The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Division of Health Care Quality
10 West Street, Boston, MA 02111-1212
617-753-8000

MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
RONALD PRESTON
SECRETARY
CHRISTINE C. FERGUSON
COMMISSIONER	
CIRCULAR LETTER   DHCQ: 03-12-437

TO: 	Administrators of Long Term Care Facilities
                           and Directors of Nurse Aide Training Programs

FROM: 	Paul I. Dreyer, Ph.D., Director

DATE: 	December 15, 2003

RE: 		Paid Feeding Assistants in Long Term Care Facilities 

On September 26, 2003, the Centers for Medicare and Medicaid Services (CMS) published final regulations allowing long term care facilities to use paid feeding assistants to supplement the services of certified nurse aides under certain conditions.  The federal regulations provide that states must approve training programs for feeding assistants, using federal requirements 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 is to provide more residents with help in eating and drinking and reduce the incidence of unplanned weight loss and dehydration.

Facilities or nurse aide training programs seeking approval of their feeding assistant training program must complete and return the attestation form in Attachment 1, below, prior to initiating the training of feeding assistants.  The Department will review each attestation form submitted, using the guidelines below and the Curriculum Specifications in Attachment 2, below, as its criteria.  Approval will be granted, for a period not to exceed two years from the date of publication of the federal regulations, to those programs that meet these minimum requirements.

Approval of feeding assistant training programs will continue in effect until the date specified by the Department unless: there is a loss of nurse aide training eligibility under 42 CFR 483.151(b)(2); the Department determines the feeding assistant training program is not being conducted as approved; or, a there is a change in minimum requirements under state or federal regulations.

Long term care facilities using paid feeding assistants must do so in accordance with the guidance contained in Attachment 3, below and the federal regulations on paid feeding assistants at 42 CFR 483 and 42 CFR 488.  This guidance reflects current standards in effect for the staff of long term care facilities providing direct patient care, and is applicable to paid feeding assistants.

Facilities or nurse aide training programs must maintain a record of all individuals who have successfully completed their training course for paid feeding assistants.

Requirements and Restrictions for Training Programs and Providers:

All feeding assistant training programs must meet the minimum curriculum standards as published by the Department of Public Health in Attachment 2, below.  Each program must conduct a comprehensive competency evaluation, consisting of a written knowledge test and a clinical skills demonstration, of each person being trained.  The training program must ensure that only those individuals who can demonstrate a significant understanding of the required skills and knowledge to perform the expected tasks are permitted to become paid feeding assistants.

Any facility subjected to a prohibition of nurse aide training under the provisions under 42 CFR 483.151(b)(2) will likewise be prohibited from conducting paid feeding assistant training.

For programs offered outside of a long term care facility, the training provider must have prior approval to offer certified nursing assistant training pursuant to 42 CFR 483.152.

Competency Evaluation Requirements

The feeding assistant competency evaluation must address each course component as specified in the minimum curriculum guidelines and consist of two components:

1)	A written knowledge test which must evaluate the theoretical knowledge conveyed through the training, but would not necessarily be immediately demonstrated by performing the required tasks; and

2)	A clinical skills demonstration which must consist of a demonstration of all tasks that an individual will be expected to perform as part of his or her function as a paid feeding assistant.

No individual may be considered competent to provide services as a paid feeding assistant until such time as he or she successfully completes a competency evaluation and demonstrates a significant understanding of the tasks and concepts required in this role.

For further information regarding the approval of paid feeding assistant programs, contact Peter Bilodeau at (617) 753-8140. 
Attachment 1:

ATTESTATION FORM

FOR USE BY FACILITIES AND TRAINING PROVIDERS INTENDING TO CONDUCT FEEDING ASSISTANT TRAINING 

TO:     Peter Bilodeau
Department of Public Health, Division of Health Care Quality
10 West Street, 5th Floor
Boston, MA  02111

NAME OF TRAINING PROVIDER: _________________________________________

ADDRESS:				 _________________________________________

__________________________________________

PHONE:				( __________ ) _____________________________

I hereby certify that the following conditions have been reviewed and met:

•	The feeding assistant training program offered by the entity listed above addresses all of the elements and meets the minimum required hours as detailed in the curriculum guidelines for feeding assistant training.

•	This program incorporates a comprehensive competency evaluation, including both a written test of conceptual understanding as well as a demonstration of all relevant skills.

•	All program records, including attendance, skills check-sheets, testing documents, and any other documentation of performance will be kept on file with the employee’s personnel record, or, in the case of non-facility-based training, will kept on file and be made available to an inquiring facility on demand.

