientation (includes prompts to eat forresidents who eat independently and, if physically dependent, lettingthe resident know what food or fluid is being offered)?

10. Offer alternative food/fluid items if the resident(s) are eating less thanhalf of the meal or complains about the served items?

11. Food and fluid items are kept separate (does not mix food/fluid itemsin an unappealing manner)? Note: mixing of foods with sauces isappropriate.

12. Provide small, manageable bites of food for the resident(s)?

13. Spend at least 20 minutes providing assistance?

14. Orient the resident(s) that the meal is complete?

Comments:




Chapter Seven

Implementing a Dining AssistantProgram

The purpose of this chapter is to review key steps in implementing

an optimal DA Program in order to achieve both immediate (e.g.,

improvements in dining assistance care) and long-term (e.g.,

reducing unintentional weight loss) program goals (see Chapter 4,

Creating Dining Assistant Program Goals). Appendix A, Worksheet #5, “Implementing the DA Program” may be used as a tool to evaluate

implementation options.

Chapter Seven 41 Dining Assistant Program



Identifying Residents Appropriate for the

Program

The first step beyond training DA staff (see Chapter 6, Training

Dining Assistants) is to identify residents appropriate for the

program. Federal requirements state that DAs can feed only

residents “without complicated feeding problems.”

Complicated feeding problems are defined in the federal

requirements as including, but not limited to, a resident who has:

Difficulty swallowing

Recurrent lung aspirations

Tube or parenteral/IV feedings

In addition, the federal requirements specify that resident selection

should be based on a current assessment of the resident’s status by

the charge nurse (RN or LPN, if allowed by state law) and the

resident’s latest comprehensive assessment and care plan. The

federal requirements also suggest that the charge nurse should

consult with the interdisciplinary team members, such as a speech-

language pathologist or other professionals, when identifying

residents appropriate for a DA Program. The requirements do not

deem residents inappropriate for a DA Program based only on their

need for staff assistance to eat. Thus, even residents who are totally

physically dependent on staff for eating may be appropriate for the

Program as long as the resident does not have “complicated feeding

needs,” as defined above.

Although the federal requirements do not explicitly provide

criteria for determining “difficulty swallowing,” the following

criteria might be helpful in practice:

Diagnosis of dysphagia

Formal swallowing evaluation by a licensed professional

(e.g., speech-language pathologist)

Prescribed diet requires pureed foods and/or thickened

liquids

Beyond the federal requirements, there are other important aspects

of identifying residents appropriate for a DA Program and assigning

DA staff to help individual residents to eat: the dining assistance

care needs of the resident, the experience level of the DA, and the

language abilities of both.

Supervisory-level staff tend to assign DAs to residents who are

totally dependent on staff to eat (spoon to mouth feeding) and/or




those who require a lot of staff time to feed (slow eating pace,

frequent refusals). The rationale is that the assignment of these

residents to a DA Program will increase the likelihood that they will

get the amount of assistance they need during meals (typically 30-45

minutes of help to eat), and will greatly reduce the work load for CNA

staff, who usually have several other residents for whom they are

responsible during meals.

Residents who are independent in eating may not be included in a

DA Program because they are perceived as not needing attention

from staff during meals, yet many of these residents eat poorly on

their own and respond well to simple verbal encouragement, social

interaction, and the availability of alternatives to the served meal. All

of these care tasks can be easily, effectively and comfortably

provided by DAs (see Chapter 4, Creating Dining Assistant Program

Goals). A good way to identify these residents is to observe

residents who eat independently during meals (in the dining room or

in their own rooms) and determine which of these residents eat less

than half of the served meal. These residents should be consideredfor a DA Program.

Another important aspect of resident assignment is to ensure there

are not significant language barriers between the resident and the

DA. A resident who is verbally communicative usually will respond

well to verbal encouragement and social interaction during the meal,

even if the resident also has mild to moderate cognitive impairment.

Thus, the DA will have the most success in encouraging a resident’s

food and fluid consumption if s/he is able to verbally communicate

with the resident. DA staff who do not speak the language of the

resident and/or are uncomfortable when they first start the program

could be assigned to non-communicative residents for diningassistance care and/or be responsible for other mealtime tasks (e.g.,

transporting residents to/from the dining room for meals, tray delivery

and set-up, retrieval of alternatives from the kitchen).


Dining Assistants new to the program

could spend the first few meals

working alongside a more experienced

CNA who could provide the new

Dining Assistant with guidance and

helpful tips for successfully feedingchallenging residents (Staff Developer,





When to Implement the Program

A DA Program need not be implemented across all meals and days.

In fact, it is best to start the program with only one meal per day and

then expand the program to other meals. This approach allows staff

to identify other barriers to program implementation early in the

process (e.g., meal trays are not delivered on time to certain floors or

units, residents need to be transported to the dining room for the

program).

In practice, the mid-day meal (lunch) seems to be the easiest meal

with which to start the program, because many residents are already

out of bed and dressed by mid-day and eat their mid-day meal in the

dining room. Morning (breakfast) and evening (dinner) meals tend to

be more challenging for a DA Program in the beginning because, in

some NHs, many residents eat their morning and/or evening meals

in their own rooms, and often in bed. At the same time, studies have

shown that a DA Program can be most helpful during the evening

meal due to lower CNA staffing levels on the evening compared to

the day shift.

Of course, DAs can provide help to residents, regardless of their

dining location (in their own rooms or the dining room), and should

be encouraged to do so. The federal requirements state that DAs

should be under the direct supervision of a licensed nurse (RN or

LPN), but the licensed nurse needs to be accessible to the DA only

in case of an emergency (i.e. through the resident call system).

However, it should be recognized that allowing residents to dine in

their own rooms means that one DA will need to be assigned to that

one resident for a given meal, resulting in less time-efficient care

delivery and less ease in supervision.

The federal requirements specify that “facilities may use [Dining

Assistants] to assist eligible residents to eat and drink at mealtimes,

snack times, or during activities or social events as needed,

whenever the NH can provide the necessary supervision.” Thus, a

DA Program need not be limited to regularly scheduled meals, and

can include a hydration program (offering residents fluids multiple

times per day between meals), a snack program (offering residents

snacks multiple times per day between meals), and even nutritional

care during organized social group activities. A NH should start theprogram during days/times where the need is greatest and/or when it

is most feasible for staff with the goal of expanding the program over

time.





How to Monitor Dining Assistant Care Quality

One of the most important components of a successful DA Program

is the involvement of one or more committed supervisors. The

supervisor(s) will handle the scheduling as well as the supervision

and monitoring of DAs. Regular, informal monitoring of meal-time

activities can help to identify potential aspects of dining assistance

that might need to be improved or discussed during staff meetings.

The supervisor(s) will also monitor the behaviors of the residents

who are being assisted for potential changes in feeding needs (e.g.,

resident is having difficulty swallowing), and be readily available to

help the DA in the event of an emergency.

The Federal Rule does not require that the supervisor(s) be in the

unit or on the floor at all times where assistance is furnished.

Rather, the supervisor(s) are required to be available during an

emergency on the resident call system (§483.35(h)(2); see Appendix

B).

Continuous Quality Improvement for Meals: An

Observation Tool

To identify problems and successes in program implementation,

supervisory-level staff can conduct more formal observations of the

program on a regular basis. The observations do not have to be

conducted during every meal or every day during which the program

is active; observations during only one to three meals per week are

sufficient to identify problems and successes. The observationsshould target residents who are part of the DA Program and also

include residents who are not currently part of the program but

maybe should be (e.g., residents who are eating poorly on their

own). Beyond dining assistance care quality provided by DAs, the

observations also can inform whether residents who are part of the

program remain appropriate for the program or need additional help

(e.g., assistive devices for eating, swallowing evaluation).

A standardized observational tool (see Appendix E) has been

developed and used extensively in both research studies and care

practice for this purpose.10

It is recommended that observations be

conducted more frequently early in program implementation (e.g.,three meals per week during the first few weeks); and, this frequency

can be reduced once the program is stable (no new staff or residents

added to the program and care quality is considered “good” during all

observed meals/days). The CMS-sponsored web-cast titled “How to

10 Simmons, SF, Babinou S, Garcia E, Schnelle JF. (2002). Quality assessment in

nursing homes by systematic direct observations: Feeding assistance. Journal ofGerontology: Medical Sciences, 57A (10), M665-671.




Enhance the Quality of Dining Assistance in Nursing Homes”

discussed earlier in this manual provides an overview of the Abt

Associates Vanderbilt study and the observational tool for program

monitoring activities (see Chapter 6, Training Dining Assistants).

The information generated by the observational tool can be reported

as dining assistance care quality indicator scores and used for DAProgram monitoring and/or ongoing quality improvement purposes.

There are two primary advantages of a quality indicator (QI) score.

First, a QI score has the potential to highlight care areas in need of

improvement. Second, a QI score efficiently summarizes the

information into understandable quality categories for which dining

assistance can be scored as either “passing” or “failing” for individual

residents and mealtime periods. The rules and rationale that guide

the scoring of eight dining assistance care QIs are also presented in

Appendix E.

Providing Feedback to Staff

The advantage of the mealtime observational tool and the QI scores

generated by the tool is that this information can be used to provide

feedback to staff about program successes and areas in need of

improvement.

Previous experience with quality improvement efforts showed

that feedback was most beneficial if delivered in the following

format:

Weekly Group Staff Meetings where all relevant staff are

present.

Brief Feedback Sessions (< 15 minutes) that can be

scheduled at convenient times for staff.

Focus on the QI Summary Scores generated by the

observational tool. For example, “Last week during

breakfast, we observed staff providing social interaction 80

percent of the time for residents who ate in the dining room.

That is a big improvement from the week before when the

rate was only 60 percent. Great job, everyone!”

Video Vignettes of desirable staff behavior are optional, but

are an excellent way to acknowledge exemplary staff care

practices and demonstrate desirable staff behavior by

showing staff and residents within the NH. Such vignettesmight include, for example, a video clip of a staff member

interacting socially with a resident (or actor) during

mealtime.11

Other video examples of proper dining

assistance care are contained in the CMS-sponsored web-

11

Note that appropriate resident and/or family consent must be obtained prior toany filming of residents.



cast titled “How to Enhance the Quality of Dining Assistance

in Nursing Homes” discussed earlier in this manual.

Who Can Be a Program Supervisor

While the federal regulation requires that DAs work under thesupervision of a licensed nurse (RN or LPN), as stated previously,

the licensed nurse needs to be accessible to the DA only in case of

an emergency (i.e. through the resident call system). The

supervisory-level person(s) responsible for monitoring DA Program

implementation need not be a licensed nurse.

The following types of staff have been effectively employed to

monitor DA Program implementation:

Exemplary CNA

Licensed nursing staff (charge nurse, unit nurse manager)

Assistant to the staff developer

Social worker

Social activities coordinator

Registered Dietitian (RD)

Other dietary staff

Upper-level management (administrator and director of

nursing)

Ideally, multiple staff should learn how to monitor care quality

provided by DAs so that the responsibility is shared among staff.Moreover, the involvement of different levels of staff in program

monitoring activities communicates to the DAs that the program is a

valued part of the resident’s overall care plan, and that their

contribution is significant in the daily life of the resident. Finally, the

advantage of having multiple disciplines involved in the observations

is that each person may notice unique aspects of the resident’s

dining experience that could be improved. For example, dietary staff

may notice residents’ food preferences while activities staff may

notice how residents’ seating could be re-arranged to be more

conducive to social interaction.


Co-ownership between the staff

developer and director of nursing

would be ideal, but also co-ownership

with a senior CNA would probably

allow for more hands-on supervising

(Staff Developer, Massachusetts ,

2008). The staff developer and charge nurse are both in an excellentposition to be the lead supervisors; however, their time is limited due

to many other responsibilities. The program works best if there is at

least one other staff member who can serve as an assistant to the

staff developer and/or charge nurse in the supervisory capacity, such

as an assistant director of nursing or an experienced CNA. The

advantage of using an experienced CNA in this position is that s/he

also can take responsibility for documenting percent eaten for

residents in the program and feeding if the meal period requires




Chapter Eight

Sustaining the Dining AssistantProgram

Successful program implementation hinges on the nursing home’s

ability to sustain it. Following are several key components to

sustaining a successful DA Program that we have either observed

through our experience working with NHs that have implemented a

Program, or that we have gathered from interviews with staffdevelopers. Appendix A, Worksheet # 6, “Monitoring and Sustaining

the Dining Assistant Program”, is provided as a tool for organizing

and tracking activities associated with monitoring and sustaining the

DA Program.

Obtain initial “buy-in” from administrator, director of

nursing, and staff developer. The NH administrator and/or the

corporate office may decide to implement a DA Program.

However, as soon as possible, the NH’s staff developer and

director of nursing should be included in discussions and the

decision-making process to ensure their support. The staff

developer will be in charge of training, and the director of nursingwill have at least some level of involvement in DA supervision.

The timing of the training sessions and Program implementation

need to coordinate with their schedules. The support of the staff

developer and director of nursing are essential to successful

Program implementation, as is that of the Registered Dietitian

(RD) and dietary manager.

Promote DA accountability and ownership. Trainers should

allow time at the beginning of the training session to go over the

fundamental philosophy of the DA Program: making a positive

impact on residents’ lives. Enlightening trainees about their

ability to effect a positive change in the quality of someone’s lifewill promote a sense of responsibility, ownership, and

accountability, not only for the residents under their care but also

for the Program overall.

Provide ongoing support from administrator, director of

nursing, staff developer. This support can be demonstrated

through involvement in the weekly observations and/or feedback

sessions, financial incentives to trainees (e.g., modest raise),

Chapter Eight 49 Dining Assistant Program


Let trainees know that they can make

a change in peoples’ lives; they can

make a difference. Dining Assistants

will be more invested and feel that

“they [the residents] are depending on

me” (Staff Developer, Massachusetts,

2008).


Before entering into a Dining Assistant

Program, make sure that the staff

developer and director of nursing areon board because if the timing isn’t

right, they may feel overwhelmed and

resist the program (Staff Developer,




Chapter Eight 50 Dining Assistant Program

and/or allocating time for other key personnel (e.g., assistant

director of nursing, lead CNA) to conduct supervisory tasks.

Provide ongoing program monitoring. Regular feedback to

DAs about the Program (see above) should include individual

and overall Program successes as well as areas that may be in

need of improvement. Getting together as a group will reinforcethe notion that the DA Program is important, and that the

services that the Assistants are providing are valuable and have

a direct impact on the residents.

Involvement of multiple supervisory-level staff so that the

program does not stop when one key person is not present (e.g.,

vacation, ill, or resigns from their position).

Consistently involve DAs. If assisting with meals becomes a

routine, DAs will be more likely to persist than if their help is

provided in a more sporadic way. Helpful tools to ensure regular

participation include a posted month-by-month calendar ofassignments and a posted sign-in sheet.

Be sensitive to staffing difficulties. Finding available staff to

train as DAs is often the biggest challenge that NHs face once

they have decided to implement a DA Program. The demands of

their primary job often prohibit regular involvement in the

Program. For example, some job descriptions require a 40-hour

work week, leaving only the lunch break or overtime without

compensation as options to make up for time spent assisting

residents with meals. In this situation, the administrator might

consider allocating a “free” 45 minutes to DAs on the day/s when

they provide meal-time care. Another possibility is to offer afinancial incentive in the form of a small raise.F rom the F i e l d :

At this facility, staff cannot work more

than 40 hours per week and it is

difficult to complete work in 40 hours.

The administrator might consider

allocating a “free” 45 minutes to

Dining Assistants on the day that they

assist with meals (Staff Developer,


Schedule repeat training sessions one to two times per year

to help retain an adequate number of trained DA staff. DAs, like

CNAs, will be lost from the Program due to turnover.

Incorporate the program into monthly care plan meetings,

so that there is an up-to-date list of all residents deemed

appropriate for the program.

Extend the program to other meals or between-meal periods

(through a snack or hydration program), so that the program hasa larger impact on the nutritional status and quality of life of

residents, and there are several available time periods

throughout the day that are options for DAs to help residents.



Appendix 51 Dining Assistant Program


Appendix



Appendix A Dining Assistant Program

Worksheets




Dining Assistant Program Worksheets

There are six worksheets designed to assist a nursing home in designing and implementing a

Dining Assistant Program.

Worksheet # 1 Conducting the Nursing Home Dining Assessment

Worksheet # 2 Assessing Nursing Home Resources Worksheet # 3 Setting Goals

Worksheet # 4 Designing the Dining Assistant Program

Worksheet # 5 Implementing the Dining Assistant Program

Worksheet # 6 Monitoring and Sustaining the Dining Assistant Program

NOTE: Before beginning, make sure your State allows dining assistants



Worksheet # 1

Conducting the Nursing Home Dining Assessment

Use this Dining Score Card to assess your nursing home’s dining program. For each category, a

variety of assessment techniques are suggested – document review, resident and staff observation, and

staff discussion. Tasks are organized by category so that if time is limited, tasks can readily be splitamong several assessors or prioritized based on available time. A ‘yes’ response likely indicates

some level of concern. No attempt has been made to quantify how many positive responses constitute

a problem.

Dining Score Card

Yes No

Document Review Review the most recent survey - are there any citations relatedto meal consumption or weight loss?

Review results of resident or family satisfaction surveys – hasfood quality, temperature or level of assistance been an issue?

Check the complaint logs – have families complained about

food/meals in the past 30 days?Review the MDS Quality Measure for weight loss – is thenursing home above the state average?

Review monthly weight documentation – are there residentswho have significant weight loss (i.e., 5% or more in the past 30days, 10% or more in the past 180 days)?

Review meal consumption records in conjunction with diningroom observations – are there instances where the mealconsumed does not agree with the percent recorded?

Review your dietary supplement policy - are there instanceswhere staff are not following the supplements’ policy?

Observation Are trays being returned to the kitchen at the end of the meal

with more than 50% of the tray untouched? Are there residents eating in the dining room who are not eatingand not receiving encouragement, cueing or offer of analternate meal?

Are there residents eating alone in their rooms who are noteating and not receiving encouragement, cueing or offer of analternate meal?

During the meal, are nurse aides talking to each other and notto the residents?

Is the dining room environment pleasant (e.g., is the musicappropriate, TV off, staff interacting with residents)?

Are supplements served on meal trays?

Are supplements returned to the kitchen untouched?

Discussion Talk with Nurse Aides regarding food complaints and the levelof assistance needed at mealtimes.

Talk with the Dietary staff about food complaints, or whetherthey notice trays returned to the kitchen untouched.

Talk with charge nurses and medication nurses – are residentsrefusing supplements? Are Nurse Aides consistently offeringbetween meal snacks and supplements?

Totals



Worksheet # 2

Assessing Nursing Home Resources

Use Worksheet # 2 to evaluate the resources likely needed to successfully implement a Dining

Assistant program. Any “yes” responses on this tool indicates encouraging prospects for designing

and implementing a Dining Assistant program. The nursing home’s decision-maker must determine

if s/he thinks the necessary resources are available. Some components may not be considered as

critical as others. In the event that adequate support is not present, the assessor may work on

achieving a comfortable level of support before moving on to Worksheet # 3 – Setting Goals. A list

of references follow that may provide more information in support of dining assistant programs.

Nursing Home Resource Assessment

Yes No

Administration

Director Of Nursing

Staff Development Coordinator

Nursing Supervisors

Dietitian

Dietary Manager

Staff Support- Isthere “ buy-in” andsupport from:

Other Department Heads potentially involved (e.g.,Laundry, Housekeeping, Activities)

Corporate Support If applicable, is there corporate support?

Finances Can the nursing home offer a financial incentive to diningassistants upon completion of the program?

Is there someone who can conduct the training?

Is there adequate space to conduct the training?

Training

Is there adequate funding to purchase training materials?

Are there non-nursing staff interested in advancing theirtraining to include direct care and perhaps eventualnurse aide certification?

Are there non-nursing staff willing to be cross trained inan area outside their current employment area?

Is there an active volunteer program to draw potentialtrainees from?

Trainees

If no active volunteer program, is therecommunity/nursing home interest and support to developthis?

Space Is there adequate dining room space to accommodateextra residents/dining assistants?

