18VAC90-25 Regulations Governing Certified Nurse Aides

REGULATIONS

Vol. 30 Iss. 10 - January 13, 2014

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF NURSING

Chapter 25

Fast-Track Regulation

Titles of Regulations: 18VAC90-25. Regulations Governing Certified Nurse Aides (amending 18VAC90-25-10, 18VAC90-25-15, 18VAC90-25-71, 18VAC90-25-72, 18VAC90-25-120; repealing 18VAC90-25-20, 18VAC90-25-30, 18VAC90-25-40, 18VAC90-25-50, 18VAC90-25-60, 18VAC90-25-90).

18VAC90-26. Regulations for Nurse Aide Education Programs (adding 18VAC90-26-10 through 18VAC90-26-70).

Statutory Authority: §§ 54.1-2400 and 54.1-3005 of the Code of Virginia.

Public Hearing Information: No public hearings are scheduled.

Public Comment Deadline: February 12, 2014.

Effective Date: February 27, 2014.

Agency Contact: Jay P. Douglas, R.N., Executive Director, Board of Nursing, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone [phone], FAX [phone], or email [e-mail].

Basis: Section 54.1-2400 of the Code of Virginia authorizes the health regulatory boards to promulgate regulations that are reasonable and necessary to administer the regulatory system. Section 54.1-3005 of the Code of Virginia authorizes the Board of Nursing to promulgate regulations for certification of nurse aides.

Purpose: The purpose of the amendments is to update language and simplify the process of applying for registration as a certified nurse aide. Elimination of unnecessary or outdated provisions and inclusion of language consistent with current practices will facilitate submission of documentation. The goal is to enable qualified applicants to obtain certification, which provides the public with some assurance of competency and accountability in the delivery of nurse aide services. The changes to the process of initial approval, continued approval, and conditional approval will result in a more efficient system to avoid unnecessary delay in the provision of educational programs for training new nurse aides. Requirements for education, practical training, and evaluation of persons seeking certification are not being changed and will continue to ensure minimal competency to serve patients with safety and skill.

Rationale for Using Fast-Track Process: The amendments are less restrictive and not controversial. They are consistent with the intent and purpose of regulatory reform.

Substance: Regulations are amended to clarify the regulations, facilitate electronic submission of documents and forms, accept a certificate of naturalization as evidence of a name change, and allow completion of one clinical nursing course within the past 12 months to qualify an applicant for registration.

This action will also repeal 18VAC90-25-20 through 18VAC90-25-60 to move the requirements for nurse aide education programs into a separate chapter, promulgated as Chapter 26 (18VAC90-26). In 18VAC90-26, the administrative processes for initial board approval, continued approval, and denial of approval are revised for consistency with current delegation of authority to professional staff for nursing education programs and the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia). Requirements for curriculum, instructors, course hours, and other essential elements of an approved program are identical to those currently in Chapter 25 (18VAC90-25).

Issues: The primary advantage to the public is facilitation of applications and elimination of outdated language. The Board of Nursing will be able to approve nurse aide education programs in a timelier manner, thus making qualified programs available to persons interested in becoming certified nurse aides. There are no disadvantages.

The advantage to the Commonwealth is clarity in the regulations, which reduces queries to board staff.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. The Board of Nursing (Board) proposes to 1) accept a certificate of naturalization as evidence of a name change for nurse aides, 2) allow electronic submission of an address change, 3) allow for electronic verification of registration, certification, or licensure by another state for applicants seeking certification by endorsement, 4) allow completion of one clinical nursing course within the past 12 months to qualify an applicant for registration, and 5) streamline the initial and continued approval processes for nurse aide education programs.

Result of Analysis. The benefits likely exceed the costs for all proposed changes.

Estimated Economic Impact. Several proposed changes will reduce the regulatory burden on the nurse aides. These include allowing the Board to accept a certificate of naturalization as evidence of a name change in addition to a marriage certificate or a court order, allowing electronic submission of an address change rather than requiring the information be sent in writing, and allowing for electronic verification of registration, certification, or licensure by another state for applicants seeking certification by endorsement instead of requiring submission of written verification. These proposed changes will reduce the costs associated with time and effort the nurse aides would normally incur to produce and submit required documents and information to the Board. In addition, electronic submission and verification of documents and information may reduce administrative costs of the Department of Health Professions (DHP) by a small margin.

