Wisconsin's Feeding Assistant
PDF Version of BQA 04-008 (PDF,
Date: March 12, 2004 -- DDES-BQA 04-008
Cross Reference: BQA 03-016
TO: Facilities for the Developmentally Disabled
- 04, Nurse
Aide Training Programs NATP 02, Nursing Homes
NH - 03
FROM: Susan Larsen, Director, Office of Caregiver
Michael Steinhauer, Chief, Resident Care Review Section
VIA: Susan Schroeder, Director, Bureau of Quality Assurance
Obsoletes: BQA-01-049, BQA-01-033, BQA-01-022, BQA-00-066,
On September 26, 2003, the Centers for Medicare and Medicaid Services
(CMS) published the final rule for paid feeding assistants. These federal
regulations may be accessed at http://www.cms.hhs.gov/
providerupdate/regs/cms2131f.pdf [link no longer operable]. Prior to publishing this federal rule, nursing homes were
required to rely on nurse aides or other health care professionals to assist
residents with eating and drinking. Providing assistance with eating and
drinking was considered a direct, nursing related service that could only be
performed by a nurse aide or other health care professional.
CMS no longer considers assisting a resident with eating or drinking who
has no feeding complications as "nursing or nursing-related"
duties. With this federal rule revision, long term care facilities are now
allowed to employ trained individuals to assist residents with eating and
The feeding assistance regulations do not impact the Code of Federal
Regulations at 42 CFR, Part 483.75(e)(1), which still allows a health care
professional to provide feeding assistance. A health care professional is
defined as "...a physician, physician assistant, nurse practitioner,
physical, speech, or occupational therapist; physical or occupational
therapy assistant; registered professional nurse; licensed practical nurse;
or licensed or certified social worker." Volunteers and family members
are also still allowed to assist residents with feeding and drinking.
With the input of the Wisconsin Feeding Assistant Training Program
Workgroup, including representatives from for-profit and not-for-profit
nursing homes, workforce associations, the Board on Aging and Long Term Care
Ombudsman Program, the Department of Public Instruction, the Department of
Workforce Development and the Wisconsin Technical College System, the
Department has established the requirements for Wisconsinís Feeding
Assistant Program. The Department will incorporate these requirements in
Chapter HFS ch. 129 of the Wisconsin Administrative Code in the near future.
The requirements of Wisconsinís Feeding Assistant Program are detailed as
1.0 Feeding Assistant Definition
1.1 Paid feeding assistant means a person who
meets the requirements specified in ß 42 CFR 483.35(h)(2), and who is paid
by a long term care facility, i.e., a nursing home or intermediate care
facility for persons with mental retardation (ICFs/MR), or a person who is
used under an arrangement with another agency or organization, to assist
residents who have no feeding complications with the activities of eating
and drinking. The feeding assistant is not permitted to provide any other
nursing or nursing related service. Paid feeding assistants must be at least
16 years old. Facilities are prohibited from counting paid feeding
assistants toward their minimum staff requirements.
1.2 A feeding assistant does not include a person who is a:
- Licensed health professional or registered dietitian;
- Volunteers without money compensation; or
- Nurse aide.
2.0 Wisconsin Feeding Assistant Training Requirements
2.1 Wisconsinís feeding assistant training programs must require
enrolled individuals to successfully complete an approved training program,
which includes the following federally-mandated topics, covered during a
minimum of eight (8) hours of instruction:
- 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
- Recognizing changes in residents that are inconsistent with the norm
and the importance of reporting changes to the nurse.
2.2 The feeding assistant training program must also provide instruction
on the following topics:
- Wisconsinís Caregiver
Program, including background check
requirements, the need to promptly report any misconduct allegations,
the definitions of abuse or neglect of a client or misappropriation of a
clientís property and the Rehabilitation Review requirements.
- The resident population who will be served by the feeding assistant in
a facility-based program. The facility-based training program curriculum
must include training specific to the identified population type(s).
This training must include, but is not limited to,
- Characteristics of the population, such as the population members'
physical, social and mental health needs, and specific medications or
treatments needed by the residents,
- Program services needed by the residents,
- Meeting the needs of persons with a dual diagnosis (co-occurrence of
mental health disorders and alcohol and/or drug dependence or abuse),
and maintaining or increasing his or her social participation;
- Self direction, self care and vocational abilities.
2.3 The program determines the number of extra hours
required for the training topics listed under 2.2, a-c. However, the
training must be in addition to the minimum eight (8) hours required for the
federally mandated topics listed under 2.1, a-h.
- Instruction of feeding assistants who have been trained by another
facilityís training program, for their specific selected population.