Totals



Worksheet # 2 ContinuedReferences on Nutrition in the Elderly and Feeding

Assistant/Dining Assistant Programs

Blaum CS, Fries BE, Fiatarone MA. (1995). Factors associated with low body mass index and weight

loss in nursing home residents. Journals of Gerontology Series A: Biological Sciences and Medical

Sciences, 50(3), 162-168.

Bertrand R, Moore T, Hurd D, Shier V, Sweetland R, Simmons S, Schnelle J. (2007). The study of

paid feeding assistant programs. The Consultant Dietitian, 32(2), 1, 4-6.

Kayser-Jones J. (1996). Mealtime in nursing homes; the importance of individualized care. Journal of

Gerontological Nursing, 3, 26-31.

Kayser-Jones J, Schell E. (1997). The effect of staffing on the quality of care at mealtime. Nursing

Outlook , 45, 64-72.

Kayser-Jones J, Schell ES, Porter D, Barbaccia JC, Shaw H, (1999). Factors contributing to

dehydration in nursing homes: Inadequate staffing and lack of professional supervision. Journal of

the American Geriatric Society, 47(10), 1187-1194.

Remsburg, RE (2004). Pros and cons of using paid feeding assistants in nursing homes. Geriatric

Nursing, 25(3), 176-177.

Richardson, B (Ed). The Consultant Dietitians in Health Care Facilities American Dietetic

Association Practice Group Pocket Resource for Management, 2006 Revision (available for purchase

on the Consultant Dietitian in Health Care Facilities website:

http://www.cdhcf.org/products/fsmgmt/details.asp?id=5016.

Simmons SF, Babinou S, Garcia E, Schnelle JF. (2002). Quality assessment in nursing homes by

systematic direct observations: Feeding assistance. Journal of Gerontology: Medical Sciences, 57A

(10), M665-M671.

Simmons SF, Garcia EF, Cadogan MP, Al-Samarrai NR, Levy-Storms LF, Osterweil D, Schnelle JF

(2003). The Minimum Data Set weight loss quality indicator: Does it reflect differences in care

processes related to weight loss? Journal of the American Geriatrics Society, 51(10), 1410-1418.

Simmons SF, Bertrand R, Shier V, Sweetland R, Moore TJ, Hurd DT, Schnelle JF (2007). A

preliminary evaluation of the paid feeding assistant regulation: Impact on feeding assistance care

process quality in nursing homes. Gerontologist , 47 184-192.



Worksheet # 3

Setting Goals

Use the worksheet below to record goals for the Dining Assistant program. See pages 18-25 for

examples of common goals. Keep in mind that goals should be specific, measurable, attainable,

realistic and timely. One example goal has been included.

Setting Goals

Date Goal Intervention Follow-Up

9/1/08 The number of people in the

main dining room available

to assist or socialize with

residents will increase by

25% by the end of the year.

Implementation of a dining

assistant program.

Nursing Supervisors will

monitor the number of staff

in the main dining room at

each meal at least one

time per week.



Worksheet # 4

Designing the Dining Assistant Program

Using all of the information gathered to this point, consider the following questions in designing the

Dining Assistant program. Evaluation of the following design options in conjunction with knowledge

of nursing home resources and goals should help users plan an optimal program well suited to the

home’s unique needs.

Designing the Dining Assistant (DA) Program

Issues Considerations Notes

Identifying DAs Volunteers from the community?

Paid workers from the community?

Non-nursing staff – voluntaryrecruitment?

Non-nursing staff – mandatoryrecruitment?

DA Tasks Transport residents to and from dining

room?

Deliver and set up trays?

Circulate around the dining room toprovide social stimulation?

Circulate around the dining room toidentify residents in need ofassistance?

Offer and retrieve alternate meal items?

Provide physical guidance to residents?

Provide encouragement/cueing toresidents?

Offer between meal snacks and fluids?

DA Assignments Where are residents’ meal time needsthe heaviest?

When are residents’ meal time needsthe heaviest?

Supervision &Training

What department will ‘own’ theprogram?

What department will do the schedulingand how will this be communicated toother departments?

Who will provide supervision?

Who will conduct the training?Who will monitor the performance of theDAs and how will this be done?

Administration Who will develop the policy andprocedure and write the jobdescription?

Will there be any incentive (financial orother) offered to participating staff?



Program Implementation

Issues Consider Notes

Nursing Home StaffRecruitment

Will this be a voluntary or mandatoryrecruitment? Make a list of pros andcons for each approach.

Involve key staff in the decision-makingprocess to obtain buy-in.

If a monetary incentive is to be offeredfor in-house staff, determine how thiswill be structured (e.g., hourly payincrease for hours worked as DA,bonus upon training completion).

Communicate program details topotential candidates – be prepared toanswer questions regarding aperceived increase in workload,scheduling, monetary incentives,opportunities for advancement andsupervision.

Training Review your State’s trainingrequirements (e.g., hours, content). See Appendix C for state contacts.

Review training materials – someStates have made training materialsavailable for download. See Pages 34 -35 for training resources.

If purchasing materials, previewmaterials and select the mostappropriate for the group being trained.

Determine the training schedule thatbest suits trainees and trainer(s).Consider including ‘practice’ time in the

dining room.

Recruit staff (e.g., administrator,dietitian, social worker, nursing director,nurse aides, occupational therapist) toassist with training.

Determine if you will offer recognitionfor DAs upon completion of trainingprogram (e.g., certificates, ceremony,bulletin board notice, photographs formarketing).

Determine how you will deal withstudents who miss training sessions.

Determine how you will deal withstudents who do not pass the program.



Program Implementation


Supervision &Scheduling

Will there be set schedules or will itvary week to week; how frequently willit be posted or otherwise communicatedto DAs?

For community workers – paid and

volunteers –Will DAs submit availabletime? How will this be communicated?

For in-house staff, how many meals willbe assigned? How will scheduleconflicts be resolved?

For in-house staff, how will DA andregular work load be managed so asnot to create stress or resentment?

Who will be responsible for monitoringDAs’ performance?

How will DA performance be monitored,and how frequently? See Appendix E

for Observation Tool.How will feedback be provided to DAs?

ResidentIdentification

Review State and Federal requirementsregarding appropriate residents (i.e.,those without complicated feedingproblems).

Conduct observations in dining areasusing the Observation Tool to identifyresidents who eat less than 50%.

Prioritize residents/dininglocations/meal times most in need ofassistance.

Match resident needs with DAresources keeping in mind that the DAprogram may be introduced in phasesdepending on availability of resources.



Worksheet # 6

Monitoring and Sustaining the Dining Assistant Program

It’s important to monitor the status of the Dining Assistant program and provide ongoing feedback to

all those involved. The Dining Assistant (DA) program has the potential to impact the quality of care

delivered to the residents, the nursing home’s standing in the community, family/resident satisfaction,

and staff morale. Even the most successful program will hit occasional “rough” patches that will

necessitate additional support to maintain and continue program activities. Ongoing monitoring will

alert leadership to problems in time to put appropriate interventions in place to keep the program on

track.

Worksheet # 6 provides some ideas for monitoring the various components of a Dining Assistant

program.

Monitoring and Sustaining the Dining Assistant (DA) Program


Review progress toward goals (e.g., as part ofContinuous Quality Improvement (CQI)).

Monitoring DAprogram goals

Provide regular feedback to staff on progresstoward goals.

Conduct regular dining observations ofresidents – including those in the program andthose not in the program.

Review findings from observations to ensurethat DA program residents remain appropriatefor the program.

Monitoring residents

Review findings from observations to identifyother residents who might benefit from the DAprogram.

Conduct regular dining observations to ensurethat DAs are performing appropriately.

Monitoring DAs

Solicit feedback from DAs on concerns, jobsatisfaction, suggestions for programimprovement, requests for additional training,etc.

Monitoring Staff Solicit feedback from Nursing, Dietary, Activities, Social Service staff on any concernsthey may have regarding the program orsuggestions for program improvement.

Look for opportunities to provide updatedinformation on program progress/successes atFamily Meetings, postings in nursing home,etc.

MonitoringFamilies/Community

Solicit feedback on the DA program during careplan meetings/conferences.



Monitoring and Sustaining the Dining Assistant (DA) Program


Meet regularly with program supervisors andtrainers to monitor the participation of DAs(e.g., number of meals covered, number ofDAs, number of residents served, trainingneeds, scheduling issues).

Sustaining the DAprogram

Schedule training programs as needed tomaintain a steady supply of trained DAs.

Seek opportunities to reward/recognize DAs’contribution to residents’ QOL.

Periodically review the nursing home DiningScore Card (Worksheet # 1) to monitor theimpact of the DA program.



Appendix B Federal Register Notice




2003 Federal Registry Notice

Requirements for Paid Feeding Assistants in Long Term Care Facilities

[ Federal Regi st er : September 26, 2003 ( Vol ume 68, Number 187) ][ Rul es and Regul at i ons][ Page 55528- 55539]Fromt he Feder al Regi st er Onl i ne vi a GPO Access [ wai s. access. gpo. gov][ DOCI D: f r 26se03- 21]- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -DEPARTMENT OF HEALTH AND HUMAN SERVI CESCent ers f or Medi care & Medi cai d Ser vi ces42 CFR Par t s 483 and 488[ CMS- 2131- F]RI N 0938- AL04

Medi care and Medi cai d Pr ogr ams; Requi r ement s f or Pai d Feedi ngAssi st ant s i n Long Ter m Car e Faci l i t i esAGENCY: Cent ers f or Medi care & Medi cai d Servi ces ( CMS) , HHS.ACTI ON: Fi nal r ul e.- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

SUMMARY: Thi s f i nal r ul e per mi t s a l ong t er m car e f aci l i t y t o use pai df eedi ng assi st ant s t o suppl ement t he ser vi ces of cer t i f i ed nur se ai desunder cer t ai n condi t i ons. St at es must appr ove t r ai ni ng pr ogr ams f orf eedi ng assi st ant s usi ng Feder al r equi r ement s as mi ni mum st andar ds.Feedi ng assi st ant s must successf ul l y compl ete a St at e- appr oved t r ai ni ngpr ogr am and work under t he super vi si on of a regi st er ed nur se orl i censed pr act i cal nur se. The i nt ent i s t o pr ovi de mor e r esi dent s wi t hhel p i n eat i ng and dr i nki ng and r educe the i nci dence of unpl annedwei ght l oss and dehydr at i on.

EFFECTI VE DATE: These r egul at i ons are ef f ect i ve on Oct ober 27, 2003.FOR FURTHER I NFORMATI ON CONTACT: Nol a Pet r ovi ch, ( 410) 786- 4671.SUPPLEMENTARY I NFORMATI ON: Copi es: Thi s Federal Regi st er document i sal so avai l abl e f r omt he Federal Regi st er onl i ne dat abase thr ough GPOaccess, a ser vi ce of t he U. S. Gover nment Pri nt i ng Of f i ce. The Web si t eaddr ess i s ht t p: / / www. access. gpo. gov/ nar a/ i ndex. ht ml .- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -I. Background

Legislation

Sect i ons 1819( a) t hr ough ( e) and 1919( a) t hr ough ( e) of t he Soci alSecur i t y Act ( t he Act ) set f or t h t he r equi r ement s t hat l ong t er m car ef aci l i t i es must meet t o par t i ci pat e i n the Medi car e and Medi cai dpr ogr ams, r espect i vel y. Sect i ons 1819( f ) ( 2) and 1919( f ) ( 2) of t he Actcont ai n r equi r ement s f or nur se ai de t r ai ni ng and competency eval uat i onpr ogr ams ( NATCEP) . Sect i ons 1819( g) and 1919( g) of t he Act cont ai n t hecri t er i a that we use t o assess a f aci l i t y' s compl i ance wi t h t he

r equi r ement s. These st at utory pr ovi si ons were mandat ed by t he Omni busBudget Reconci l i at i on Act of 1987 ( OBRA ' 87) ( Pub. L. 100- 203, enactedDecember 22, 1987) . The requi r ement s f or l ong ter m car e f aci l i t i es arecodi f i ed at 42 CFR par t 483, subpar t B; t he nur se ai de t r ai ni ng andcompet ency eval uat i on program r equi r ement s are codi f i ed at 42 CFR par t483, subpar t D; and t he sur vey, cer t i f i cat i on and enf orcementpr ocedur es ar e codi f i ed at 42 CFR part 488, subpart s E and F.

Sect i ons 1819( b) ( 5) ( F)and 1919( b) ( 5) ( F) of t he Act and regul at i onsat Sec. 483. 75( e) def i ne a nur se ai de as any i ndi vi dual f ur ni shi ng



nur si ng or nur si ng- r el at ed ser vi ces t o resi dent s i n a f aci l i t y, who i snot a l i censed heal t h pr of essi onal , a r egi st er ed di et i t i an, or someonewho vol unt eer s t o pr ovi de servi ces wi t hout pay. Sect i ons 1819( f ) ( 2) and1919( f ) ( 2) of t he Act set f ort h t he r equi r ement s f or appr oval of anur se ai de t r ai ni ng and compet ency eval uat i on program, but do notdef i ne ``nur si ng' ' or ` `nur si ng r el at ed' ' ski l l s. Secti on 483. 152 oft he r egul at i ons speci f i es nur se ai de t r ai ni ng r equi r ement s. Thesei ncl ude, f or exampl e, basi c nur si ng ski l l s, per sonal car e ski l l s,communi cat i on and i nt er per sonal ski l l s, i nf ect i on cont r ol , saf et y andemergency pr ocedur es, ment al heal t h and soci al servi ce needs,r esi dent s' r i ght s, car e of cogni t i vel y i mpai r ed r esi dent s, and basi cr est or at i ve ser vi ces.

On March 29, 2002, we publ i shed i n the Federal Regi st er a pr oposedr ul e, ``Requi r ement s f or Pai d Feedi ng Assi st ant s i n Long Ter m Car eFaci l i t i es' ' ( 67 FR 15149) , t hat of f er ed l ong- t erm care f aci l i t i es theopt i on t o use pai d f eedi ng assi st ant s, i f consi st ent wi t h St at e l aw.

Current Program Experience

Cur r ent l y, t her e i s no pr ovi si on i n t he r egul at i ons f or t he use of

si ngl e- t ask worker s, such as pai d f eedi ng assi st ant s, i n nur si ng homes. To ensure t he saf et y of f aci l i t y r esi dent s, we r equi r e t hat qual i f i ednur si ng st af f pr ovi de assi st ance wi t h eat i ng and dr i nki ng, al t hought here i s some quest i on whether or not al l r esi dent s need medi calsuper vi si on. Thi s gr oup of per sonnel i ncl udes r egi st er ed nur ses,l i censed pr act i cal nur ses, and cer t i f i ed nur se ai des who have compl et ed75 hour s of t r ai ni ng. However , vol unt eer s, who ar e usual l y f ami l ymember s, may al so f eed r esi dents, because t he l aw and r egul at i onsexcl ude vol unt eer s f r om t he def i ni t i on of cer t i f i ed nur se ai de.

Nur si ng homes i n many St ates r epor t a cont i nui ng shor t age ofcer t i f i ed nur se ai des1 2 3. Nur si ng homes ar e f i ndi ng i t i ncreasi ngl ydi f f i cul t t o t r ai n and r et ai n suf f i ci ent number s of qual i f i ed nur si ngst af f , especi al l y cer t i f i ed nur se ai des. Cer t i f i ed nur se ai des per f or mt he maj or i t y of r esi dent car e tasks. Ot her empl oyer s of t en pay si mi l arwages f or l ess physi cal l y and emot i onal l y demandi ng j obs. Thi s makes i tharder f or nur si ng homes t o empl oy enough nur si ng st af f t o per f ormr out i ne nur si ng care and t o f eed resi dent s who need mi ni mal hel p or

j ust encouragement at meal t i mes. Feedi ng r esi dent s i s of t en a sl owprocess and compet es wi t h more compl ex tasks, such as bathi ng,t oi l et i ng, and dr essi ng changes, as wel l as urgent medi cal car e.

For many el der l y nur si ng home resi dent s, physi cal and psychol ogi calchanges of t en i nt er f er e wi t h eat i ng abi l i t y and meal consumpt i on.Resi dent s may need assi st ance wi t h f eedi ng i f t hey have, f or exampl e,cogni t i ve i mpai r ment , i mpai r ed swal l owi ng due t o muscul ar weakness orpar al ysi s, a t endency t o aspi r at e or choke, poor t eet h, i l l - f i t t i ng

1 Stone, R. I . ( 2001) Fr ont l i ne wor ker s i n l ong- t er m car e:Research challenges and opportunities. Generations, 25(1), 49-57.2 St one, R. I . , wi t h Wei ner , J . A. ( 2001) . Who wi l l car e f orus? Addr essi ng t he l ong- t er m car e wor kf or ce cr i si s. Washi ngt on, D. C:Robert Wood Johnson Foundation.3 Uni t ed St at es Gener al Account i ng Of f i ce. Nur si ng Workf orce:Recrui t ment and Ret ent i on of Nurses and Nurses Ai des I s a Gr owi ngProblem. (Washington, DC., May 2001)



i s assi gned t o one resi dent who needs mi ni mal assi st ance. As t heassi st ant gai ns ski l l and conf i dence, he or she i s assi gned t o mor er esi dent s at a meal or t o a r esi dent who r equi r es a hi gher l evel ofski l l t o f eed. Typi cal l y, f eedi ng assi st ant s wor k onl y about 1 ½ hour sper day, pr ovi di ng assi st ance at ei t her t he noon or eveni ng meal .

Conclusion

We ar e commi t t ed t o ensuri ng t hat l ong t er m car e resi dent s r ecei vet he best possi bl e car e. We recogni ze that a short age of cer t i f i ed nur seai des may adver sel y af f ect r esi dent care and pr event many r esi dent sf r om r ecei vi ng adequat e hel p wi t h eat i ng and dr i nki ng. Fur t her , we ar epersuaded by t he experi ence of St ates t hat have used pai d f eedi ngassi st ant s, t hat pr oper t r ai ni ng and medi cal di r ect i on of t hese f eedi ngassi st ant s mi ni mi zes t he r i sk to resi dent s, whi l e pr ovi di ng subst ant i albenef i t s t o r esi dent s. Af t er t hor oughl y consi der i ng t hi s i ssue, webel i eve t hat t he benef i t s t o r esi dent s out wei gh t he pot ent i al r i sks. Webel i eve t hat a pol i cy change t o al l ow t he use of f eedi ng assi st ant s canbe accommodat ed under exi st i ng st at ut e. There i s not hi ng i n the st atut egover ni ng r equi r ement s f or l ong t er m car e f aci l i t i es ( sect i ons 1819 and1919 of t he Act ) t hat woul d pr ecl ude the use of t hese workers and we

bel i eve t hat t her e i s no conf l i ct wi t h ot her st at ut or y requi r ement s.

II. Provisions of the Proposed Regulations

We pr oposed t hat f eedi ng assi st ant s must compl ete successf ul l y aSt ate- approved t r ai ni ng cour se that meet s mi ni mum Federal r equi r ement sspeci f i ed i n proposed Sec. 483. 160. These cour se r equi r ement s woul dconsi st of r el evant i t ems f r om t he nur se ai de t r ai ni ng cur r i cul um andwoul d i ncl ude f eedi ng t echni ques; assi st ance wi t h f eedi ng andhydr at i on; communi cat i on and i nt er per sonal ski l l s; appr opr i at er esponses t o resi dent behavi or ; saf ety and emergency pr ocedur es,i ncl udi ng t he Hei ml i ch Maneuver ; i nf ect i on cont r ol ; r esi dent r i ght s;and r ecogni zi ng changes i n r esi dent s t hat ar e i nconsi st ent wi t h t hei rnormal behavi or , and t he i mpor t ance of r epor t i ng t hose changes t o t hesupervi sory nur se. Faci l i t i es or St at es may want t o add i t ems t o t hesemi ni mum r equi r ement s.

We pr oposed that each f aci l i t y t hat uses f eedi ng assi st ant smai nt ai n a r ecord of t he i ndi vi dual s who have successf ul l y compl et edt he f eedi ng assi st ance t r ai ni ng. Faci l i t i es woul d be r equi r ed t o r epor tt o t he St at e any i nci dent s i n whi ch a f eedi ng assi st ant has been f oundt o negl ect or abuse a r esi dent , or mi sappr opr i at e a resi dent ' spr oper t y. The St at e must t hen mai nt ai n a r ecord of al l r eport edi nci dent s.