One of the proposed changes will also allow completion of one clinical nursing course within the past 12 months to qualify an applicant for registration instead of requiring current enrollment in a nursing education program. This change will allow an applicant to qualify for registration without incurring the time and costs of completing a nurse aide education course for a possible savings of $200.

Finally, the proposed changes will streamline the initial and continued approval processes for nurse aide education programs. Currently, a committee of the Board (Education Special Conference Committee) receives and reviews the initial applications and makes a recommendation to the Board. If the recommendation is to deny approval, the program must request a hearing before the full Board or a panel. Under the proposed changes, initial approval may be issued upon determination that requirements for establishing a program have been met by the Board's professional staff. If the program is denied approval following the staff review, then no further action will be necessary unless the program requests an informal conference with the committee of the Board. If the decision of the committee is to uphold the denial, the program may request a hearing before the full Board or the panel. This proposed change will eliminate the need to convene the committee of the Board and the possible delay in the approval process. In case of a denial following the staff review, an informal conference instead of a hearing before the full Board or a panel will be utilized.

Similarly, current regulations require the committee to receive and review the report of the site visit or program evaluation report and make a recommendation to the Board to grant continued approval, place a program on conditional approval, or deny continued approval. Under the proposed regulation, the Board will be able to delegate that determination to the professional staff, so there would be no need to convene the committee and no delay in continued approval process. Also, an informal conference instead of a hearing before the full Board or a panel will be utilized in cases of denial or conditional approval.

The proposed, more streamlined, initial and continued approval processes are expected to shift a significant portion of the review and appeal process from the Board members to the Board staff and provide administrative cost savings and reduce possible delays.

Businesses and Entities Affected. There are currently 53,877 registered certified nurse aides and 230 nurse aide education programs in the Commonwealth.

Localities Particularly Affected. The proposed regulations do not affect any particular locality more than others.

Projected Impact on Employment. The proposed electronic submission and verification of documents may provide small savings in staff time at DHP. However, the proposed changes to initial and continued approval process for nurse aide education programs will shift some administrative workload from Board members to the staff.

Effects on the Use and Value of Private Property. To the extent streamlined initial and continued approval and appeal process reduce compliance costs, a positive impact on the asset value of nurse aide education programs may be expected.

Small Businesses: Costs and Other Effects. Most of the 230 nurse aide education programs in the Commonwealth are likely to be small businesses. The proposed changes do not impose costs on them.

Small Businesses: Alternative Method that Minimizes Adverse Impact. No adverse impact on small businesses is expected.

Real Estate Development Costs. No impact on real estate development costs is expected.

Legal Mandate. The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Administrative Process Act and Executive Order Number 14 (10). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, a determination of the public benefit, the projected number of businesses or other entities to whom the regulation would apply, the identity of any localities and types of businesses or other entities particularly affected, the projected number of persons and employment positions to be affected, the projected costs to affected businesses or entities to implement or comply with the regulation, and the impact on the use and value of private property. Further, if the proposed regulation has an adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include (i) an identification and estimate of the number of small businesses subject to the regulation; (ii) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the regulation, including the type of professional skills necessary for preparing required reports and other documents; (iii) a statement of the probable effect of the regulation on affected small businesses; and (iv) a description of any less intrusive or less costly alternative methods of achieving the purpose of the regulation. The analysis presented above represents DPB's best estimate of these economic impacts.

Agency's Response to Economic Impact Analysis: The Board of Nursing concurs with the analysis of the Department of Planning and Budget on proposed amended regulations for 18VAC90-25 and 18VAC90-26, relating to regulations for certified nurse aides and nurse aide education programs.

Summary:

The amendments (i) provide that a certificate of naturalization may be accepted as evidence of a name change for nurse aides; (ii) allow for electronic submission of an address change; (iii) allow for electronic verification of registration, certification, or licensure by another state for applicants seeking certification by endorsement; (iv) allow completion of one clinical nursing course within the past 12 months to qualify an applicant for registration; and (v) relocate requirements for nurse aide education programs into a separate chapter and streamline the initial and continued approval processes for nurse aide education programs.

