CMS SOM App. PP, Tag F811

§483.60(h)(1) State approved training course. A facility may use a paid feeding

assistant, as defined in § 488.301 of this chapter, if—

(i) The feeding assistant has successfully completed a State-approved training

course that meets the requirements of §483.160 before feeding residents; and

(ii) The use of feeding assistants is consistent with State law.

§483.60(h)(2) Supervision.

(i) A feeding assistant must work under the supervision of a registered nurse

(RN) or licensed practical nurse (LPN).

(ii) In an emergency, a feeding assistant must call a supervisory nurse for help.

§483.60(h)(3) Resident selection criteria.

(i) A facility must ensure that a feeding assistant provides dining assistance only

for residents who have no complicated feeding problems.

(ii) Complicated feeding problems include, but are not limited to, difficulty

swallowing, recurrent lung aspirations, and tube or parenteral/IV feedings.

(iii) The facility must base resident selection on the interdisciplinary team’s

assessment and the resident’s latest assessment and plan of care.

Appropriateness for this program should be reflected in the comprehensive

care plan.

NOTE: Paid feeding assistants must complete a training program with the following

minimum content as specified at §483.160.

a. Minimum training course contents. A State-approved training course for paid

feeding assistants must include, at a minimum, 8 hours of training in the

following:

(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; and

(8) Recognizing changes in residents that are inconsistent with their normal

behavior and the importance of reporting those changes to the supervisory

nurse.

b. Maintenance of records. A facility must maintain a record of all individuals, used

by the facility as feeding assistants, who have successfully completed the training

course for paid feeding assistants.

INTENT §483.60(h)(1)-(3) - To ensure that residents are assessed for appropriateness

for a feeding assistant program, receive services as per their plan of care, and feeding

assistants are trained and supervised. The use of paid feeding assistants is intended to

supplement certified nurse aides, not substitute for nurse aides or licensed nursing staff.

DEFINITIONS §483.60(h)(1)-(3)

“Paid feeding assistant” is defined in the regulation at 42 CFR §488.301 as “an

individual who meets the requirements specified at 42 CFR §483.60(h)(1)(i) and who is

paid by the facility to feed residents, or who is used under an arrangement with another

agency or organization.”

NOTE: The regulation uses the term “paid feeding assistant.” While we are not using

any other term, facilities and States may use whatever term they prefer, such as dining

assistant, meal assistant, resident assistant, nutritional aide, etc. in order to convey more

respect for the resident. Facilities may identify this position with other titles; however,

the facility must be able to identify those employees who meet the requirements under the

paid feeding assistant regulation. While the facility is still responsible for ensuring the

safety and care of all residents, this regulation does not apply to family members or to

volunteers.

GUIDANCE §483.60(h)(1)-(3)

NOTE: The regulation requires that paid feeding assistants must work under the

supervision of an RN or LPN, and they must call the supervisory nurse in case of an

emergency. Therefore, a facility that has received a waiver and does not have either an

RN or LPN available in the building cannot use paid feeding assistants during those

times.

Interdisciplinary Team Assessment of Resident Eligibility for Feeding Assistance

When determining whether a resident may be assisted by a paid feeding assistant facility

staff must base resident selection on the interdisciplinary team’s current assessment of the

resident's condition and the resident’s latest comprehensive assessment and plan of care.

Appropriateness should be reflected in the resident’s comprehensive care plan.

Paid feeding assistants are only permitted to assist residents who have no complicated

eating or drinking problems as determined by their comprehensive assessment. Examples

of residents that a paid feeding assistant may assist include residents who are independent

in eating and/or those who have some degree of minimal dependence, such as needing

cueing or partial assistance, as long as they do not have complicated eating or drinking

problems.

Paid feeding assistants are not permitted to assist residents who have complicated eating

problems, such as (but not limited to) difficulty swallowing, recurrent lung aspirations, or

who receive nutrition through parenteral or enteral means. Nurses or nurse aides must

continue to assist residents who require the assistance of staff with more specialized

training to eat or drink.