We pr oposed t hat a f aci l i t y may use a pai d f eedi ng assi st ant t of eed r esi dent s who do not have a cl i ni cal condi t i on t hat woul d r equi r e

t he t r ai ni ng of a nur se or nur se ai de. Sel ect i on of r esi dent s t o be f edwoul d be made by t he pr of essi onal nur si ng st af f , usi ng thecomprehensi ve assessment . Nurses or nur se ai des woul d cont i nue to f eedr esi dent s who requi r e t he assi st ance of st af f wi t h mor e speci al i zedt r ai ni ng, such as t hose r esi dent s wi t h r ecur r ent l ung aspi r at i ons,di f f i cul t y swal l owi ng, or t hose r esi dent s on f eedi ng t ubes orPar ent er al / I V f eedi ngs. Feedi ng assi st ant s woul d wor k under t he di r ectsuper vi si on of r egi st er ed nur ses ( RN) or l i censed pr act i cal nur ses( LPN) , who ar e i n t he uni t or on t he f l oor wher e t he f eedi ng assi st ancei s f ur ni shed. I n pr oposed Sec. 483. 75( e) , we r evi sed t he def i ni t i on of



``nur se ai de' ' t o cl ar i f y that pai d f eedi ng assi st ant s ar e notper f or mi ng nur si ng or nur si ng- r el at ed t asks.

Feedi ng assi st ant s coul d be pai d by t he f aci l i t y or pai d under anarr angement wi t h another agency or organi zat i on ( Sec. 488. 301) .Faci l i t i es woul d be abl e to use staf f who ar e not heal t h car e per sonnelas f eedi ng assi st ant s i f t hey successf ul l y compl et e the t r ai ni ngpr ogr am. Thi s mi ght i ncl ude t he admi ni st r at or , act i vi t y st af f ,cl er i cal , l aundr y, housekeepi ng st af f , or other s who see r esi dent s on adai l y basi s. However , f eedi ng assi st ant s are i nt ended t o suppl ementcer t i f i ed nur se ai des, not subst i t ut e f or cer t i f i ed or l i censed nur si ngs t a f f .

We proposed t hat t hese requi r ement s woul d not appl y t o vol unt eer sand f ami l y members.

III. Analysis of and Responses to Public Comments

We recei ved over 6, 000 publ i c comment s on t he proposed r ul e. About99 per cent of comment ers were overwhel mi ngl y suppor t i ve of t he

pr oposal , but r ai sed a l arge number of i ssues and of f ered manysuggest i ons f or cl ar i f i cat i ons and r evi si ons to the f i nal r egul at i on.Comment er s support i ng t he pr oposal i ncl uded f or- pr of i t and not - f or-pr of i t nur si ng homes, nat i onal and St ate nur si ng home associ at i ons,nat i onal and St at e heal t h car e associ at i ons, St at e heal t h and humanser vi ces agenci es, Uni t ed St at es Congr essper sons, and pr i vat e ci t i zens.Many benef i ci ary advocat es and empl oyee uni ons opposed gi vi ngf aci l i t i es t he opt i on t o use pai d f eedi ng assi st ant s. A summar y of t hemaj or i ssues and our r esponses f ol l ow.

Facility Option To Use Feeding Assistants

Comment : One comment er r ecommended t hat we conduct a pi l ot st udy ordo f ur t her r esear ch bef or e f i nal i zi ng t he pr oposal because t her e i s al ack of dat a t hat woul d suppor t t he pr oposal . Another comment ersuggest ed t hat we i mpl ement t he proposal , but r eeval uate t he pol i cy i n3 year s t o see i f t he obj ect i ve i s bei ng met .

Response: We bel i eve t hat t he exper i ence of Wi sconsi n and Nor t hDakot a has pr ovi ded a demonst r at i on of t he meri t s of t he use of pai df eedi ng assi st ant s. Bot h St at es have r epor t ed t hat i n f aci l i t i es t hatuse f eedi ng assi st ant s, t he benef i t s t o r esi dent s i ncl ude f ewer casesof unexpl ai ned wei ght l oss and dehydr at i on t han i n f aci l i t i es t hat donot use f eedi ng assi st ant s, wi t h no repor t ed i l l ef f ects.

Comment : Some comment ers bel i eved t hat t he pr oposal i s i l l egal , t hati s, t her e i s no basi s i n t he l aw t o suppor t t he use of pai d f eedi ng

assi stant s.

Response: Our r evi ew of t he l aw i ndi cat es t hat t her e i s nothi ngt hat woul d pr ohi bi t t he use of f eedi ng assi st ant s and we bel i eve t hatwe have t he aut hor i t y and di scr et i on under t he l aw t o i mpl ement t hi spract i ce. Al t hough comment ers have f ocused on t he l anguage of t hest at ut e, at sect i ons 1819( b) ( 5) ( F) and 1919( b) ( 5) ( F) of t he Act t hatr equi r es per sons engaged i n nur si ng or nur si ng rel at ed care t o bet r ai ned ei t her as a nur se or nur se ai de, we do not consi der t he ki ndsof t asks f aci l i t i es may ask f eedi ng assi st ant s t o pr ovi de as ei t her



nur si ng or nur si ng r el ated. Whi l e f eedi ng has been par t of t he nur seai de t r ai ni ng cur r i cul um, t hat r equi r ement was predi cat ed on t he nur seai de havi ng t o tend t o persons wi t h pr onounced eat i ng compl i cat i ons( such as swal l owi ng di sor der s) f or whi ch speci al i zed t r ai ni ng i sessent i al . What f aci l i t i es woul d be f r ee t o do as a r esul t of t hi sr ul e, however , i s t o use per sons who have had a l esser l evel oft r ai ni ng t o assi st r esi dent s who have no f eedi ng i ssues t hat r equi r eany speci al i zed at t ent i on. Thus, we do not consi der f eedi ng assi st ant swho may be used by f aci l i t i es under t hi s r ul e t o be engaged i n nur si ngor nursi ng rel at ed acti vi t i es.

Comment : Sever al comment ers ci t ed t he l ack of Federal over si ghtbui l t i nt o t he pr oposal .

Response: The survey pr ocess wi l l pr ovi de t he Feder al over si ght off aci l i t i es' use of f eedi ng assi stant s, as i t does f or ot herpar t i ci pat i on r equi r ement s. Dur i ng sur veys of nur si ng homes, surveyor swi l l obser ve t he meal or snack ser vi ce t o not e i f any of t he resi dent sr ecei vi ng f eedi ng assi st ance ar e havi ng t r oubl e, such as coughi ng orchoki ng. I f t hi s i s obser ved, sur veyor s wi l l i nvest i gat e t o det er mi ne

i f t hi s i s an unusual occur r ence or a chr oni c pr obl emand whet herf eedi ng assi st ant s have successf ul l y compl et ed t he 8- hour t r ai ni ngcour se. Sur veyor s wi l l al so det er mi ne i f t he r esi dent r ecei vi ng t hef eedi ng assi st ance i s one who has no compl i cated f eedi ng pr obl ems. Thi swi l l be done by a r evi ew of medi cal char t s and di scussi on wi t h thepr of essi onal nur si ng st af f . Si mi l ar l y, sur veyor s wi l l not e concer nsabout super vi si on of pai d f eedi ng assi st ant s and i nvest i gat e how t hef aci l i t y pr ovi des super vi si on by i nt er vi ewi ng st af f dur i ng meal orsnack t i mes and dr awi ng thei r own concl usi ons f r omobservat i ons.Def i ci enci es wi l l be ci t ed by sur veyor s when t hey i dent i f y pr obl ems. Byr et ai ni ng t r ai ni ng and empl oyment r ecords of f eedi ng assi st ant s, af aci l i t y wi l l hel p document i t s compl i ance wi t h Feder al r equi r ement s,and have a record that sur veyor s may revi ew when they sur vey t hef aci l i t y.

Comment : Some commenter s were convi nced that t he use of f eedi ngassi st ant s wi l l not i mpr ove t he qual i t y of car e and may, i n f act , l oweri t . One comment er cont ended t hat Wi sconsi n' s use of f eedi ng assi st ant sdi d not l ead to a document ed i mpr ovement i n qual i t y of care. Ot herscomment ed that use of f eedi ng assi st ant s woul d di sr upt t he cont i nui t yof care and r educe qual i t y by creat i ng an assembl y l i ne atmosphere.

Response: We ar e not aware of any dat a t hat woul d suggest t hatt here i s an i mpr ovement i n t he qual i t y of care when r esi dent s arehel ped t o eat by f eedi ng assi st ant s, nor are we aware of any data t hatwoul d suggest a decl i ne i n qual i t y of car e. We ar e r el yi ng on supportf or t he use of pai d f eedi ng assi st ant s t hat has been pr ovi ded by the

Wi sconsi n and Nor t h Dakot a survey agenci es. Nei t her agency hasi ndi cat ed t hat use of f eedi ng assi st ant s has r esul t ed i n di mi ni shedqual i t y of car e.

Comment : A f ew comment er s r ecommended t hat we pr ohi bi t a f aci l i t yf r om t r ai ni ng f eedi ng assi st ant s when i t has cer t ai n def i ci enci es, i nt he same way we cur r ent l y pr ohi bi t a f aci l i t y f r om t r ai ni ng nur seai des. For exampl e, comment ers suggest ed t hat we pr ohi bi t f aci l i t i esf r om t r ai ni ng f eedi ng assi st ant s i f t he f aci l i t y has (1) any def i ci encyat l evel F or above; ( 2) a def i ci ency at any l evel i n t he ar ea of



nut r i t i on, st af f i ng, and r esi dent s' r i ght s; ( 3) i mposed agai nst i t aper i nst ance ci vi l money penal t y ( CMP) of $5, 000 or more, a per day CMPof $5, 000 or more cumul at i vel y, a St ate moni t or , or t emporary manager;( 4) an appr oved nur se- st af f i ng wai ver .

Several consumer advocacy groups r ecommended t hat we l i mi t t heaut hori t y f or a f aci l i t y t o use f eedi ng assi stant s to f aci l i t i es thatar e aut hori zed t o conduct nur se ai de t r ai ni ng pr ogr ams. I n other words,i f a f aci l i t y l oses t he r i ght t o t rai n nurse ai des, i t shoul d al so l oset he r i ght t o t r ai n f eedi ng assi st ant s. Many pr ovi der s t ook t he opposi t eposi t i on, t hat a f aci l i t y t hat l oses nur se ai de t r ai ni ng r i ght s shoul dr et ai n t he r i ght t o t r ai n f eedi ng assi st ant s.

Response: The pr ohi bi t i on t o whi ch comment ers r ef er i s a st at ut oryr equi r ement t hat causes a f aci l i t y to l ose t he r i ght t o t r ai n nur seai des when t he f aci l i t y has cer t ai n def i ci enci es speci f i ed i n t he l aw.We di sagree wi t h comment ers and bel i eve t hat each St at e needs t hef l exi bi l i t y t o r espond t o speci f i c si t uat i ons and make i t s own deci si onwhet her or not t o per mi t a f aci l i t y to t r ai n and use f eedi ngassi stant s.

Faci l i t i es t hat have an appr oved nur se- st af f i ng wai ver , whi chwai ves requi r ement s i n Sec. 483. 30 t o have a RN on st af f 8 hours perday, 7 days per week, are st i l l r equi r ed t o have adequate number s ofLPNs on st af f at al l t i mes. Thus, even i f RNs ar e unavai l abl e, t hesupervi si on r equi r ement f or f eedi ng assi st ant s woul d be met by havi ngLPNs on duty.

Comment : Many comment ers sai d that t hey di d not want us t o l i mi thours worked by f eedi ng assi st ant s t o meal t i mes and advocatedper mi t t i ng f eedi ng assi st ant s t o work whenever needed by a f aci l i t y.Some f aci l i t i es t hought t hat f eedi ng assi st ant s coul d be used f ul l t i met o pr ovi de snacks and l i qui ds t o r esi dent s, par t i cul ar l y those whocannot l eave t hei r r oom. These comment ers bel i eved t hat t hi s woul d be agood way t o reduce the potent i al f or dehydr at i on si nce assi st ant s woul dhave t i me t o del i ver l i qui ds, pr ovi de soci al st i mul at i on, and encour agebedf ast r esi dent s t o dr i nk mor e f l ui ds.

Response: The t ext of t he r egul at i ons does not l i mi t worki ng hour st o meal t i mes. Accor di ng to Sec. 483. 35( h) , f aci l i t i es may use f eedi ngassi st ant s at any t i me that t he super vi si on r equi r ement s are met .

Comment : Many pr ovi der s and i ndi vi dual s expr essed st r ong suppor tf or t he use of exi st i ng st af f as f eedi ng assi st ant s, af t er propert r ai ni ng. A l ar ge number of pr ovi der s r epor t ed t hat t hey f avor t hi sbecause exi st i ng st af f , such as cl er i cal , di et ar y, and housekeepi ngstaf f , ar e al r eady t rai ned i n f aci l i t y pol i c i es, are usual l y wel l

acquai nt ed wi t h r esi dent s, and have t i me avai l abl e to devot e to f eedi ngr esi dent s.

A number of ot her comment ers were opposed t o usi ng exi st i ng st af fas f eedi ng assi stant s, ci t i ng t hei r f ul l - t i me r esponsi bi l i t i es andconcern about added burden.

Response: The t ext of t he pr oposed r egul at i ons per mi t s anyi ndi vi dual t o act as a f eedi ng assi st ant i f he or she meet s t het r ai ni ng and super vi si on r equi r ement s ( Sec. 483. 35( h) ) . Each



f aci l i t y' s admi ni str at or i s responsi bl e f or al l ocat i ng avai l abl e stafft o necessary tasks and we bel i eve t hat i t i s r easonabl e t o l eave t hedeci si on to t he admi ni st r at or whet her t o use as f eedi ng assi st ant sst af f who ar e not heal t h car e per sonnel .

Comment : Some comment ers suggest ed r equi r i ng t hat f aci l i t i es assi gnf eedi ng assi st ant s t o cer t ai n r esi dent s t o ensur e cont i nui t y of car e.

Response: We bel i eve t hat t hi s deci si on i s best l ef t t o eachf aci l i t y and t he super vi sor y nur ses.

Comment : Consumer advocat es were concerned t hat i nsuf f i ci ent l yt r ai ned f eedi ng assi st ant s woul d endanger r esi dent s. Ot her comment erswere concerned t hat f eedi ng assi st ant s mi ght make cl i ni cal j udgment sand take act i ons t hat are beyond thei r scope of t r ai ni ng or be unabl et o handl e emer gency si t uat i ons.

Response: The pur pose of t he t r ai ni ng i s t o ensure t hat f eedi ngassi st ant s ar e pr oper l y pr epar ed t o f eed r esi dent s and r ecogni zeemergency si t uat i ons t hat need the i mmedi ate hel p of a supervi sory

nur se. We bel i eve t hat a t r ai ni ng pr ogr am t hat meet s t he requi r ement sl i st ed i n Sec. 483. 160 wi l l ensur e t hat a f eedi ng assi st ant r ecei vespr oper t r ai ni ng.

Comment : One commenter suggest ed t hat we consi der expandi ng t her ol e and t r ai ni ng of f eedi ng assi st ant s so t hat t hey can event ual l yassi st i n f eedi ng r esi dent s wi t h compl ex f eedi ng pr obl ems.

Response: I ndi vi dual s who have compl ex f eedi ng probl ems, such ast he need f or I V or par ent er al f eedi ngs, swal l owi ng pr obl ems, and t hosewi t h r ecur r ent l ung aspi r at i ons, need t he assi st ance of pr of essi onalnur ses or cert i f i ed nur ses ai des who have been t r ai ned t o work wi t hr esi dent s who have these needs. We do not bel i eve t hat i t i sappr opr i at e f or f eedi ng assi st ant s t o f eed any resi dent s other t hant hose who are l ow r i sk and whose eat i ng probl ems ar e uncompl i cat ed.

Comment : Two senator s and one congr essman wr ot e i n suppor t of t hepr oposal , not i ng the success of one st at e t hat used f eedi ng assi st ant sand exper i enced reduced wei ght l oss and dehydrat i on among nursi ng homer esi dent s. These comment ers al so repor t ed t hat t he Boar d of Nurs i ng ofone st ate had def i ned f eedi ng as a nur si ng t ask and was concerned t hatt hi s mi ght pr event t he st at e f r om usi ng f eedi ng assi st ant s. ( I n t hepr oposal , we i ndi cat ed t hat f eedi ng assi st ant s woul d not be perf ormi ngnur si ng or nur si ng- r el ated t asks. ) Another comment er bel i eved t hatf eedi ng i s a nur si ng- r el at ed ser vi ce and shoul d not be perf ormed by ani ndi vi dual wi t h mi ni mal t r ai ni ng.

Response: The def i ni t i on of t he ter m, ``nur si ng and nur si ng- r el at edt asks, ' ' i s f r equent l y pr escr i bed by St at e l aw and, t her ef or e, we ar edecl i ni ng t o i mpose a Feder al def i ni t i on of t hi s t er m on al l St at es. Webel i eve t he mat t er shoul d be l ef t wi t h t he St at e i n t hose si t uat i ons i nwhi ch St ate l aw or st andar ds- set t i ng organi zat i ons have establ i shed adef i ni t i on t hat i s mor e r est r i cti ve t han t he Feder al def i ni t i onper mi t t i ng t he use of f eedi ng assi st ant s. We suggest t hat t he St at ei nvest i gat e whet her a r evi si on t o St at e l aw woul d r esol ve t hi s i ssue.

Staffing Issues



Comment : One consumer advocacy group suggest ed t hat we r equi r e

st at e sur vey agenci es t o use t he i nvest i gat i ve pr ot ocol f or st af f i ngf r om t he St at e Oper at i ons Manual i n al l f aci l i t i es t hat r equest t o useor use f eedi ng assi st ant s. Thi s pr ot ocol , used t o i dent i f y pr obl emst hat may be associ at ed wi t h i nsuf f i ci ent nur si ng st af f , woul d ensur et hat a f aci l i t y has an appr opr i ate number of RNs and LPNs t o supervi sef eedi ng assi st ant s.

Response: We bel i eve t hat f aci l i t i es t hat r equest t o use or usef eedi ng assi st ant s shoul d be surveyed i n t he same way as any ot herf aci l i t y. Sur veyor s shoul d use t he i nvest i gat i ve pr ot ocol f or st af f i ngonl y when systemi c pr obl ems rel at e t o i nsuf f i ci ent nur si ng st af f .

Comment : A consumer advocate asked t hat we requi r e f aci l i t i es t opost i nf ormat i on about t he number s of f eedi ng assi st ant s, i n addi t i ont o t he cur r ent r equi r ement t o post t he number of l i censed andunl i censed st af f empl oyed per shi f t . The comment er al so suggest ed t hatwe requi r e that f eedi ng assi st ant s wear badges or name tags so t hatt hey wi l l be cl ear l y r ecogni zed by ot her st af f .

Response: A pr ovi si on i n the Medi car e, Medi cai d & St ate Chi l dHeal t h I nsur ance Progr am( SCHI P) Benef i t s I mpr ovement & Protect i on Actof 2000 ( BI PA) r equi r es f aci l i t i es t o post dai l y f or each shi f t t hecur r ent number of l i censed and unl i censed nur si ng st af f di r ect l yresponsi bl e f or resi dent car e i n t he f aci l i t y. Thi s provi si on i sef f ect i ve J anuar y 1, 2003. Because pai d f eedi ng assi st ant s do notqual i f y as l i censed or unl i censed nur si ng st af f , f aci l i t i es do not needt o post t he number s of f eedi ng assi st ant s used by the f aci l i t y.However , we wi l l consi der at a l ater dat e whet her t hi s mi ght be usef uland what addi t i onal bur den i t may i mpose on f aci l i t i es.

Wi t h r egard t o name t ags, we bel i eve i t i s probabl y a good i dea,but l eave t hat deci si on t o each f aci l i t y and do not see t he need f or ust o make t hi s a r equi r ement .

