Department of Health and Social Services

Division of Long Term Care Residents Protection

PROPOSED

3220 Training and Qualifications for Nursing Assistants and Certified Nursing Assistants

PUBLIC NOTICE

In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code) and under the authority of Title 29 of the Delaware Code, Section 7903(10), Delaware Health and Social Services (DHSS) / Division of Long Term Care Residents Protection is proposing to amend Regulation 3220 - Training and Qualifications for Nursing Assistants and Certified Nursing Assistants.

Any person who wishes to make written suggestions, compilations of data, testimony, briefs or other written materials concerning the proposed new regulations must submit same to Deborah Gottschalk, Chief Policy Advisor, Office of the Secretary, Main Admin Building, 1901 North DuPont Highway, P.O. Box 906, New Castle, Delaware 19720-0906 or by fax to (302) 255-4429 by Thursday, November 1, 2012.

The action concerning the determination of whether to adopt the proposed regulation will be based upon the results of Department and Division staff analysis and the consideration of the comments and written materials filed by other interested persons.

SUMMARY OF PROPOSED CHANGES

This regulatory proposal amends the existing regulations by establishing reporting requirements for Certified Nurse Aide training program providers and makes some minor revisions in training curricula.

Statutory Authority

29 Del.C. §7903(10), Powers, duties and functions of the Secretary.

3220 Training and Qualifications for Nursing Assistants and Certified Nursing Assistants

“Advanced Practice Nurse” shall mean an individual whose education and licensure meet the criteria outlined in 24 Del.C. Ch. 19 and who is certified in at least one of the following specialty areas: (1) Adult nurse practitioner; (2) Gerontological clinical nurse specialist; (3) Gerontological nurse practitioner; (4) Psychiatric/mental health clinical nurse specialist; (5) Family nurse practitioner.

“Assisted Living Facility” Assisted living facility is a residential arrangement for fee licensed pursuant to 16 Del.C. Ch. 11.

“CE Track” is the Division’s website www.CNADECE.org used for recording and tracking CNA continuing education hours counted toward CNA recertification requirements.

“CE Hour” Continuing education offered by an education provider consisting of 60 minutes of instruction. For formal college nursing courses completed, one (1) semester hour is equivalent to five (5) CE hours.

“Certified Nursing Assistant (CNA)” a duly certified individual under the supervision of a licensed nurse, who provides care which does not require the judgment and skills of a licensed nurse. The care may include, but is not limited to, the following: bathing, dressing, grooming, toileting, ambulating, transferring and feeding, observing and reporting the general well‑being of the person(s) to whom they are providing care.

“Department” the Department of Health and Social Services.

"Direct Supervision" means actually observing students performing tasks.

“Division” the Division of Long Term Care Residents Protection.

“Education Provider” is a facility, agency or other entity that offers continuing education courses approved by the Division. Education Provider approval is contingent upon the education provider recording attendance, confirming participant identity and otherwise ensuring that CE hours are accurately recorded in CE Track.

"General Supervision" is providing necessary guidance for the program and maintaining ultimate responsibility.

“Intermediate Care Facility” Facility licensed pursuant to 16 Del.C. Ch. 11 with a license designated for intermediate care beds.

“Licensed Nurse” shall mean a licensed practical nurse, registered nurse and/or advanced practice nurse whose education and licensure meet the criteria in 24 Del.C. Ch. 19.

"Licensed Nursing Facility" is a residential institution, as defined in 16 Del.C., §11042(4), which provides services to residents which include resident beds, continuous nursing services, and health and treatment services for individuals who do not currently require continuous hospital care. Care is given in accordance with physician's orders and requires the competences of a registered nurse (RN).

“Licensed Practical Nurse (LPN)” a nurse who is licensed as a practical nurse in Delaware or whose license is recognized to practice in the State of Delaware, and who may supervise LPN’s, CNA’s, NA’s and other unlicensed personnel.

“Nursing Assistant (NA)” an individual who has completed the requisite training to become a Certified Nursing Assistant but is awaiting certification.

“Nursing Related Services” those health related services that include supervision of, and direct assistance to, individuals in their activities of daily living and/or those physical and psychosocial basic skills encompassed in the certified nursing assistant curriculum.

“Nursing Services Direct Caregivers” those individuals, as defined in 16 Del.C., §1161(e), assigned to the direct care of nursing facility residents.

“Physician” a physician licensed to practice in the State of Delaware.

“Registered Nurse (RN)” a nurse who is a graduate of an approved school of professional nursing and who is licensed in Delaware or whose license is recognized to practice in the State of Delaware.

“Rehabilitation” the restoration or maintenance of an ill or injured person to self‑sufficiency at his or her highest attainable level.

“Resident” a person admitted to a nursing facility or similar facility licensed pursuant to 16 Del.C. Ch 11.

“Restraint” “Chemical Restraints” are defined as a psychopharmacologic drug that is used for discipline or convenience and not required to treat medical symptoms.

“Physical Restraints” are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.

“Senior Certified Nursing Assistant” a Certified Nursing Assistant who has met the requirements and training specified in Section 4 of these regulations.

“Skilled Care Facility” Facility licensed pursuant to 16 Del.C. Ch. 11 with a license designated for skilled care beds.

“Student” a person enrolled in a course offering certification as a CNA.

Each Nursing Assistant/Certified Nursing Assistant employed by any nursing facility either as contract/ agency or facility staff shall be required to meet the following:

2.1 An individual shall complete a nursing assistant training course approved by the Department on the recommendation of the CNA Training Curriculum Committee. The Committee shall consist of individuals with experience in the knowledge and skills required of CNAs.

2.2 Nursing Assistants are required to pass a competency test provided by the Department or by a contractor approved by the Department.

