Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-7B

Nursing Assistant Training and Competency Evaluation Program

Notice of Proposed Rule

(Amendment)

DAR File No.: 34211
Filed: 11/01/2010 05:53:34 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify terminology in the rule text to match federal verbiage, and to clarify other requirements for certified nursing assistants (CNAs) in the Nurse Aide Training and Competency Evaluation Program.

Summary of the rule or change:

This amendment changes the term of "nursing assistant" to "nurse aide" to match verbiage in the federal statute. It also clarifies the renewal process and program access requirements for CNAs, the competency evaluation for CNAs, and training and orientation requirements for CNAs. This amendment further clarifies the limitations of a Nurse Aide Training and Competency Evaluation Program.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because this change only clarifies the requirements of a CNA in a Nurse Aide Training and Competency Evaluation Program.

local governments:

There is no impact to local governments because they do not fund or provide Medicaid programs or services.

small businesses:

The Department does not anticipate any impact to small businesses because this change only clarifies the requirements of a CNA in a Nurse Aide Training and Competency Evaluation Program.

persons other than small businesses, businesses, or local governmental entities:

The Department does not anticipate any fiscal impact to Medicaid providers, Medicaid clients, nursing facilities, and CNAs because this change only clarifies the requirements of a CNA in a Nurse Aide Training and Competency Evaluation Program.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider, Medicaid client, nursing facility, or CNA because this change only clarifies the requirements of a CNA in a Nurse Aide Training and Competency Evaluation Program.

Comments by the department head on the fiscal impact the rule may have on businesses:

The changes imposed by this rule are technical and not expected to have a fiscal impact.

David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

12/15/2010

This rule may become effective on:

12/22/2010

Authorized by:

David Sundwall, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-7B. [ Nursing Assistant ] Nurse Aide Training and Competency Evaluation Program.

R414-7B-1. Introduction and Authority.

The [Nursing Assistant]Nurse Aide Training and Competency Evaluation Program is authorized by the Omnibus Budget Reconciliation Act of 1987 (OBRA), Pub. L. No. 100 203, 101 Stat. 1330, Sec. 4211,(b)(5)(A)(B)(C)(D)(E)(F)(G), (e)(1)(2), f(2)(A)(B), which the Department adopts and incorporates by reference. The purpose of this program is to allow a certified [nursing assistant]nurse aide (CNA) to provide quality nursing services to nursing facility residents.

 

R414-7B-2. Definitions.

([a]1) "Certified [Nursing Assistant]nurse aide" means any person who completes a [UNAR-approved nursing assistant]nurse aide training and competency evaluation program (NATCEP) and passes the state certification examination.

([b]2) "Competency evaluation" means a written or oral examination that addresses each requirement of OBRA for a [nursing assistant]nurse aide and a demonstration of the tasks the [nursing assistant]nurse aide is expected to perform as part of the [ assistant's]aide's function.

[(c) "Deemed competency" means that an individual is deemed to be competent if the individual completed a state-approved nursing assistant training program on or before July 1, 1989.

]([d]3) "[Nursing assistant]Nurse aide" means any individual who provides nursing or nursing-related services to residents in a nursing facility, but does not include an individual who is a licensed professional or who volunteers to provide these services without monetary consideration.

([e]4) "[Nursing Assistant]Nurse Aide" Training and Competency Evaluation Program" (NATCEP) means any program that the Utah Nursing Assistant Registry (UNAR) approves to offer training to an individual who is interested in becoming a certified [nursing assistant in the state of Utah]nurse aide.

([f]5) "Nursing facility" means any institution that is licensed and Medicare or Medicaid-certified to provide long-term care.

([g]6) "Resident" means an individual who resides in and receives medical long-term nursing services in a Medicare or Medicaid-certified nursing facility.

(7) "Renewal" means a two-year renewal for a CNA who has performed paid services for at least 200 hours of nursing or nursing-related services under the direction of a licensed nurse during the 24 months following the completion date of the NATCEP or certification renewal.

([h]8) "Retraining" means training for a CNA who has not performed paid services for a total of 200 hours of nursing or nursing-related services under the direction of a licensed nurse during the 24 months following the completion date of the state-approved nursing assistant training or certification renewal.