Use of Volunteers

Comment : Sever al comment ers suggest ed that we r equi r e vol unt eer s t ocompl et e the t r ai ni ng r equi r ement s f or f eedi ng r esi dent s, poi nt i ng outt hat i t i s i nconsi st ent not t o do so.

Response: Whi l e we bel i eve t hat i t i s a good i dea f or f ami l ymember s and vol unt eer s t o take t he t r ai ni ng, and we encourage i t , wear e not maki ng thi s a r equi r ement . Many vol unt eer s i n f aci l i t i es aref ami l y member s who ar e onl y t her e t o f eed a r el at i ve. Of t en, f ami l ymember s have been f eedi ng t he ai l i ng resi dent f or years , both at home

and i n t he f aci l i t y. We ar e l eavi ng i t t o each f aci l i t y t o det er mi newhet her or not t o requi r e vol unt eer s and f ami l y member s t o compl etef eedi ng assi st ance t r ai ni ng. Ul t i mat el y, f aci l i t i es ar e r esponsi bl e f ort he car e and saf et y of r esi dent s, even i f t he r esi dent i s f ed by arel at i ve or f r i end.

Payment Issues

Comment : Some provi ders were concer ned about how t hey woul d be pai df or t he t r ai ni ng and servi ces of f eedi ng assi st ant s. A f ew comment ers



r ecommended t hat we al l ocat e payment f or f eedi ng assi st ant s t o t henur si ng cost cent er .

Response: Ski l l ed nur si ng f aci l i t i es wi l l not r ecei ve addi t i onalMedi car e payment f or t he cost s of usi ng f eedi ng assi st ant s. Medi car epayment f or r esi dent s i n ski l l ed nur si ng f aci l i t i es i s made t hr ough apr ospect i ve payment system, whi ch cover s al l cost s ( r out i ne, anci l l ar y,and capi t al ) of cover ed ski l l ed nur si ng f aci l i t y ser vi ces f ur ni shed t obenef i ci ari es under Par t A of t he Medi car e pr ogr am. For Medi car epayment , t he t er m and concept , ``nur si ng cost cent er , ' ' i s out dat ed,but st i l l may be used i n some St at e Medi cai d pr ogr ams. The Medi care SNFPPS per di em payment r ate i s based, i n par t , on l evel s of car e andr esour ces r equi r ed and r ecei ved by resi dent s, establ i shed by ther esi dent assessment i nst r ument speci f i ed i n Sec. 483. 20. The syst emdoes not r equi r e that t asks per f ormed by a st af f per son f i t wi t hi n adi r ect car e or i ndi r ect car e cat egor y ( such as a nur si ng cost cent er ) .

Medi cai d payment s f or nur si ng f aci l i t i es are est abl i shed by eachSt at e. Ther ef ore, i t woul d be up t o i ndi vi dual St at es t o det er mi newhet her t hey woul d need to change t hei r payment r ates f or t hose

f aci l i t i es t hat use f eedi ng assi st ant s and how t he r at es woul d bechanged. However , because f eedi ng assi st ant s wi l l l i kel y be pai d at ami ni mum wage, whi ch i s l ess t han t he wage pai d t o cert i f i ed nurseai des, f aci l i t i es par t i ci pat i ng i n Medi car e and Medi cai d may i ncur l esscost t han i f t hey had hi r ed addi t i onal cer t i f i ed nur se ai des t o per f or mf eedi ng and hydr at i on dut i es.

Comment : One provi der r epor t ed usi ng workers who pass out t r ays,pr ovi de beverages and condi ment s, t al k t o and encour age resi dent s,r ecor d f ood i nt ake, and per f or m r out i ne di ni ng r oom t asks. Thecomment er asked i f t he f aci l i t y woul d be abl e t o cont i nue t o use t heseworkers .

Response: A f aci l i t y may cont i nue t o use worker s who perf orm t hedi etary servi ce f unct i ons descr i bed by t he comment er . They need not bet r ai ned as f eedi ng assi st ant s i f t hey do not f eed r esi dent s. Faci l i t i esar e requi r ed t o empl oy suf f i ci ent suppor t per sonnel t o car r y out t hef unct i ons of t he di et ar y ser vi ce. I f t hese wor ker s successf ul l ycompl et e t he f eedi ng assi st ant t r ai ni ng cour se, t he f aci l i t y may al souse t hem t o f eed r esi dent s. However , as we i ndi cat ed i n t he l astr esponse, t he Medi car e pr ogr am pays ski l l ed nur si ng f aci l i t i es apr ospect i vel y det er mi ned per di em r at e, whi ch does not r equi r e t hatt asks per f or med by per sonnel f i t i nt o a di r ect or i ndi r ect car ecat egory. For Medi cai d payment , payment i s det ermi ned by each Medi cai dst at e agency.

Determining Which Residents Can Be Fed by Feeding Assistants

Comment : One st at e comment ed that i t i s cumber some t o r el y on t hecomprehensi ve assessment t o det ermi ne whi ch r esi dents may be saf el y f edby a f eedi ng assi st ant . I nst ead, t he deci si on shoul d be l ef t ent i r el yup t o the pr of essi onal j udgment of t he l i censed nur se. A consumeradvocacy gr oup al so i ndi cat ed t hat t he comprehensi ve assessment / annualeval uat i on i s not an ef f ect i ve t ool f or t he assessment of r esi dent s t obe f ed because t he i nf ormat i on may not be cur r ent . Sever alorgani zat i ons suggest ed t hat we emphasi ze t he i mpor t ance of t he RN orLPN' s pr of essi onal j udgment al ong wi t h i nput f r om t he i nt er di sci pl i nar y



t eam, as r ef l ected i n t he compr ehensi ve assessment , when sel ect i ngr esi dent s f or f eedi ng assi st ance.

Response: We agree wi t h comment ers and are revi si ng Sec.483. 35( h) ( 1) ( i i ) t o say t hat t he deci si on about whet her a resi dent i st o be f ed by a f eedi ng assi st ant i s based on t he charge nur se' sassessment and the resi dent ' s l atest assessment and pl an of care. Wenot e t hat f aci l i t i es t hat choose t o use pai d f eedi ng assi st ant s r emai nr esponsi bl e f or any adver se act i ons r esul t i ng f r om t he use of t heseassi st ant s, as wi t h any ot her empl oyee.

Comment : An or gani zat i on r epr esent i ng l i censed pr of essi onal ssuggest ed t hat t he RN or LPN shoul d consul t wi t h a speech- l anguagepat hol ogi st when a resi dent i s suspect ed t o have, or i s at r i sk f or ,swal l owi ng di f f i cul t i es .

Response: We have no obj ect i on t o t hi s and f aci l i t i es may use t hi sappr oach i f t hey choose.

Comment : Several comment ers i ndi cated t hat t he cr i t eri a f or

sel ect i ng resi dent s t o be f ed i s i nadequat e and suggest ed t hat wedef i ne t he cl i ni cal condi t i ons t hat woul d r equi r e f eedi ng by an RN orLPN or nur se ai de. Anot her comment er suggest ed t hat we prohi bi t f eedi ngassi st ant s f r omf eedi ng r esi dent s wi t h swal l owi ng pr obl ems.

Response: We bel i eve t hat t he cl i ni cal deci si ons as t o whi chr esi dent s may be f ed by f eedi ng assi st ant s ar e best l ef t t o t heprof essi onal j udgment and exper i ence of RNs and LPNs who work i n t hef aci l i t y and have per sonal knowl edge of a resi dent ' s day- t o- daycondi t i on. I f we wer e t o def i ne cl i ni cal condi t i ons, we woul d onl y besubst i t ut i ng t he j udgment of pr of essi onal nur ses empl oyed by t heFederal gover nment f or t he j udgment of nur ses worki ng i n f aci l i t i es. Webel i eve t hat pr of essi onal nur ses concl ude t hat cer t ai n cl i ni calcondi t i ons r el at i ng to eat i ng and dr i nki ng woul d r equi r e the ski l l s andknowl edge of an RN or LPN. These condi t i ons i ncl ude, but are notl i mi t ed t o, r ecur r ent l ung aspi r at i ons, di f f i cul t y swal l owi ng, and t ubeor par ent er al / I V f eedi ngs.

Comment : One comment er suggest ed a number of mor e st r i ngentr equi r ement s f or f aci l i t i es, i ncl udi ng ( 1) obt ai ni ng i nf or med consentf r om t he resi dent or r esi dent ' s r epr esent at i ve that t he r esi dent agr eest o be f ed by a f eedi ng assi st ant and accept s t he r i sks and benef i t s;( 2) an i ndi vi dual i zed f eedi ng pl an; and ( 3) a cer t i f i cat i on by al i censed nur se i n a r esi dent ' s medi cal r ecor d that t he resi dent can besaf el y f ed by a f eedi ng assi st ant pr i or t o each i nst ance of f eedi ng.

Response: We underst and t hat t he comment er i ntends t he pr oposed

pr ovi si ons t o be i n the best i nt er est of r esi dent s, but we bel i evet hat , f or t he most par t , t hey ar e undul y bur densome f or f aci l i t i es t oi mpl ement . To r equi r e consent bef ore a resi dent can recei ve hel p f r omaf eedi ng assi st ant i mpl i es t hat t hi s i s a hi gh r i sk pr ocedur e, whi ch webel i eve i t i s not . We bel i eve t hat t he Wi sconsi n and Nort h Dakot aexper i ence i ndi cat es t hat i t i s saf e t o use wel l - t r ai ned f eedi ngassi st ant s who ar e pr oper l y super vi sed. I t woul d be i nconsi st ent t or equi r e r esi dent s t o gi ve i nf ormed consent f or f eedi ng assi st ance whent hey need not do so f or any ot her ser vi ces pr ovi ded by a f aci l i t y.



Fur t her , a f eedi ng pl an woul d ver y l i kel y dupl i cat e par t of t he car epl anni ng pr ocess. Consequent l y, we ar e not r evi si ng t he r ul e t oaccommodat e t he comment er ' s suggest i ons.

Supervision

Comment : Comment ers, concerned about l ack of supervi si on, poi ntedout t hat t he pr oposed r equi r ement , i n Sec. 483. 35( h) ( 2) ( i i ) , t hat anur se i s i n t he uni t or on t he f l oor , exceeds t he l i censed nur si ngr equi r ement s i n most st ates. Ot her comment ers worr i ed t hat t he shor t ageand hi gh tur nover r at es of l i censed and unl i censed nur si ng staf f coul dmean t hat f ewer st af f ar e f ami l i ar wi t h r esi dent s and coul d r esul t i ni nadequat e moni t ori ng.

Response: Faci l i t i es ar e r equi r ed by Sec. 483. 30, Nur si ngser vi ces, t o have suf f i ci ent qual i f i ed nur si ng st af f avai l abl e on adai l y basi s t o meet r esi dent s' needs f or nur si ng car e. The r equi r ementi n Sec. 483. 30, Nur si ng ser vi ces, i s t hat , unl ess wai ved, a f aci l i t ymust have a RN on duty 8 consecut i ve hours per day, 7 days a week. Af aci l i t y must al so have a suf f i ci ent number of l i censed nur ses and

other nur si ng personnel on a 24- hour basi s t o provi de nur si ng andr el ated servi ces t o resi dent s. The pr oposed r equi r ement t hat a f eedi ngassi st ant work under t he di r ect super vi si on of a RN or LPN bui l ds ont he r equi r ement t hat suf f i ci ent l i censed nur si ng st af f ar e on dut y 24hour s a day. We bel i eve t hat , i f a f aci l i t y chooses t o use f eedi ngassi stant s , i t i s t he f aci l i t y' s responsi bi l i t y, and i n i t s besti nt er est , t o ensur e that adequat e super vi sor y nur si ng st af f i savai l abl e.

However, we r ecogni ze t hat t he supervi si on r equi r ement i s uncl earand subj ect t o a var i et y of i nt er pr et at i ons. Ther ef or e, we ar e revi si ngSec. 483. 35( h) ( 2) by r emovi ng t he wor d, ``di r ect ' ' f r om t he phr ase,``di r ect super vi si on, ' ' because i t may uni nt ent i onal l y i mpl y vi sualcont act bet ween a f eedi ng assi st ant and a super vi sory nur se. Thi s i snot possi bl e i n most f aci l i t i es, especi al l y i f assi st ant s ar e f eedi ngr esi dent s i n t hei r r ooms. Next , we are r emovi ng t he r equi r ement t hat anur se be i n t he uni t or on t he f l oor wher e the f eedi ng assi st ance i sf ur ni shed and i mmedi atel y avai l abl e to gi ve hel p. As comment ers not ed,t hi s sent ence i s uncl ear . Whi l e we ar e not pr escr i bi ng t he pr eci semeans by whi ch f aci l i t y RNs or LPNs asser t t hei r super vi soryr esponsi bi l i t i es, we wi l l expect t hat f aci l i t i es do so i n a way t hatavoi ds negat i ve out comes f or t hei r r esi dent s. Addi t i onal l y, we ar er equi r i ng t hat a f eedi ng assi st ant cal l a super vi sor y nur se on t her esi dent cal l syst emwhen t her e i s an emer gency or a need f or hel p. Al lf aci l i t i es ar e cur r ent l y r equi r ed t o have a r esi dent cal l syst em.

Comment : Consumer advocat es expressed concern about a pot ent i al

l ack of super vi si on and suggest ed t hat al l r esi dent s who ar e f ed byf eedi ng assi st ant s be f ed i n the di ni ng room or ot her congr egat e ar eat o ensur e that a l i censed nur se i s physi cal l y pr esent . Ot her comment er ssuppor t ed al l owi ng f eedi ng assi st ant s t o f eed r esi dent s i n t hei r r ooms,ci t i ng t he f act t hat many of t he most f r ai l r esi dent s do not go to t hedi ni ng r oom and ar e l east l i kel y t o get adequat e assi st ance wi t heat i ng. Numerous comment ers ci t ed exampl es of bedf ast r esi dents, unabl et o f eed themsel ves or r each the f ood, r ecei vi ng no hel p at meal t i me,af t er whi ch t he t r ay i s r emoved, unt ouched by t he resi dent .



Response: We share comment ers' concerns about adequat e super vi si onof f eedi ng assi st ant s t o ensur e t he saf et y of r esi dent s. We ar e equal l yconcer ned, however , t hat t hose r esi dent s who ar e unabl e or unwi l l i ng togo t o a congr egate di ni ng area r ecei ve needed f eedi ng assi st ance i nt hei r r ooms. We ar e conf i dent t hat t he nur se i n char ge, usi ng hi s orher pr of essi onal j udgment i n assessi ng resi dent s who ar e appr opr i at ef or f eedi ng assi st ance, wi l l be abl e t o sel ect r esi dent s who can saf el ybe f ed i n thei r own rooms.

Comment : An organi zat i on r epr esent i ng nur si ng home empl oyees not edt hat nur si ng st af f i s al r eady overworked and super vi si ng f eedi ngassi st ant s woul d onl y add to t he bur den. Anot her comment er i ndi catedt hat t he pr oposed supervi si on r equi r ement woul d f ur t her bur den RNs andLPNs because t hey woul d have to st ay i n t he di ni ng r oom dur i ngmeal t i mes and t hi s woul d l i mi t t hei r avai l abi l i t y el sewher e i n t hef aci l i t y.

Response: Adequat e super vi sor y st af f i s j ust one f act or t hat af aci l i t y needs t o consi der when deci di ng whet her or not t o use f eedi ngassi st ant s. I f a f aci l i t y chooses to use pai d f eedi ng assi st ant s, i t

woul d be t he f aci l i t y' s responsi bi l i t y t o ensur e t hat i t has suf f i ci entRNs and LPNs avai l abl e t o adequat el y super vi se f eedi ng assi st ant swi t hout addi ng undue bur den on t he st af f . When usi ng f eedi ngassi st ant s, t her e wi l l be a need f or a f aci l i t y to bal ance t he i ncreasei n st af f avai l abl e t o meet r esi dent needs wi t h t he i ncr eased need t osuper vi se t hese assi st ant s.

Training

State-Approved Training Course

Comment : Sever al pr ovi ders asked whether f aci l i t i es woul d be abl et o hi r e pai d f eedi ng assi st ant s i f t he St at e does not appr ove at r ai ni ng pr ogr am f or f eedi ng assi st ant s. Many pr ovi der s suppor t edgi vi ng f aci l i t i es maxi mum f l exi bi l i t y to i mpl ement t he pr oposal wi t houtl engthy st ate approval r equi r ement s. One comment er suggest ed t hat wer equi r e al l st at es t o mandat e f eedi ng assi st ant pr ogr ams i n al lf aci l i t i es.

Ot her comment er s bel i eved t hat , bef ore f aci l i t i es may opt t o usef eedi ng assi st ant s, St ates shoul d be abl e t o deci de whet heri mpl ement i ng f eedi ng assi st ant pr ogr ams i s i n the best i nt er est of t heSt at e or consi st ent wi t h St at e l aw.

Sever al pr ovi ders, pr ovi der organi zat i ons, and St at es asked t hat wer emove t he r equi r ement t hat a t r ai ni ng cour se f or f eedi ng assi st ant s beSt at e appr oved, ci t i ng pot ent i al bur den on St at es, cost , and del ays i ni mpl ement i ng f eedi ng progr ams. One Stat e wi t h a l arge number of

f aci l i t i es and a shor t age of r esour ces was concer ned about t hepotent i al bur den of approvi ng a l arge number of f eedi ng programs.Comment ers, i nst ead, suggest ed t hat we r equi r e t hat an i ndi vi dualcompl ete a t r ai ni ng cour se that meet s t he r equi r ement s of Sec.483. 160. I n t hi s case, t he f aci l i t y woul d mai nt ai n document at i on ofcompl i ance wi t h t he r equi r ement s and sur veyors woul d r evi ew t het r ai ni ng r ecor ds at annual sur veys.

Many st at es and pr ovi der s asked f or cl ar i f i cat i on on ourexpectat i ons i n t erms of st ate appr oval . They wondered whet her other



ent i t i es, such as communi t y col l eges, woul d be per mi t t ed t o of f er t het r ai ni ng. One comment er noted t hat t r avel t o communi t y col l eges andcost woul d di scour age i ndi vi dual s f r om t aki ng t he t r ai ni ng. Ther e wasal so a quest i on about t he f r equency wi t h whi ch a st ate woul d need tor evi ew or r eappr ove a f eedi ng assi st ant progr am. Anot her comment ersuggest ed t hat we of f er more speci f i c gui dance t o st at es t o assi st t hemi n est abl i shi ng cr i t er i a f or t r ai ni ng pr ogr ams and other s suggest edusi ng est abl i shed model s f r om Wi sconsi n and Nor t h Dakota.

Response: We have chosen t o retai n t he r equi r ement t hat Statesappr ove t r ai ni ng pr ogr ams f or f eedi ng assi st ant s. We bel i eve t hat t hi swi l l gi ve St at es t he necessar y cont r ol and f l exi bi l i t y to str uctur eappr oval pr ocesses f or t r ai ni ng pr ogr ams t o f i t t he needs of eachSt at e. St at es t hat have l ar ge number s of f aci l i t i es and r esour ces t hatare st r etched t o t he l i mi t may want t o mi ni mi ze any bur den associ atedwi t h St at e appr oval of t r ai ni ng pr ogr ams, whi l e St at es wi t h f ewerf aci l i t i es may str uct ur e appr oval i n a ver y di f f er ent way.

However , St at es al so have t he f l exi bi l i t y not t o i mpl ement apr ogr am f or appr oval of f eedi ng assi st ant t r ai ni ng pr ogr ams. I f a St at e

does not i mpl ement an appr oval pr ogr am, t he resul t i s t hat f aci l i t i esi n t hat St at e wi l l not be abl e t o hi r e any pai d f eedi ng assi st ant s.

Training Content

Comment : We r ecei ved a vari et y of comment s on t r ai ni ng, i ncl udi ngr equest s f or addi t i onal r equi r ement s, r emoval of r equi r ement s, andcl ar i f yi ng changes. Many comment ers asked t hat we pr ovi de morespeci f i ci t y on t r ai ni ng r equi r ement s and est abl i sh a mi ni mum number ofhour s of t r ai ni ng. Suggest i ons f or hour s of t r ai ni ng r anged f r om 5 t o75.