Part I
Nurse Aide Education Programs General Provisions

18VAC90-25-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Board" means the Virginia Board of Nursing.

"Client" means a person receiving the services of a certified nurse aide, to include a patient in a health care facility or at home or a resident of a long-term care facility.

"Committee" means the Education Special Conference Committee, comprised of not less than two members of the board in accordance with § 2.2-4019 of the Code of Virginia.

"Nurse aide education program" means a program designed to prepare nurse aides for certification.

"Nursing facility" means a licensed nursing home or an entity that is certified for Medicare or Medicaid long-term care reimbursement and licensed or certified by the Virginia Department of Health.

"Primary instructor" means a registered nurse who is responsible for teaching and evaluating the students enrolled in a nurse aide education program.

"Program coordinator" means a registered nurse who is administratively responsible and accountable for a nurse aide education program.

"Program provider" means an entity that conducts a nurse aide education program.

18VAC90-25-15. Identification; accuracy of records.

A. Any person regulated by this chapter who provides direct patient care shall, while on duty, wear identification that is clearly visible and indicates the person's first and last name and the appropriate title issued to such person by the board under which he is practicing in that setting. Any person practicing in hospital emergency departments, psychiatric and mental health units and programs, or in health care facilities units offering treatment for patients in custody of state or local law-enforcement agencies may use identification badges of first name and first letter only of last name and appropriate title.

B. A certificate holder who has changed his name shall submit as legal proof to the board a copy of the marriage certificate, a certificate of naturalization, or court order evidencing the change. A duplicate certificate shall be issued by the board upon receipt of such evidence.

C. Each certificate holder shall maintain an address of record with the board. Any change in the address of record or in the public address, if different from the address of record, shall be submitted in writing or electronically to the board within 30 days of such change. All notices required by law and by this chapter to be mailed by the board to any certificate holder shall be validly given when mailed to the latest address of record on file with the board.

18VAC90-25-20. Establishing and maintaining a nurse aide education program. (Repealed.)

A. Establishing a nurse aide education program.

1. A program provider wishing to establish a nurse aide education program shall submit an application to the board at least 90 days in advance of the expected opening date.

2. The application shall provide evidence of the ability of the institution to comply with subsection B of this section.

3. The committee shall, in accordance with § 2.2-4019 of the Code of Virginia, receive and review the application and shall make a recommendation to the board to grant or deny approval.

4. If the committee's recommendation is to deny approval, no further action will be required of the board unless the program requests a hearing before the board or a panel thereof in accordance with § 2.2-4020 and subdivision 11 of § 54.1-2400 of the Code of Virginia.

B. Maintaining an approved nurse aide education program. To maintain approval, the nurse aide education program shall:

1. Demonstrate evidence of compliance with the following essential elements:

a. Curriculum content and length as set forth in subsection A of 18VAC90-25-40 and subsection C of 18VAC90-25-50.

b. Maintenance of qualified instructional personnel as set forth in 18VAC90-25-30.

c. Classroom facilities that meet requirements set forth in subsection D of 18VAC90-25-50.

d. Maintenance of records as set forth in subsection A of 18VAC90-25-50.

e. Skills training experience in a nursing facility that has not been subject to penalty or penalties as provided in 42 CFR 483.151(b)(2) (Medicare and Medicaid Programs: Nurse Aide Training and Competency Evaluation and Paid Feeding Assistants, revised October 1, 2005) in the past two years. The foregoing shall not apply to a nursing facility that has received a waiver from the state survey agency in accordance with federal law.

f. Agreement that board representatives may make unannounced visits to the program.

g. Financial support and resources sufficient to meet requirements of this chapter as evidenced by a copy of the current annual budget or a signed statement from the administration specifically detailing its financial support and resources.

h. Completion and submission of biennial on-site review reports and program evaluation reports as requested by the board.

2. Impose no fee for any portion of the program on any nurse aide who, on the date on which the nurse aide begins the program, is either employed or has an offer of employment from a nursing facility.

3. Provide documentation that each student applying to or enrolled in such program has been given a copy of applicable Virginia law regarding criminal history records checks for employment in certain health care facilities, and a list of crimes that pose a barrier to such employment.