([i]9) "State survey agency" means the Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Health, which is responsible for nursing facility certification and for conducting surveys to determine compliance with Medicare and Medicaid requirements.

([j]10) "Supervised practical training" means training in a nursing facility in which the trainee demonstrates knowledge while performing tasks on an individual under the direct supervision of a licensed nurse, who is a UNAR-approved instructor.

([k]11) "Train-the-[t]Trainer program" means a UNAR-approved program that consists of formal instructions to potential instructors on how to train adults through demonstrations and lectures.

([l]12) "Waiver of CNA Training Program" means a waiver that allows a qualified nursing professional and qualified in-state expired CNA to challenge the state written and skill examination.

([m]13) "Utah Nursing Assistant Registry" means the state agency that approves [nursing assistant]nurse aide training programs, monitors all UNAR test sites, maintains an abuse registry for all substantiated allegations of resident neglect, abuse or misappropriation of resident property by a CNA in a nursing , [facility or] Medicare [and]or Medicaid facility, certifies [nursing assistants]nurse aides who have completed a [nursing assistant training program]NATCEP, and renews certifications of qualified CNAs.

 

R414-7B-3. Program Access Requirements.

(1) A [nursing assistant]nurse aide is required to complete a [UNAR-approved nursing assistant training program]NATCEP and become certified within 120 days of the first date of employment.

(2) An individual who was certified as a [nursing assistant]nurse aide on or before July 1, 1989, [is deemed to be competent and to have met]meets the OBRA requirement upon completion of the approved in-service training on mental retardation and mental illness.

(3) If specific requirements are met in the following cases, the UNAR office may grant a waiver to:

(a) a nursing student who has completed the first semester of nursing school within the past two years and to a current nursing student. An official transcript of a nursing fundamentals class must accompany the [waiver request]Application for Certification Testing. If the candidate does not pass either the skills or written portion of the CNA examination after three attempts, [she]the candidate must complete a [UNAR-approved nursing assistant training program]NATCEP;

(b) an expired licensed nurse who can show proof of previous licensure in any state and who was in good standing with [her]that state's professional board. UNAR shall grant the candidate one attempt to pass both the skills and written portion of the examination. If the candidate does not pass either portion, [she]the candidate must complete a [UNAR-approved nursing assistant training program]NATCEP.

(c) an expired Utah CNA who is in good standing with UNAR. UNAR shall grant the candidate one attempt to pass both the skills and written portion of the examination within one year of the certification expiration date. If the candidate does not pass either portion, the candidate must [complete a UNAR-approved nursing assistant training program]retrain;

(d) any out-of-state CNA [deemed]who is certified and in good standing with another state's survey agency. UNAR grants reciprocity upon the CNA providing proof of certification in [her]that other state.

(4) An out-of-state expired CNA must complete a [UNAR-approved nursing assistant training program]NATCEP in the state of Utah.

 

R414-7B-4. Competency Evaluation.

(1) An entity that proctors competency evaluations using both written or oral examinations and demonstrations of skills to [nursing assistants]nurse aides must be UNAR-approved.

(a) An individual shall perform the skills demonstration component in a facility or laboratory setting comparable to the setting in which the individual will function as a [nursing assistant]nurse aide, and a UNAR-approved representative must administer and evaluate the demonstration.

(b) The examiner must be a registered nurse (RN) with a current active license to practice nursing as an RN, who is in good standing with the Division of Occupational and Professional Licensing (DOPL) in the state of Utah, with at least one year of experience in providing care for the elderly or chronically ill of any age;

(c) If the individual fails to satisfactorily complete the skills or written examination after three attempts at either, the candidate must be advised of the areas in which the candidate is inadequate and must retrain at an approved [nursing assistant training program]NATCEP;

(d) UNAR [must]shall advise an individual who takes the competency evaluation that a record of the outcome of the evaluation [shall]will be included in the nursing assistant registry. Further, UNAR shall require the individual to sign a Release of Information form that indicates the [nursing assistant's]nurse aide's understanding of information that UNAR requires to be entered into the registry;

(e) UNAR shall periodically update and validate the competency evaluations;