Response: We bel i eve t hat bei ng over l y pr escr i pt i ve on t he cont entof t r ai ni ng i s unnecessar y, woul d r educe f l exi bi l i t y t o of f er t heset r ai ni ng pr ogr ams, and woul d unnecessar i l y l i mi t t he abi l i t y of St at esand pr ovi ders t o devel op t hese pr ogr ams wi t hi n t he scope of t hei rconsi der abl e knowl edge. However , t o ensur e that t r ai ni ng i s notconduct ed i n a superf i ci al manner , we ar e r evi si ng Sec. 483. 160( a) t or equi r e t hat a t r ai ni ng cour se f or f eedi ng assi st ant s i ncl ude, at ami ni mum, 8 hour s of t r ai ni ng.

Comment : A f ew comment er s suggest ed t hat we speci f y i n the t ext oft he r egul at i on t hat a f eedi ng assi st ant must ``successf ul l y' ' compl et et he ent i r e t r ai ni ng cour se bef or e he or she i s qual i f i ed t o work wi t hres i dent s i n t he f aci l i t y.

Response: We agree wi t h t he comment ers t hat successf ul compl et i onof t he t r ai ni ng cour se i s essent i al and ar e r evi si ng Sec.

483. 35( h) ( 2) ( i ) by addi ng t he wor d ``successf ul . ' ' We bel i eve that i ti s r easonabl e t o expect t hat a f eedi ng assi st ant wi l l successf ul l ycompl et e t he t r ai ni ng cour se bef ore worki ng di r ect l y wi t h r esi dent s.

Thi s i s a basi c saf et y precaut i on t o ensure t hat r esi dent s arepr ot ect ed. Af t er compl et i on of t r ai ni ng, a f aci l i t y may want t o sl owl yease a f eedi ng assi st ant i nt o the work by f eedi ng a resi dent who needsmi ni mal assi st ance, as Nort h Dakot a does.

Comment : Many commenter s advocated requi r i ng a competency t estbef ore f eedi ng assi st ant s are per mi t t ed t o wor k wi t h resi dent s.



Response: We are not i ncl udi ng a r equi r ement f or a compet ency t esti n t he f i nal r ul e. We bel i eve t hat t he i nst r uct or or super vi sor y nur sewi l l be abl e to assess t he compet ency of t r ai ned f eedi ng assi st ant s.

Comment : Sever al comment ers obj ect ed t o the i ncl usi on of t heHei ml i ch Maneuver i n the t r ai ni ng cour se and i t s use by f eedi ngassi st ant s. They were concer ned t hat i t s use by a r obust f eedi ngassi st ant on a f r ai l r esi dent mi ght r esul t i n r i b f r actur es or ot heri nj ur i es. Comment er s emphasi zed t hat onl y nur si ng st af f shoul ddetermi ne t he need f or , and admi ni st er , t he Hei ml i ch Maneuver . I nst ead,t hey suggest ed t hat t he t r ai ni ng cour se emphasi ze the need f or f eedi ngassi st ant s t o recogni ze symptoms t hat shoul d be i mmedi atel y report ed t ol i censed super vi sor y st af f f or f ur t her acti on.

Response: The Hei ml i ch Maneuver i s an emergency pr ocedure t hat i st aught t o the publ i c, as wel l as medi cal personnel . I t seems r easonabl et o retai n t hi s t r ai ni ng r equi r ement i n vi ew of t he f act t hat nur seai des ar e t r ai ned t o use t hi s procedur e and they may al so be st r ongi ndi vi dual s. Pr oper t r ai ni ng i s essent i al and f eedi ng assi st ant s wi l lr ecei ve t he same t r ai ni ng on the Hei ml i ch Maneuver as nur se ai des.

Al so, exper i enced RNs t el l us t hat t r ai ni ng i n handl i ng emer genci eswi l l emphasi ze t he need f or a f eedi ng assi st ant t o cal l f or hel pi mmedi at el y, and t hen, i f necessary, begi n a pr ocedur e l i ke t heHei ml i ch.

Comment : One comment er suggest ed t hat , i f a f aci l i t y uses a f eedi ngassi st ant under an ar r angement wi t h anot her or gani zat i on, t he f aci l i t ymust ver i f y t hat t he f eedi ng assi st ant has successf ul l y compl eted t het rai ni ng.

Response: Sect i on 483. 35( h) ( 2) al r eady pr ovi des f or t hi s. I t sayst hat , i f a f aci l i t y uses a pai d f eedi ng assi stant , t he f aci l i t y mustensure t hat t he i ndi vi dual has compl et ed a St at e- appr oved t r ai ni ngcour se. The bur den of pr oof i s on t he f aci l i t y t o ensur e that anyf eedi ng assi st ant i t uses i s pr oper l y tr ai ned.

Comment : Comment ers suggest ed a number of addi t i ons t o t he generalt r ai ni ng r equi r ement s. One suggest i on was t o r equi r e t hat t r ai ni ngpr ogr ams expl i ci t l y i ncl ude f eedi ng pr obl ems of t he cogni t i vel yi mpai r ed, si nce 60- 70 per cent of nur si ng home r esi dent s are cogni t i vel yi mpai r ed. Ot her suggest i ons i ncl uded t r ai ni ng i n dement i a, f ood anddr ug i nt eract i ons, di et consi st enci es, how much and how t o f eed,r esi dent pr ef er ences, di f f i cul t y swal l owi ng, and emphasi s on per f or mi ngonl y f eedi ng t asks f or whi ch t r ai ni ng has been pr ovi ded. A consi st entconcern of comment ers was a need f or a t r ai ni ng emphasi s on r ecogni t i onand pr event i on of emer gency si t uat i ons associ at ed wi t h f eedi ng, such asdysf unct i onal swal l owi ng, t r acheal aspi r at i on, esophageal obst r uct i on,

and other potent i al l y sever e emer gency si t uat i ons.

Response: I t i s i mpor t ant t o not e t hat t he t r ai ni ng cour ser equi r ement s pr oposed i n Sec. 483. 160 are mi ni mum r equi r ement s. St atesand f aci l i t i es are f r ee to add t o t hose r equi r ement s. However , many oft he t r ai ni ng addi t i ons suggest ed by comment ers appear t o be more usef uli n t he t r ai ni ng of nur se ai des t han f eedi ng assi st ant s, who wi l l f eedr esi dent s wi t hout any si gni f i cant eat i ng pr obl ems.



Comment : Several commenter s suggest ed t hat we addr ess payment f ort r ai ni ng i n t he same way t hat we do i n t he regul at i ons f or nur se ai des.One comment er asked that we pr ohi bi t f aci l i t i es f r om char gi ng pot ent i alf eedi ng assi st ant s f or t r ai ni ng. Anot her asked i f a f aci l i t y mayr equi r e t hat a tr ai ned f eedi ng assi st ant r epay the f aci l i t y f ort r ai ni ng i f he or she l eaves? A comment er asked i f a f aci l i t y canr equi r e t hat a t r ai ned f eedi ng assi st ant work f or a set per i od of t i me.

Response: J udgi ng f r ompr ovi der comment s r ecei ved, t her e wi l l be ast r ong demand f or f eedi ng assi st ant s and i t i s unl i kel y t hat f aci l i t i eswi l l want t o char ge f or t r ai ni ng. Gener al l y, t hese posi t i ons wi l l bepar t t i me and wi l l not r equi r e extensi ve t r ai ni ng t hat woul d be cost l yf or t he f aci l i t y. We t hi nk i t i s unnecessar y t o amend t he r egul at i onst o pr ovi de f or payment pr ovi si ons si mi l ar t o t hose f or nur se ai des.Wi t h r egar d t o a f aci l i t y ent er i ng i nt o a cont r act wi t h a f eedi ngassi st ant t hat woul d r equi r e that i ndi vi dual t o wor k f or a cer t ai nper i od of t i me, t her e i s not hi ng i n our r egul at i ons t hat woul d pr ohi bi tt hi s pr acti ce. Thi s i s st r i ctl y bet ween t he f aci l i t y and t he f eedi ngassi stant .

Qualifications of InstructorsComment : Many i ndi vi dual comment ers and prof essi onal organi zat i ons

asked t hat we est abl i sh st andar ds or qual i f i cat i ons f or i nst r uct or s oft he t r ai ni ng progr am. Comment ers suggest ed numerous l i censed orcer t i f i ed heal t h car e pr of essi onal s who coul d conduct t he t r ai ni ng,i ncl udi ng RNs, r egi st er ed di et i t i ans, l i censed physi cal t her api st s,l i censed speech t her api st s, and occupat i onal t her api st s. Di et i t i ansar gued that t hey have t he exper t i se i n f ood and nut r i t i on i ssues i nl ong- t er m car e set t i ngs, ar e t r ai ned t o t each sel f - hel p f eedi ngdevi ces, and basi c rest or at i ve f eedi ng ser vi ces, ci t i ng est abl i shedmanual s and mater i al s t hat woul d support t hi s pract i ce. Occupat i onalt her api st s ar gued t hat t hey ar e t r ai ned t o mat ch an anal ysi s ofdi sabi l i t i es wi t h ef f ecti ve i nt er vent i ons, r esour ces and adapt at i ons.

Sever al comment ers st r ongl y r ecommended t hat we pr ohi bi t f eedi ngassi st ant s f r om t eachi ng each ot her on- t he- j ob.

Response: I t i s appar ent t hat a number of opt i ons ar e avai l abl e i nt er ms of t he var i et y of l i censed or cer t i f i ed heal t h car e pr of essi onal st hat may be qual i f i ed t o conduct t r ai ni ng f or f eedi ng assi st ant s. Some,RNs and LPNs, ar e empl oyed f ul l t i me i n f aci l i t i es and woul d beavai l abl e wi t hout addi t i onal cost t o conduct t he t r ai ni ng. Di et i t i ansmay be empl oyed by a f aci l i t y f ul l t i me, part t i me, or on a consul t antbasi s. Ot her heal t h car e pr of essi onal s may be avai l abl e at addi t i onalcost ; however we bel i eve t hat i t woul d be i nappr opr i at e to per mi t af eedi ng assi st ant t o t r ai n anot her . Consi st ent wi t h t he f l exi bi l i t y f orSt at es t o devel op a St ate- appr oved t r ai ni ng pr ogr am, we ar e def er r i ng

t o St at es t he deci si on as t o whi ch i ndi vi dual s woul d be qual i f i ed t ot each t he f eedi ng assi st ant t r ai ni ng.

Maintenance of Records

Comment : Sever al comment ers poi nted out t hat t her e i s nor equi r ement f or st at es t o mai nt ai n a f or mal r egi st r y of f eedi ngassi st ant s or t o check wi t h ot her st at es f or backgr ound i nf or mat i on.One comment er suggest ed t hat st at es repor t i nf ormat i on on f eedi ngassi st ant s t o t he nur se ai de r egi st r y and pr ovi de t hi s i nf or mat i on t of aci l i t i es f or hi r i ng pur poses. Ot her s suggest ed t hat we requi r e



f aci l i t i es t o check wi t h t he nur se ai de r egi st r y bef or e empl oyi ngi ndi vi dual s as f eedi ng assi st ant s i n case t he i ndi vi dual had wor ked asa nur se ai de pr evi ousl y.

Response: We have deci ded t o i ncl ude onl y nurse ai des i n t he nur seai de regi st r y, l ar gel y because t he l aw i s so speci f i c about t her equi r ement s. Al so, we bel i eve i t i s not necessar y t o f ur t her bur denSt at es by requi r i ng t hem t o est abl i sh and mai nt ai n a separ at e regi st r yf or f eedi ng assi st ant s. As we expl ai n l at er i n t he pr eambl e, st at es ar eal r eady r equi r ed by Sec. 488. 335 t o r evi ew and i nvest i gate al lal l egat i ons of abuse, negl ect , and mi sappr opr i at i on of r esi dentpr oper t y. Thi s i nf ormat i on can be accessed by any hi r i ng f aci l i t y.Faci l i t i es need t o scr een f eedi ng assi st ant s, as any ot her empl oyee, t ot r y t o ensur e that i ndi vi dual s have no hi st or y t hat woul d pr ecl udet hei r i nt eract i on wi t h f rai l el derl y r esi dent s.

Comment : Sever al comment ers r eport ed t hat t here i s no pr ovi si on f orf eedi ng assi stant s t rai ned i n one f aci l i t y, ci t y, or stat e t o carr yt hat t r ai ni ng f or war d so t hat i t does not have t o be repeat ed. Ther e i sno requi r ement f or a f aci l i t y to r equest a copy of an i ndi vi dual ' s

t r ai ni ng r ecor d bef or e he or she i s hi r ed as a f eedi ng assi st ant . Acomment er suggest ed t hat we est abl i sh a r equi r ement f or st ates t o haver eci pr oci t y agr eement s wi t hi n each st ate or bet ween st at es.

Response: I t i s not our i nt ent t hat i ndi vi dual s repeat t r ai ni ngwhen movi ng t o another f aci l i t y. However , we bel i eve t hat i t i sunnecessar y to est abl i sh extensi ve r egul at ory pr ovi si ons f or r equest i ngr ecor ds or f or st at e r eci pr oci t y agr eement s i n t hi s case. As wi t h anyot her j ob appl i cant , a f eedi ng assi st ant shoul d i ndi cat e wher e he orshe was l ast empl oyed and a hi r i ng f aci l i t y may cont act t he f ormerempl oyer t o veri f y empl oyment and t r ai ni ng. St ates are cur r ent l yr equi r ed t o r evi ew al l egat i ons of abuse, negl ect , or mi sappr opr i at i onof r esi dent pr oper t y. A hi r i ng f aci l i t y shoul d be abl e t o cont act t hest at e f or t hat i nf or mat i on.

Reporting Abuse, Neglect, and Misappropriation of Residents' Property

Comment : Commenter s had a number of suggest i ons concerni ng pr oposedSec. 483. 160( c), whi ch r equi r es a f aci l i t y t o r epor t t o t he st at e al li nci dent s of a pai d f eedi ng assi st ant who has been f ound to negl ect orabuse a r esi dent , or mi sappr opr i at e a resi dent ' s pr oper t y. That sect i onal so r equi r es a st at e t o mai nt ai n a r ecor d of al l r epor t ed i nci dent s.One st at e r eport ed t hat i t al r eady has a r equi r ement f or cr i mi nalbackgr ound checks and a l aw r equi r i ng t hat f aci l i t i es r epor tal l egat i ons of abuse and negl ect . Ot her comment ers suggest ed l anguagechanges to t he t ext . One comment er not ed t hat Sec. 483. 160( c) i si nconsi st ent wi t h Sec. 488. 335, whi ch r equi r es a st at e t o revi ew al l

al l egat i ons of r esi dent negl ect , abuse, and mi sappr opr i at i on ofpr oper t y, and f ol l ow pr ocedur es i n Sec. 488. 332. Sect i on 488. 332r equi r es a st at e t o est abl i sh pr ocedur es t o i nvest i gat e compl ai nt s ofpar t i ci pat i on requi r ement s.

Response: We agree wi t h the comment er r egardi ng r equi r ement s i npr oposed Sec. 483. 160( c) . Par agr aph ( c) i s unnecessary because i tr epeat s cer t ai n pr ovi si ons of exi st i ng Sec. 488. 335. Si nce Sec.488. 335 al r eady est abl i shes st at e r equi r ement s f or r evi ew of



al l egat i ons of negl ect , abuse, mi sappr opr i at i on of pr oper t y, andpr ocedur es f or i nvest i gat i on of compl ai nt s and hear i ngs, we ar er emovi ng pr oposed par agr aph ( c) i n Sec. 483. 160.

Definition of Paid Feeding Assistant

Comment : Many comment ers obj ect ed t o t he t erm, f eedi ng assi st ant ,sayi ng t hat i t has a pej or at i ve connot at i on and i t l acks sensi t i vi t y t ot he el der l y. Ot her s t hought t hat t he t er m f ai l ed t o i ncl ude t hei mpor t ance of f l ui d i nt ake. Comment ers suggest ed a var i ety ofal t er nat i ves, i ncl udi ng t he f ol l owi ng: meal assi st ant ; f ood andhydr at i on ai de or assi st ant ; nour i shment ai de, nut r i t i on assi st ant ,nut r i t i onal ai de, nut r i t i on- hydr at i on assi st ant ; di ni ng assi st ant ; andr esi dent assi st ant .

Response: The commenter s make a good poi nt , whi ch we had notr ecogni zed when dr af t i ng t he pr oposal . However, t he t erm, f eedi ngassi st ant , was wi del y used by st ates and organi zat i ons bef ore ourpr oposal . Rat her t han change the ter m i n t he r egul at i ons, we suggestt hat f aci l i t i es and st at es use what ever t er m t hey pr ef er .

I V. Pr ovi si ons of t he Fi nal Regul at i ons

For t he most par t , t hi s f i nal r ul e i ncor por at es t he pr ovi si ons oft he pr oposed r ul e. The f ol l owi ng pr ovi si ons of t hi s f i nal r ul e di f f erf r om t he pr oposed r ul e:

[ sbul l ] We ar e r eor gani zi ng and r evi si ng Sec. 483. 35( h) so t hatpar agr aph ( h) ( 1) appl i es t o St at e appr oval of t r ai ni ng cour ses f orf eedi ng assi st ant s. We are addi ng t he r equi r ement t hat a f eedi ngassi st ant must successf ul l y compl et e a St at e- appr oved t r ai ni ng cour se,and do so bef ore f eedi ng r esi dent s.

[ sbul l ] Al so, i n r evi sed Sec. 483. 35( h) ( 1) , we ar e cl ar i f yi ng t hata f aci l i t y may use a pai d f eedi ng assi st ant i f i t i s consi st ent wi t hSt at e l aw.

[ sbul l ] I n r evi sed Sec. 483. 35( h) ( 2) , we ar e r evi si ng t hesuper vi si on r equi r ement t o r emove t he wor d, ``di r ect , ' ' f r om t hephrase, ``di rect supervi si on. ' '

[ sbul l ] Al so, i n r evi sed Sec. 483. 35( h) ( 2) , we ar e r emovi ng t her equi r ement t hat a supervi sory nur se be i n t he uni t or on t he f l oorwher e t he f eedi ng assi st ance i s f ur ni shed and i s i mmedi at el y avai l abl et o gi ve hel p, i f necessar y. I n pl ace of t hat sent ence, we ar e addi ngt he requi r ement t hat a f eedi ng assi st ant cal l a super vi sory nur se f orhel p dur i ng an emergency on the resi dent cal l syst em.

[ sbul l ] I n r evi sed Sec. 483. 35( h) , we are addi ng a new par agr aph( 3) concer ni ng resi dent sel ect i on cr i t er i a t o repl ace pr oposed Sec.483. 35( h) ( 1) ( i i ) . I n new par agr aph ( 3) , we ar e r epl aci ng t he t er m,``cl i ni cal condi t i on' ' wi t h t he phr ase, ``compl i cat ed f eedi ngpr obl em. ' '

[ sbul l ] I n Sec. 483. 35, we al so speci f y t hat a compl i cat ed f eedi ngprobl em i ncl udes, but i s not l i mi t ed t o, di f f i cul t y swal l owi ng,r ecur r ent l ung aspi r at i ons, and t ube or par ent er al / I V f eedi ngs.



[ sbul l ] Al so, i n Sec. 483. 35, we pr ovi de t hat a f aci l i t y must baser esi dent sel ect i on on t he char ge nur se' s assessment and t he r esi dent ' sl at est assessment and pl an of car e.

[ sbul l ] I n Sec. 483. 160( a) , we ar e addi ng a r equi r ement t hat t heSt at e- appr oved t r ai ni ng cour se i ncl ude a mi ni mum of 8 hour s of t r ai ni ngcover i ng t he t opi cs l i st ed i n Sec. 483. 160( a) .