Paid feeding assistants may assist eligible residents to eat and drink at meal times, snack

times, or during activities or social events as needed, whenever the facility can provide

the necessary supervision.

Supervision of Paid Feeding Assistants - Paid feeding assistants must work under the

supervision of an RN or LPN. While we are not prescribing the exact means by which

facility RNs and LPNs assert their supervisory responsibilities, we expect that facilities

will do so in a way that avoids negative outcomes for their residents. If a facility chooses

to use paid feeding assistants, it is the facility’s responsibility to ensure that adequate

supervisory nursing staff are available to supervise these assistants.

Adequate supervision by a supervising nurse does not necessarily mean constant visual

contact or being physically present during the meal/snack time, especially if a feeding

assistant is assisting a resident to eat in his or her room. However, in the event that an

emergency should occur, the feeding assistant must be aware of and know how to access

the supervisory nurse immediately and the nurse must be located close enough to the

resident that he or she can promptly respond. Should an emergency arise, a paid feeding

assistant must immediately call a supervisory nurse for help.

Supervisory nurses should monitor the provision of the assistance provided by paid

feeding assistants to evaluate on an ongoing basis:

• Their use of appropriate feeding techniques;

• Whether they are assisting assigned residents according to their care planned

eating and drinking needs;

• Whether they are providing assistance in recognition of the rights and dignity of

the resident; and

• Whether they are adhering to safety and infection control practices.

Use of Existing Staff as Paid Feeding Assistants - Facilities may use existing staff, i.e.,

licensed nurses, certified nursing assistants, to assist residents in feeding. However, other

employees for example, administrative, clerical, housekeeping, dietary staff, or activity

specialists, etc. must have successfully completed a State-approved training course for

paid feeding assistants, as required in §483.160.

Maintenance of Training Records - The facility must maintain a record of all

employees used as paid feeding assistants. The record should include verification that

they have successfully completed a State-approved training course as required in

§483.160.

INVESTIGATIVE PROTOCOL - Use of Paid Feeding Assistants

Objectives - To determine if:

• Individuals used as paid feeding assistants successfully completed a State-approved training course;

• Sampled residents who were selected to receive assistance from paid feeding

assistants were assessed and determined to be eligible to receive these services

based on the latest assessment and plan of care;

• Paid feeding assistants are supervised by an RN or LPN; and,

• Paid feeding assistants know how to obtain assistance in emergencies.

Use - When through observation, record review, or interview(s) with residents, family, or

staff, a surveyor identifies concerns that the facility may not be following the

requirements regarding paid feeding assistants, including proper training and supervision,

and proper assessment and selection of residents for feeding assistance.

Procedures - Review the resident’s comprehensive assessment and interdisciplinary care

plan to guide observations and interviews.

Observations - If a concern was discovered through resident or family interview(s),

observe the resident while he or she is being assisted to eat and drink by a paid feeding

assistant. Determine if the assistant is using proper feeding technique and is providing the

type of assistance specified in the resident’s care plan. Note the resident’s condition and

observe for the presence of complicated feeding problems that may require the assistance

of a nurse aide or licensed nursing staff. The use of paid feeding assistants is intended to

supplement, not substitute for, nursing staff. Also, during observation note whether:

• A paid feeding assistant was observed assisting a resident in a location without a

call system available or other means of emergency notification;

• A resident who was assessed as ineligible for services due to complicated

eating/drinking problems, or a resident who has not been assessed for eligibility,

is being assisted by a paid feeding assistant; and,

• RN or LPN staff members assigned to supervise paid feeding assistants were

observed to be unavailable (for example, not available in case of emergency).

If the concern was discovered through observations that were already made, only conduct

additional observations if necessary to complete the investigation.

Resident and Family Interviews - If a resident is selected for this protocol through

surveyor observation that he or she is having difficulties in eating or drinking and he or

she is being assisted by a paid feeding assistant, interview the resident if the resident is

interviewable. Ask questions to gain information about why the resident is receiving

these services and the resident's experience with receiving assistance to eat and drink. If

concerns are identified, inquire if the resident has reported these problems to a nurse. If

the resident is not interviewable, ask these questions of a family member or the resident’s

representative.