(f) UNAR shall establish a written and oral examination that addresses each requirement as prescribed in OBRA. [The questions shall be developed]UNAR must develop this examination from a pool of test questions, only a portion of which [shall be used]to use in any one evaluation, under a system that maintains the integrity of both the pool of questions and individual evaluations;

([f]g) The competency evaluation must include a demonstration of the tasks the [nursing assistant]nurse aide is expected to perform as part of the [assistant's]nurse aide's function as a CNA;

([g]h) For the skills training component of the evaluation, UNAR shall establish a performance record for each [nursing assistant training program]NATCEP of major duties and skills [taught] that include:

(i) a list[ing] of the duties and skills that UNAR expects a CNA to learn in the program in accordance with [Section R414-7B-4]this section;

(ii) a record that documents when the [nursing assistant]nurse aide performs this duty or skill;

(iii) documentation of satisfactory or unsatisfactory performance;

(iv) the date of the performance; and

(v) the instructor supervising the performance.

(2) At the completion of the [nursing assistant training program, the]NATCEP, the NATCEP shall give [nursing assistant]the nurse aide [shall receive] a copy of this record.

(3) The demonstration aspect of the skills training portion of the competency evaluation [consists of a minimum performance of]must have at least five performance tasks, all of which are included in the performance record. UNAR shall select five tasks for each [nursing assistant]nurse aide from a pool of evaluation items ranked according to degree of difficulty. UNAR shall make a random selection of tasks with at least one task from each degree of difficulty.

 

R414-7B-5. [Nurse Assistant Training Program]Nurse Aide Training Requirements Under UNAR.

(1) UNAR shall administer a NATCEP through a contract with the Department of Health.

(2) An agency that conducts a NATCEP must be UNAR-approved.

(3) Applicants for approval of a [nursing assistant training program]NATCEP and all new instructors must be fingerprinted and have their records checked in state and national bureaus. Before receiving NATCEP approval, a [nursing assistant training program]NATCEP must send a background check and fingerprinting to UNAR to be placed in the file of the proposed new training program.

(4) In accordance with [Section R414-7B-5]this section, UNAR shall review and render a determination [regarding]of approval or disapproval of any [nursing assistant training program]NATCEP when a Medicare or Medicaid participating nursing facility requests the determination. UNAR at its option, may also agree to review and render approval or disapproval of any private [nursing assistant training program]NATCEP.

(5) UNAR must, within 90 days of the date of an application, either advise the requestor of UNAR 's determination, or must seek additional information from the requesting entity with respect to the program for which it is seeking approval.

(6) UNAR shall approve a [nursing assistant training program]NATCEP that meets the criteria specified in OBRA, the Centers for Medicare and Medicaid Service's guidelines, guidelines [desginated]designated by the Department of Health, and all UNAR requirements.

(a) UNAR shall admit a student who is 16 years of age and older on or before the first day that the student begins class; and

(b) shall include an orientation to the training program.

(7) The [nursing assistant]nurse aide training program must meet [minimal]certain content requirements to be UNAR-approved.

(a) NATCEP must consist of [no less than]at least 80 hours of supervised and documented training by a licensed nurse.

(b) The curriculum of the training program must include the following subjects:

(i) communication and interpersonal skills;

(ii) infection control;

(iii) safety and emergency procedures;

(iv) promoting resident[s'] independence;

(v) respecting resident[s'] rights; and

(vi) basic nursing skills.

(c) The trainee must complete at least 16 hours of supervised practical training in a long-term care facility, and complete all skill curriculum and skill competencies [prior to]before training in any facility. The skills training must ensure that each [nursing assistant]nurse aide demonstrates competencies in the following areas:

(i) Basic nursing skills:

(A) taking and recording vital signs;

(B) measuring and recording height;

(C) caring for residents' environment; and

(D) recognizing abnormal signs and symptoms of common diseases and conditions.

(ii) Personal care skills:

(A) bathing that includes mouth care;

(B) grooming;

(C) dressing;

(D) using the toilet;

(E) assisting with eating and hydration;

(F) proper feeding techniques; and

(G) skin care.

