Free Feeding Assistant Training Program Application-F-62588 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 1 of 12

FEEDING ASSISTANT TRAINING PROGRAM APPLICATION
TABLE OF CONTENTS Introduction ................... Page 1 Instructions .............. Pages 2 - 4 Application ............. Pages 5 - 12

INTRODUCTION (Page 1)
The U.S. Department of Health and Human Services (DHHS), Centers for Medicare and Medicaid Services (CMS) authorizes the State to review and determine eligibility for feeding assistant training programs under the requirements of the Medicare and Medicaid programs. This application form meets federal and state requirements for feeding assistant training program eligibility determination.

APPLICATION COMPLETION · · · · No fee will be charged for submitting the Feeding Assistant Training Program Application form for review and program determination. All items on the application must be answered completely. Incomplete applications will be returned without being processed. The submitted application and accompanying materials will not be returned. Retain a copy of the application you submit to the Department. Mail the completed application to: Wisconsin Feeding Assistant Training Program Office of Caregiver Quality Division of Quality Assurance P.O. Box 2969 Madison, WI 53701-2969 · Direct questions regarding completion of the application to: Division of Quality Assurance Office of Caregiver Quality (OCQ) (608) 261-8328 · The Department will approve or deny the application in writing within 45 days of receiving the completed application.

REPORT OF CHANGE Approved programs must report the following changes to the Department within ten days: · · · Change of the Primary Instructor. The Primary Instructor is responsible for the overall operation of the training program. Submit the qualifications of the proposed Primary Instructor for Department review. Change in the feeding assistant training curriculum. Change in location of the training program classroom or clinical site. An onsite review may be completed at the discretion of the Department.

Programs must operate according to their specifications submitted with their Feeding Assistant Training Program Application. Failure to do so may result in suspension or revocation of Feeding Assistant Training Program approval.

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 2 of 12

INSTRUCTIONS
(Pages 2 ­ 4)

The instructions listed below are designed to clarify specific application items. Items that are self-explanatory have not been included. I. GENERAL INFORMATION A. Applicant Information: 1. 2. The applicant is the facility, agency, organization, or individual that is responsible for the development and administration of the training program. The program contact is the individual within the organization who bears direct responsibility for the administrative and operational aspects of the program. In a facility-based program, this could be the administrator, director of nursing, or the primary instructor. Do not use nicknames.

B.

Authorized Person Information: Indicate the name and the address of the person authorized to accept personal service and where registered and certified mail can be received.

C.

Program Information: 1. 2. This date reflects the date the program will first be offered. Program Type: Indicate the program area of service. The Division of Quality Assurance maintains a list of approved feeding assistant training programs. To ensure accurate information is maintained on this list, notify the Department of any changes.

II.

PROGRAM STANDARDS A. B. C. Classroom Setting: List the appropriate information for each classroom setting. Clinical Practice Setting: List the appropriate information for each clinical practice setting. Record Retention: The program must indicate provisions that must be made for retrieving records in the event of program termination, revocation or suspension. The program must indicate provisions for retaining the following records: 1. 2. 3. 4. 5. D. All skill checklists, written tests, certificates, and other relevant training records for a minimum of three years. Documentation of the training that was conducted and identification of the instructor who conducted the training. A record of all individuals who have successfully passed the training and testing program for paid feeding assistants. A copy of the feeding assistant training certificate. The training program must maintain security of the testing materials and certificates.

Bias-free program: 1. 2. The training program (curriculum, presentation, quizzes, and competency test) must avoid racial, cultural, and gender bias. Enclose your policy concerning the provision of a bias-free program. Instructional programs are required to make accommodations for individuals with handicapping conditions. A "handicapping condition" is defined as a "physical or mental impairment which makes ability to care for oneself unusually difficult or limits the capacity to work." This may be a physical condition that requires special accommodations for the trainee or may involve a mental impairment, such as a learning disability that prevents the trainee from learning through traditional methods of instruction.

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 3 of 12

E.