2.3 Nursing Assistants shall take the competency test within 30 days of completion of an approved program. Nursing assistants who fail to obtain a passing score may repeat the test two additional times. Nursing assistants who fail to obtain a passing score after testing three times must repeat the CNA training program before retaking the test. The certificate of completion of an approved program, a prerequisite to testing, must be dated within 24 months of the available testing date. Nursing assistants who are trained in a facility and are counted for staffing purposes pursuant to 16 Del.C. §1162(f) must pass the test within 90 days of completion of the facility program to continue to be counted in staffing calculations.

2.4 In order to qualify for recertification, a CNA must, during each 24 month certification period: (1) complete 24 hours of approved continuing education including 6 hours of dementia training and 2 hours of patient abuse prevention training and (2) perform at least 64 hours of nursing related services for pay under the supervision of a licensed nurse or physician. A CNA who does not perform at least 64 hours of nursing related services in a certification period, or fails to complete the required continuing education, or fails to renew their certification before the expiration date, must pass the competency test again. Nursing assistants who fail to obtain a passing score after testing three times must repeat the CNA training program before additional testing will be permitted.

2.4.1 All The CNAs shall receive dementia specific training that shall include: communicating with persons diagnosed as having Alzheimer's disease or other forms of dementia; the psychological, social, and physical needs of those persons; and safety measures which need to be taken with those persons. All CNAs shall also receive training in the prevention of patient abuse that shall include: definitions and signs and symptoms of abuse and neglect, reporting requirements and prevention strategies.

2.4.2 CE Track commenced operations January 1, 2012. CE hours earned after January 1, 2012, must be recorded in CE Track in order to be counted for recertification.

2.4.3 Education Providers shall enter courses in CE Track for Division approval prior to offering a class.

2.4.4 Education Providers shall enter classes into CE Track.

2.4.5 Education Providers shall enter CNA class attendance into CE Track within fourteen (14) working days from class completion. No CE hours will be considered for CNA recertification requirements if attendance is not entered by the Education Provider in CE Track.

2.5 A Certified Nursing Assistant trained and certified outside the State of Delaware in a program that equals or exceeds the federal nurse aide training program requirements in the Code of Federal Regulations §483.152 cannot work in Delaware without a Delaware certificate. Delaware certification is required prior to being employed as a CNA. The Department will grant reciprocity if the following conditions are met:

2.5.1 The CNA must have a current certificate from the jurisdiction where he or she currently practices, except that candidates from the State of Maryland must hold a current Geriatric Nursing Assistant certificate.

2.5.2 The CNA must have 3 months of full-time experience as a CNA performing nursing related services for pay under the supervision of a licensed nurse or physician, or have completed a training and competency evaluation program with the number of hours at least equal to that required by the State of Delaware.

2.5.3 The CNA must be in good standing in the jurisdiction where he/she is currently certified.

2.5.4 The CNA submits $30 to the Department to cover the costs associated with granting the reciprocity.

2.6 Nursing students who are currently enrolled in a nursing program and have satisfactorily completed a Fundamentals/Basic Nursing course with a 75 hour clinical component in a long term care setting will be deemed to meet the training requirements. These individuals will be approved to take the competency test upon submission of a letter from their school of nursing attesting to current enrollment status and satisfactory course completion as described.

2.7 Nursing students who have graduated from an RN or LPN program within 24 months prior to application for certification are deemed qualified to meet the Department’s nurse aide training and competency evaluation program requirements and are eligible for certification upon submission of a sealed copy of their diploma. Individuals who have graduated from an RN or LPN program more than 24 months prior to application for certification are deemed qualified to meet the Department’s nurse aide training program requirements and are eligible to take the competency test upon submission of a sealed copy of their diploma.

2.8 For the purpose of calculating minimum staffing levels, any individual who has completed all of the classroom training and half of the clinical training in a facility sponsored training program may be considered as a member of such facility’s staff while undergoing the last 37.5 hours of clinical training at such facility.

2.9 A nursing assistant who is employed by, or who has received an offer of employment from, a federally certified nursing facility on the date on which the aide begins a nurse aide training and competency evaluation program may not be charged for any portion of the program including tuition, any tests taken and fees for textbooks or other required course materials.

2.10 If a Certified Nursing Assistant who is not employed, or does not have an offer to be employed as a nurse aide becomes employed by, or receives an offer of employment from, a federally certified nursing facility not later than 12 months after completing a nurse aide training and competency evaluation program, the federally certified nursing facility shall reimburse all documented personally incurred costs in completing the program. Facilities shall accept as documentation canceled checks, paid receipts, written verification from a training program or other written evidence which reasonably establishes the CNA’s personally incurred costs. Such costs include tuition, tests taken and fees for textbooks or other required course materials. Such costs shall be reimbursed in equal quarterly payments with full reimbursement to coincide with the CNA’s completion of one year of employment including the orientation period.

2.11 Any nursing facility which reimburses a Certified Nursing Assistant for documented personally incurred costs of a nurse aide training and competency evaluation program shall notify the Division of Long Term Care Residents Protection of such reimbursement. Notice of such reimbursement shall be entered in the CNA Registry database and information regarding such reimbursement shall be available to facilities upon request.

3.1 General. Program approval must be obtained from the Division prior to operating a CNA program. To obtain approval, the curriculum content for the Certified Nursing Assistant training programs shall meet each of the following requirements:

3.1.1 The curriculum shall include material that will provide a basic level of both knowledge and demonstrable skills for each individual completing the program.

3.1.2 The program shall be a minimum of 150 hours in length, consisting of: (1) classroom instruction including laboratory time of 75 hours, and (2) clinical skills training of 75 hours in a long term care setting Delaware licensed skilled and Intermediate care nursing facility or a certified nursing facility defined in 42 CFR § 483.5(a). Additional hours may be added in either of these areas or both.