4. Report all substantive changes in subdivision 1 of this subsection within 10 days of the change to the board to include, but not be limited to, a change in the program coordinator, primary instructor, program ownership, physical location of the program or licensure status.

5. Provide each student with a copy of his certificate of completion.

18VAC90-25-30. Requirements for instructional personnel. (Repealed.)

A. Program coordinator.

1. Each program shall have a program coordinator who must be a registered nurse who holds a current, unrestricted license in Virginia or a multistate licensure privilege.

2. The program coordinator in a nursing facility based program may be the director of nursing services. The director of nursing may assume the administrative responsibility and accountability for the nurse aide education program but shall not engage in the actual classroom and clinical teaching.

3. The primary instructor may be the program coordinator in any nurse aide education program.

B. Primary instructor.

1. Each program shall have a primary instructor who must be a registered nurse who holds a current, unrestricted license in Virginia or a multistate licensure privilege.

2. Qualifications. The primary instructor, who does the majority of the actual teaching of the students shall:

a. Hold a current, unrestricted Virginia license as a registered nurse who holds a current, unrestricted license in Virginia or a multistate licensure privilege; and

b. Have two years of experience as a registered nurse within the previous five years and at least one year of experience in the provision of long-term care facility services. Such experience may include, but not be limited to, employment in a nurse aide education program or employment in or supervision of nursing students in a nursing facility or unit, geriatrics department, chronic care hospital, home care or other long-term care setting. Experience should include varied responsibilities, such as direct resident care, supervision and education.

3. Responsibilities. The primary instructor is responsible for the teaching and evaluation of students and, in addition, shall:

a. Participate in the planning of each learning experience;

b. Ensure that course objectives are accomplished;

c. Ensure that the provisions of subsection F of this section are maintained;

d. Maintain records as required by subsection A of 18VAC90-25-50;

e. Perform other activities necessary to comply with subsection B of 18VAC90-25-20; and

f. Ensure that students do not perform services for which they have not received instruction and been found proficient by the instructor.

C. Other instructional personnel.

1. Instructional personnel who assist the primary instructor in providing classroom or clinical supervision shall be registered nurses or licensed practical nurses.

a. A registered nurse shall:

(1) Hold a current, unrestricted Virginia license as a registered nurse; and

(2) Have had at least one year of direct patient care experience as a registered nurse.

b. A licensed practical nurse shall:

(1) Hold a current, unrestricted Virginia license as a practical nurse;

(2) Hold a high school diploma or equivalent;

(3) Have been graduated from a state‑approved practical nursing program; and

(4) Have had at least two years of direct patient care experience as a licensed practical nurse.

2. Responsibilities. Other instructional personnel shall provide instruction under the supervision of the primary instructor.

D. Prior to being assigned to teach the nurse aide education program, all instructional personnel shall demonstrate competence to teach adults by one of the following:

1. Satisfactory completion of a course in teaching adults that includes (i) basic principles of adult learning; (ii) teaching methods and tools for adult learners; and (iii) evaluation strategies and measurement tools for assessing the learning outcomes; or

2. Have experience in teaching adults or high school students.

E. To meet planned program objectives, the program may, under the direct, on-site supervision of the primary instructor, use other persons who have expertise in specific topics and have had at least one year of experience in their field.

F. When students are giving direct care to clients in clinical areas, instructional personnel must be on site solely to supervise the students. The ratio of students to each instructor shall not exceed 10 students to one instructor.

18VAC90-25-40. Requirements for the curriculum. (Repealed.)

A. Curriculum content. The curriculum shall include, but shall not be limited to, classroom and clinical instruction in the following:

1. Initial core curriculum. Prior to the direct contact with a nursing facility client, a student shall have completed a total of at least 24 hours of instruction. Sixteen of those hours shall be in the following five areas:

a. Communication and interpersonal skills.

b. Infection control.

c. Safety and emergency procedures, including dealing with obstructed airways and fall prevention.

d. Promoting client independence.

e. Respecting clients' rights.