Floor Plan: Submit a floor plan of the instructional setting which provides the following: · Location of classrooms · Dimensions of classrooms · Description of lighting systems · Description of heating systems · Description of ventilation systems NOTE: These floor plans should coincide with the classroom(s) listed in item 1 above, but do not need to be the "official" blueprints.

F.

Supervision: The training program must ensure supervision of the trainees' successful completion of the training and competency program. Describe the supervision students will receive during their classroom and clinical training. Program Evaluation: Programs must provide a method for students to evaluate the program and for accepting and reviewing complaints. Describe the program's process and attach a copy of the program's evaluation form.

G.

III.

PRIMARY INSTRUCTOR / PROGRAM TRAINER QUALIFICATIONS A. Primary Instructor: The Primary Instructor bears overall responsibility for the training program. Complete the Feeding Assistant Training Program Primary Instructor Application (F-62692) for each primary instructor. Program Trainer: Personnel from health related fields may serve as program trainers to meet specialized instructional needs. Program trainers must have 1 year experience in the area in which they will provide training. Complete the Feeding Assistant Training Program Trainer Application (F-62688) for each program trainer. This application need not be completed if the program uses the primary instructor to train all aspects of the program. Instructor to Trainee Ratio: Please indicate the number of students to instructor in classroom and clinical settings.

B.

C.

IV.

CURRICULUM A. Standardized Curriculum: The feeding assistant training program must provide at least 8 hours of classroom and clinical training for Units 1 - 8, and must provide an additional, specified number of hours for training the selected resident population techniques and behaviors and the Wisconsin Caregiver Program requirement. All units of training must be provided prior to offering a trainee the State standardized competency test. If the program chooses to increase the training requirements, the additional hours of instruction and proposed training materials must be submitted with the application. Programs must choose one of the listed standardized curriculums, which have been pre-approved by the Department to provide a minimum of eight (8) hours of theory and practice instruction for the following topics (1 - 8). 1. 2. 3. 4. 5. 6. 7. 8. Feeding techniques Assistance with feeding and hydration Communications and interpersonal skills Appropriate responses to resident behavior Safety and emergency procedures, including the Heimlich maneuver Infection control Resident rights Recognizing changes in residents inconsistent with the norm and the importance of reporting changes to the nurse

Training must be provided on units 9 and 10. The training hours must be in addition to the minimum eight hours required for the units listed above (1 - 8). Indicate the training hour(s) for each unit.

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 4 of 12

9.

Wisconsin Caregiver Program: "The Wisconsin Caregiver Program: A Blueprint for Excellence" videotape will be used to provide standardized instruction regarding caregiver misconduct definitions (i.e., abuse or neglect of a client or misappropriation of a client's property, the need to promptly report any misconduct allegations to supervisor, substantiated findings, Rehabilitation Review). The tape is approximately 20 minutes and may be stopped to allow an interaction discussion. Selected Resident Population: Each facility-based program must identify their selected resident population proposed to be served by trained feeding assistants. The training program's curriculum must include instruction specific to the selected resident population (e.g., specialized feeding and cueing techniques for selected residents, behavioral problems, confusion, wandering, etc.). Federal regulations do not allow feeding assistants to serve residents who have complicated feeding problems. Complicated feeding problems include, but are not limited to, difficulty in swallowing, recurrent lung aspirations, and tube or parenteral / IV feedings. Facility-based training programs must develop and attach proposed training materials that will be used to provide instruction regarding the needs of the selected resident population.

10.

B.

Training Program Developed Curriculum: Training programs may choose to offer additional instruction beyond the minimum training covered under the pre-approved curriculum. Submit any training materials developed by the program to the Department for review and approval. Attach training documents, e.g., completed script, curriculum, instructor's manual, and other supporting documents. DO NOT send copies of audio-visual teaching aids, e.g., videotapes, cassettes, copies of textbooks. If textbooks are utilized, send a bibliography. In this section of the application, outline the following information for each of the core areas: · · · Unit of Instruction Behavioral objectives of unit Time required for instruction

NOTE: · · C. All facility-based programs must complete Core Area 10, "Selected Resident Population." Application materials will not be returned to the applicant.