3.1.3 Classroom instruction and demonstrated proficiency in each skill shall be completed prior to students’ performing direct resident care. Programs shall maintain documentation of required skills that each student has successfully demonstrated to the RN instructor.

3.1.4 The training of nursing assistant must be done by or under the general supervision of a RN who possesses a minimum of two years of nursing experience, at least 1 year of which must be in the provision of long term care facility services. The required one year of full-time (35-hours per week) long term care experience can be met by work experience in, or supervision or teaching of students in a certified Delaware licensed skilled and Intermediate care nursing facility or a certified nursing facility defined in 42 CFR § 483.5(a).

3.1.5 All instructors (classroom and clinical) must have completed a course in teaching adults or have experience teaching adults in a group classroom/clinical setting or in the case of high school programs, be a state licensed high school teacher. Instructors do not have to have one year of long term care experience if the school has identified a RN supervisor as described in 3.1.4. The RN supervisor shall be available to all instructors, shall assist in developing lesson plans based on experience in taking care of nursing home residents, shall periodically ensure and document that instructors are operating effectively and that the program is operating in accordance with all state and federal regulations. Classroom ratios of student to instructor shall not exceed 24:1

3.1.6 LPN instructors are limited to instruction of students during the clinical phase of the CNA training program and must have at least three years of nursing experience and must work under the general supervision of a RN.]

3.1.7 Clinical instructors shall provide general supervision of students at all times during clinical instruction. Clinical instructors shall provide direct supervision to students in the clinical setting while the student is learning a competency until proficiency has been both demonstrated and documented. Clinical and laboratory ratios of student to Registered Nurse or Licensed Practical Nurse instructor shall not exceed 8:1.

3.1.8 Other personnel from the health profession may supplement the instructor, including but not limited to, registered nurses, licensed practical/vocational nurses, pharmacists, dieticians, social workers, sanitarians, fire safety experts, nursing home administrators, gerontologists, psychologists, physical and occupational therapists, activity specialist, speech/language/hearing therapists and resident rights experts. Supplemental personnel must have at least 1 year of experience in their respective fields.

3.1.9 Programs must notify the Division in writing (which may be faxed) at least 21 days prior to implementing permanent and/or substantial changes to the program or the program's personnel. Examples of substantial changes include, but are not limited to, instructor(s), clinical or classroom site, major revision of course structure, change in textbook. The 21 day time period may be waived by the Division for good cause shown.

3.2 Equipment

All programs shall have available at a minimum the following equipment:

3.2.1 Audio/Visual (Overhead projector and/or TV with VCR)

3.2.2 Teaching Mannequin, Adult, for catheter and perineal care

3.2.3 Hospital Bed

3.2.4 Bedpan/Urinal

3.2.5 Bedside commode

3.2.6 Wheelchair

3.2.7 Scale

3.2.8 Overbed Table

3.2.9 Sphygmomanometer

3.2.10 Stethoscope

3.2.11 Resident Gowns, linens and at least four (4) pillow

3.2.12 Thermometers

3.2.13 Crutches

3.2.14 Canes (Variety)

3.2.15 Walker

3.2.16 Gait Belt

3.2.167 Miscellaneous Supplies: i.e., Bandages, Compresses, Heating Pad, Hearing Aid, Dentures, Toothbrushes, Razors, bath and emesis basins and compression stockings.

3.2.178 Foley Catheter Drainage Bag

3.2.189 Hydraulic Lift

3.2.1920 Adaptive eating utensils/equipment

3.3 Curriculum Content

The following material identifies the minimum competencies that the curriculum content shall develop. Nursing assistants being prepared to work in skilled, intermediate, or assisted living facilities either as direct or contract staff shall master each competency. All demonstrable competencies for each student must be documented as mastered by the RN instructor in order for a student to qualify as successfully having completed that section of programming.

3.3.1 The Nursing Assistant Role And Function

Introduces the characteristics of an effective nursing assistant: personal attributes, on‑the‑job conduct, appearance, grooming, health and ethical behavior. Also presented are the responsibilities of the nursing assistant as a member of the resident care team. Legal aspects of resident care and resident rights are presented. Relevant Federal and State statutes are also reviewed.

Competencies:

3.3.1.1 Function as a nursing assistant within the standards described below:

3.3.1.1.1 Define the role and functions of the nursing assistant and provide awareness of the legal limitations of being a nursing assistant.

3.3.1.1.2 Recognize the responsibilities of the nursing assistant as a member of the health care team. Understand the relevant State and Federal regulations for long term care and legalities of reporting and documenting incidents and accidents.

3.3.1.1.3 Understand the role of Long Term Care advocates, investigators and surveyors.

3.3.1.1.4 Identify the “chain of command” in the organizational structure of the health care agency.

3.3.1.1.5 Maintain personal hygiene and exhibit dress practices which meet professional standards.

3.3.1.1.6 Recognize the importance of punctuality and commitment to the job.

3.3.1.1.7 Differentiate between ethical and unethical behavior on the job.

3.3.1.1.8 Understand the role, responsibility and functional limitations of the nursing assistant.

3.3.1.2 Demonstrate behavior that maintains resident’s rights.

3.3.1.2.1 Provide privacy and maintenance of confidentiality.

3.3.1.2.2 Promote the resident’s right to make personal choices to accommodate individual needs.

3.3.1.2.3 Give assistance in resolving grievances.

3.3.1.2.4 Provide needed assistance in going to and participating in resident and family groups and other activities.

3.3.1.2.5 Maintain care and security of resident’s personal possessions as per the resident’s desires.

3.3.1.2.6 Provide care which ensures that the residents are free from abuse, mistreatment, neglect or financial exploitation and report any instances of such poor care to the Division of Long Term Care Residents Protection. Discuss the psychological impact of abuse, neglect, mistreatment, misappropriation of property of residents and/or financial exploitation.

