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Back to index of statements May 28, 2002 Mr. Thomas A. Scully, Administrator Ref: File Code CMS-2131-P Comments on Proposed Rule: Medicare and Medicaid Programs: Requirements for Paid Feeding Assistants in Long Term Care Facilities. Dear Tom: The Alzheimer's Association appreciates the opportunity to submit the following comments on the above-referenced proposed rule, which was published in the Federal Register March 29, 2002. This proposal is particularly relevant for nursing home residents who have Alzheimer's disease or other cognitive impairments, many of whom need a great deal of individual attention, encouragement, support, and in some cases physical assistance to assure adequate nutritional intake and hydration and to make mealtime a pleasant and dignified experience. Indeed, the lack of adequate numbers of qualified personnel to provide this kind of person-centered care has multiple adverse outcomes for quality of care and quality of life for residents and for the quality of the work experience for direct care staff. In a well-staffed and well-managed nursing home, a well-designed program utilizing mealtime companions or nutrition assistants might in fact enhance person-centered care for persons with dementia. We would support an effort at the Centers for Medicare and Medicaid Services (CMS) to test and evaluate that hypothesis and, if this yields positive outcomes for residents and staff, to find appropriate ways to allow facilities to use such supplemental staff in ways that would enhance and not undermine the quality goals that are at the heart of current federal law. (Unfortunately, the limited use of feeding assistants that has occurred in states that have authorized their use has never been evaluated. While the Notice of Proposed Rule-Making points to positive anecdotal evidence about their use, negative anecdotes exist as well. Neither is a substitute for careful evaluation of resident and staff outcomes and cannot serve as the basis for fundamental policy change.) Our objections to the proposed rule are two-fold: First, the basic purpose of the rule as set forth in the supplementary information is wrong. CMS states its intent in proposing this rule is to address the current shortage of certified nursing assistants (CNAs.) Thus, feeding assistants would become a substitute for rather than an enhancement of even a minimally adequate number of direct care staff. As your Department's own report to Congress makes clear, the shortage of CNAs in the nation's nursing homes is widespread and seriously jeopardizes the basic health and safety of residents. It is a shortage that is not confined to mealtimes but extends twenty-four hours a day. That is an issue that must be addressed directly. There is no way to escape the fact that it will take substantial additional expenditure of funds to attract and retain adequate numbers of fully trained staff. (We cannot alleviate the crisis through a no-cost solution, which is what the NPRM implies. Even the addition of feeding assistants as supplements rather than replacement of existing staff would cost money.) Part-time feeding assistants trained for that single task will not alleviate the fundamental shortage of trained nursing staff. Only with minimum staffing standards in place and enforced should a well-designed program of supplementary nutrition assistants be considered or allowed. Second, the rule itself falls short of minimum requirements that would be necessary to assure good person-centered care, even if these feeding assistants were allowed only in facilities that meet minimum staffing standards. Because there has been no careful evaluation of a program utilizing feeding assistants, we cannot say with certainty what all of the components of a well-designed program would be. We can point, however, to the following concerns with the proposed rule:
Second, Sec. 488.301 authorizes employment of feeding assistants "under an arrangement with another agency or organization." Use of agency or pool workers is antithetical to continuity of person-centered care, which is important for every resident but particularly for those who have dementia and would most likely be assigned a feeding assistant. Feeding assistants, if they are to be used at all, should be regular employees of the facility who are scheduled to be in the facility for sufficient time and are integrated into the care team. In conclusion, we recommend that CMS withdraw this proposed rule and instead design a careful time-limited demonstration or pilot program that would provide the kind of evidence that would make possible a well-informed policy decision about whether and how supplementary staff might be utilized in facilities, consistent with federal law, in a way that would enhance quality person-centered care. In the interim, CMS might consider a more limited approach that could allow non-nursing staff already employed in a facility to be cross-trained to assist residents at mealtimes, in much the way a facility utilizes trained volunteers. These are people who already know residents and direct care staff and are accountable to the facility for their performance. Finally, we urge CMS to address directly the critical shortage of well-trained certified nursing assistants and nursing staff in our nation's nursing facilities. There are no inexpensive shortcuts to solving this fundamental problem that jeopardizes quality and leaves our most vulnerable elderly at risk. We appreciate the opportunity to comment. The Association looks forward to working with CMS as you continue to wrestle with the critical challenge of adequate staffing for Long Term Care in our nation's nursing homes. Sincerely, Judith A. Riggs 
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