2. Basic skills.

a. Recognizing changes in body functioning and the importance of reporting such changes to a supervisor.

b. Measuring and recording routine vital signs.

c. Measuring and recording height and weight.

d. Caring for the clients' environment.

e. Measuring and recording fluid and food intake and output.

f. Performing basic emergency measures.

g. Caring for a client when death is imminent.

3. Personal care skills.

a. Bathing and oral hygiene.

b. Grooming.

c. Dressing.

d. Toileting.

e. Assisting with eating and hydration, including proper feeding techniques.

f. Caring for skin, to include prevention of pressure ulcers.

g. Transfer, positioning and turning.

4. Individual client's needs, including mental health and social service needs.

a. Modifying the aide's behavior in response to the behavior of clients.

b. Identifying developmental tasks associated with the aging process.

c. Demonstrating principles of behavior management by reinforcing appropriate behavior and causing inappropriate behavior to be reduced or eliminated.

d. Demonstrating skills supporting age-appropriate behavior by allowing the client to make personal choices, and by providing and reinforcing other behavior consistent with the client's dignity.

e. Utilizing the client's family or concerned others as a source of emotional support.

f. Responding appropriately to the client's behavior; including, but not limited to, aggressive behavior and language.

g. Providing appropriate clinical care to the aged and disabled.

h. Providing culturally sensitive care.

5. Care of the cognitively or sensory (visual and auditory) impaired client.

a. Using techniques for addressing the unique needs and behaviors of individuals with dementia (Alzheimer's and others).

b. Communicating with cognitively or sensory impaired clients.

c. Demonstrating an understanding of and responding appropriately to the behavior of cognitively or sensory impaired clients.

d. Using methods to reduce the effects of cognitive impairment.

6. Skills for basic restorative services.

a. Using assistive devices in transferring, ambulation, eating and dressing.

b. Maintaining range of motion.

c. Turning and positioning, both in bed and chair.

d. Bowel and bladder training.

e. Caring for and using prosthetic and orthotic devices.

f. Teaching the client in self-care according to the client's abilities as directed by a supervisor.

7. Clients' rights.

a. Providing privacy and maintaining confidentiality.

b. Promoting the client's right to make personal choices to accommodate individual needs.

c. Giving assistance in resolving grievances and disputes.

d. Providing assistance necessary to participate in client and family groups and other activities.

e. Maintaining care and security of the client's personal possessions.

f. Promoting the client's rights to be free from abuse, mistreatment and neglect and the need to report any instances of such treatment to appropriate staff.

g. Avoiding the need for restraints in accordance with current professional standards.

8. Legal and regulatory aspects of practice as a certified nurse aide, including, but not limited to, consequences of abuse, neglect, misappropriation of client property and unprofessional conduct.

9. Occupational health and safety measures.

10. Appropriate management of conflict.

B. Unit objectives.

1. Objectives for each unit of instruction shall be stated in behavioral terms that are measurable.

2. Objectives shall be reviewed with the students at the beginning of each unit.

C. Curriculum changes. Changes in curriculum shall be approved by the board prior to implementation and shall be submitted at the time of the on-site visit or with the report submitted by the program coordinator in the intervening year.

18VAC90-25-50. Other program requirements. (Repealed.)

A. Records.

1. Each nurse aide education program shall develop and maintain an individual record of major skills taught and the date of performance by the student. At the completion of the nurse aide education program, the program shall provide each nurse aide with a copy of this record and a certificate of completion from the program.

2. A record of the reports of graduates' performance on the approved competency evaluation program shall be maintained.

3. A record that documents the disposition of complaints against the program shall be maintained.

B. Student identification. The nurse aide students shall wear identification that clearly distinguishes them as a "nurse aide student."

C. Length of program.

1. The program shall be at least 120 clock hours in length.

2. The program shall provide for at least 24 hours of instruction prior to direct contact of a student with a nursing facility client.

3. Skills training in clinical settings shall be at least 40 hours of providing direct client care. Five of the clinical hours may be in a setting other than a nursing home. Hours of observation shall not be included in the required 40 hours of skills training.

4. Employment orientation to facilities used in the education program must not be included in the 120 hours allotted for the program.