2.4 Programs may choose to add increased training requirements.
2.5 Training programs must stress the only direct, hands-on duty a
feeding assistant is permitted to perform is assisting residents to eat or
drink who have no complicated feeding problems.
3.0 Standardized Feeding Assistant Curriculum
3.1 Feeding assistant training programs must use a training curriculum,
which has been pre-approved by the Department and determined to comply with
the federal requirements. Entities are allowed to choose one of the
following pre-approved, standardized curriculum models:
- Assisted Dining: The Role and Skills of Feeding Assistants, by the
American Health Care Association (exit
- Eating Matters-A Training Manual for Feeding Assistants, by the
American Dietetic Association
- Paid Feeding Assistant Training Program, by the Wisconsin
Department of Health and Family Services
3.2 Training programs must select one of the model curriculums listed
above to provide feeding assistant students instruction on the federally
mandated topics (see 2.1, a-h).
3.3 Feeding assistant training programs must utilize the Department of
Health and Family Services, Bureau of Quality Assurance video, The
Wisconsin Caregiver Program: A Blueprint for Excellence [see Caregiver
Program - Publications], to provide
feeding assistant students instruction regarding the requirements of the
3.4 Facility-based training programs must submit their proposed training
materials to provide feeding assistants instruction regarding the facilityís
selected resident population.
3.5 Although the pre-approved standardized training curriculums include
additional skill information (e.g., intake and output, special care needs
for residents with dysphagia, etc.), the instructor must stress the feeding
assistant will not be permitted to perform any other hands-on duty, beyond
assisting residents to eat and drink who have no complicated feeding
4.0 Successful Training Program Completion
4.1 An individual may not provide hands-on assistance with feeding or
hydrating residents unless the individual has successfully completed the
4.2 The instructor must observe the trainee's
performance and initial and date each skill to verify the satisfactory or
- A State-approved training program for feeding assistants, including
additional instruction on the selected resident population and the
Wisconsin Caregiver Program requirements.
- After completing the training course, a State-approved standardized
written quiz with a score of 75 percent or greater. Individuals may
request the quiz to be administered orally. Instructors should consider
the needs of persons who have limited English proficiency or reading
- A State-approved standardized skill demonstration, determining
handwashing and resident feeding competency with a score of 75 percent
4.3 Programs may choose to add increased testing requirements.
4.4 Students who do not successfully pass the initial competency
evaluation will be allowed the opportunity to review the training materials
and retake the test. Programs can
establish the number of times a candidate may retake the test. However, the
program must document the failure, opportunity for review and subsequent
retake testing date.
4.5 The instructor must issue a State approved certificate to each
participant who successfully completes the program, documenting the name of
the participant, the training program and the date of successful completion.
5.0 Qualified Instructor
5.1 Feeding assistant training programs shall
determine the appropriate qualifications for their instructors (e.g.,
registered nurse, dietitian, speech therapist, etc.), based on the needs of
the selected resident and facility.
5.2 Training programs must provide the name and qualifications of the
proposed instructor to BQAís Office of Caregiver Quality (OCQ).
5.3 The primary instructor may supplement the course by including other
individuals for lecture or demonstration whose qualifications or experience
add benefit to the training program.
5.4 A paid feeding assistant is not permitted to lead the training
of another feeding assistant students.
6.0 Feeding Assistant Training Program Approval Process
6.1 Entities wishing to operate a feeding assistant
training program must submit the Wisconsin Feeding Assistant Training
Program Application form, DDE-2588, (see attached found at
http://www.dhs.wisconsin.gov/forms1/F6/ F62588.pdf (PDF, 112 KB), with their proposed selected resident population
curriculum and proposed feeding assistant instructor information to the
Office of Caregiver Quality. Priority will be given to new program
applications, as BQA has not accepted requests to train single task workers
since October 2000.
6.2 All facilities currently approved to train single task workers will
also be required to submit the Wisconsin
Feeding Assistant Training Program Application form, F62588 (PDF,
along with their proposed training curriculum, selected resident population
curriculum and feeding assistant instructor information to the Office of
Caregiver Quality no later than Wednesday, June 30, 2004.
6.3 The Office of Caregiver Quality will review the application and
supporting materials and will determine whether to approve or deny the
feeding assistant training program. OCQ will issue a written notice
regarding BQAís decision, with a copy to the appropriate Regional
Field Operations Director (RFOD), within 45 calendar days of receiving a complete
6.4 The Department is obtaining a supply of the pre-approved feeding
assistant training program curricula. Approved feeding assistant training
program curricula will be issued, at no cost, one copy (instructor and
student, if applicable) of their selected standardized training curriculum,
a Wisconsin Caregiver Program video cassette, standardized competency
evaluation materials, feeding assistant training program and grandparented
certificate templates, and a feeding assistant roster template.