3.3.1.2.7 Maintain the resident’s environment and care through appropriate nursing assistant behavior so as to keep the resident free from physical and chemical restraints.

3.3.1.2.8 Discuss the potential negative outcomes of physical restraints, including side rails.

3.3.2 Environmental Needs Of The Resident

Key Concepts: Introduces the nursing assistant to the need to keep residents safe from injury and infection in the long‑term care setting. The nursing assistant is taught why and how to use infection control and isolation techniques. Safety through prevention of fires and accidents, and emergency procedures for fire and other disasters are presented.

Competencies:

3.3.2.1 Apply the basic principles of infection control.

3.3.2.1.1 Identify how diseases are transmitted and understand concepts of infection prevention.

3.3.2.1.2 Demonstrate proper hand washing technique.

3.3.2.1.3 Demonstrate appropriate aseptic techniques in the performance of normal duties and understand the role of basic cleaning, disinfecting, and sterilization tasks.

3.3.2.1.4 Demonstrate proper isolation and safety techniques in the care of the infectious resident and proper handling and disposal of contaminated materials.

3.3.2.2 Assist with basic emergency procedures.

3.3.2.2.1 Follow safety and emergency procedures.

3.3.2.2.2 Identify safety measures that prevent accidents to residents.

3.3.2.2.3 Recognize signs when a resident is choking or may have an obstructed airway.

3.3.2.2.4 Assist with clearing obstructed airway.

3.3.2.2.5 Call for help when encountering convulsive disorders, loss of consciousness, shock, hemorrhage, and assist the resident until professional help arrives.

3.3.2.2.6 Follow disaster procedures.

3.3.2.2.7 Report emergencies accurately and immediately.

3.3.2.2.8 Identify potential fire hazards.

3.3.2.3 Provide a safe, clean environment.

3.3.2.3.1 Identify the resident’s need for a clean and comfortable environment. Describe types of common accidents in the nursing home and their preventive measures. Be aware of the impact of environmental factors on the resident in all areas including but not limited to light and noise levels.

3.3.2.3.2 Report unsafe conditions to appropriate supervisor. Use the nurse call system effectively.

3.3.2.3.3 Report evidence of pests to appropriate supervisory personnel.

3.3.2.3.4 Report nonfunctioning equipment to appropriate supervisory/charge personnel.

3.3.2.3.5 Prepare soiled linen for laundry.

3.3.2.3.6 Make arrangement of furniture and equipment for the resident’s convenience and to keep environment safe.

3.3.3 Psychosocial Needs Of The Resident

Key Concepts: Focus is placed on the diverse social, emotional, recreational and spiritual needs of residents in a long term care setting. The curriculum shall describe some of the physical, mental, and emotional changes associated with aging and institutionalization, and present ways in which the nursing assistant may effectively communicate with residents and their families.

Competencies:

3.3.3.1 Demonstrate basic skills by identifying the psychosocial characteristics of the populations being served in the nursing facility including persons with mental retardation, mental illness and persons with dementia, Alzheimer’s disease, developmental disabilities and other related disorders.

3.3.3.1.1 Indicate the ways to meet the resident’s basic human needs for life and mental well being.

3.3.3.1.2 Modify his/her own behavior in response to resident’s behavior. Respect the resident’s beliefs recognizing cultural differences in holidays, spirituality, clothing, foods and medical treatments.

3.3.3.1.3 Identify methods to ensure that the resident may fulfill his/her maximum potential within the normal aging process.

3.3.3.1.4 Provide training in, and the opportunity for, self‑care according to the resident’s capabilities.

3.3.3.1.5 Demonstrate principles of behavior management by reinforcing appropriate behavior and reducing or eliminating inappropriate behavior. For persons with dementia, recognize that cognitive functions are impaired, determine what the resident is trying to communicate and respond appropriately.

3.3.3.1.6 Demonstrate skills which allow the resident to make personal choices and promote the resident’s dignity.

3.3.3.1.7 Utilize resident’s family as a source of emotional support and recognize the family’s need for emotional support.

3.3.3.1.8 Recognize how age, illness and disability affect memory, sexuality, mood and behavior, including wandering.

3.3.3.1.9 Recognize aggressive behavior and learn management techniques. Recognize that certain behaviors, such as wandering, are a form of communication. Learn to apply strategies to promote safe behaviors.

3.3.3.1.10 Discuss how appropriate activities are beneficial to residents with cognitive impairments.

3.3.3.1.11 Recognize and utilize augmentative communication devices and methods of nonverbal communication.

3.3.3.2 Demonstrate appropriate and effective communication skills.

3.3.3.2.1 Demonstrate effective verbal and nonverbal communications in keeping with the nursing assistant’s role with residents, their families and staff.

3.3.3.2.2 Observe by using the senses of sight, hearing, touch and smell to report resident behavior to the licensed nurse.

3.3.3.2.3 Document observations using appropriate terms and participate in the care planning process.

3.3.3.2.4 Recognize the importance of maintaining the resident’s record accurately and completely.

3.3.3.2.5 Communicate with residents according to their state of development. Identify barriers to effective communication. Recognize the importance of listening to residents.

3.3.3.2.6 Participate in sensitivity training in order to understand needs of residents with physical or cognitive impairments.

3.3.4 Physical Needs of the Resident

Key Concepts: Presents the basic skills which nursing assistants use in the physical care of residents. The nursing assistant will learn basic facts about body systems and what is needed to promote good functioning. The nursing assistant will learn to provide physical care to residents safely and to keep the resident nourished, hydrated, clean, dry and comfortable. The nursing assistant will also learn to make observations regarding residents and to record and/or report observations. The nursing assistant will be introduced to the basics of range of motion and learn to integrate range of motion into routine personal care activities.