D. Classroom facilities. The nurse aide education program shall provide facilities that meet federal and state requirements including:

1. Comfortable temperatures.

2. Clean and safe conditions.

3. Adequate lighting.

4. Adequate space to accommodate all students.

5. Instructional technology and equipment needed for simulating client care.

18VAC90-25-60. Requirements for continued approval; interruption or closing of a program. (Repealed.)

A. Program review.

1. Each nurse aide education program shall be reviewed annually either by a visit on site by an agent of the board or by a written program evaluation. Each program shall be reviewed by an on-site visit at least every two years following initial review or whenever deemed necessary by the board to ensure continued compliance.

2. The program coordinator shall prepare and submit a program evaluation report on a form provided by the board in the intervening year that an on-site review is not conducted.

B. Decision on continued approval. The committee, in accordance with § 2.2-4019 of the Code of Virginia, shall receive and review the report of the on-site visit or program evaluation report and shall make recommendations to the board to grant continued approval, place a program on conditional approval or deny continued approval.

a. Granting continued approval. A nurse aide education program shall continue to be approved provided the requirements set forth in subsection B of 18VAC90-25-20 are maintained.

b. Placing a program on conditional approval. If the committee determines that a nurse aide education program has not filed its program evaluation report or is not maintaining the requirements of subsection B of 18VAC90-25-20, the committee may recommend to the board that the program be placed on conditional approval and the program provider shall be given a reasonable period of time to correct the identified deficiencies.

(1) The committee shall receive and review reports of progress toward correcting identified deficiencies and, when a final report is received at the end of the specified time showing corrections of deficiencies, make a recommendation to the board to grant continued approval.

(2) If the program provider fails to correct the identified deficiencies within the time specified by the committee or the board, the board or a panel thereof may withdraw approval following a hearing in accordance with § 2.2-4020 and subdivision 11 of § 54.1-2400 of the Code of Virginia.

(3) The program provider may request a formal hearing before the board or a panel thereof pursuant to § 2.2-4020 and subdivision 11 of § 54.1-2400 of the Code of Virginia if it objects to any action of the board relating to conditional approval.

c. Denying continued approval. If the committee determines that a nurse aide education program is not maintaining the requirements of subsection B of 18VAC90-25-20, it may recommend that continued approval be denied and refer the matter to the board or a panel of the board for a hearing in accordance with § 2.2-4020 of the Code of Virginia.

C. Interruption of program.

1. When a program provider does not hold classes for a period not to exceed one year, the provider may request that the program be placed on inactive status and shall not be subject to compliance with subsection B of 18VAC90-25-20 for the specified time.

2. Unless the program provider notifies the board that it intends to admit students, the program will be considered closed at the end of the one-year period and be subject to the requirements of subsection D of this section.

3. If the program provider does not hold classes for two consecutive years, the program shall be considered closed and shall be subject to the requirements of subsection D of this section.

D. Closing of a nurse aide education program. When a nurse aide education program closes, the program provider shall:

1. Notify the board of the date of closing.

2. Submit to the board a list of all graduates with the date of graduation of each.

18VAC90-25-71. Certification by examination.

To be placed on the registry and certified by examination, the nurse aide must:

1. (i) Satisfactorily complete Have satisfactorily completed:

a a. A nurse aide education program approved by the board;

(ii) be enrolled in a nursing education program preparing for registered nurse or practical nurse licensure, and have satisfactorily completed at b. At least one clinical nursing course that includes at least 40 hours of clinical experience involving direct client care within the past 12 months while enrolled in a nursing education program preparing for registered nurse or practical nurse licensure; or

(iii) have completed a c. A nursing education program preparing for registered nurse licensure or practical nurse licensure;

2. Pass the competency evaluation required by the board; and

3. Submit the required application and testing fee as prescribed by the board.

18VAC90-25-72. Certification by endorsement.

To be placed on the registry and be certified by endorsement, the nurse aide shall:

1. Be a graduate of a state-approved nurse aide education program that meets the requirements for clinical training and competency set forth in 42 CFR 483.152;

2. Have satisfactorily completed a competency evaluation program;

3. Be currently registered in another state, with no finding of abuse, neglect or misappropriation of property;

4. Submit the required application; and

5. Submit the required verification form to the credentialing agency in each state in which the applicant has been registered, certified, or licensed, unless electronic verification is available.