If the concern was discovered through resident, resident representative or family

interviews already conducted, focus any additional interview on questions specific to

complete the investigation.

Paid Feeding Assistant Interviews - Interview paid feeding assistants assisting the

selected resident. Determine whether there are concerns with their training, supervision,

or the selection of the resident such as:

• What training did you successfully complete in providing feeding assistance?

• What information did you receive about this resident's needs for assistance (type

of assistance needed, any precautions)?

• In what manner and by whom are you supervised while assisting residents?

• What issues/problems do you report (such as coughing, choking, changes in the

resident’s usual responses, or level of alertness) and to whom do you report?

• What would you do if an emergency occurred while you were assisting a resident

to eat or drink? Who would you contact and how would you contact them?

Interdisciplinary Team Interview - Interview the nurse or other member(s) of the

interdisciplinary team responsible for assessing if the resident is eligible and appropriate

to receive assistance by a paid feeding assistant. Ask:

• How they determined that this resident has no complicated feeding problems and

is eligible to be assisted by a paid feeding assistant?

• If a resident is appropriate to receive assistance from a paid feeding assistant, how

is this resident’s needs reflected in his or her comprehensive care plan?

• How they determine that each eligible resident remains free of emergent

complicated feeding problems?

• Who supervises paid feeding assistants and how is the supervision accomplished?

• Describe the processes in place to handle emergencies when a supervisor is not

present in the area where paid feeding assistants are assisting residents.

Review of Resident Assessment of Eligibility to Receive Assistance from a Paid

Feeding Assistant - Determine whether the resident’s assessment regarding his or her

ongoing eligibility to be assisted by a paid feeding assistant is based on identification of

the current condition of the resident and any additional or new risk factors or condition

changes that may impact on the resident's ability to eat or drink. This information may be

contained in the RAI or in other supporting documents such as progress notes, etc. The

assessment of eligibility to receive assistance from a paid feeding assistant is ongoing and

should be reflected in a resident’s comprehensive care plan.

Requirements for Training of Paid Feeding Assistants - Determine how the facility

identifies that paid feeding assistants have successfully completed a State-approved

training course that meets the requirements at 42 CFR §483.160 before they are allowed

to assist eligible residents with eating and drinking. If the facility uses temporary

(agency) staff as paid feeding assistants, request documentation that these staff have met

the minimum training requirements at 42 CFR §483.160. Review facility’s records for all

employees used as paid feeding assistants to verify their completion of a State approved

training course (it is recommended the survey team coordinator assign one surveyor to

obtain and verify these records).

NOTE: If the facility has not ensured any paid feeding assistant has completed a State-approved training course, do not cite here. Cite 42 CFR §483.95(h), F948, Required

training of feeding assistants.

POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION §483.60(h)(1)-(3)

During the investigation of F811, the surveyor may have identified concerns with

additional requirements related to outcome, process, and/or structure requirements. The

surveyor is cautioned to investigate these related requirements before determining

whether non-compliance may be present at these other tags. Examples of some of the

related requirements that may be considered when non-compliance has been identified

include, but are not limited to, the following:

• §483.10, F550, Resident Rights

o Determine if staff are attentive and responsive to the resident’s requests, and if

they provide assistance to eat in a manner that respects the resident’s dignity,

meets needs in a timely manner, and minimizes potential feelings of

embarrassment, humiliation, and/or isolation related to inability to assist

themselves with food or fluid intake.

• §483.10(c), F552 and F578, Planning and Implementing Care

o Determine if the facility addressed the resident’s right to choose or refuse

treatment, including receiving assistance to eat or drink by a paid feeding

assistant.

• §483.20(b), F636, Comprehensive Assessments

o Review whether facility staff initially and periodically conducted a

comprehensive, accurate assessment of the resident’s ability to eat and drink

with or without assistance and/or identified a condition that makes the resident

ineligible for this service.

• §483.21(b)(1), F656, Comprehensive Care Plans

o Review whether facility staff developed or implemented a comprehensive care

plan that was based on the assessment of the resident’s conditions, needs, and

behaviors, and was consistent with the resident’s goals in order to provide

assistance with nutrition and hydration as necessary.