Competencies:

3.3.4.1 Apply the principles of basic nutrition in the preparation and serving of meals.

3.3.4.1.1 Incorporate principles of nutrition and hydration in assisting residents at meals.

3.3.4.1.2 Understand basic physiology of nutrition and hydration.

3.3.4.1.3 Understand basic physiology of malnutrition and dehydration.

3.3.4.1.4 Identify risk factors for poor nutritional status in the elderly:

3.3.4.1.4.1 compromised skin integrity

3.3.4.1.4.2 underweight or overweight

3.3.4.1.4.3 therapeutic or mechanically altered diet

3.3.4.1.4.4 poor dental status

3.3.4.1.4.5 drug‑nutrient interactions

3.3.4.1.4.6 acute/chronic disease

3.3.4.1.4.7 depression or confusion

3.3.4.1.4.8 decreased appetite

3.3.4.1.5 Recognize how the aging process affects digestion.

3.3.4.1.6 Accurately calculate and document meal intake and report inadequate intake or changes in normal intake.

3.3.4.1.7 Accurately calculate and document fluid intake and report inadequate intake or changes in normal intake.

3.3.4.1.8 Recognize and report signs and symptoms of malnutrition and dehydration.

3.3.4.1.9 Understand concepts of therapeutic diets including dysphagia diets and the related risks associated with dysphagia including aspiration and aspiration pneumonia.

3.3.4.1.10 Incorporate food service principles into meal delivery including:

3.3.4.1.10.1 distributing meals as quickly as possible when they arrive from the kitchen to maintain food temperature.

3.3.4.1.10.2 assisting residents with meal set‑up if needed (i.e., opening packets or cartons, buttering bread if desired).

3.3.4.1.10.3 serving meals to all residents seated together at the same time.

3.3.4.1.10.4 offering appropriate substitutions if the residents don’t like what they have received.

3.3.4.1.11 Utilize tray card or other mechanism to ensure the resident is served his/her prescribed diet and identify who to notify if a resident receives the wrong diet.

3.3.4.1.12 Demonstrate understanding of how to read menus.

3.3.4.1.13 Assist residents who are unable to feed themselves.

3.3.4.1.14 Demonstrate techniques for feeding someone who:

3.3.4.1.14.1 bites down on utensils

3.3.4.1.14.2 can’t or won’t chew

3.3.4.1.14.3 holds food in mouth

3.3.4.1.14.4 pockets food in cheek

3.3.4.1.14.5 has poor lip closure

3.3.4.1.14.6 has missing or no teeth

3.3.4.1.14.7 has ill fitting dentures

3.3.4.1.14.8 has a protruding tongue or tongue thrust

3.3.4.1.14.9 will not open mouth

3.3.4.1.15 Demonstrate proper positioning of residents at mealtime.

3.3.4.1.16 Demonstrate skills for feeding residents who:

3.3.4.1.16.1 are cognitively impaired

3.3.4.1.16.2 have swallowing difficulty

3.3.4.1.16.3 have sensory problems

3.3.4.1.16.4 have physical deformities

3.3.4.1.17 Demonstrate positioning techniques for residents who:

3.3.4.1.17.1 have poor sitting balance

3.3.4.1.17.2 must take meals in bed

3.3.4.1.17.3 fall forward when seated

3.3.4.1.17.4 lean to one side

3.3.4.1.17.5 have poor neck control

3.3.4.1.17.6 have physical deformities

3.3.4.1.18 Demonstrate use of assistive devices.

3.3.4.1.19 Identify signs and symptoms that require alerting a nurse, including:

3.3.4.1.19.1 difficulty swallowing or chewing

3.3.4.1.19.2 coughing when swallowing liquids

3.3.4.1.19.3 refusal of meal

3.3.4.1.19.4 choking on food or fluids

3.3.4.1.19.5 excessive drooling

3.3.4.1.19.6 vomiting while eating

3.3.4.1.19.7 significant change in vital signs

3.3.4.1.20 Incorporate principles of a pleasant dining environment when assisting residents at mealtime including ensuring adequate lighting and eliminating background noise.

3.3.4.1.21 Demonstrate positive interaction with residents recognizing individual resident needs.

3.3.4.1.22 Ensure residents are dressed appropriately.

3.3.4.1.23 Allow residents to eat at their own pace.

3.3.4.1.24 Encourage independence and assist as needed.

3.3.4.1.25 Recognize and report as appropriate the risk factors and signs and symptoms of malnutrition, dehydration and fluid overload.

3.3.4.1.26 Accurately calculate and document intake and output including meal percentages and fluids.

3.3.4.2 Demonstrate understanding of basic anatomy and physiology in the following areas:

3.3.4.2.1 Respiratory system

3.3.4.2.2 Circulatory system

3.3.4.2.3 Digestive system

3.3.4.2.4 Urinary system

3.3.4.2.5 Musculoskeletal system

3.3.4.2.6 Endocrine system

3.3.4.2.7 Nervous system

3.3.4.2.8 Integumentary system

3.3.4.2.9 Sensory system

3.3.4.2.10 Reproductive system

3.3.4.3 Recognize abnormal signs and symptoms of common illness and conditions. Examples are:

3.3.4.3.1 Respiratory infection – Report coughing, sneezing, elevated temperatures.

3.3.4.3.2 Diabetes – Report excessive thirst, frequent urination, change in urine output, drowsiness, excessive perspiration and headache. Understand the healing process as it relates to diabetes.

3.3.4.3.3 Urinary tract infection – Report frequent urination, burning or pain on urination, elevated temperature, change in amount and color of urine, blood or sediment in urine and strong odors.

3.3.4.3.4 Cardiovascular conditions – Report shortness of breath, chest pain, blue color to lips, indigestion, sweating, change in pulse, edema of the feet or legs.

3.3.4.3.5 Cerebral vascular conditions – Report dizziness, changes in vision such as seeing double, change in blood pressure, numbness in any part of the body, or inability to move arm or leg.