18VAC90-25-90. Requirements for certified nurse aides. (Repealed.)

A. Evidence of change of name. A certificate holder who has changed his name shall submit as legal proof to the board a copy of the marriage certificate or court order authorizing the change. A duplicate certificate shall be issued by the board upon receipt of such evidence and the required fee.

B. Requirements for current mailing address.

1. All notices required by law and by this chapter to be mailed by the board to any certificate holder shall be validly given when mailed to the latest address on file with the board.

2. Each certificate holder shall maintain a record of his current mailing address with the board.

3. Any change of address by a certificate holder shall be submitted in writing to the board within 30 days of such change.

18VAC90-25-120. Renewal and reinstatement of certification as an advanced certified nurse aide.

A. Current certification as a nurse aide in Virginia must be maintained in order to hold certification as an advanced certified nurse aide.

B. Renewal. If an individual is not eligible to renew as a certified nurse aide, certification as an advanced certified nurse aide may not be renewed. An advanced certification shall be renewed concurrently with the biennial renewal of the basic certification as a nurse aide in Virginia by:

1. Submitting a completed renewal form and renewal fee of $20; and

2. Attesting to completion of at least three contact hours per year of continuing education and training in any of the competency areas identified in the advanced certification training program. The board may grant an extension or waiver of the continuing education requirement based on good cause shown by the certified nurse aide.

C. Late renewal. An advanced certified nurse aide may renew certification for 90 days following the expiration date by meeting the requirements of subsection A of this section.

D. Reinstatement. If an advanced certification has not been renewed for 90 days following the expiration date, it shall only be reinstated if the applicant for reinstatement:

1. Holds current certification as a nurse aide in Virginia;

2. Submits a completed reinstatement application on a form provided by the board;

3. Pays the reinstatement fee of $30; and

4. Provides evidence that he has completed all required hours of continuing education and training.

NOTICE: The following forms used in administering the regulation were filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form with a hyperlink to access it. The forms are also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia 23219.

FORMS (18VAC90-25)

Instructions for Application for Nurse Aide Certification by Endorsement (rev. 1/11)

Application for Nurse Aide Certification by Endorsement (rev. 8/08)

Nurse Aide Certification Verification Form (rev. 11/07)

Instructions and Application for Certification as Advanced Certified Nurse Aide (rev. 8/07)

Instructions and Application for Reinstatement of Nurse Aide Certification (rev. 8/08)

Instructions and Application for Reinstatement of Advanced Nurse Aide Certification (rev. 8/07)

Application to Establish Nurse Aide Education Program (rev. 7/11)

Application to Establish an Advanced Certification Nurse Aide Education Program (rev. 8/07)

Nurse Aide Education Program Evaluation Report (rev. 8/07)

Nurse Aide Education Program-On-site Review Report (rev. 8/07)

Advanced Certification Nurse Aide Education Program Evaluation Report (rev. 8/08)

Advanced Certification Nurse Aide Education Program-On-site Review Report (rev. 8/07)

Request for Statistical Information (rev. 6/08)

CHAPTER 26
REGULATIONS FOR NURSE AIDE EDUCATION PROGRAMS

18VAC90-26-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Board" means the Virginia Board of Nursing.

"Client" means a person receiving the services of a certified nurse aide, to include a patient in a health care facility or at home or a resident of a long-term care facility.

"Committee" means the Education Special Conference Committee, comprised of not less than two members of the board in accordance with § 2.2-4019 of the Code of Virginia.

"Nurse aide education program" means a program designed to prepare nurse aides for certification.

"Nursing facility" means a licensed nursing home or an entity that is certified for Medicare or Medicaid long-term care reimbursement and licensed or certified by the Virginia Department of Health.

"Primary instructor" means a registered nurse who is responsible for teaching and evaluating the students enrolled in a nurse aide education program.

"Program coordinator" means a registered nurse who is administratively responsible and accountable for a nurse aide education program.

"Program provider" means an entity that conducts a nurse aide education program.

18VAC90-26-20. Establishing and maintaining a nurse aide education program.

A. Establishing a nurse aide education program.

1. A program provider wishing to establish a nurse aide education program shall submit an application to the board at least 90 days in advance of the expected opening date.