(iii) Basic restorative services:

(A) use of assistive devices in ambulation, eating, and dressing;

(B) maintenance of range of motion;

(C) proper turning and positioning in bed and chair;

(D) bowel and bladder training;

(E) care and use of prosthetic and orthotic devices; and

(F) transfer techniques.

(iv) Mental Health and Social Service Skills:

(A) modifying [her own]one's behavior in response to the resident's behavior;

(B) identifying developmental tasks associated with the aging process;

(C) training the resident in self-care according to the resident's ability;

(D) behavior management by reinforcing appropriate resident behavior and reducing or eliminating inappropriate behavior;

(E) allowing the resident to make personal choices, providing and reinforcing other behavior consistent with the resident's dignity; and

(F) using the resident's family as a source of emotional support.

(v) Resident's rights:

(a) providing privacy and maintaining confidentiality;

(b) promoting the resident's right to make personal choices to accommodate the resident's needs;

(c) giving assistance in solving grievances;

(d) providing needed assistance in getting to and participating in resident and family groups and other activities;

(e) maintaining care and security of resident's personal possessions;

(f) providing care that keeps a resident free from abuse, mistreatment, or neglect, and reporting any instances of poor care to appropriate facility staff; and

(g) maintaining the resident's environment and care through appropriate nurse aide behavior to minimize the need for physical and chemical restraints.

(8) Qualification of Instructors:

(a) a [nursing assistant training program]NATCEP must have a program coordinator who is a registered nurse with a current and active Utah license to practice;

(b) who is in good standing with DOPL;

(c) with two years of nursing experience, at least one of which is the provision of long-term care facility services or caring for the elderly or chronically ill of any age; and

(d) must have at least three hours of documented consulting time per month with the respective program.

(9) Nursing facility-based programs:

(a) the program coordinator in a nursing facility-based program may be the director of nursing for the facility as long as the facility remains in full compliance with OBRA requirements[.];

(b) the primary instructor must be a licensed nurse with a current and active Utah license to practice and must be in good standing with DOPL; and

(c) must have two years of nursing experience, at least one of which is the provision of long-term care facility services or caring for the elderly or chronically ill of any age.

(10) Before approval of a [nursing assistant training program]NATCEP, the program coordinator and primary instructor must successfully complete a UNAR-approved "Train-the-Trainer" program or demonstrate competence to teach adult learners as defined by UNAR.

(11) Students who provide services to residents must be under the direct supervision of a licensed nurse who is a UNAR-approved clinical instructor and whose clinical time is separate from her facility employment.

(12) Qualified personnel from the health professions may supplement the program coordinator [or]and primary instructor. The program coordinator or primary instructor must be present during all provided supplemental training.

(13) Qualified personnel include registered nurses, licensed practical or vocational nurses, pharmacists, dietitians, social workers, sanitarians, fire safety experts, nursing home administrators, gerontologists, psychologists, physical and occupational therapists, activities specialists, speech or language therapists, and any other [appropriate and duly] qualified personnel.

(14) UNAR requires qualified personnel to have at least one year of current experience in the care of the elderly or chronically ill of any age, or to have equivalent experience. Qualified personnel must also meet current licensure requirements, whether they are registered or certified in their field.

(15) A [nursing assistant training program]NATCEP must have a student-to-instructor ratio of 12:1 for clinical instruction and shall not exceed a 30:1 ratio for theory instruction. UNAR requires an instructor assistant when the program has more than 20 students.

(16) A [nursing assistant training program]NATCEP must provide a classroom with the following:

(a) adequate space and furniture for the number of students;

(b) adequate lighting and ventilation;

(c) comfortable temperature;

(d) appropriate audio-visual equipment;

(e) skills lab equipment to simulate a resident's unit;

(f) clean and safe environment; and

(g) appropriate textbooks and reference materials.

(17) Initial post-approval and ongoing reviews:

(a) After the initial approval of a [nursing assistant training program]NATCEP, UNAR grants a one-year probationary period;

(b) During the probationary period, UNAR may withdraw program approval if there is a violation of OBRA, state, federal, or UNAR requirements;

(c) After the probationary period, UNAR shall complete an on-site review and then complete subsequent on-site reviews at least every two years;

(d) The CNA training program shall submit a self-evaluation to UNAR during the interim year that UNAR does not complete an on-site review;

(e) In the event that UNAR does not complete an on-site review within two years, the CNA training program is responsible to send a self-evaluation to UNAR for the applicable two-year period;

(f) If UNAR does not make an on-site visit within two years and the CNA training program sends in a self-evaluation, UNAR must make an on-site visit within one year of the self-evaluation.