3.3.4.3.6 Skin conditions – Report break in skin, discoloration such as redness, black and blue areas, rash, itching.

3.3.4.3.7 Gastrointestinal conditions – Report nausea, vomiting, pain, inability to swallow, bowel movement changes such as color, diarrhea, and constipation.

3.3.4.3.8 Infectious diseases.

3.3.4.4 Provide personal care and basic nursing skills as directed by the licensed nurse in the appropriate licensed entity.

3.3.4.4.1 Provide for resident’s privacy and dignity when providing personal care.

3.3.4.4.2 Assist the resident to dress and undress.

3.3.4.4.3 Assist the resident with bathing and personal grooming.

3.3.4.4.4 Observe and report condition of the skin.

3.3.4.4.5 Assist the resident with oral hygiene, including prosthetic devices.

3.3.4.4.6 Administer oral hygiene for the unconscious resident.

3.3.4.4.7 Demonstrate measures to prevent decubitus ulcers, i.e., positioning, turning and applying heel and elbow protectors.

3.3.4.4.8 Assist the resident in using the bathroom. Understand consequences of not assisting resident to the bathroom.

3.3.4.4.9 Assist the resident in using a bedside commode, urinal and bedpan.

3.3.4.4.10 Demonstrate proper bed making procedures for occupied and unoccupied beds.

3.3.4.4.11 Feed residents oral table foods in an appropriate manner. Demonstrate proper positioning of residents who receive tube feeding.

3.3.4.4.12 Distribute nourishment and water.

3.3.4.4.13 Accurately measure and record with a variety of commonly used devices:

3.3.4.4.13.1 Blood pressure

3.3.4.4.13.2 Height and weight

3.3.4.4.13.3 Temperature, pulse, respiration

3.3.4.4.14 Assist the resident with shaving.

3.3.4.4.15 Shampoo and groom hair.

3.3.4.4.16 Provide basic care of toenails unless medically contraindicated.

3.3.4.4.17 Provide basic care of fingernails unless medically contraindicated.

3.3.4.4.18 Demonstrate proper catheter care.

3.3.4.4.19 Demonstrate proper perineal care.

3.3.4.4.20 Assist the licensed nurse with a physical examination.

3.3.4.4.21 Apply a non‑sterile dressing properly.

3.3.4.4.22 Apply non‑sterile compresses and soaks properly and safely.

3.3.4.4.23 Apply cold and/or heat applications properly and safely.

3.3.4.4.24 Demonstrate how to properly apply elastic stockings.

3.3.4.4.25 Demonstrate proper application of physical restraints including side rails.

3.3.4.5 Demonstrate skills which incorporate principles of restorative care under the direction of a licensed nurse.

3.3.4.5.1 Assist the resident in bowel and bladder training.

3.3.4.5.2 Assist the resident in activities of daily living and encourage self‑help activities.

3.3.4.5.3 Assist the resident with ambulation aids, i.e., cane, quadcane, walker, crutches, wheelchair and transfer aids, i.e., hydraulic lifts.

3.3.4.5.4 Perform range of motion exercise as instructed by the physical therapist or the licensed nurse.

3.3.4.5.5 Assist in care and use of prosthetic devices.

3.3.4.5.6 Assist the resident while using proper body mechanics.

3.3.4.5.7 Assist the resident with dangling, standing and walking.

3.3.4.5.8 Demonstrate proper turning and/or positioning both in bed and in a chair.

3.3.4.5.9 Demonstrate proper technique of transferring resident from low and high bed to chair.

3.3.4.6 Demonstrate safety and emergency procedures including proficiency in the Heimlich maneuver and certification in cardiopulmonary resuscitation (CPR).

3.3.4.7 Provide care to resident when death is imminent.

3.3.4.7.1 Discuss own feelings and attitude about death.

3.3.4.7.2 Explain how culture and religion influence a person’s attitude toward death.

3.3.4.7.3 Discuss the role of the CNA, the resident’s family and significant others involved in the dying process.

3.3.4.7.4 Discuss the stages of death and dying and the role of the nurse assistant.

3.3.4.7.5 Provide care, if appropriate, to the resident’s body after death.

4.1 Skilled And Intermediate Care Facilities

4.1.1 General Requirements

4.1.1.1 All Nursing Assistants hired to work in a skilled or intermediate care facility, after completing 150 hours of training, shall undergo a minimum of 80 hours of orientation at least 40 of which shall be clinical. An exception to this requirement is that any Nursing Assistant who has undergone 150 hours of training, sponsored by the facility where the Nursing Assistant will be employed immediately thereafter, shall only be required to complete additional facility specific orientation of 40 hours in the same facility.

4.1.1.2 All Certified Nursing Assistants hired to work in a skilled or intermediate care facility shall undergo a minimum of 80 hours of orientation; at least 40 of which shall be clinical.

4.1.1.3 While undergoing orientation, Nursing Assistants shall have direct physical contact with residents only while under the visual observation of a Certified Nursing Assistant or licensed nurse employed by the facility.

4.1.1.4 Any Certified Nursing Assistant or Nursing Assistant undergoing orientation may be considered a facility employee for purposes of satisfying the minimum facility staffing requirements.