Competency Evaluation: At the conclusion of the training course, the program must administer a State standardized competency evaluation examination to the trainee. The program must indicate their provisions for the following: 1. 2. Successful completion of the State approved standardized written quiz with a score of 75% or greater. Successfully perform a State approved standardized skill demonstration by feeding a resident in the clinical setting. Each skill must be initialed and dated by the instructor to verify satisfactory or unsatisfactory performance. If the candidate does not successfully complete the initial evaluation, the candidate will be allowed the opportunity to review the materials and retake the test on a subsequent date. Programs can establish the number of times a candidate may retake the test. However, the program must document the initial failure, opportunity for review and subsequent retake testing date. The instructor must issue a State approved certificate to all participants who successfully complete the program, indicating the name of the participant, the training program and the date of successful completion. Training programs must maintain security of the test materials and certificate template.

3.

4. 5.

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 5 of 12

FOR OFFICE USE ONLY
Program No.

FEEDING ASSISTANT TRAINING PROGRAM APPLICATION
(Pages 5 ­ 12)

Date Entered Reviewer

A feeding assistant training program must satisfy the federal and state requirements to qualify for approval by the Department. All entities must submit an application to the Department for review and approval determination. Instructions: If you are not completing this form electronically, type or print clearly in black ink. I. A.
1.

GENERAL INFORMATION Applicant Information
Name (Last, First, MI or Agency Name) Current Address (Street Address / PO Box) Telephone Number FAX Number City E-mail Address Social Security No. or FEIN State Zip Code

2.

Name - Program Contact (Last, First, MI) Telephone Number FAX Number E-mail Address

B.

Authorized Person Information
Name (Last, First, MI) Title

Current Address (Street Address / PO Box)

City

State

Zip Code

Telephone Number

FAX Number

E-mail Address

C.

Program Information
Date This Program Will be First Offered (mm/dd/yyyy)

The program will be available only to employees or students of the following nursing home(s): Name Name Name Name Name

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 6 of 12

II. A.

PROGRAM STANDARDS Complete for Each Classroom Setting of the Program
Name - Facility Providing Classroom Current Address (Street Address / PO Box) Telephone Number FAX Number City E-mail Address State Zip Code

B.

Complete for Each Clinical Practice Setting of the Program
Yes No Do you have more than one facility? If "Yes," attach additional pages.

Name ­ Facility Providing Clinical Site

Current Address (Street Address / PO Box) Telephone Number FAX Number

City E-mail Address

State

Zip Code

Name - Contact Person (Last, First, MI) Telephone Number FAX Number E-mail Address

C.

Record Retention Policy
Submit a copy of the policies describing the program record retention policy, including the disposition of records in the event of termination of the program. (See instructions.)

D.

Cultural Bias / Accommodating Handicapping Conditions
Submit a copy of the policies for avoiding cultural, sexual, and racial bias and for making responsible accommodations for students with handicapping conditions. See instructions.

E.

Floor Plan
Submit a floor plan of the instructional setting. See instructions.

F.

Supervision
Submit a copy of the policy that describes the supervision available to the trainee during the skills training component in the clinical practice setting. Attach additional sheets, if necessary.

G.

Program Evaluation
Submit a copy of the policy that describes the method that will be used for written evaluation of the program and for accepting and reviewing program complaints. Provide a copy of the program evaluation.

III. A.

PRIMARY INSTRUCTOR QUALIFICATIONS Primary Instructor
Complete the Feeding Assistant Training Program Primary Instructor Application (F-62692) for each primary instructor.

B.

Program Trainer
Complete the Feeding Assistant Training Program Trainer Application (F-62688) for each program trainer.

C.