[ sbul l ] I n Sec. 483. 160( c) , we ar e r emovi ng t he r equi r ement t hat af aci l i t y r epor t t o t he St at e al l i nci dent s of a pai d f eedi ng assi st antwho has been f ound to negl ect or abuse a resi dent , or mi sappr opr i ate ar esi dent ' s pr oper t y, and t hat a St at e must mai nt ai n a r ecor d of al lr eport ed i nci dent s. Thi s par agr aph unnecessar i l y dupl i cat es exi st i ngr equi r ement s i n Sec. 488. 335, Act i on on compl ai nt s of r esi dent negl ectand abuse, and mi sappr opr i at i on of r esi dent pr oper t y.

V. Collection of Information Requirements

Under t he Paper work Reduct i on Act of 1995, we ar e requi r ed t opr ovi de 30- day not i ce i n t he Feder al Regi st er and sol i ci t publ i c

comment bef ore a col l ect i on of i nf ormat i on r equi r ement i s submi t t ed tot he Of f i ce of Management and Budget ( OMB) f or r evi ew and appr oval . I norder t o f ai r l y eval uate whether OMB shoul d approve an i nf ormat i oncol l ect i on, sect i on 3506( c) ( A) of t he Paper work Reduct i on Act of 1995r equi r es t hat we sol i ci t comment on t he f ol l owi ng i ssues:

[ sbul l ] The need f or t he i nf or mat i on col l ect i on and i t s usef ul nessi n car r yi ng out t he pr oper f unct i ons of our agency.

[ sbul l ] The accur acy of our est i mat e of t he i nf ormat i on col l ect i onbur den.

[ sbul l ] The qual i t y, ut i l i t y, and cl ar i t y of t he i nf ormat i on t o becol l ected.

[ sbul l ] Recommendat i ons t o mi ni mi ze the i nf ormat i on col l ect i onbur den on the af f ect ed publ i c, i ncl udi ng aut omat ed col l ect i ont echni ques.

Nur si ng homes i n two St ates cur r ent l y use f eedi ng assi st ant s andei ght other St at es have expr essed an i nt er est i n i mpl ement i ng t hi spol i cy. Whi l e publ i c comment s f r om nur si ng homes and pr ovi deror gani zat i ons i ndi cat ed st r ong suppor t f or t he use of f eedi ngassi st ant s, onl y 13 St ates r esponded to t he pr oposal . Some St atesi ndi cat ed i nt erest and other s had concer ns about t he cost ofi mpl ement at i on and ot her i ssues, so we do not now have a bet t er i dea ofhow many St ates wi l l choose t o appr ove the use of f eedi ng assi st ant s i n

nur si ng homes. I n addi t i on, i t r emai ns a f aci l i t y opt i on, so we st i l ldo not know how many f aci l i t i es i n whi ch St at es wi l l choose thi sopt i on, nor do we know how many f eedi ng assi st ant s woul d be used byeach f aci l i t y. Ther e ar e appr oxi mat el y 17, 000 nur si ng homes i n thenat i on, and t hey ar e not evenl y di st r i but ed wi t hi n St at es. Wi sconsi nr epor t ed t hat about 25 percent of nur si ng homes i n the St ate usedf eedi ng assi st ant s. On a nat i onwi de basi s, we bel i eve t hat i t i sr easonabl e t o pr oj ect t hat 20 per cent of f aci l i t i es wi l l use f eedi ngassi st ant s. We ar e sol i ci t i ng publ i c comment on each of t hese i ssues



f or t he f ol l owi ng sect i ons of t hi s document t hat cont ai n i nf or mat i oncol l ect i on requi r ement s:

Sect i on 483. 160( b)

1. Requirement

A f aci l i t y must mai nt ai n a r ecor d of al l i ndi vi dual s, used by t hef aci l i t y as f eedi ng assi st ant s, who have successf ul l y compl et ed t het r ai ni ng cour se f or pai d f eedi ng assi st ant s.

2. Burden

We est i mat e that 20 per cent of nur si ng homes may i mpl ement t hi spol i cy ( 20 per cent of 17, 000 = 3, 400 f aci l i t i es/ r espondent s) . I f weassume t hat each f aci l i t y wi l l hi r e t wo f eedi ng assi st ant s, t hi sr esul t s i n a t otal of 6, 800 f eedi ng assi st ant s. Dependi ng on t he methodchosen by a f aci l i t y to col l ect t hi s i nf or mat i on, we bel i eve t hat eachf aci l i t y ( r espondent ) woul d spend no more t han 30 mi nut es per mont h ( 6hour s per year ) ent er i ng f eedi ng assi st ant i nf or mat i on i nt o i t s r ecor d-

keepi ng syst em. Some mont hs, f aci l i t i es may have no i nf ormat i on t o add.Wi t h 3, 400 f aci l i t i es at 6 hour s/ year , t he t ot al woul d be 20, 400 hour sf or f aci l i t i es. Usi ng a cl er i cal wage cost of $10 per hour , t he t ot alf aci l i t y bur den i s esti mat ed t o be $204, 000.

We are submi t t i ng a copy of r egul at i on Sec. 483. 160 t o OMB f or i t sr evi ew of t he i nf or mat i on col l ect i on r equi r ement s. The r evi si on i s notef f ect i ve unt i l OMB has appr oved i t .

I f you comment on t hese i nf ormat i on col l ect i on and r ecor dkeepi ngr equi r ement s, pl ease mai l copi es di r ect l y t o t he f ol l owi ng addr esses:

Cent er s f or Medi car e & Medi cai d Ser vi ces, Of f i ce of I nf ormat i onServi ces, I nf ormat i on Technol ogy I nvest ment Management Gr oup, At t n. :

J ul i e Br own, Room C5- 16- 03, 7500 Secur i t y Boul evard, Bal t i mor e, MD21244- 1850; and

Of f i ce of I nf ormat i on and Regul at ory Af f ai r s, Of f i ce of Management andBudget , Room 10235, New Execut i ve Of f i ce Bui l di ng, Washi ngt on, DC20503, At t n: Br enda Agui l ar , CMS Desk Of f i cer .

Comment s submi t t ed to OMB may al so be emai l ed to t he f ol l owi ngaddr ess: emai l : bagui l ar@omb. eop. gov; or f axed t o OMB at ( 202) 395-6974.

VI. Regulatory Impact Statement

A. Overall Impact

We have exami ned t he i mpact s of t hi s r ul e as requi r ed by Execut i veOr der 12866 (September 1993, Regul atory Pl anni ng and Revi ew) , t heRegul at or y Fl exi bi l i t y Act ( RFA) ( Sept ember 16, 1980, Pub. L. 96- 354) ,sect i on 1102( b) of t he Soci al Secur i t y Act , t he Unf unded MandatesRef orm Act of 1995 (Pub. L. 104- 4) , and Execut i ve Or der 13132.

Execut i ve Or der 12866 di r ect s agenci es t o assess al l cost s andbenef i t s of avai l abl e r egul at or y al t er nat i ves and, i f r egul at i on i s



necessary, t o sel ect r egul at ory appr oaches t hat maxi mi ze net benef i t s( i ncl udi ng pot ent i al economi c, envi r onment al , publ i c heal t h and saf et yef f ect s, di st r i but i ve i mpact s, and equi t y) . A r egul at or y i mpactanal ysi s ( RI A) must be pr epared f or maj or r ul es wi t h economi cal l ysi gni f i cant ef f ect s ( $100 mi l l i on or mor e i n any 1 year ) . Thi s r ul e i snot a maj or r ul e. The cost s of usi ng f eedi ng assi st ant s wi l l be cover edby exi st i ng Medi care payment and, most l i kel y Medi cai d payment ,dependi ng on how a St ate est abl i shes payment r ates. Ski l l ed nurs i ngf aci l i t i es recei ve an al l - i ncl usi ve per di em Medi car e payment r at e f oreach r esi dent ' s car e. Thi s i ncl udes al l cost s ( r out i ne, anci l l ar y, andcapi t al ) of cover ed ski l l ed nur si ng f aci l i t y ser vi ces f ur ni shed t obenef i ci ar i es under Par t A of t he Medi car e pr ogr am. Ski l l ed nur si ngf aci l i t i es wi l l not r ecei ve addi t i onal Medi car e payment f or t he cost sof usi ng f eedi ng assi st ant s.

Medi cai d payment s f or nur si ng f aci l i t i es are est abl i shed by eachSt at e. Ther ef ore, i t woul d be up t o i ndi vi dual St at es t o det er mi newhet her t hey woul d need to change t hei r payment r ates f or t hosef aci l i t i es t hat use f eedi ng assi st ant s and how t he r at es woul d bechanged. However , because f eedi ng assi st ant s wi l l l i kel y be pai d at a

mi ni mum wage, whi ch i s l ess t han t he wage pai d t o cert i f i ed nurseai des, f aci l i t i es par t i ci pat i ng i n Medi car e and Medi cai d t hat usef eedi ng assi st ant s may i ncur l ess cost t han i f t hey had hi r edaddi t i onal cer t i f i ed nur se ai des t o per f or m f eedi ng and hydr at i ondut i es.

St at e cost s associ at ed wi t h f eedi ng assi st ant t r ai ni ng pr ogr ams areconsi dered admi ni st r at i ve expenses and ar e f unded under Medi cai d wi t hmat chi ng f unds at 50 per cent Feder al f i nanci al par t i ci pat i on. Anyi nf ormat i on we have on potent i al St at e cost s of i mpl ement i ng f eedi ngassi st ant pr ogr ams comes f r om St ates t hat have used such pr ogr ams i nt he past . One St at e, Wi sconsi n, has a wel l - st r uct ur ed pr ogr am and hasexperi enced r el at i vel y mi ni mal costs. One regi st er ed nur se spendsappr oxi matel y 10 percent of her t i me r evi ewi ng and appr ovi ng f aci l i t yf eedi ng assi st ant t r ai ni ng pr ogr ams. Thi s r epr esent s 10 per cent of af ul l - t i me equi val ent posi t i on ( FTE) , whi ch i s r epor t ed by Wi sconsi n tobe a cost of about $7, 000 per year . At a t i me when t he use of f eedi ngassi st ant s was hi ghest , a quar t er of Wi sconsi n' s 420 nur si ng homes, or100 to 110 f aci l i t i es, used f eedi ng assi st ant s. The number of f eedi ngassi st ant s used by each f aci l i t y var i es accor di ng t o the si ze of t hehome, wi t h the maxi mumnumber est i mated t o be 5 f or a l arge, 200- t o250- bed home. Feedi ng assi st ant s ar e t ypi cal l y pai d at t he same mi ni mumwage. The number of hour s each f eedi ng assi st ant works at a f aci l i t y i sal so var i abl e and di f f er ent f or each wor ker and f aci l i t y. Fur t her , somef aci l i t i es use onl y exi sti ng staf f as t rai ned f eedi ng assi stant s.Because of t he number of hours worked by each f eedi ng assi st ant i svar i abl e, we do not have an exact est i mat e of t he t otal cost t o

Wi sconsi n f or usi ng f eedi ng assi st ant s. However , t hi s summar y ofWi sconsi n' s pr ogr am may be hel pf ul t o ot her St ates, whi ch ar ei nt er est ed i n est abl i shi ng f eedi ng assi st ant pr ogr ams.

The RFA r equi r es agenci es t o anal yze opt i ons f or r egul at or y r el i efof smal l busi nesses. For pur poses of t he RFA, smal l ent i t i es i ncl udesmal l busi nesses, nonpr of i t organi zat i ons, and smal l government

j ur i sdi ct i ons. Most hospi t al s and most ot her provi ders and suppl i er sar e smal l ent i t i es, ei t her by nonpr of i t st at us or by havi ng r evenues of



$6 t o $29 mi l l i on i n any 1 year . For pur poses of t he RFA, al l l ong- t er mcar e f aci l i t i es ar e consi der ed t o be smal l ent i t i es. I ndi vi dual s andSt at es ar e not i ncl uded i n t he def i ni t i on of a smal l ent i t y. The Smal lBusi ness Admi ni st r at i on consi der s 62 per cent of l ong t er m car ef aci l i t i es to meet t hei r def i ni t i on of smal l ent i t y ( t hose f ac i l i t i eswi t h t otal r evenues of $11. 5 mi l l i on or l ess i n any 1 year. We havedet er mi ned t hat t hi s rul e wi l l af f ect t hese ent i t i es, but , i n gener al ,we expect any cost t o be cover ed by Medi car e and Medi cai d pr ogrampayments.

I n addi t i on, sect i on 1102( b) of t he Act r equi r es us t o pr epar e ar egul at ory i mpact anal ysi s i f a r ul e may have a si gni f i cant i mpact ont he oper at i ons of a subst ant i al number of smal l r ur al hospi t al s. Thi sanal ysi s must conf orm t o the pr ovi si ons of sect i on 604 of t he RFA. Forpur poses of sect i on 1102( b) of t he Act , we def i ne a smal l r ur alhospi t al as a hospi t al t hat i s l ocat ed out si de of a Met r opol i t anSt at i st i cal Ar ea and has f ewer t han 100 beds. Thi s f i nal r ul e does notaf f ect smal l r ural hospi t al s.

For t hese reasons, we ar e not pr epar i ng anal yses f or ei t her t he RFA

or sect i on 1102( b) of t he Act because we have det ermi ned t hat t hi s r ul ewi l l not have a si gni f i cant economi c i mpact on a subst ant i al number ofsmal l ent i t i es or a si gni f i cant i mpact on t he oper at i ons of asubst ant i al number of smal l r ur al hospi t al s.

Sect i on 202 of t he Unf unded Mandat es Ref orm Act of 1995 al sor equi r es t hat agenci es assess ant i ci pat ed cost s and benef i t s bef or ei ssui ng any rul e t hat may resul t i n expendi t ur e i n any 1 year by St at e,l ocal , or t r i bal gover nment s, i n t he aggr egat e, or by t he pr i vat esector, of $110 mi l l i on. Thi s f i nal r ul e wi l l not have a cost gr eat ert han $110 mi l l i on on t he government s ment i oned or on t he pr i vatesect or. I n gener al , we bel i eve t hat exi st i ng Medi car e and Medi cai dpayment s wi l l cover t he f aci l i t y cost s of usi ng f eedi ng assi st ant s.Cost s associ at ed wi t h sur veys of l ong t er m car e f aci l i t i es ar eFeder al l y f unded, as are cost s of St at e appr oval of t r ai ni ng pr ogr ams.

Execut i ve Or der 13132 est abl i shes cert ai n r equi r ement s t hat anagency must meet when i t promul gat es a f i nal r ul e that i mposessubst ant i al di r ect r equi r ement costs on St ate and l ocal gover nment s,pr eempt s St at e l aw, or ot her wi se has Feder al i sm i mpl i cat i ons. Webel i eve t hat t hi s r ul e cont r i but es t o St at e f l exi bi l i t y by gi vi ngSt at es t he opt i on t o al l ow t he use of f eedi ng assi st ant s, cont r ol overhow t o st r uct ur e t he pr ocess of t he appr oval of f aci l i t y f eedi ngassi st ant pr ogr ams, and over el ement s of t r ai ni ng, i ncl udi ng i nst r uct orqual i f i cat i ons. I n t hi s way, St at es can establ i sh pol i c i es t hat f i tt hei r uni que ci r cumst ances. We bel i eve t hat t hi s r ul e wi l l not have asubst ant i al ef f ect on St at e or l ocal gover nment s.

B. Ant i ci pat ed Ef f ects

These provi si ons wi l l af f ect l ong t erm car e f aci l i t i es. We expectt he pr ovi si ons t o be a subst ant i al benef i t bot h t o f aci l i t i es t hat ar eshort - st af f ed and t o r esi dent s who need hel p wi t h eat i ng and dr i nki ng.By usi ng f eedi ng assi st ant s t o hel p r esi dent s wi t h eat i ng and dr i nki ng,f aci l i t i es can use t r ai ned, cer t i f i ed nur se ai des to per f or m ot her ,more compl ex r esi dent care t asks.



Based on t he l arge number of comment s we r ecei ved f r om nur si nghomes i n a var i ety of States, we now bel i eve t hat t her e i s wi despreadsuppor t f or t he pr oposal and wi despr ead i nt ent t o i mpl ement t hepr ovi si ons. However , because thi s i s an opt i onal pr ovi si on, and someStat es may have l egal bar r i ers t o i mpl ement at i on, we do not know howmany St ates or f aci l i t i es may i mpl ement t hese provi si ons, or how manyf eedi ng assi st ant s wi l l be used by f aci l i t i es. Based on publ i ccomment s, we ant i ci pat e that some f aci l i t i es may hi r e no addi t i onalst af f as f eedi ng assi st ant s, opt i ng i nst ead t o use exi st i ng st af f whosepr i mar y f unct i on i s not di r ect car e of r esi dent s, such asadmi ni st r at i ve or acti vi t i es st af f . We bel i eve that f eedi ng assi st antt r ai ni ng most l i kel y wi l l be conducted by exi st i ng f aci l i t y st af f andt hat t her e wi l l be some nomi nal t r ai ni ng cost s t o t he f aci l i t y si ncet r ai ni ng requi r es t i me away f r om ot her dut i es t hat other st af f may havet o per f or m.

State-Approved Training Programs

We requi r e that a f eedi ng assi st ant successf ul l y compl et e an 8- hourSt at e- appr oved t r ai ni ng cour se, whi ch meet s t he Federal r equi r ement s i n

Sec. 483. 160(a) . We have est abl i shed no r equi r ement s on how States ar et o appr ove t hese pr ogr ams, t her eby gi vi ng each St at e the f l exi bi l i t y todeci de what met hod makes t he most sense i n t erms of use of i t sr esour ces. There are sever al ways i n whi ch St at es may approach appr ovalof t r ai ni ng pr ogr ams. St at es mi ght choose t o devel op a model t r ai ni ngpr ogr am t hat compl i es wi t h Feder al r equi r ement s and requi r e t hat anyf aci l i t y that t r ai ns and uses f eedi ng assi st ant s use t hat speci f i cprogr am. One model mi ght be based on an exi st i ng t r ai ni ng progr amal r eady est abl i shed, such as t hose conduct ed i n Wi sconsi n or Nort hDakot a. A St at e mi ght choose to do a paper r evi ew of each f aci l i t y' st r ai ni ng pr ogr am, or t he St at e mi ght i nsi st on a si t e vi si t t o revi ew af aci l i t y' s pr ogr am. Last l y, a St at e mi ght i ni t i al l y deem eachf aci l i t y' s t r ai ni ng pr ogr am appr oved and then revi ew t he pr ogr am whent he f aci l i t y i s next surveyed. For some of t hese opt i ons, a St at e mayneed addi t i onal st af f hour s t o revi ew and appr ove t r ai ni ng pr ogr ams.However, St ates al r eady r evi ew and approve t r ai ni ng pr ogr ams f or nurseai des, so t her e i s an exi st i ng admi ni st r at i ve st r uct ur e i n pl ace. Ther ei s t he potent i al f or i ncreased St at e cost s associ at ed wi t h r evi ew andappr oval of f aci l i t y f eedi ng assi st ant pr ogr ams. However , any cost wi l ldepend on t he approval method that i s chosen by each St at e.

1. Effects on the Medicare and Medicaid programs.

Ther e are appr oxi mat el y 17, 000 f aci l i t i es nat i onal l y. Long t ermcar e f aci l i t i es t hat par t i ci pat e i n t he Medi car e and Medi cai d pr ogr amsmust pr ovi de t he necessary car e and ser vi ces t o r esi dent s so t hat t heyat t ai n or mai nt ai n t he hi ghest pr act i cabl e physi cal , ment al , and

psychosoci al wel l bei ng. To do t hi s, f aci l i t i es must empl oy suf f i ci entst af f on a 24- hour basi s, i ncl udi ng nur si ng st af f , admi ni st r at i ve,medi cal l y- r el at ed soci al ser vi ces, di et ar y, housekeepi ng, andmai nt enance st af f .

The Medi car e program pays f or ski l l ed nursi ng f aci l i t y ser vi ces t oel i gi bl e benef i ci ar i es t hr ough a pr ospect i ve payment system t hat cover sal l cost s of cover ed ser vi ces f ur ni shed t o r esi dent s on a per di embasi s. Thi s Medi car e SNF PPS per di em payment r at e i s based, i n par t ,on l evel s of car e and r esour ces r equi r ed and r ecei ved by resi dent s. The



payment r ate cover s al l care r equi r ed and r ecei ved by a resi dent anddoes not r equi r e that t asks per f ormed by a st af f per son f i t wi t hi n adi r ect or i ndi r ect car e cat egor y. Ther ef or e, t he Medi car e pr ogr am woul dnot pay a ski l l ed nursi ng f aci l i t y any addi t i onal f unds i f t he f aci l i t ychooses t o use f eedi ng assi st ant s.