4.1.2 Orientation Program Requirements

4.1.2.1 The mandatory orientation program shall include but is not limited to a review and written instruction on the following material by a licensed nurse:

4.1.2.1.1 Tour of the facility and assigned residents’ rooms

4.1.2.1.2 Fire and disaster plans

4.1.2.1.3 Emergency equipment and supplies

4.1.2.1.4 Communication (including the facility chain of command) and documentation requirements

4.1.2.1.5 Process for reporting emergencies, change of condition and shift report

4.1.2.1.6 Operation of facility equipment and supplies, including scales, lifts, special beds and tubs.

4.1.2.1.7 Review of the plan of care for each assigned resident including:

4.1.2.1.7.1 ADL/personal care needs

4.1.2.1.7.2 Nutrition, hydration and feeding techniques and time schedules

4.1.2.1.7.3 Bowel and bladder training programs

4.1.2.1.7.4 Infection control procedures

4.1.2.1.7.5 Safety needs

4.1.2.1.7.5.1 Role and function of the CNA/NA

4.1.2.1.7.5.2 Resident rights/abuse reporting

4.1.2.1.7.5.3 Safety and body mechanics: transfer techniques

4.1.2.1.7.5.4 Vital signs

4.1.2.1.7.5.5 Psychosocial needs

4.1.2.1.7.5.6 Facility policies and procedures

4.1.1.2 Nursing Assistants shall satisfactorily demonstrate competency in clinical skills including:

4.1.1.2.1 Taking and recording vital signs

4.1.1.2.2 Measuring and recording height and weight

4.1.1.2.3 Handwashing and infection control techniques

4.1.1.2.4 Caring for the resident’s environment

4.1.1.2.5 Bathing and skin care, including foot and nail care

4.1.1.2.6 Grooming and mouth care, including denture care

4.1.1.2.7 Dressing

4.1.1.2.8 Toileting, perineal and catheter care

4.1.1.2.9 Assisting with eating and hydration

4.1.1.2.10 Proper feeding techniques

4.1.1.2.11 Positioning, turning and transfers

4.1.1.2.12 Range of motion

4.1.1.2.13 Bowel and bladder training

4.1.1.2.14 Care and use of prosthetic and orthotic devices

4.1.1.2.15 Assisting with ambulation

4.1.1.2.16 Measuring intake and output

4.1.1.2.17 Use of elastic stockings, heel and ankle protectors

4.1.1.2.18 Bedmaking skills

4.2 Assisted Living Facilities

4.2.1 General Requirements

4.2.1.1 Nursing Assistants hired to work in an assisted living facility, after completing 150 hours of instruction, shall undergo a minimum 64 hours of orientation, at least 24 of which shall be clinical. An exception to this requirement is that any Nursing Assistant who has undergone 150 hours of training in a training program sponsored by the facility where the Nursing Assistant will be employed immediately thereafter shall only be required to complete an additional 32 hours of facility specific orientation in the same facility.

4.2.1.2 Certified Nursing Assistants hired to work in an assisted living facility shall undergo a minimum of 64 hours of orientation at least 24 of which shall be clinical.

4.2.1.3 While undergoing orientation, Nursing Assistants shall have direct physical contact with residents only while under the visual observation of a Certified Nursing Assistant or licensed nurse employed by the facility.

4.2.1.4 Any Certified Nursing Assistant or Nursing Assistant undergoing orientation may be considered a facility employee for purposes of satisfying the minimum facility staffing requirements as set forth by the Department.

4.2.2 Orientation Program Requirements

4.2.2.1 The mandatory orientation program shall include but is not limited to a review and written instruction on the following material by a licensed nurse:

4.2.2.1.1 Tour of the facility and assigned residents’ rooms

4.2.2.1.2 Fire and disaster plans

4.2.2.1.3 Emergency equipment and supplies

4.2.2.1.4 Communication and documentation requirements

4.2.2.1.5 Process for reporting emergencies, change of condition and shift report

4.2.2.1.6 Operation of facility equipment and supplies, including but not limited to scales, lifts, and wheelchairs.

4.2.2.1.7 Review of the plan of care for each assigned resident including:

4.2.2.1.7.1 ADL/personal care needs

4.2.2.1.7.2 Nutrition, hydration and feeding techniques and time schedules

4.2.2.1.7.3 Bowel and bladder training programs

4.2.2.1.7.4 Infection control procedures

4.2.2.1.7.5 Safety needs

4.2.2.1.8 Role and function of the CNA/NA

4.2.2.1.9 Resident rights/abuse reporting

4.2.2.1.10 Safety and body mechanics: transfer techniques

4.2.2.1.11 Vital signs

4.2.2.1.12 Psychosocial needs

4.2.2.1.13 Facility policies and procedures

4.2.2.2 Nursing Assistants shall satisfactorily demonstrate competency in clinical skills including:

4.2.2.2.1 Taking and recording vital signs

4.2.2.2.2 Measuring and recording height and weight

4.2.2.2.3 Handwashing and infection control techniques

4.2.2.2.4 Caring for the resident’s environment

4.2.2.2.5 Bathing and skin care

4.2.2.2.6 Grooming and mouth care, including denture care

4.2.2.2.7 Dressing

4.2.2.2.8 Toileting, perineal and catheter care

4.2.2.2.9 Assisting with eating and hydration

4.2.2.2.10 Proper feeding techniques

4.2.2.2.11 Positioning, turning and transfers

4.2.2.2.12 Range of motion

4.2.2.2.13 Bowel and bladder training

4.2.2.2.14 Care and use of prosthetic and orthotic devices

4.2.2.2.15 Assisting with ambulation

4.2.2.2.16 Measuring intake and output

4.2.2.2.17 Use of elastic stockings, heel and ankle protectors

4.2.2.2.18 Bedmaking skill

4.3 Temporary Agencies

4.3.1 General Requirements

4.3.1.1 All Certified Nursing Assistants employed by temporary agencies and placed in a facility in which they have not worked within the previous six (6) months shall undergo a minimum of two (2) hours of orientation prior to beginning their first shift at the facility.

4.3.1.2 Any Certified Nursing Assistant employed by a temporary agency and undergoing orientation shall not be considered a facility employee for purposes of satisfying the minimum facility staffing requirements.