I also acknowledge that all program records are subject to review as part of the employee record in a standard recertification survey or during a complaint investigation; or, in the case of a non-facility-based program, during a standard training program site review. 

FORM COMPLETED BY: _______________________________________________ 

TITLE:                                 _______________________________________________

SIGNATURE:                      _______________________________________________ 

DATE: 		         _______________________________________________  

Attachment 2:

Paid Feeding Assistant Training Program Curriculum Specifications

For ease of use, each of these training modules has been structured as follows:

Name of module
Minimum hours
Recommended Instructional methods
Content outline

1. 	Nutrition and Hydration 
2.5 hours
Instructional methods: lecture, discussion, demonstration, practice, return demonstration

A.	Changes that affect eating and drinking

B.	Food
-	Basic nutrition requirements
-	Special diets
-	Types
-	Reasons for special diets

C.	Fluids
-	Basic fluid requirements
-	Basic signs and symptoms of dehydration
-	Problems that could result from dehydration

D.	Serving meals
-	Sanitation: hand washing, foodservice, feeding
-	How to make meals pleasant
-	How to serve food
-	How to feed someone
-	Special eating needs

E.	The responsibilities of the aide
-	Observation and reporting
-	Measuring food/fluid intake
-	Feeding skills

2. 	Communication Skills 

1.5 hours
Instructional methods: lecture, discussion, role-play, demonstration, practice, return demonstration

A.	How to be a good communicator
-	How to address a resident
-	How to explain before doing
-	How to end a conversation properly
-	How to communicate without words
-	How to be a respectful communicator

B.	How to be a good listener
-	Why listening helps residents feel better
-	How the residents are like ourselves

C.	Changes due to aging and illness that might affect communication
-	Special problems that influence communication and listening; communicating with:
-	psychotic residents
-	confused residents
-	residents with hearing or vision impairments
-	residents with Alzheimer’s disease and those with other memory loss
-	wandering residents
-	aphasic residents

3. 	Safety

2 hours
Instructional methods: lecture, discussion, role-play, demonstration, practice, return demonstration

A.	Environmental Safety
-	Orientation to space
-	Dining room
-	Resident’s room
-	Cords, equipment, call lights, etc.
-	Isolation rooms and procedures
-	Preventing accidents

B.	Resident Safety
-	Emergencies: seizures, choking, bleeding, cardiopulmonary arrest
-	Immediate action (including Heimlich maneuver)
-	Reporting
-	Falls and other injuries
-	Immediate action
-	Reporting

C.	Personal Safety
-	How to prevent injury to yourself by combative, emotionally or physically uncooperative residents
-	How to manage time effectively
-	When and how to set limits
-	What to do when you feel stressed or sad
-	Grieving; dealing with death and dying

4. 	Infection Control Practices
1 hour
Instructional methods: lecture, discussion, demonstration, practice, return demonstration

A.	How to prevent the spread of infections
-	Hand washing
-	Use of appropriate utensils and tools
-	Clean v. soiled

5. 	Residents’ Rights

1 hour
Instructional methods: lecture, discussion, role play

A.	Privacy needs
-	We all like privacy
-	Obstacles to privacy
-	How to provide privacy

B.	Residents’ Bill of Rights

Attachment #3:
Guidance on the Use of Paid Feeding Assistants

Training and Evaluation:
Abuse Training
In addition to the minimum of eight hours required training for paid feeding assistants, each individual who is a new employee to the facility shall receive an orientation before they begin an assignment to care for a patient or resident. Such orientation shall include: 
(a)	provision of information about the requirements of M.G.L. c. 111, 72F through 72L, and 105 CMR 155.000;
(b)	instruction on the obligation to report suspected patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property, and the reporting procedures as set forth in 105 CMR 155.000.
Immediately after beginning employment and at least once a year thereafter, all paid feeding assistants shall receive in service training which shall include, but not be limited to, the following:
(a)	provision of information about the requirements of M.G.L. c. 111, 72F through 72L and 105 CMR 155.000;
(b)	instruction on the obligation to report suspected patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property, and the reporting procedures. as set forth in 105 CMR 155.000;
(c)	instruction in techniques for the management of patients or residents with difficult behavior problems;
(d)	identification of factors which contribute to or escalate patient or resident behavior which is threatening or assaultive;
(e)	assessment of personal responses to patient or resident behavior which is aggressive, threatening or assaultive;
(f)	identification and reinforcement of positive and adaptive employee and patient or resident coping behavior;
(g)	training in the use of intervention techniques, including verbal responses and safe, non-injurious physical control techniques, as therapeutic tools for threatening or assaultive patients or residents; and
(h)	interdisciplinary program and treatment planning for patients and residents, as appropriate.
See 105 CMR 155.010(F)

