The 'feeding assistant rule': pros and cons: CMS's new regulation allowing paid feeding assistants in nursing homes hasn't been universally applauded.

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 Alzheimer'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 my-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 Ewie 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.

"I spoke to one AAHSA member whose facility had a rotation of dietary assistants coming in from a local high school for a couple hours a day," she continues. "They didn't directly assist with eating, just with serving trays, opening milk cartons, and things of that nature. Our member said that doing this enhanced intergenerational relationships, and that the residents really looked forward to the visits. It was a great way to show these young people who are at this transition point in their lives, trying to decide future career paths and the like, how rewarding long-term care can be as a career."

Being able to train and utilize these new workers is a benefit of the rule that many facilities are looking forward to, but Munley doesn't see it as a threat to the job security of existing CNAs: "Some providers are looking to a labor pool of part-time people who are going to be brought in to provide this assistance. For a lot of AAHSA members, the emphasis has been on allowing existing personnel to go through the training. There are non-nursing-care staff who get to know the residents and are willing to provide this kind of assistance. Now, they will be able to do just that."

Proponents of the rule also say that the use of feeding assistants may lead to better care planning and creation of a warmer atmosphere, as well as increased customer satisfaction with facility dining programs.

The Next Step

Now that CMS has adopted this new regulation, its implementation rests in the hands of the states. Some states say they are ready to go and simply need to plug in some details to get their programs up and running. Others must go to their respective state legislatures for approval before proceeding. North Dakota and Wisconsin have allowed paid feeding assistants to supplement nursing staff for a number of years (which at least partly explains former Wisconsin Gov. Tommy Thompson's long-standing interest in this). Florida and Illinois have already passed laws allowing for such workers but have yet to implement them. A handful of other states have expressed interest in allowing feeding assistants but have been waiting for a federal rule. Most other states are simply sitting back and watching the others to see what happens before they make a move. In any case, the future of feeding assistants in nursing homes is still a long way from being set in stone.

To comment on this article, please send e-mail to [e-mail].