4.3.1.3 Nursing Assistants employed by a temporary agency must be certified prior to placement in any nursing home.

4.3.2 Orientation Program Requirements

4.3.2.1 The mandatory two‑hour orientation program shall include but is not limited to a review and written instruction on the following material by a licensed nurse:

4.3.2.1.1 Tour of the facility and assigned residents’ rooms

4.3.2.1.2 Fire and disaster plans

4.3.2.1.3 Emergency equipment and supplies

4.3.2.1.4 Communication and documentation requirements

4.3.2.1.5 Process for reporting emergencies, change of condition and shift report

4.3.2.1.6 Operation of facility equipment and supplies including but not limited to scales, lifts, special beds and tubs

4.3.2.1.7 Review of the plan of care for each assigned resident including:

4.3.2.1.7.1 ADL/personal care needs

4.3.2.1.7.2 Nutrition, hydration and feeding techniques and time schedules

4.3.2.1.7.3 Bowel and bladder training programs

4.3.2.1.7.4 Infection control procedures

4.3.2.1.7.5 Safety needs

5.1 Training Requirements and Competency Test

Any Certified Nursing Assistant may pursue designation as a Senior Certified Nursing Assistant and shall be so designated if such individual meets the following minimum requirements:

5.1.1 Has been a Certified Nursing Assistant for a minimum of three years, in good standing with no adverse findings entered on the Nurse Aide Registry;

5.1.2 Has successfully completed an additional 50 hours of advanced training in a program approved by the Department;

5.1.3 Has passed a competency test provided by the Department or by a contractor approved by the Department.

5.2 Voluntary Senior CNA Curriculum

The Senior CNA program must meet the same requirements as those specified in Section 2 of these regulations in terms of classroom ratios of students to instructors. The Senior CNA curriculum must meet the following minimum course content, which will provide an advanced level of knowledge and demonstrable skills. All demonstrable competencies shall be documented by the RN instructor.

5.2.1 Leadership Training And Mentoring Skills

Key Concepts: Senior Certified Nursing Assistants will learn how to teach new Nursing Assistants standards of care. Senior CNAs will learn how to be a role model and preceptor for new Nursing Assistants and CNAs. Senior CNAs will learn how prepare assignments, conduct team meetings and resolve conflicts.

Competencies: Function effectively as a team leader and mentor/preceptor within the facility.

5.2.1.1 Define the role and functions of an effective team leader and mentor.

5.2.1.2 Identify principles of adult learning.

5.2.1.3 Recognize various learning styles and communication barriers.

5.2.1.4 Assess learner knowledge.

5.2.1.5 Reserved

5.2.1.6 Demonstrate effective communication techniques.

5.2.1.7 Recognize the importance of teamwork.

5.2.1.8 Actively participate in resident care plan and team meetings.

5.2.1.9 Identify strategies for conflict management.

5.2.1.10 Learn how to prepare assignments, assist with scheduling and other administrative duties.

5.2.2 Dementia Training

Key Concepts: The senior CNA will gain greater knowledge of Alzheimer’s Disease and related dementias. The senior CNA will gain the skills necessary to effectively care for residents exhibiting signs and symptoms of dementia. The senior CNA will act as a role model and resource person for other CNAs.

Competencies: Demonstrate appropriate skills and techniques necessary to provide care to residents exhibiting signs and symptoms of dementia.

5.2.2.1 Recognize signs and symptoms of Alzheimer’s Disease and related disorders.

5.2.2.2 Identify types of dementias.

5.2.2.3 Discuss methods for managing difficult behavior.

5.2.2.4 Demonstrate effective communication techniques.

5.2.2.5 Recognize specific issues that arise in providing care to persons with Alzheimer’s Disease and other memory loss conditions and appropriate interventions for dealing with these problems including, but not limited to, agitation, combativeness, sundown syndrome, wandering.

5.2.3 Advanced Geriatric Nursing Assistant Training

Key Concepts: The senior CNA will gain greater knowledge of anatomy and physiology with emphasis on the effects of aging. The senior CNA will effectively carry out restorative nursing skills as specified in the resident’s plan of care.

Competencies:

5.2.3.1 Verbalize understanding of anatomy, physiology and pathophysiology of common disorders of the elderly.

5.2.3.1.1 Describe the effects of aging on the various organs and systems within the body.

5.2.3.1.2 Describe signs and symptoms of common disorders.

5.2.3.1.3 Describe the pathophysiology of common disorders.

5.2.3.1.4 Identify measures to assist residents with common medical problems (e.g., promoting oxygenation in residents with breathing problems).

5.2.3.1.5 Observe, report and document condition changes using appropriate medical terminology.

5.2.3.1.6 Recognize basic medical emergencies and how to respond appropriately.

5.2.3.2 Maintain or improve resident mobility and the resident’s ability to perform activities of daily living. Understand the reasons for rehabilitation (physiologically), reasons for, and benefits of Restorative Nursing and be able to demonstrate the same.

5.2.3.2.1 Assist the resident with exercise routine as specified in his/her care plan.

5.2.3.2.2 Carry out special rehabilitation procedures as ordered including working with the visually impaired, special feeding skills/devices, splints, ambulatory devices and prostheses.

5.2.3.2.3 Identify ways to prevent contractures.

5.2.3.2.4 Effectively communicate with the Rehabilitation Department.

6.1 Each train‑the‑trainer program shall meet the following minimum requirements:

6.1.1 Training Course Content

6.1.1.1 Role of Trainer

6.1.1.2 Communication techniques

6.1.1.3 Demonstration skills

6.1.1.4 Teaching a process

6.1.1.5 Teaching techniques

6.1.1.6 Training techniques

6.1.1.7 Developing a formal training plan

6.1.2 Course Management Information

6.2.1.1 Training time shall consist of sixteen minimum hours.

6.2.1.2 The train‑the‑trainer instructor must have formal educational preparation or experience with skills of adult learning. Or in the case of High School Programs be a state-licensed high school teacher.