Instructor to Trainee Ratio
Classroom Identify the ratio of instructors to trainees for the following: Clinical

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 7 of 12

IV. A.

CURRICULUM Standardized Pre-Approved Curriculum
Programs may choose one of four (4) feeding assistant training program curriculums pre-approved by the Department. Indicate your choice by checking one of the boxes below. If the program is offering increased instruction, beyond the federal and state minimum training requirements, indicate the name of the curriculum in Units of Instruction 1 - 8 and the number of training hours. In addition, all facility-based programs must submit a complete copy of the curriculum for instruction provided to trainees for the facility's selected resident population to be served by trained feeding assistants. See instructions. "Assisted Dining: The Role and Skills of Feeding Assistants" by American Health Care Association "Eating Matters - A Training Manual for Feeding Assistants" by American Dietetic Association "Paid Feeding Assistant Training Program" by Wisconsin Association of Health and Aging Services "Assisting with Nutrition and Hydration in Long-Term Care" by Hartmahn Publishing, Inc.

B.

Training Program Developed Curriculum
Programs may choose to provide additional training beyond the minimum instruction covered under their selected standardized preapproved curriculum. Training programs offering additional training must provide information regarding their proposed curriculum for each core area, completing the "Unit of Instruction" format. See instructions for a completed sample. Additional pages may be necessary depending on the number of units of instruction and number of behavioral objectives for each unit of instruction.

NOTE: All facility-based programs must complete their proposed curriculum for Core Area 10 - Selected Resident Population.

UNITS OF INSTRUCTION
CORE AREA 1 ­ Feeding Techniques [HFS 129.11(1)(a)]
The program must cover principles and requirements relating to feeding techniques. a. Title of Unit of Instruction

b.

Behavioral Objective of Unit The feeding assistant must be able to:

c.

Time Required for Instruction Hours Minutes

1. Classroom Time
Hours Minutes

2. Clinical Time
Calculate the total classroom time and clinical time for these units of instruction. Hours Minutes

TOTAL TIME

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 8 of 12

CORE AREA 2 ­ Assistance with Feeding and Hydration [HFS 129.11(1)(b)]
The program must cover principles and requirements relating to feeding and hydration. a. Title of Unit of Instruction

b.

Behavioral Objective of Unit The feeding assistant must be able to:

c.

Time Required for Instruction Hours Minutes Minutes

1. 2.

Classroom Time
Hours

Clinical Time

Calculate the total classroom time and clinical time for these units of instruction. Hours Minutes

TOTAL TIME

CORE AREA 3 ­ Communication and Social Interaction [HFS 129.11(1)(c)]
The program must include theory and practice in communicating and interacting on a one-to-one basis with clients. a. Title of Unit of Instruction

b.

Behavioral Objective of Unit The feeding assistant must be able to:

c.

Time Required for Instruction Hours Minutes

1. 2.

Classroom Time
Hours Minutes

Clinical Time

Calculate the total classroom time and clinical time for these units of instruction. Hours Minutes

TOTAL TIME

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 9 of 12

CORE AREA 4 ­ Appropriate Responses to Resident's Behavior [HFS 129.11(1)(d)]
The program must cover instruction about appropriate responses and techniques for meeting the basic needs of the residents selected to be served by the feeding assistant as follows: a. Title of Unit of Instruction

b.

Behavioral Objective of Unit The feeding assistant must be able to:

c.

Time Required for Instruction

1. 2.

Classroom Time Clinical Time

Hours Hours

Minutes Minutes

Calculate the total classroom time and clinical time for these units of instruction. Hours Minutes

TOTAL TIME

CORE AREA 5 ­ Safety and Emergency Procedures [HFS 129.11(1)(e)]
The program must cover instruction about proper safety and emergency procedures, including the Heimlich maneuver as follows: a. Title of Unit of Instruction

b.

Behavioral Objective of Unit The feeding assistant must be able to:

c.

Time Required for Instruction Hours Minutes

1. 2.

Classroom Time
Hours Minutes

Clinical Time

Calculate the total classroom time and clinical time for these units of instruction.
Hours Minutes

TOTAL TIME

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 10 of 12

CORE AREA 6 ­ Infection Control [HFS 129.11(1)(f)]
The program must cover principles and requirements relating to infection control, including hand washing, universal precautions, proper disposal of body fluids, etc. a. Title of Unit of Instruction

b.