Medi cai d payment s f or nur si ng f aci l i t i es are est abl i shed by eachSt at e. Ther ef ore, i t woul d be up t o i ndi vi dual St at es t o det er mi newhet her t hey woul d need to change t hei r payment r ates f or t hosef aci l i t i es t hat use f eedi ng assi st ant s and how t he r at es woul d bechanged.

C. Al t er nat i ves Consi der ed

Ther e has been a cont i nui ng short age of cer t i f i ed nur se ai des i nr ecent year s, al ong wi t h a shor t age of RNs and LPNs wi l l i ng to work i nnur si ng homes. Cer t i f i ed nur se ai des per f or m t he maj or i t y of r esi dentcar e i n a l ong t er m car e f aci l i t y and ar e t he l owest pai d wor ker s,whi l e RNs and LPNs r ecei ve hi gher wages commensur at e wi t h thei radvanced tr ai ni ng, exper i ence, and super vi sor y r esponsi bi l i t i es.

One al t er at i ve t o the use of pai d f eedi ng assi st ant s i s t o br oadent he hour s dur i ng whi ch meal s are ser ved so t hat everyone i s not f ed att he same t i me wi t hi n a one- hour meal t i me. Expanded meal ser vi ce,cover i ng per haps a 3- hour meal t i me, or a rest aur ant model , wher e meal sar e avai l abl e most of t he t i me, woul d al l ow exi st i ng st af f more t i me t ohel p f eed r esi dent s. However , t hi s opt i on al r eady exi st s i nr egul at i ons, and ot her t han a f ew i nnovat i ve f aci l i t i es, nur si ng homeshave chosen not t o use t hi s method. The cur r ent pref erence of mostnur si ng homes i s f or an i nst i t ut i onal appr oach i n whi ch meal s areserved t o al l r esi dent s ear l y morni ng, noon, and eveni ng at f i xedhour s. As a r esul t , t he nur si ng home i ndust r y pr ef er s t he use off eedi ng assi st ant s r ather t han an expanded meal servi ce. The ot heral t er nat i ve i s not t o publ i sh a r egul at i on on t he use of f eedi ngassi st ant s and, i nst ead, make gr eat er use of vol unt eer s t o assi st wi t hf eedi ng. The use of vol unt eer s t o assi st wi t h f eedi ng assi st ance i sper mi t t ed i n t he cur r ent r egul at i ons. However , i t i s quest i onabl ewhet her f aci l i t i es coul d f i nd suf f i ci ent number s of vol unt eer s t o meett hei r needs.

D. Conclusion

We bel i eve t hat bot h r esi dent s and pr ovi der s wi l l benef i t f r omt hese pr ovi si ons. Resi dent s wi l l r ecei ve more assi st ance wi t h eat i ngand dr i nki ng, bot h at meal s and at snack t i me. Faci l i t i es wi l l be abl et o use exi st i ng st af f t o assi st at meal t i mes and hi r e addi t i onal st af ft o meet t he needs of r esi dent s, f r eei ng cer t i f i ed nur se ai des t o

per f or m mor e compl ex t asks t hat r equi r e t hei r t r ai ni ng.

I n accor dance wi t h t he pr ovi si ons of Execut i ve Or der 12866, t hi sr egul at i on was r evi ewed by the Of f i ce of Management and Budget .

Li st of Subj ects

42 CFR Par t 483



Gr ant pr ogr ams- heal t h, Heal t h f aci l i t i es, Heal t h pr of essi ons, Heal t hr ecords, Medi cai d, Medi car e, Nur si ng homes, Nut r i t i on, Report i ng andr ecordkeepi ng r equi r ement s, Saf et y.

42 CFR Par t 488Heal t h f aci l i t i es, Medi car e, Report i ng and r ecor dkeepi ng r equi r ement s.

0

For t he r easons set f or t h i n the preambl e, CMS i s amendi ng 42 CFRchapt er I V as set f or t h bel ow:

0

A. Par t 483 i s amended as f ol l ows:PART 483- - REQUI REMENTS FOR STATES AND LONG TERM CARE FACI LI TI ES

Subpar t B- - Requi r ement s f or Long Ter m Car e Faci l i t i es

0

1. The aut hor i t y ci t at i on f or par t 483 cont i nues t o read as f ol l ows:Aut hori t y: Secs. 1102 and 1871 of t he Soci al Secur i t y Act ( 42 U. S. C.1302 and 1395hh) .

0

2. I n Sec. 483. 35, t he i nt r oduct ory text i s r epubl i shed, par agr aph ( h)i s r edesi gnated as paragraph ( i ) , and a new paragr aph ( h) i s added t or ead as f ol l ows:

Sec. 483. 35 Di et ar y ser vi ces.

The f aci l i t y must provi de each r esi dent wi t h a nour i shi ng,pal at abl e, wel l - bal anced di et t hat meet s t he dai l y nut r i t i onal andspeci al di et ar y needs of each r esi dent .

* * * * *( h) Pai d f eedi ng assi st ant s— ( 1) St at e- appr oved t r ai ni ng cour se. A f aci l i t y may use a pai d f eedi ngassi st ant , as def i ned i n Sec. 488. 301n of t hi s chapt er , i f - -( i ) The f eedi ng assi st ant has successf ul l y compl et ed a St at e- appr ovedt r ai ni ng cour se that meet s t he r equi r ement s of Sec. 483. 160 bef oref eedi ng r esi dent s; and ( i i ) The use of f eedi ng assi st ant s i s consi st entwi t h St at e l aw.

( 2) Super vi si on.( i ) A f eedi ng assi st ant must wor k under t he super vi si on of a regi st er ednur se ( RN) or l i censed pr act i cal nur se ( LPN) . ( i i ) I n an emer gency, af eedi ng assi st ant must cal l a super vi sory nur se f or hel p on t her esi dent cal l syst em.

( 3) Resi dent sel ecti on cr i t er i a.( i ) A f aci l i t y must ensur e t hat a f eedi ng assi st ant f eeds onl yr esi dent s who have no compl i cated f eedi ng probl ems. ( i i ) Compl i cated



( 5) Saf ety and emergency pr ocedur es, i ncl udi ng t he Hei ml i chmaneuver.

( 6) I nf ect i on cont rol .( 7) Resi dent r i ght s.( 8) Recogni zi ng changes i n r esi dent s t hat ar e i nconsi st ent wi t h

t hei r normal behavi or and t he i mpor t ance of r eport i ng t hose changes t ot he super vi sor y nur se.

( b) Mai nt enance of r ecor ds. A f aci l i t y must mai nt ai n a r ecor d ofal l i ndi vi dual s, used by t he f aci l i t y as f eedi ng assi st ant s, who havesuccessf ul l y compl et ed t he t r ai ni ng cour se f or pai d f eedi ng assi st ant s.

0B. Par t 488, subpar t E i s amended as f ol l ows:

PART 488- - SURVEY, CERTI FI CATI ON, AND ENFORCEMENT PROCEDURES

Subpar t E- - Sur vey and Cer t i f i cat i on of Long Ter m Car e Faci l i t i es

01. The aut hor i t y ci t at i on f or par t 488 cont i nues t o read as f ol l ows:

Aut hori t y: Secs. 1102 and 1871 of t he Soci al Secur i t y Act ( 42U. S. C. 1302 and 1895hh) .

02. Sect i on 488. 301 i s amended by addi ng a new def i ni t i on of `` Pai df eedi ng assi st ant ' ' i n al phabet i cal or der t o read as f ol l ows:

Sec. 488. 301 Def i ni t i ons.

As used i n thi s subpar t - -* * * * *

Pai d f eedi ng assi st ant means an i ndi vi dual who meet s t her equi r ement s speci f i ed i n Sec. 483. 35( h) ( 2) of t hi s chapt er and who i spai d t o f eed r esi dent s by a f aci l i t y, or who i s used under anarr angement wi t h another agency or organi zat i on.* * * * *

( Cat al og of Feder al Domest i c Assi st ance Pr ogr am No. 93. 773,Medi car e- - Hospi t al I nsurance; and Progr am No. 93. 774, Medi car e- -Suppl ement ary Medi cal I nsur ance Progr am)

Dat ed: May 22, 2003. Thomas A. Scul l y,Admi ni st r at or, Cent er s f or Medi car e & Medi cai d Ser vi ces.

Appr oved: J une 24, 2003. Tommy G. Thompson,

Secret ar y.[ FR Doc. 03- 24362 Fi l ed 9- 25- 03; 8: 45 am]

BI LLI NG CODE 4120- 03- U



Appendix C State Contacts




State Contact Agency Information on State Websites Description of

http://www.dhfs.state.wi.us/caregiver/FeedingAssistant/FAstandCurr.htm

Standardized F

http://www.dhfs.state.wi.us/RL_DSL/Publications/04-008.htm Feeding Assist

https://www.dhfs.state.wi.us/caregiver/FeedingAssistant/FAprog

Apprvl.htm

Training Appro

WV West Virginia Department of Health and Human

Resources, Office of Health Facility Licensure and

Certification

http://www.wvdhhr.org/ohflac/NursingHome/Resources/Feeding

%20assistant%20guidelines%20-%207May04.pdf

Guidelines for

WY Wyoming Department of Health, Office of Healthcare

Licensing and Surveys

http://wdh.state.wy.us/Media.aspx?mediaId=682 Nutrition Suppo

Manual

WI Department of Health and Family Services, Office ofCaregiver Quality

Note: N/A - Information not Available

Source: Abt Associates Inc. September 2008



DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-12-25

Baltimore, Maryland 21244-1850

Center for Medicaid and State Operations/Survey and Certification GroupRef: S&C-07-30

DATE: August 10, 2007 (revised)

TO: State Survey Agency Directors

FROM: DirectorSurvey and Certification Group

SUBJECT: Nursing Homes - Issuance of New Tag F373 (Paid Feeding Assistants) as Part ofAppendix PP, State Operations Manual, Including Training Materials

***The effective date of this guidance has been changed to coincide with the earlier than anticipated

release of the official transmittal on August 17, 2007***

Memorandum Summary

• New guidance for long-term care surveyors regarding the requirements for Paid

Feeding Assistants will be published August 17, 2007.

• An advance copy of this guidance and training materials are attached.

• This training packet is to be used to train all surveyors who survey nursing homes by the implementation date.

The Centers for Medicare & Medicaid Services (CMS) published a final rule on September 26,2003 (68 FR 55528) that allowed long-term care facilities to use paid feeding assistants under

certain conditions. States must approve training programs for feeding assistants using federalrequirements as minimum standards. Feeding assistants must successfully complete a State-approved training program and work under the supervision of a registered nurse or licensed

practical nurse. The intent of this rule is to provide more residents with help in eating and

drinking and reduce the incidence of unplanned weight loss and dehydration.

New surveyor guidance including interpretive guidelines and severity guidance has been

developed for the implementation of this regulation through the new Tag F373 – Paid Feeding

Assistants. This new guidance for surveying long-term care facilities will become effectiveAugust 17, 2007. At that time, a final copy of this new guidance will be available at

http://www.cms.hhs.gov/Transmittals/ and ultimately incorporated into Appendix PP of the State

Operations Manual.

We are providing you with an advance copy of the new Paid Feeding Assistant guidance whichcontains the interpretive guidelines, investigative protocol, and deficiency categorization. The

interpretive guidelines provide terminology and information regarding the use of paid feeding

assistants that surveyors will need to apply the regulation. The investigative protocol explainsthe investigation’s objectives and procedures surveyors will need for their investigation and

determination of compliance. The deficiency categorization provides criteria for the

determination of the correct level of the severity of outcome to any resident(s) from any deficient

practice(s) found at Tag F373.

http://www.cms.hhs.gov/Transmittals/

http://www.cms.hhs.gov/Transmittals/



Page 2 – State Survey Agency Directors

Also attached to this memo are training materials for the new Tag F373. These training

materials are to be used to train all surveyors who survey nursing homes by the implementation

date. We encourage training to be conducted in person with group discussion to optimize

learning. However, if this is not feasible to meet the needs of your surveyors, it is acceptable touse other methods. The training materials may also be used to communicate with provider

groups and other stakeholders.

Regional Office (RO) and State Survey Agency (SA) training coordinators must document the

completion of training on this new guidance for all RO and State nursing home surveyors within

their region utilizing the Learning Management System (LMS) – a course code will be providedthrough one of the Survey and Certification Regional Training Administrator (RTA)

teleconferences.

Enclosed with this memorandum are the following files:

• Advance copy of Paid Feeding Assistants guidance (F373) – (PDF);

•

Training Instructor Guide – (PDF); and• PowerPoint presentation file – (PowerPoint file).

For questions on this memorandum, please contact Susan Joslin at 410-786-3516 or via email [email protected]).

Effective Date: This guidance is expected to be published in final on August 17, 2007.

Training: The materials should be distributed immediately to all State Agencies and training

coordinators.

/s/Thomas E. Hamilton

cc: Survey and Certification Regional Office Management

Enclosures: Advance copy of Paid Feeding Assistants guidance (F373)

PowerPoint Presentation

Training Instructor Guide

mailto:[email protected]

mailto:[email protected]



State Operations Manual, Appendix P, Task 2, Entrance Conference – ADVANCE COPY

Ask the administrator if the facility utilizes paid feeding assistants. If yes, request further

information about how and where the paid feeding assistants receive their training. Determine

whether the training for the paid feeding assistant was provided through a State-approved

training program by qualified professionals as defined by State law, with a minimum of eighthours of training.

Request the names of staff (including agency staff) who have successfully completed training for

paid feeding assistants, and who are currently assisting selected residents with eating meals

and/or snacks;

NOTE: Paid feeding assistants must work under the supervision of a registered nurse

(RN) or licensed practical nurse (LPN). Therefore, if a facility has a nursing waiver, that

facility cannot use paid feeding assistants when a licensed nurse is not available.



State Operations Manual, Appendix P, Investigative Protocol: Dining and Food Service, Procedures Part 4:

• If you observe a resident who is being assisted by a staff member to eat or drink, and the

resident is having problems with eating or drinking, inquire if the staff member who is

assisting them is a paid feeding assistant. If so, follow the procedures at tag F373.



(5) Safety and emergency procedures, including the Heimlich maneuver.

(6) Infection control.

(7) Resident rights.

(8) Recognizing changes in residents that are inconsistent with their normal behavior and

the importance of reporting those changes to the supervisory nurse.

(b) Maintenance of records. A facility must maintain a record of all individuals used by the

facility as feeding assistants, who have successfully completed the training course for paid

feeding assistants.

Intent: §483.35(h)

The intent of this regulation is to ensure that employees who are used as paid feeding assistants

are:

•

Properly trained (in accordance with the requirements at §483.160, including

maintenance of records);

• Adequately supervised;

• Assisting only those residents without complicated feeding problems and who have been

selected as eligible to receive these services from a paid feeding assistant; and

• Providing assistance in accordance with the resident’s needs, based on individualized

assessment and care planning.

Definitions

“Paid feeding assistant” is defined in regulation at 42 C.F.R. § 488.301 as “an individual who

meets the requirements specified in 42 C.F.R. § 483.35(h)(1)(i) of this chapter and who is paid to

feed residents by a facility, or who is used under an arrangement with another agency or

organization.”

NOTE: The regulation uses the term, “paid feeding assistant.” While we are not using any

other term, facilities and States may use whatever term they prefer, such as dining

assistant, meal assistant, resident assistant, nutritional aide, etc. in order to conveymore respect for the resident. Facilities may identify this position with other titles;

however, the facility must be able to identify those employees who meet the

requirements under the paid feeding assistant regulation. These requirements do not

apply to family and/or volunteers who may be providing the resident with assistance.



“Resident call system,” for the purposes of this requirement includes not only the standard hard-

wired call system but other means in an emergency situation by which a paid feeding assistant

can achieve timely notification of a supervisory nurse (when not present in the room).

Overview

The intent behind the use of paid feeding assistants by nursing homes is to provide nutrition and

hydration support to residents who may be at risk for unplanned weight loss and dehydration.

These are residents with no complicated problems associated with eating or drinking, who

cannot or do not eat independently due to physical or cognitive disabilities, or those who simply

need cueing or encouragement to eat. The use of paid feeding assistants is intended to

supplement certified nurse aides, not substitute for nurse aides or licensed nursing staff. Use of

paid feeding assistants is an option for nursing homes if their State approves the use of paid

feeding assistants and establishes a mechanism to approve training programs for paid feeding

assistants.

Interpretive Guidelines §483.35(h)

NOTE: The regulation at §483.30(a)(2) requires that "Except when waived under paragraph (c)

of this section, the facility must designate a licensed nurse to service as a charge nurse on each

tour of duty." In the paid feeding assistant regulation, the term charge nurse is used to identify

who is responsible for assessing the eligibility of a resident to be assisted by a paid feeding

assistant. The regulation also states that a paid feeding assistant must work under the

supervision of an RN or LPN, and they must call the supervisory nurse in case of an emergency.

Therefore, a facility that has received a waiver and does not have either an RN or LPN available

in the building cannot use paid feeding assistants during those times.

Charge Nurse Assessment of Resident Eligibility for Feeding Assistance

The facility must base resident selection on the charge nurse’s (RN, or LPN if allowed by State

law) current assessment of the resident's condition and the resident’s latest comprehensive

assessment and plan of care. Charge nurses may wish to consult with interdisciplinary team

members, such as speech-language pathologists or other professionals, when making their

decisions.

Paid feeding assistants are permitted to assist only those residents who have no complicated

eating or drinking problems. This includes residents who are dependent in eating and/or those

who have some degree of dependence, such as needing cueing or partial assistance, as long as

they do not have complicated eating or drinking problems.

Paid feeding assistants are not permitted to assist residents who have complicated eating

problems, such as (but not limited to) difficulty swallowing, recurrent lung aspirations, or who

receive nutrition through parenteral or enteral means. Nurses or nurse aides must continue to

assist residents to eat or drink who require the assistance of staff with more specialized training.



Facilities may use paid feeding assistants to assist eligible residents to eat and drink at meal

times, snack times, or during activities or social events as needed, whenever the facility can

provide the necessary supervision.

Supervision (by RN/LPN) of Paid Feeding Assistants

A paid feeding assistant must work under the supervision of an RN or LPN. While we are not prescribing the exact means by which facility RNs and LPNs assert their supervisory

responsibilities, we expect that facilities will do so in a way that avoids negative outcomes for

their residents. If a facility chooses to use paid feeding assistants, it is the facility’s

responsibility to ensure that adequate supervisory nursing staff are available to supervise these

assistants.

The supervisory nurse should monitor the provision of the assistance provided by paid feeding

assistants to evaluate on an ongoing basis:

•

Their use of appropriate feeding techniques;

• Whether they are assisting assigned residents according to their identified eating and

drinking needs;

• Whether they are providing assistance in recognition of the rights and dignity of the

resident; and

• Whether they are adhering to safety and infection control practices.

Adequate supervision by a supervising nurse does not necessarily mean constant visual contact

or being physically present during the meal/snack time, especially if a feeding assistant is

assisting a resident to eat in his or her room. However, whatever the location, the feeding

assistant must be aware of and know how to access the supervisory nurse immediately in the

event that an emergency should occur. Should an emergency arise, a paid feeding assistant must

immediately call a supervisory nurse for help on the resident call system.

The charge nurse and the supervisory nurse may or may not be the same individuals.

Resident Call System

The regulatory language at this Tag states that, "in an emergency, a feeding assistant must call a

supervisory nurse for help on the resident call system." Residents may be receiving assistance in

eating or drinking in various locations throughout the facility, such as dining areas, activity

rooms, or areas such as patios or porches in which a resident call system is not readily

available. The resident call system requirement at §483.70(f), F463, only specifies that the call

system be available in the residents rooms and bathrooms. Regardless of where a resident is

being assisted to eat or drink, in the case of an emergency, the facility needs to have a means for

a paid feeding assistant to obtain timely help of a supervisory nurse. Therefore, for the purposes

of this requirement, a “resident call system” includes not only the standard hard-wired or



wireless call system but other means in an emergency situation by which a paid feeding assistant

can achieve timely notification of a supervisory nurse.

