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The "Feeding Assistant Rule": Pros and Cons

January 1, 2004
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Why employing feeding assistants is controversial, and demands careful thought BY TODD HUTLOCK, ASSISTANT EDITOR
The 'Feeding Assistant Rule': Pros and Cons
CMS's new regulation allowing paid feeding assistants in nursing homes hasn't been universally applauded

BY TODD HUTLOCK, ASSISTANT EDITOR In late September 2003, the Centers for Medicare and Medicaid Services (CMS) published in the Federal Register a new rule that allows skilled nursing facilities to employ trained assistants to help some residents with eating and drinking; the rule went into effect on October 27, 2003. To say that the new rule has stirred up controversy is putting it mildly. Essentially, the so-called "Feeding Assistant Rule," which applies to any nursing home that receives Medicare or Medicaid funding, breaks down this way: Nursing homes are now allowed to hire feeding assistants who have passed a minimum eight-hour, state-approved training course. These assistants are required to work under the supervision of an RN or LPN. Also, the assistants may only help residents who do not have complicated feeding needs. The decision as to which residents are eligible to be helped by these assistants falls to a facility's charge nurse. The rule also states that staff should review each resident's last assessment and plan of care to help determine his or her eligibility.

Several large interest groups-including the American Health Care Association (AHCA) and the American Association of Homes and Services for the Aging (AAHSA)-have come out in support of this new rule; others have expressed serious concerns. And all of this before most states have decided how they plan to implement the rule, if at all. How and why has this seemingly simple concept polarized much of the long-term care community?

Pros and Cons
Critics of the Feeding Assistant Rule have focused on two sets of issues: staffing and safety. Prominent consumer-oriented groups, such as AARP and the Alzhei-mer's Association, came out against the rule. David M. Certner, director of federal affairs for AARP, was quoted in the New York Times saying the rule would cause "real harm to nursing home residents"; Donna R. Lenhoff, Esq., executive director of the National Citizens' Coalition for Nursing Home Reform (NCCNHR), called the rule a "cynical attempt to avoid the nation's nursing home staffing crisis and related problems like resident malnutrition and dehydration." Rep. Henry Waxman (D-Calif.) and Sen. Chuck Grassley (R-Iowa) also sent a letter to Health and Human Services Secretary Tommy Thompson expressing their opposition to the rule.

For every criticism that these nay-saying groups have raised, though, there has been an equally compelling rebuttal. This has left many in the industry looking for guidance and finding nothing but conflict. "On the whole, we think this is a good rule," says Evvie Munley, a senior health policy analyst at AAHSA, one of the prominent groups supporting the rule. "But we have never suggested that it would be a solution in and of itself to the staffing problem, and we have never presented this as any kind of silver bullet. The staffing shortage is a reality, and the biggest staffing shortage right now is for CNAs. This rule can provide some relief, however, and give residents more individual attention."

Munley maintains that many of the rule's critics are making assumptions about resident safety that may turn out to be untrue: "Assistance with eating can cover a broad range of tasks, including doing things that will help residents eat for themselves. There is a clear distinction between the need for assistance by individuals with swallowing problems or an inclination to aspirate, and residents who have, for example, severe arthritis and have difficulty managing utensils, or those who simply require cueing or encouragement to continue to eat. People have to remember that these workers are not assisting residents who have complicated eating problems."

Regarding staffing issues, in a statement raising their concerns about the rule, NCCNHR claims that the "real problem" with staffing is that nursing homes cannot retain workers because the pay and work environment are poor, and that the authorization of feeding assistants may exacerbate this problem by reducing wages and job satisfaction. NCCNHR also claims that giving the responsibility of working with residents at mealtimes to feeding assistants will take away one of the more pleasant aspects of CNAs' jobs, thus increasing the proportion of heavier tasks among their responsibilities. Munley disagrees with that assessment: "Implementation of this rule will augment the number of staff available during prime caregiving times, enabling nursing facilities to allocate resources more effectively to meet the needs of their residents. The ability to free up staff time is one of the greatest single benefits of the rule. It allows licensed personnel to attend to those people who have more complex eating problems. Even where facilities are highly staffed, the rule still affords an opportunity for more one-on-one attention. It also may expose some of these part-time workers to long-term care as a profession, which could actually be a good thing for the staffing problem.