• §483.21(b)(2)(iii), F657, Comprehensive Care Plan Revision

o Determine if the care plan was reviewed and revised periodically, as

necessary, related to eligibility to eat and drink with assistance of a paid

feeding assistant.

• §483.25(g)(1)-(3), F692, Nutrition/Hydration Status

o Review if facility staff had identified, evaluated, and responded to a change in

nutritional parameters, anorexia, or unplanned weight loss, dysphagia, and/or

swallowing disorders in relation to the resident’s ability to eat.

o Review if facility staff had identified, evaluated, and responded to a change in

the resident’s ability to swallow liquids.

• §483.25 (b)(4), F676, ADL Assistance for Dependent Residents

o Determine if staff identified and implemented appropriate measures to provide

food and fluids for the resident who cannot perform relevant activities of daily

living.

• §483.35(a), F725, Sufficient Staff

o Determine if the facility has qualified staff in sufficient numbers to provide

assistance to eat or drink to those residents who require such assistance. For

residents who are not eligible to receive assistance from paid feeding

assistants, determine if there are sufficient staff to provide this assistance to

these residents in a timely fashion.

• §483.70(g), F841, Medical Director

o Determine whether the medical director collaborates with the facility to help

develop, implement, and evaluate resident care policies and procedures based

on current standards of practice, e.g., the use of paid feeding assistants, their

supervision, and the criteria for determining which residents are eligible to

receive assistance to eat or drink from paid feeding assistants.

• §483.95(h), F948, Required training of feeding assistants.

o Determine if the facility has ensured the paid feeding assistant(s) has

completed a State-approved training course prior to employment.

KEY ELEMENTS OF NONCOMPLIANCE:

To cite F811, the surveyor’s investigation will generally show the facility failed to do any

one or more of the following:

• Prohibit an employee who did not complete a State-approved training to assist a

resident to eat or drink; or

• Ensure all paid feeding assistants (permanent or temporary) are used consistent

with State law; or

• Maintain documentation of a paid feeding assistant’s successful completion of a

State-approved paid feeding training course; or

• Ensure paid feeding assistants were supervised by a licensed nurse; or

• Ensure a paid feeding assistant called a supervisory nurse in an emergency; or

• Ensure paid feeding assistants are assisting only those residents without

complicated feeding problems and who have been selected as eligible to receive

these services from a paid feeding assistant; or

• Ensure the interdisciplinary team assessed the resident’s appropriateness for paid

feeding assistance and this need is reflected in the comprehensive care plan.

DEFICIENCY CATEGORIZATION

• An example of Level 4, immediate jeopardy to resident health and safety,

includes, but is not limited to:

o A resident is being assisted to eat by a paid feeding assistant and begins to

experiencing choking. The assistant was not trained to provide abdominal

thrusts or the Heimlich maneuver and the supervising nurse or other qualified

staff were not available to assist.

• An example of Level 3, Actual harm (physical or psychological) that is not

immediate jeopardy, includes, but is not limited to:

o A resident who did not have a complicated feeding problem and who was

assessed to have the potential to improving his or her eating ability was

assisted to eat by a paid feeding assistant. The assistant provided too much

food too quickly and the resident was pocketing the food in their cheeks. The

assistant did not notice this was happening and as a result the resident

experienced coughing and subsequently vomited.

• Examples of Level.2 - No actual harm with a potential for more than minimal

harm (physical or psychological) that is not immediate jeopardy, includes but

are not limited to:

o Residents are being assisted to eat by individuals who have not successfully

completed a State-approved paid feeding assistant training course and who

otherwise by State law would not be allowed to feed residents (note that RNs,

LPNs or CNAs are permitted to feed residents), and there were no resident

negative outcomes.

o Paid feeding assistants are assisting eligible residents; however supervising

nurses are not nearby or immediately available to promptly respond to an

emergency, but there have been no negative resident outcomes.

Level 1 - Severity 1 does not apply for this regulatory requirement.