Issue Paper
Use of "Single Task" Employees in Nursing Homes
Proposal:
The language below should be added to the Medicare and Medicaid statutes to give nursing facilities the flexibility to use non-nursing, “single task” employees to assist residents with eating under certain circumstances.
Create ss.1819(b)(5)(H) and 1919(b)(5)(H) of the Social Security Act to read:
(H) Non-Nursing Personnel Performing Limited Duties.
- Nursing facilities may permit personnel other than nurse aides to provide assistance with eating without completing the nurse aide training and competency evaluation program or the competency evaluation program if they have acquired necessary knowledge and skills through an inservice training program that includes dining skills and assistance with eating and that has been reviewed and approved by the regulatory authority, and they have been found competent to perform their duties.
- The determination of ability to provide assistance with eating will be made by an interdisciplinary team, to include at a minimum, licensed nursing, dietary, speech therapy and occupational therapy staff responsible for the care of the resident. The determination will be based on the needs and potential risks to the resident as observed and documented in the comprehensive resident assessment and care plan.
- The facility will document that the interdisciplinary team has assessed the resident to determine that his or her health status does not require the assistance with eating to be performed by nursing personnel.
- Non-nursing personnel providing assistance with eating may augment, but not replace, existing staff and cannot be counted toward meeting or complying with requirements for nursing care staff and functions.
Background:
A “single task” employee is an employee who neither is a licensed professional nurse nor a certified nursing assistant (CNA) listed on the State’s nurse aide registry who is permitted to perform a single direct care task. Examples include an activities assistant assigned to help feed a resident or a dietary aide who pushes a resident in her wheelchair to dinner. “Single task” employees are non-nursing personnel used to provide support to nursing staff primarily in the areas of feeding, transportation and mobility, and activities. Because they are not CNAs, “single task” employees have not completed the nurse aide training and competency evaluation program.
Wisconsin has reviewed and approved requests by nursing facilities to use “single task” employees since 1993. Last month, however, officials from the federal Health Care Financing Administration (HCFA) challenged Wisconsin’s “single task” employee policy during a visit to the Bureau of Quality Assurance (BQA) in Wisconsin’s Department of Health and Family Services (DHFS). According to those HCFA officials, federal law does not allow facilities to use single task employees to assist residents with feeding (no concerns were raised with transporting residents). As a result, HCFA has demanded that BQA provide it with additional information on the use and prevalence of single task employees in Wisconsin facilities.
NOTE: BQA disagrees with HCFA’s interpretation of federal law and intends to challenge that interpretation in order to continue Wisconsin’s current practice.
Supporting Arguments:
- The proposed statutory change offered above is consistent with current policy in Wisconsin. It bases the ability of non-nursing employees to provide direct care services on the documented needs and potential risks to the individual and also requires those employees to complete relevant in-service training approved by the DHFS and to demonstrate competence in the duties assigned.
- The most significant challenge facing nursing homes in Wisconsin and throughout the country today is the recruitment and retention of caring and competent staff. The rationale for using “single task” employees is to respond to this staffing crisis. Simply stated, if competent nursing staff were available, they would be working in our nursing facilities. Since they’re not, use of a “single task” employee is a necessary alternative.
- How bad is the staffing crisis? So bad that last year, Wisconsin’s long-term care provider associations issued a formal consumer advisory on possible restricted access to nursing homes in Wisconsin because of developing staff shortages. So bad that the provider associations’ joint survey of over 200 Wisconsin nursing homes found that 4 out of 5 nursing homes in the State reported their ability to be fully staffed was worse or significantly worse than it was three years ago and that on average, Wisconsin nursing homes have over 7 vacant CNA positions at any given time. So bad that a recent survey of WAHSA members found that 74.7% of the 83 respondents are using temporary nursing help, or “pools”, to meet their staffing needs. Reliance on nurse pools is the course of last resort for nursing facilities: not only does it have a negative impact on continuity of care; the cost to purchase pool nursing staff is more than double the cost to pay in-house RNs, LPNs and CNAs.
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Many WAHSA facilities describe as “invaluable” the work of their “single task” employees. In response to HCFA’s challenge to the use of “single task” employees for feeding, WAHSA conducted a survey of its members. The findings:
Of the 106 respondents, 49 facilities currently use “single task” employees to assist residents with feeding.