Behavioral Objective of Unit The feeding assistant must be able to:

c.

Time Required for Instruction Hours Minutes

1. 2.

Classroom Time
Hours Minutes

Clinical Time

Calculate the total classroom time and clinical time for these units of instruction. Hours Minutes

TOTAL TIME

CORE AREA 7 ­ Resident Rights [HFS 12911(1)(g)]
The program must cover principles and requirements relating to clients' rights. a. Title of Unit of Instruction

b.

Behavioral Objective of Unit The feeding assistant must be able to:

c.

Time Required for Instruction Hours Minutes

1. 2.

Classroom Time
Hours Minutes

Clinical Time

Calculate the total classroom time and clinical time for these units of instruction. Hours Minutes

TOTAL TIME

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 11 of 12

CORE AREA 8 ­ Recognizing Resident Changes [HFS 129.11(1)(h)]
Recognizing changes in residents that are inconsistent with the norm and the importance of reporting changes to the nurse. a. b. Title of Unit of Instruction Behavioral Objective of Unit The feeding assistant must be able to:

c.

Time Required for Instruction

1. 2.

Classroom Time Clinical Time

Hours Hours

Minutes Minutes

Calculate the total classroom time and clinical time for these units of instruction.

TOTAL TIME

Hours

Minutes

Training MUST be provided on units 9 and 10 and must be IN ADDITION to the minimum 8 hours for units 1- 8. CORE AREA 9 ­ Wisconsin Caregiver Program [HFS 129.11(2)(a)]
The training program must provide instruction about Wisconsin's Caregiver Program by presenting "The Wisconsin Caregiver Program: A Blueprint for Excellence" video tape. a. Title of Unit of Instruction

DHS Video Tape: "Wisconsin's Caregiver Program: A Blueprint for Excellence"
b. Behavioral Objective of Unit The feeding assistant must be able to:

· · · ·
c.

Identify abuse, neglect, misappropriation and injuries of unknown source scenarios, based on definitions. Understand the importance of reporting all allegations of caregiver misconduct and injuries of unknown source. Identify the correct procedure and to whom caregiver misconduct allegations must be reported. Understand the impact of a substantiated finding on the Wisconsin Caregiver Misconduct Registry and the Rehabilitation Review.
Hours Minutes Minutes

Time Required for Instruction

1. 2.

Classroom Time Clinical Time
Hours

Calculate the total classroom time and clinical time for these units of instruction. Hours Minutes

TOTAL TIME

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62588 (Rev. 12/08)

STATE OF WISCONSIN
42 CFR 483.160 and 488.301 Page 12 of 12

CORE AREA 10 ­ Selected Resident Population [HFS 129.11(2)(b)]
The program must provide instruction about the needs and behaviors of their selected resident population to be served by the feeding assistant (e.g., dementia, Alzheimer's disease, developmental disabilities, brain trauma, etc.) and specific techniques for meeting the behaviors of the selected clients. a. Title of Unit of Instruction

b.

Behavioral Objective of Unit The feeding assistant must be able to:

c.

Time Required for Instruction Hours Minutes

1. 2.

Classroom Time
Hours Minutes

Clinical Time

Calculate the total classroom time and clinical time for these units of instruction. Hours Minutes

TOTAL TIME

Calculate the total classroom time and clinical time for units 1 - 10. Classroom Clinical

TOTAL TIME C. Competency Evaluation

Submit a copy of the policy that describes the program's policies and procedures in administering the State competency evaluation examination, procedures to ensure accurate test scoring, and provisions to ensure the security for the examination and certificate templates.

ATTESTATION
The Approved Program is responsible for notifying the Office of Caregiver Quality, in writing, of any changes in the information provided on this application. I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a fine of up to $10,000 or imprisonment not to exceed 6 years, or both (Chapter 946.32, Wis. Stats.).

_______________________________________________ SIGNATURE _______________________________________________
Name (Print or type.)

_________________________
Date Signed

_____________________________________________
Title