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Wisconsin's Feeding Assistant Program Requirements

PDF Version of BQA 04-008 (PDF, 65 KB)

Date: March 12, 2004 -- DDES-BQA 04-008
Cross Reference: BQA 03-016

TO: Facilities for the Developmentally Disabled FDD - 04, Nurse Aide Training Programs NATP 02, Nursing Homes NH - 03

FROM: Susan Larsen, Director, Office of Caregiver Quality
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, BQA-93-024


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 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 drinking.

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 follows:

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:

    1. Licensed health professional or registered dietitian;
    2. Volunteers without money compensation; or
    3. 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:

  1. Feeding techniques
  2. Assistance with feeding and hydration
  3. Communication and interpersonal skills
  4. Appropriate responses to resident behavior
  5. Safety and emergency procedures, including the Heimlich maneuver
  6. Infection control
  7. Resident rights
  8. 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:

  1. 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.
  2. 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,
    1. Characteristics of the population, such as the population members' physical, social and mental health needs, and specific medications or treatments needed by the residents,
    2. Program services needed by the residents,
    3. 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;
    4. Self direction, self care and vocational abilities.
  1. Instruction of feeding assistants who have been trained by another facilityís training program, for their specific selected population.
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.

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:

  1. Assisted Dining: The Role and Skills of Feeding Assistants, by the American Health Care Association (exit DHFS)
  2. Eating Matters-A Training Manual for Feeding Assistants, by the American Dietetic Association
  3. 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 Caregiver Program.

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 problems.

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 following:

  1. A State-approved training program for feeding assistants, including additional instruction on the selected resident population and the Wisconsin Caregiver Program requirements.
  2. 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 difficulties.
  3. A State-approved standardized skill demonstration, determining handwashing and resident feeding competency with a score of 75 percent or greater.
4.2 The instructor must observe the trainee's performance and initial and date each skill to verify the satisfactory or unsatisfactory performance.

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 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, 112 KB), 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 application.

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:

  1. Successfully completed a feeding assistant training and competency evaluation program; or
  2. Met the feeding assistant grandparenting requirements and has been determined competent to provide feeding and hydration services;
  3. Reached 16 years of age;
  4. 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 KB), that bar employment as a caregiver.
7.2 Facilities must ensure feeding assistants only serve residents who have no complicated feeding problems with eating and hydration.

7.3 Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube or parenteral/IV feedings.

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 satisfactory.

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 grandparented status.

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 competency evaluation.

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):
  1. 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.
  2. 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 records:

  1. For a minimum of three (3) years, all student skill checklists, written examinations, certificates and other relevant training records.
  2. Documentation of the training conducted and identification of the instructor conducting the training.
  3. 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 personnel records:

  1. 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 skill demonstration).
  2. A copy of the feeding assistant training or grandparenting certificate, kept in the individualís personnel file.
  3. The selected residentís medical record, documenting no complicated feeding condition exists.
  4. Annual inservice session(s), relating to feeding assistant duties.
  5. 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 to review.

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 case-by-case basis.

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 correction.

15.0 Appeals

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):

  1. A denial of an application to operate a feeding assistant training program.
  2. A denial of an approval of a feeding assistant instructor.
  3. A termination or suspension of an approved feeding assistant training program.
  4. An imposed plan of correction.
  5. 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
(608) 243-2084

Cindy Hinzte, Nurse Consultant, Office of Caregiver Quality
(608) 243-2083

Feeding assistant survey requirements:

Dolores Zwiers, Regional Field Operations Director
Northeastern (Green Bay) Regional Office
(920) 448-5249

Joanne Powell, Regional Field Operations Director
Northern (Rhinelander) Regional Office
(715) 365-2802

Kitty Friend, Regional Field Operations Director
Southeastern (Milwaukee) Regional Office
(414) 227-4908

Juan Flores, Regional Field Operations Director
Southern (Madison) Regional Office
(608) 243-2374

Joe Bronner, Regional Field Operations Director
Western (Eau Claire) Regional Office
(715) 836-4753

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