Orientation to Fire Safety and Evacuation Protocols
According to state and federal laws, facilities are required to provide a general orientation program to all employees which must include the safety and emergency procedures for the facility.  This orientation is additional to any other required training that the employee must receive.  
See 105 CMR 150.002 (D)(3), 150.004, and 150.015 (D) and (E), as well as 42 CFR 483.75 (m)(1-4)
Required Retraining
If, since a feeding assistant’s last completion of a training program, there has been a continuous period of 24 consecutive months during none of which the individual provided feeding assistant services for monetary compensation, the individual’s employer or prospective employer must conduct an evaluation of his or her skills.  If the individual does not demonstrate competency, he or she must complete a new training program before being allowed to perform as a paid feeding assistant.
Modeled on 42 CFR 483.75 (e) (7)

Annual Performance Reviews 
The facility must complete a performance review of the paid feeding assistant at least once every 12 months.

Hiring Practices:

Registry verification
Facilities are required to contact the Nurse Aide Registry prior to hiring an individual as a paid feeding assistant pursuant to 105 CMR 155.010 (E) (2) which reads: “All facilities shall contact the Registry prior to hiring any employee to ascertain if there is any remedy, finding, or adjudicated finding of patient or resident abuse, neglect, or mistreatment, or misappropriation of patient or resident property against the prospective employee.”

CORI Checks
Because the duties of the paid feeding assistant involve the provision of direct personal care to patients or residents, facilities are also expected to obtain all available criminal offender record information from the criminal history systems board pursuant to 105 CMR 155.010 (G)(3).  For practical purposes, it is expected that the CORI request be submitted by the end of the first day in which an individual was employed as a paid feeding assistant.  
See 105 CMR 155.010 (G)(3).  

Multi-state verification
Before employing an individual as a paid feeding assistant, a facility must seek information from the registry of every state in which the facility believes that prospective employee may have been employed.    Federal regulations prohibit hiring any individual who has a finding of abuse, neglect, mistreatment or misappropriation entered against them on a state nurse aide registry.
See 42 CFR 483.13 (c)(1)(i) and 483.13 (c)(1)(ii).

Prohibition of employment
Facilities are prohibited from employing an individual as a paid feeding assistant if that individual has been subject to a finding of patient or resident abuse, neglect or mistreatment, or misappropriation of patient or resident property pursuant to the following rules:

105 CMR 155.010 (E) (4)  “No facility… shall hire or employ an individual whose name appears in the Registry with a finding or adjudicated finding of patient or resident abuse, neglect, or mistreatment, or misappropriation of patient or resident property, or, if a remedy was imposed upon that individual, such individual may not be hired or employed until the terms of such remedy have been fulfilled.  Furthermore, no facility… shall hire or employ an individual if such an individual has been found guilty of, or pleaded guilty or nolo contendere to, or admitted to facts sufficient to support a finding of patient or resident abuse, neglect, or mistreatment, or misappropriation of patient or resident property in a court of law.” 

42 CFR 483.13 (c)(1)(ii) “The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities.”

Ability to Communicate with Residents
Facilities are required to ensure that an individual employed as a paid feeding assistant be able to successfully communicate with the residents of the facility to whom that individual is providing services pursuant to the requirements at 42 CFR 483.15 (a) and 483.10 (b)(3).  In the process of providing care and services, individuals employed as paid feeding assistants are expected to respect resident’s social status; to speak respectfully; to listen carefully; to treat the resident with respect (e.g. addressing the resident with name of the resident's choice, not excluding the resident from conversations or discussing the resident in community settings); and to focus on the resident as an individual and to address the resident as an individual when speaking to him or her.  The paid feeding assistant should also be able to communicate information in a manner that is understandable to a resident at a time when it could be most useful to the resident, such as when they are expressing concerns or raising questions, as well as on an ongoing basis.

Utilization of Paid Feeding Assistants:

Supervision
A feeding assistant must work under the supervision of a registered nurse (RN) or licensed practical nurse (LPN).  In an emergency, a feeding assistant must call a supervisory nurse for help on the resident call system.  42 CFR 483.35(h)(2).

Resident Selection Criteria
Facilities must ensure that a feeding assistant feeds only residents who have no complicated feeding problems.  Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube or parenteral/IV feedings.  The facility must base resident selection on the charge nurse’s assessment and the resident’s latest assessment and plan of care.  42 CFR 483.35(h)(3).