(18) The training and evaluation program review must include:

(a) skills training experience;

(b) maintenance of qualified faculty members for both classroom and skills portions of the [nursing assistant]nurse aide training program;

(c) maintenance of the security of the competency evaluation examinations;

(d) a record of complaints received about the program;

(e) a record that each nursing facility has provided certified [nursing assistants]nurse aides with at least 12 hours of staff development training [per]each year with the compensation for the training;

(f) curriculum content that meets state and federal requirements; and

(g) classroom facilities and required equipment that meet state, federal , and UNAR requirements.

(19) In addition to the [nursing assistant]nurse aide training that UNAR requires, [all nursing assistants shall receive an orientation program from the nursing facility where they are employed, which is not included in the required 80 hours of training.]a nursing facility shall provide an orientation program for any nurse aide whom it employs. For a student who is not employed at a nursing facility, the NATCEP shall provide an orientation of the clinical site for that student prior to beginning the clinical rotation. The orientation hours are not included in the required 80 hours of training. This orientation phase [shall]must include an explanation of:

(a) the organizational structure of the facility;

(b) the facility policies and procedures;

(c) the philosophy of care of the facility;

(d) the description of the resident population; and

(e) the employee rules.

 

R414-7B-6. Nurse Aide Registry.

(1) UNAR is the central registry for all certified [nursing assistants]nurse aides. This registry must [include identification of]identify all individuals who have successfully completed [and passed] a [nursing assistant training program]NATCEP with a passing score of 75.

(2) A [nursing assistant training program]NATCEP must report to UNAR, within five days [of the completion date of]after the program ends, the names of all individuals who [have] satisfactorily completed the [certified nursing assistant training] program.

(3) UNAR processes all renewals for each nurse aide who has performed paid services for at least 200 hours of nursing or nursing-related services under the direction of a licensed nurse during the 24 months following the completion date of the NATCEP or certification renewal.

([3]4) The state survey agency shall enforce the standards of UNAR described in OBRA, Secs. 4211 and 4212.

([4]5) The state survey agency shall investigate all complaints of resident neglect, abuse or misappropriation of resident property by a CNA. A CNA is entitled to a hearing through the Division of Medicaid and Health Financing before a substantiated claim can be entered into the registry.

([5]6) After notification from the health facility licensing, certification and resident assessment agency of a substantiated claim of abuse, neglect or misappropriation of property of a vulnerable adult by a CNA, the name of the CNA and an accurate summary of the findings are placed in the abuse registry in accordance with UNAR protocol.

 

R414-7B-7. Limitations.

(1) UNAR may approve a facility-based NATCEP only if the facility's participation in the Medicare and Medicaid programs has not been terminated within the last two years.

(2) UNAR must review and reapprove a [nursing assistant training program]NATCEP at least every two years.

(3) A skilled nursing facility that participates in a Medicare or Medicaid facility may not administer the written and skills components of the competency evaluation.

(4) A nursing facility may employ a [nursing assistant]nurse aide for more than 120 days only if the [assistant]aide has completed a [nursing assistant training program]NATCEP.

(5) Upon review of program performance standards, UNAR shall terminate a program that does not provide an acceptable plan to correct deficiencies.[

(6) A nursing assistant who does not perform paid services that total at least 200 hours of nursing or nursing-related services under the direction of a licensed nurse during the 24 months that follow the completion date of the state-approved nursing assistant training program or certification renewal, must retrain and repeat the skills and written examination.

(7) A candidate has one attempt to pass both the skills and written portion of the examination. If the candidate fails either portion of the examination, the candidate must complete a UNAR-approved nursing assistant training program.]

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [March 29], 2010

Notice of Continuation: October 20, 2009

Authorizing, and Implemented or Interpreted Law: [ 26-1-4.1; ]26-1-5; 26-18-3