Use of Existing Staff as Paid Feeding Assistants

Facilities may use their existing staff to assist eligible residents to eat and drink. These

employees must have successfully completed a State-approved training course for paid feedingassistants, which has a minimum of 8 hours of training as required in 483.160. Staff may

include, for example, administrative, clerical, housekeeping, dietary staff, or activity specialists.

Employees used as paid feeding assistants, regardless of their position, are subject to the same

training and supervisory requirements as any other paid feeding assistant.

Maintenance of Training Records

The facility must maintain a record of all employees used by the facility as paid feeding

assistants. The record should include verification that they have successfully completed a State-

approved training course for paid feeding assistants.

Investigative Protocol

Use of Paid Feeding Assistants

Objectives

The objectives of this protocol are to determine, for a facility that uses paid feeding assistants:

• If individuals used as paid feeding assistants successfully completed a State-approved

training course;

• If sampled residents who were selected to receive assistance from paid feeding assistants

were assessed by the charge nurse and determined to be eligible to receive these services

based on the latest assessment and plan of care; and

• If the paid feeding assistants are supervised by an RN or LPN.

Use

This protocol is used when a surveyor identifies concerns through observation; interview with

residents, family, or staff; or record review, that the facility may not be following the

requirements regarding paid feeding assistants, including proper training and supervision of feeding assistants, and proper selection of residents for feeding assistance.

Procedures

Briefly review the comprehensive assessment and interdisciplinary care plan to guide

observations to be made. The team coordinator assigns one surveyor to obtain the facility’s



records of all employees used by the facility as paid feeding assistants, for review for completion

of the training course for paid feeding assistants.

Observations

If the concern was discovered through resident or family interview, observe the resident whilethey are being assisted to eat and drink by a paid feeding assistant. Determine if the assistant is

using proper feeding technique and is providing the type of assistance specified in the resident’s

care plan. Note the resident’s condition and observe for the presence of complicated feeding

problems.

If the concern was discovered through observations that were already made, only conduct

additional observations if necessary to complete the investigation.

Interviews

Resident and Family Interviews

If a resident is selected for this protocol through surveyor observation that they are having

difficulties in eating or drinking and they are being assisted by a paid feeding assistant,

interview the resident if the resident is interviewable. Ask questions to gain information about

why the resident is receiving these services and the resident's experience with receiving

assistance to eat and drink. If concerns are identified, inquire if they have reported these

problems to a nurse. If the resident is not interviewable, ask these questions of a family member.

If the concern was discovered through resident or family interviews already conducted as part of

Task 5D, focus any additional interview on questions specific to the investigation.

Paid Feeding Assistant Interviews

Interview the paid feeding assistant who was assisting the selected resident. Determine whether

there are concerns with the paid feeding assistant’s training, supervision, or the selection of the

resident such as:

• What training did you successfully complete in providing feeding assistance?

• What information did you receive about this resident's needs for assistance (type of

assistance needed, any precautions)?

•

In what manner and by whom are you supervised while assisting residents?

• What issues/problems do you report (such as coughing, choking, changes in the

resident’s usual responses, or level of alertness) and to whom do you report?

• What would you do if an emergency occurred while you were assisting a resident to eat

or drink? Who would you contact and how would you contact them if you are not near

the resident call system?



Charge Nurse Interview

Interview the charge nurse who is responsible for assessing this resident as eligible to receive

assistance by a paid feeding assistant. Ask:

•

How they determined that this resident has no complicated feeding problems and iseligible to be assisted by a paid feeding assistant;

• How they determine that each eligible resident remains free of emergent complicated

feeding problems;

• Who supervises paid feeding assistants and how is the supervision accomplished;

• Describe the processes in place to handle emergencies when a supervisor is not

present in the area where paid feeding assistants are assisting residents.

Supervisory Nurse Interview

Interview the nurse who is supervising the resident during the meal or other times when the paid

feeding assistant is assisting the resident to eat or drink. Ask how they supervise paid feeding

assistants.

Review of Assessment of Eligibility to Receive Assistance from a Paid Feeding Assistant

Determine whether the charge nurse based her/his assessment of the resident's ongoing

eligibility to be assisted by a paid feeding assistant on identification of the current condition of

the resident and any additional or new risk factors or condition changes that may impact on the

resident's ability to eat or drink. This information may be contained in the RAI or in othersupporting documents such as progress notes, etc. The assessment of eligibility to receive

assistance from a paid feeding assistant is ongoing and should be in place from the day of

admission.

Requirements for Training of Paid Feeding Assistants

Determine how the facility identifies that paid feeding assistants have successfully completed a

State-approved training course that meets the requirements of 42 C.F.R. §483.160 before they

are allowed to assist eligible residents with eating and drinking.

If the facility uses temporary (agency) staff as paid feeding assistants, request documentationthat these staff have met the minimum training requirements specified by the State.

Determination of Compliance (Task 6, Appendix P)

The information below should be used by the survey team for their deficiency determination at

Task 6 in Appendix P. The survey team must evaluate the evidence documented during the



survey to determine if a deficiency exists due to a failure to meet a requirement and if there are

any negative resident outcomes or potential for negative outcomes due to the failure.

Synopsis of Regulation (42 C.F.R. 483.35)

The paid feeding assistant requirement has five aspects:

• Staff who are used as paid feeding assistants must have completed a State-approved

training course;

• The facility must base resident selection to be fed by a paid feeding assistant on the

charge nurse’s assessment and resident’s latest assessment and care plan;

•

Paid feeding assistants must work under the supervision of an RN or LPN, and, in an

emergency, must call a supervisory nurse for help on the resident call system;

•

Paid feeding assistants assist only residents who have no complicated health problemsrelated to eating or drinking that make them ineligible for these services; and

•

The facility must maintain a record of all individuals used by the facility as paid feeding

assistants, and must maintain documentation of successful completion of a State-

approved training course by these individuals.

Criteria for Compliance

Compliance with 42 CFR 483.35(h), F373, Paid Feeding Assistants

The facility is in compliance with this requirement if all the following are met:

•

The facility only employs paid feeding assistants who have successfully completed a

State-approved training course before providing assistance;

• The facility selected qualified residents based on the charge nurse’s ongoing assessment

and the latest assessment and plan of care;

•

The facility provides supervision by an RN or LPN;

• The facility provides, in cases of emergency, a working call system (and other means for

areas without a call system) for the paid feeding assistant to summon help in anemergency;

• The facility ensures that the paid feeding assistant only assists residents who have no

complicated health problems related to eating or drinking that make them ineligible for

these services; and



considered when non-compliance has been identified include the following (but are not limited

to):

• 42 CFR 483.15(a), F241, Dignity

o

Determine if staff are attentive and responsive to the resident’s requests, and ifthey provide assistance to eat in a manner that respects the resident’s dignity,

meets needs in a timely manner, and minimizes potential feelings of

embarrassment, humiliation, and/or isolation related to inability to assist

themselves with food or fluid intake.

• 42 CFR 483.20(b), F272, Comprehensive Assessments

o Review whether the facility initially and periodically conducted a comprehensive,

accurate assessment of the resident’s ability to eat and drink with or without

assistance and/or identified a condition that makes the resident ineligible for this

service.

• 42 CFR 483.20(k)(1), F279, Comprehensive Care Plans

o Review whether the facility developed a comprehensive care plan that was based

on the assessment of the resident’s conditions, needs, and behaviors, and was

consistent with the resident’s goals in order to provide assistance with nutrition

and hydration as necessary.

• 42 CFR 483.20(k)(2)(iii), F280, Comprehensive Care Plan Revision

o

Determine if the care plan was reviewed and revised periodically, as necessary,related to eligibility to eat and drink with assistance of a paid feeding assistant.

• 42 CFR 483.25(i)(1), F325, Nutritional Parameters

o Review if the facility had identified, evaluated, and responded to a change in

nutritional parameters, anorexia, or unplanned weight loss, dysphagia, and/or

swallowing disorders in relation to the resident’s ability to eat.

•

42 CFR 483.25(i)(2), F327, Hydration

o

Review if the facility had identified, evaluated, and responded to a change in theresident’s ability to swallow liquids.

• 42 CFR 483.25(a)(3), F312, ADL Assistance for Dependent Residents

o

Determine if staff identified and implemented appropriate measures to provide

food and fluids for the resident who cannot perform relevant activities of daily

living.



• 42 CFR 483.30(a), F353, Sufficient Staff

•

Determine if the facility has qualified staff in sufficient numbers to provide

assistance to eat or drink to those residents who require such assistance. For

residents who are not eligible to receive assistance from paid feeding assistants,

determine if there are sufficient CNAs to provide this assistance to these residentsin a timely fashion.

• 42 CFR 483.75(i)(2), F501, Medical Director

o Determine whether the medical director collaborates with the facility to help

develop, implement, and evaluate resident care policies and procedures based on

current standards of practice, e.g., the use of paid feeding assistants, their

supervision, and the criteria for determining which residents are eligible to

receive assistance to eat or drink from paid feeding assistants.

IV. DEFICIENCY CATEGORIZATION (Part IV, Appendix P)

Once the team has completed its investigation, analyzed the data, reviewed the regulatory

requirement, and identified any deficient practice(s) that demonstrate that non-compliance with

the regulation at F373 exists, the team must determine the severity of the deficient practice(s)

and the resultant harm or potential for harm to the resident. The key elements for severity

determination for F373 are as follows:

1. Presence of harm/negative outcome(s) or potential for negative outcomes because of lack of

appropriate use of paid feeding assistants.

Non-compliance related to an actual or potential harm/negative outcome for F373 mayinclude, but is not limited to:

• A resident who is not eligible to receive these services is assisted by a paid feeding

assistant;

• A resident who is eligible to receive these services is assisted by a paid feeding assistant

and develops coughing and/or choking episodes related to the paid feeding assistant

using poor techniques indicating lack of appropriate supervision.

2. Degree of harm (actual or potential) related to the non-compliance:

Identify how the facility practices caused, resulted in, allowed, or contributed to the actual or

potential for harm:

•

If harm has occurred, determine if the harm is at the level of serious injury, impairment,

death, compromise, or discomfort; or



Severity Level 3 Considerations: Actual Harm that is not Immediate Jeopardy

Level 3 indicates non-compliance that results in actual harm, and can include but may not be

limited to clinical compromise, decline, or the failure to maintain and/or reach the resident’s

highest practicable well-being.

Examples of the facility’s non-compliance that may cause or contribute to negative outcomes at

severity level 3 include, but are not limited to:

• An eligible resident who was assessed to have the potential to improving their eating

ability was assisted to eat by a paid feeding assistant. The assistant provided too much

food too quickly and the resident was pocketing the food in her cheeks. The

resident experienced choking and coughing and subsequently vomited. As a result, the

resident became fearful, refused solid foods, and would only consume liquid dietary

supplements.

NOTE: If severity level 3 (actual harm that is not immediate jeopardy) has been ruled outbased upon the evidence, then evaluate as to whether level 2 (no actual harm with the

potential for more than minimal harm) exists.

Severity Level 2 Considerations: No Actual Harm with potential for more than minimal harm

that is Not Immediate Jeopardy

Level 2 indicates non-compliance that results in a resident outcome of no more than minimal

discomfort and/or has the potential to compromise the resident’s ability to maintain or reach his

or her highest practicable level of well being. The potential exists for greater harm to occur if

interventions are not provided.



• Paid feeding assistants are assisting eligible residents to eat in an area with no call

system, and the supervising nurses are not nearby, but there have been no resident

outcomes; and

• Eligible residents are being assisted to eat by employees who have not successfully

completed a State-approved paid feeding assistant training course and who otherwise by

State law would not be allowed to feed residents (such as RNs, LPNs or CNAs), and there

were no resident negative outcomes.

Severity Level 1: No actual harm with potential for minimal harm

Level 1 is a deficiency that has the potential for causing no more than a minor negative impact

on the resident(s).





• Facility did not maintain a record of employees who had completed a State approved

paid feeding assistant training program and were used by the facility as paid feeding

assistants.



Appendix E Dining Assistant Observation

Tool and Scoring Rules




February 1, 2007

CONTINUOUS QUALITY IMPROVEMENT FOR MEALS: SCORING RULES AND RATIONALE

The information generated by the observational tool can be reported as feeding assistance care qualityindicator scores (e.g., proportion of residents within a facility who had low oral intake but who did not receiveassistance from staff during a particular meal) and used for quality improvement purposes. There are twoprimary advantages of a quality indicator (QI) score. First, a QI score has the potential to highlight care areasin need of improvement. Second, a QI score efficiently summarizes the data into understandable qualitycategories for which feeding assistance can be scored as either “passing” or “failing” for individual residentsand mealtime periods. The percentage of residents who receive a “pass” or “fail” score provides a summarymeasure of the quality of care provision, which is useful for making comparisons within a facility over time (e.g.staff shifts, meals). These types of comparisons inform quality improvement because it provides an objectiveand specific way to track changes in staff behavior and identify problems with care delivery (e.g., specificmeals or days of the week wherein there are quality issues). The rules and rationale that guide the scoring of8 feeding assistance care QIs are presented below. These QIs are operationalized into specific nursing homestaff behaviors that can be reliably observed during meals. The focus on care processes under the directcontrol of nursing home staff is critical to any quality improvement effort, because it is possible for poor clinicaloutcomes to occur (e.g., unintentional weight loss) in the context of optimal care quality. This observationaltool is not intended to comprehensively assess all issues relevant to nutritional care; rather, it provides a toolthat supervisory-level staff can use to monitor the quality of feeding assistance provided to residents as well asthe accuracy of corresponding medical record documentation. Supervisory-level staff should conductobservations during one to three meals (breakfast, lunch, and dinner) per week to effectively monitor theadequacy and quality of daily feeding assistance care provision. The scoring rule for each of the QIs listedbelow reflects a liberal approach that maximizes the opportunity for staff to “pass”.

Feeding Assistance Care Quality Indicators for Meals

1. Staff ability to get residents out of bed and to the dining room for meals.Scoring Rule: Score as “fail” if less than half of the resident population, as defined by those residents capableof oral food and fluid intake (exclude residents who are bed-bound, tube-fed and/or on hospice) is eating themeal in the dining room, or other common location. Count all dining rooms and other common eating area(s).Rationale: Residents eating in the dining room are more likely to receive help to eat from staff, socialinteraction during the meal, and accurate documentation of their percent eaten. Residents are often allowed toeat meals in their rooms in bed, not necessarily due to their own preference but because it is easier for staff.Moreover, residents who eat in their beds are often not positioned properly for eating (semi-reclined), whichplaces them at greater risk for choking. Finally, social isolation during meals may contribute to low oral intakeand depressive symptoms.

2. Staff ability to provide verbal instruction to residents who receive physical assistance at mealtimes. Scoring Rule: Score as “fail” any resident who receives physical assistance to eat from staff without alsoreceiving at least one episode of verbal instruction directed toward eating (e.g., “Please try your beans.”).Rationale: Graduated prompting protocols using verbal instruction increase residents’ independent eatingbehaviors and oral food and fluid intake. Staff often provides excessive physical assistance to residents whocould otherwise eat independently with just verbal instruction. Ideally, the verbal instruction should precedephysical assistance to encourage independence in eating; but, the scoring rule for this indicator allows staff to“pass” if verbal instruction is provided at any point during the meal (before, during or after physical assistance).

3. Staff ability to provide social interaction to all residents during mealtimes .Scoring Rule: Score as “fail” any resident who does not receive at least one episode of social interaction (i.e.,verbal interaction that does not include a specific instruction to eat, “how are you today?”) during the meal.Rationale: Social interaction has been shown to enhance oral food and fluid intake in residents. Socialinteraction during meals is also important to residents’ quality of life and should not be limited to those with loworal intake.

4. Staff ability to provide adequate feeding assistance to residents who receive an oral liquid nutritionalsupplement during mealtimes.



February 1, 2007

RELATED PUBLISHED RESEARCH STUDIES

1. Simmons SF & Reuben D. (2000). Nutritional intake monitoring among nursing home residents: Acomparison of staff documentation, direct observation, and photographs. Journal of the AmericanGeriatrics Society, 48(2):209-213.

2. Simmons SF, Alessi C & Schnelle JF. (2001). An intervention to increase fluid intake in nursing homeresidents: Prompting and preference compliance. The Journal of the American Geriatrics Society,

49(7):926-933.

3. Simmons SF, Osterweil D & Schnelle JF. (2001). Improving food intake in nursing home residents withfeeding assistance: A staffing analysis. Journal of Gerontology: Medical Sciences, 56A(12): M790-M794.

4. Simmons SF, Lim B & Schnelle JF. (2002). Accuracy of Minimum Data Set in identifying residents atrisk for undernutrition: Oral intake and food complaints. Journal of the American Medical Directors’

Association, May/June:140-145.

5. Simmons SF, Babinou S, Garcia E & Schnelle JF. (2002). Quality assessment in nursing homes bysystematic direct observations: Feeding assistance. Journal of Gerontology: Medical Sciences,57A(10):M665-M671.

6. Simmons SF, Lam H, Rao G & Schnelle JF. (2003). Family members’ preferences for nutritioninterventions to improve nursing home residents’ oral food and fluid intake. Journal of the AmericanGeriatrics Society, 51(1):69-74.

7. Simmons SF, Garcia EF, Cadogan MP, Al-Samarrai NR, Levy-Storms LF, Osterweil D & Schnelle JF.(2003). The Minimum Data Set weight loss quality indicator: Does it reflect differences in careprocesses related to weight loss? Journal of the American Geriatrics Society 51(10):1410-1418.

8. Simmons SF, Walker K, Osterweil D. (2004). The effect of Megestrol Acetate on oral food and fluidintake in nursing home residents: A pilot study. Journal of the American Medical Directors’

Association, 5(1):24-30.

9. Schnelle JF, Simmons SF, Harrington C, Cadogan MP, Garcia E & Bates-Jensen B. (2004).Relationship of nursing home staffing to quality of care. Health Services Research, 39(2):225-250.

10. Schnelle JF, Bates-Jensen B, Chu L & Simmons SF. (2004). Accuracy of nursing home medical recordinformation about care process delivery: Implications for staff management and improvement. Journalof the American Geriatrics Society, 52(8):1378-1383.

11. Simmons SF & Schnelle JF. (2004). Individualized feeding assistance care for nursing home residentsStaffing requirements to implement two interventions. Journal of Gerontology: Medical Sciences,59A(9):966-973.

12. Schnelle JF, Osterweil D & Simmons SF. (2005). Improving the quality of nursing home care andmedical record accuracy with direct observational technologies. The Gerontologist 45(5):576-582.

13. Simmons SF & Levy-Storms L. (2006). The effect of dining location on nutritional care quality innursing homes. Journal of Nutrition, Health, & Aging, 9(6):434-439.

14. Simmons SF & Levy-Storms L. (2006). The effect of staff care practices on nursing home residents’preferences: Implications for individualizing care. Journal of Nutrition, Health, & Aging, 10(3):216-221.

15. Simmons SF, Schnelle JF. (2006). Feeding assistance needs of long-stay nursing home residents andthe staff time to provide care. Journal of the American Geriatrics Society, 54(6):919-924.



16. Simmons SF, Patel AV. (2006). Nursing home staff delivery of oral liquid nutritional supplements toresidents at risk for unintentional weight loss. Journal of the American Geriatrics Society, 54(9):1372-1376.

17. Simmons SF, Schnelle JF. (2006). A continuous quality improvement pilot study: Impact on nutritionalcare quality. Journal of the American Medical Directors’ Association, 7(8):480-485.

18. Schnelle JF, Ouslander JG, Simmons SF. Direct observations of nursing home care quality: Doescare change when observed? Journal of the American Medical Directors Association. (In Press).

19. Simmons SF, Bertrand R, Shier V, Sweetland R, Moore T, Hurd D, Schnelle JF. A preliminaryevaluation of the Paid Feeding Assistant regulation: Impact on feeding assistance care process qualityin nursing homes. The Gerontologist. (In Press).

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