7.0 Wisconsin Feeding Assistant Employment Requirements
7.1 A long term care facility (nursing home or ICF/MR) may not employ or
use any individual as a feeding assistant unless the individual has:
7.2 Facilities must ensure feeding assistants only
serve residents who have no complicated feeding problems with eating and
- Successfully completed a feeding assistant training and competency
evaluation program; or
- Met the feeding assistant grandparenting requirements and has been
determined competent to provide feeding and hydration services;
- Reached 16 years of age;
- Successfully passed a caregiver background check, having no offenses
on the Offenses Affecting Caregiver Eligibility Misconduct Offenses
List, HFS 12, Appendix A (exit DHFS; PDF, 205
that bar employment as a caregiver.
7.3 Complicated feeding problems include, but are not limited to,
difficulty swallowing, recurrent lung aspirations, and tube or parenteral/IV
7.4 Residents with a clinical condition, such as the conditions listed
above, require the employee providing feeding or hydration services to be a
licensed health care professional or nurse aide.
7.5 The facility must base their resident selection on the charge nurseís
assessment and the residentís latest assessment and plan of care.
7.6 Feeding assistants 18 years and older must work under the general
supervision of a registered nurse (RN), or licensed practical nurse (LPN).
While the Department anticipates most feeding assistants will serve
residents in the dining room, feeding assistants are allowed to serve
residents in their own rooms. The feeding assistant is not permitted to
perform other nursing or nursing-related duties (e.g., measuring or
recording input or output, transferring, toileting, etc.). In an emergency,
a feeding assistant must immediately call a supervisory nurse on the
resident call system.
7.7 Feeding assistants between the ages of 16 and 18 years must be
supervised more closely than assistants who are over 18 years. Feeding
assistants between 16 and 18 years must work under the direct
supervision of an RN or LPN, i.e., the RN or LPN must be on the same
floor or unit as the feeding assistant, but not necessarily side-by-side.
7.8 Feeding assistants must receive an annual inservice on relevant
feeding assistant topics (any topic area included in the curriculum is
appropriate). In addition, feeding assistants must be evaluated on a yearly
basis to document that their skill performance and feeding competence is
8.0 Current Single Task Worker Grandparenting Policy
8.1 Single task worker programs that were previously
approved by BQA, must verify the single task worker completed a training
course that meets the federal minimum eight-hour training requirements for a
feeding assistant (see 2.1, a-h). Facilities may give these employees credit
for their work experience with the selected resident population to satisfy
the requirements of 2.2. Facilities may issue their single task workers who
meet the federal minimum training requirements a certificate to verify their
8.2 Single task workers, who have not met the minimum feeding assistant
training requirements outlined in 2.1, a-h, covering the federally mandated
topics in the eight (8) hour minimum, must be provided the necessary hours
of instruction on those missing topics by Saturday, July 31, 2004.
8.3 An employee who does not meet the minimum feeding assistant training
requirements by July 31, 2004, may not be used as a feeding assistant
until s/he has satisfactorily completed a feeding assistant training and
9.0 Feeding Assist ant Training Program Operation
9.1 Approved feeding assistant training programs must
submit the following information to the Office of Caregiver Quality (OCQ):
Substantial Change: Any substantial changes in the program must be
reported to the Office of Caregiver Quality in writing within 10 calendar
days. The program must not implement the change
until OCQ approves the programís proposed change in writing.
"Substantial change" includes changes regarding the classroom
site, clinical site, primary instructor, or curriculum.
Annual Report: The program must submit an annual report to the
Office of Caregiver Quality on a form provided by the Department, and must
indicate the number of feeding assistants who were trained and tested during
the year, including the number of individuals who dropped out or who failed
the program. The Office of Caregiver Quality will provide a copy of the
annual report to the appropriate BQA Regional Field Office Director.
10.0 Program Record Retention Requirements
10.1 Feeding assistant training programs must maintain the following
- For a minimum of three (3) years, all student skill checklists,
written examinations, certificates and other relevant training records.
- Documentation of the training conducted and identification of the
instructor conducting the training.
- Record of all individuals who have successfully completed the feeding
assistant training and competency testing program.
10.2 Training programs must maintain the security of the test materials
and certificate templates, to ensure disclosure or forgery does not occur.
10.3 Facilities employing feeding assistants must maintain the following
- Feeding assistant roster, recording all individuals employed by the
facility as feeding assistants who successfully completed the feeding
assistant training and competency evaluation (written or oral exam and
- A copy of the feeding assistant training or grandparenting
certificate, kept in the individualís personnel file.
