Previously, federal regulations did not support the hiring of a single-task unlicensed worker to assist residents in performing activities of daily living, but instead required the use of nursing aides who have completed the requisite 75 hours of training and are certified to perform multiple tasks. Although federal statutory provisions delineate specific criteria for the training and certification of nursing aides utilized in long term care facilities, these provisions do not expressly define "nursing" or "nursing-related" tasks.

CMS concluded that the use of feeding assistants does not conflict with existing statutory requirements that nursing functions be performed by licensed nursing staff or certified nursing assistants (CNAs). To arrive at this conclusion, CMS determined that it is not a nursing or nursing-related task to provide assistance to residents who have "no feeding issues that require any specialized attention."

As long term care facilities have experienced nursing staffing shortages over the past several years, various strategies have been utilized to try and ensure adequate staffing, especially during peak hours. When conducting its staffing study, CMS noted that one variable that seemed to have the most impact on the number of required nursing staff was whether the care needed to be provided within a short, defined time period, such as during morning care and meal times. See Centers for Medicare and Medicaid Services, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II Final Report (December 2001) available at http://www.cms.hhs.gov/medicaid/reports/ rp1201home.asp. CMS further observed that facilities effectively met resident needs during these peak periods by enlisting the support of non-nursing staff.

Wanting to ensure that adequate standards exist "to protect residents from unskilled workers who might injure a resident by not recognizing serious medical complications associated with eating," CMS developed requirements for the use of feeding assistants. In adopting these requirements, CMS relied upon the successful implementation of programs supporting single-task feeding assistants in states such as Wisconsin and North Dakota.

Why Feeding Assistants?
Providing feeding assistance was deemed to be a less complex process than other tasks such as bathing, toileting, or providing dressing changes. Because of the time required to assist a resident in feeding, CMS determined that having additional workers to render this level of care would free CNAs to perform these other, more complex tasks.

Furthermore, CMS believes the use of feeding assistants will reduce the incidence of unplanned weight loss and dehydration, benefits reported in Wisconsin and North Dakota. Interestingly, these program benefits appear to be self-reported findings that have not been validated through research.

Although not expressly stated as a reason for allowing the use of feeding assistants, CMS anticipates facilities would be able to fill such positions utilizing part-time workers, such as retired persons, homemakers, or even older students who are available a few hours per day. For instance, homemakers might have some flexibility to work during the noon meal whereas school students could fill in during the dinner meal.

Key Criteria for Using Feeding Assistants
Feeding Assistants Must Complete a State-approved Course
Federal regulations require the training to include certain topics and be a minimum of eight hours. States have flexibility in determining standards for instructor credentials and specific course content.

The Use of Feeding Assistants Must Be Consistent with State Law
CMS noted the potential conflict in states that expressly define feeding assistance as a nursing task. In establishing federal requirements, CMS was aware that certain states already had laws defining what constitutes a nursing task. CMS chose to allow the terms nursing and nursing-related to remain undefined at the federal level so that each state would continue to have the flexibility to set its own standards.

Resident Selection
Selection of residents for whom the use of a feeding assistant is appropriate is to be based upon the charge nurse's assessment utilizing the resident's current assessment and plan of care. Selection is to include residents primarily needing encouragement or minimal assistance, but not requiring medical attention. CMS cautioned that feeding assistants are not intended to replace CNAs, but rather, should supplement the CNA staff members who have the added necessary training to assist in feeding residents with complicated feeding deficits. Feeding assistants are not to be used with residents who need intravenous or parenteral feedings, have swallowing problems, or have recurrent lung aspirations.

Level of Supervision
CMS requires that feeding assistants work under the supervision of a licensed nurse and receive adequate supervision to avoid negative outcomes. Additionally, since feeding assistants are likely to be working in resident rooms, the onus is on the feeding assistant, when working without direct supervision, to utilize the call system should an emergency or the need for help arise.

Feeding Assistants Versus Certified Nursing Assistants
Similarities

Facilities offering CNA training have the expertise to provide feeding assistant training courses.
Facilities have an obligation to maintain adequate records demonstrating successful completion of the respective training programs.
Mandatory reporting requirements apply to individuals found to have neglected, abused, or misappropriated the property of a resident.

Differences

Because feeding assistants are not performing nursing tasks, feeding assistant hours are not counted as nursing staffing hours.
Since feeding assistants are not nursing staff, there is no requirement that facilities post the number of feeding assistants on duty.
Unlike nursing assistants, who may have resident contact prior to completing their training, feeding assistants must successfully complete the state-approved training course before providing resident care.
There is no federal requirement for a competency examination for feeding assistants.
For facilities who lose the ability to offer CNA training programs as a survey sanction, there is no comparable loss of feeding assistant training programs.
There is no prohibition on charging individuals to attend a feeding assistant training program.

Potential Survey Citation Issues

Surveyor observation of meals reveals a resident coughing or choking. Further review of the records results in a determination that this resident has a diagnosis of dysphagia, requiring the specialized skill of a CNA to assist in chewing and swallowing.
Surveyor review of employee records reveals a lack of documentation that a certain feeding assistant completed the required eight-hour training course.
Surveyor observation during meal times and interviews of facility staff reveals the lack of appropriate supervision of feeding assistants.