Seventeen (17) additional facilities plan to employ “single task” employees within the next 6 months; 22 within the next 12 months; and 5 more within 2 years.
If those predictions hold true and the responses from 93 facilities are representative of long-term care facilities statewide, approximately 88% of Wisconsin’s nursing facilities will be employing “single task” workers to assist in feeding residents within the next two years, IF HCFA ALLOWS THAT PRACTICE.
The 49 facilities currently using “single task” employees employ 244 “single task” workers. Those workers assist with the feeding of 525 residents every day.
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A recent study by the General Accounting Office identified nutrition and hydration as areas of major concern in nursing home care. The advantages in the use of “single task” employees, specifically to address residents’ nutrition and hydration needs, are numerous:
Since feeding residents for most “single task” employees is their only responsibility, they are able to provide the attention to detail and the social interaction that nursing home residents deserve and overworked CNAs are unable to provide. This helps ensure the nutrition and hydration needs of the resident are being met without rushing the resident through or making others wait for their meals, while freeing CNAs for other caregiving duties. The end result is intended to be the enhancement of the nursing home resident’s quality of life.
Many workers in today’s tight labor market are seeking the flexibility in working arrangements that are provided under the “single task” function, where individuals often work only during the mealtime hours.
Retirees serve the role of “single task” employees in many facilities and, with their depth of life’s experiences and caring commitment, serve that role admirably. Many of them, however, would be unable to meet the physical requirements of a CNA and if the single task designation were eliminated, so, too, would be their trusted services. High school students also have served the “single task” function, providing them with the positive experience that has led many to a future career in long-term care. The “single task” function enables many who either are unwilling or unable to become CNAs to add dignity to the eating experience in a nursing home.
As noted above, the use of a “single task” employee to assist in feeding residents enables the overworked CNA to provide patient care in other potentially-neglected areas. For those CNAs who do assist with eating, federal rules and interpretations prohibit them from feeding multiple residents at the same time, require them to ensure the proper temperature of hot (and cold) foods, require them to take the time to encourage and assist each resident individually, require them to toilet those residents who need to be toileted during mealtime and require them to meet each resident’s rehabilitative dining needs as outlined in their individualized care plan. Not surprisingly, one administrator indicated his facility’s CNAs are spending up to 4 hours of their 8-hour shift in the dining room feeding dependent residents and not on the floor caring for those same residents.
- HCFA apparently is interpreting ss.1819(b)(5)(F) and 1919(b)(5)(F) of the Social Security Act to mean any individual who performs even one nursing or nursing-related service is by definition a “nurse aide” and must meet the nurse aide training and competency evaluation requirements. We ask you to join us and the Wisconsin BQA in challenging that interpretation. But if HCFA’s interpretation of the statute is deemed to be correct, we ask you to please support statutory changes to the Social Security Act (see above) which would enable nursing facilities to use “single task” employees.
Today, in Wisconsin’s long-term care facilities, “single task” employees are providing invaluable services to the frail elderly and disabled persons entrusted to the care of those facilities. Every day, these caring individuals make a difference in the lives of those individuals: The difference between a nutritious meal served with dignity by a person who has time to share, time to care and time to converse, or a meal that is simply served. If you or your loved one were the resident, which would you prefer?
The Wisconsin Association of Homes and Services for the Aging (WAHSA) is a statewide membership organization of not-for-profit corporations principally serving elderly and disabled persons. Membership is comprised of 190 religious, fraternal, private and governmental organizations which own, operate and/or sponsor 194 not-for-profit nursing homes, 71 community-based residential facilities, 39 residential care apartment complexes, 100 independent living facilities, and 446 community service programs which provide services ranging from Alzheimer's support, child day care, hospice and home care to Meals on Wheels. For more information, please contact the WAHSA staff at (608) 255-7060: John Sauer, Executive Director; Tom Ramsey, Director of Government Relations; or Brian Schoeneck, Financial Services Director.
WAHSA 204 South Hamilton Street Madison, WI 53703
Telephone: (608)255-7060 FAX:(608)255-7064