- The selected residentís medical record, documenting no complicated
feeding condition exists.
- Annual inservice session(s), relating to feeding assistant duties.
- Annual evaluation documentation, determining a feeding assistantís
continued competence in feeding residents.
11.0 Caregiver Misconduct Reporting Requirements
11.1 Wisconsinís Caregiver Law, implemented in October 1998, requires
all BQA-regulated entities to report allegations of misconduct (abuse or
neglect of a client, or misappropriation of a clientís property) regarding
any caregiver who is an employee of or contractor with the facility and who
has regular, direct contact with clients. Feeding assistants meet Wisconsinís
definition of a caregiver and allegations involving a feeding assistant are
subject to the caregiver misconduct reporting requirements. The name of any
noncredentialed caregiver (including a feeding assistant), with a
substantiated finding of misconduct will be entered on the Wisconsin
Caregiver Misconduct Registry.
12.0 Survey Process
12.1 BQAís current survey process provides oversight of facilitiesí
use of feeding requirements. During surveys of nursing homes and ICFs/MR,
surveyors may observe the meal or snack service to note if any of the
residents receiving feeding assistance are showing signs of difficulty
eating or drinking. If such difficulty is observed, surveyors investigate to
determine if this is an unusual occurrence or a chronic problem and whether
the feeding assistant has successfully completed an approved feeding
assistant training program or met the grandparenting requirements. The
feeding assistantís personnel records must contain a copy of the approved
feeding assistant training or grandparenting certificate.
12.2 Surveyors will may determine if residents being served by a feeding
assistant are persons with no complicated feeding problems. This
determination may include a review of medical charts and discussion with the
professional nursing staff.
12.3 BQA surveyors may monitor the facilityís residents during feeding, to
ensure only the residents included in the approved selected population are
fed or hydrated by the feeding assistants.
12.4 A facility may be subject to citation if deficiencies are identified
by the surveyor. The facility will be required to retain training and
employment records of feeding assistants, to document the facilityís
compliance with program requirements and to provide a record for surveyors
12.5 If the surveyors observe inadequacies in the feeding assistant
training program, that information will be referred to the Office of
Caregiver Quality. Feeding assistant training program complaints that
warrant further investigation will result in an unannounced on-site review.
13.0 NATCEP Prohibition
13.1 Substandard quality of care citations that result
in a nurse aide training and competency evaluation program (NATCEP)
prohibition, will be reviewed to determine the appropriate action for the
feeding assistant training program. Program decisions will be made on a
13.2 Citations normally resulting in a NATCEP prohibition, that directly
relate to poor quality care due to the feeding assistant program, may result
in termination of the feeding assistant training program.
13.3 Feeding assistant programs may request a training program waiver by
submitting a request in writing to BQAís Office of Caregiver Quality.
After consulting with the Ombudsman Program and CMS, OCQ will issue a
written decision, either approving or denying the request, within 45
calendar days of receiving a complete waiver request.
14.0 Training Program Suspension or Termination
14.1 Training programs failing to meet their program requirements or
operating under conditions other than those contained in the approved
application, may be issued a notice of suspension, revocation of the feeding
assistant training program approval, or a voluntary or imposed plan of
15.1 For any of the following Department actions, a feeding assistant
training program may request a hearing by filing an appeal with the Division
of Hearings and Appeals (DHA):
- A denial of an application to operate a feeding assistant training
- A denial of an approval of a feeding assistant instructor.
- A termination or suspension of an approved feeding assistant training
- An imposed plan of correction.
- A denial of a request for a waiver or the revocation of a waiver.
15.2 The request for a hearing must be in writing and must be filed with
the Division of Hearings and Appeals no later than 30 days after the date of
the denial, suspension or revocation. The appeal is considered filed when
received by DHA.
Contact the following individuals for information regarding Wisconsinís
Feeding Assistant Program:
Feeding assistant training program requirements:
Shari Busse, Director,
Office of Caregiver Quality
Cindy Hinzte, Nurse Consultant,
Office of Caregiver Quality
Feeding assistant survey requirements:
Dolores Zwiers, Regional Field Operations Director
Northeastern (Green Bay) Regional Office
Joanne Powell, Regional Field Operations Director
Northern (Rhinelander) Regional Office
Kitty Friend, Regional Field Operations Director
Southeastern (Milwaukee) Regional Office
Juan Flores, Regional Field Operations Director
Southern (Madison) Regional Office
Joe Bronner, Regional Field Operations Director
Western (Eau Claire) Regional Office
PDF: The free Acrobat Readerģ
software is needed to view and print portable document format (PDF) files.