2. The application shall provide evidence of the ability of the institution to comply with subsection B of this section.

3. Initial approval may be granted when all documentation of the program's compliance with requirements as set forth in subsection B of this section has been submitted and deemed satisfactory to the board.

4. If approval is denied, the program may request, within 30 days of the mailing of the decision, an informal conference to be convened in accordance with § 2.2-4019 of the Code of Virginia.

5. If denial is recommended following an informal conference, which is accepted by the board or a panel thereof, no further action will be required of the board unless the program requests a hearing before the board or a panel thereof in accordance with § 2.2-4020 and subdivision 11 of § 54.1-2400 of the Code of Virginia.

6. If the decision of the board or a panel thereof following a formal hearing is to deny initial approval, the program shall be advised of the right to appeal the decision to the appropriate circuit court in accordance with § 2.2-4026 of the Code of Virginia and Part 2A of the Rules of the Supreme Court of Virginia.

B. Maintaining an approved nurse aide education program. To maintain approval, the nurse aide education program shall:

1. Demonstrate evidence of compliance with the following essential elements:

a. Curriculum content and length as set forth in subsection A of 18VAC90-26-40 and subsection C of 18VAC90-26-50.

b. Maintenance of qualified instructional personnel as set forth in 18VAC90-26-30.

c. Classroom facilities that meet requirements set forth in subsection D of 18VAC90-26-50.

d. Maintenance of records as set forth in subsection A of 18VAC90-26-50.

e. Skills training experience in a nursing facility that has not been subject to penalty or penalties as provided in 42 CFR 483.151(b)(2) (Medicare and Medicaid Programs: Nurse Aide Training and Competency Evaluation and Paid Feeding Assistants, October 1, 2013 edition) in the past two years. The foregoing shall not apply to a nursing facility that has received a waiver from the state survey agency in accordance with federal law.

f. Agreement that board representatives may make unannounced visits to the program.

g. Financial support and resources sufficient to meet requirements of this chapter as evidenced by a copy of the current annual budget or a signed statement from the administration specifically detailing its financial support and resources.

h. Completion and submission of biennial onsite review reports and program evaluation reports as requested by the board.

2. Impose no fee for any portion of the program on any nurse aide who, on the date on which the nurse aide begins the program, is either employed or has an offer of employment from a nursing facility.

3. Provide documentation that each student applying to or enrolled in such program has been given a copy of applicable Virginia law regarding criminal history records checks for employment in certain health care facilities, and a list of crimes that pose a barrier to such employment.

4. Report all substantive changes in subdivision 1 of this subsection within 10 days of the change to the board to include, but not be limited to, a change in the program coordinator, primary instructor, program ownership, physical location of the program, or licensure status.

5. Provide each student with a copy of his certificate of completion.

18VAC90-26-30. Requirements for instructional personnel.

A. Program coordinator.

1. Each program shall have a program coordinator who must be a registered nurse who holds a current, unrestricted license in Virginia or a multistate licensure privilege.

2. The program coordinator in a nursing facility based program may be the director of nursing services. The director of nursing services may assume the administrative responsibility and accountability for the nurse aide education program but shall not engage in the actual classroom and clinical teaching.

3. The primary instructor may be the program coordinator in any nurse aide education program.

B. Primary instructor.

1. Qualifications. Each program shall have a primary instructor who does the majority of the actual teaching of the students and who shall:

a. Hold a current, unrestricted Virginia license as a registered nurse who holds a current, unrestricted license in Virginia or a multistate licensure privilege; and

b. Have two years of experience as a registered nurse within the previous five years and at least one year of experience in the provision of long-term care facility services. Such experience may include, but not be limited to, employment in a nurse aide education program or employment in or supervision of nursing students in a nursing facility or unit, geriatrics department, chronic care hospital, home care, or other long-term care setting. Experience should include varied responsibilities, such as direct client care, supervision, and education.

2. Responsibilities. The primary instructor is responsible for the teaching and evaluation of students and, in addition, shall:

a. Participate in the planning of each learning experience;

b. Ensure that course objectives are accomplished;

c. Ensure that the provisions of subsection F of this section are maintained;

d. Maintain records as required by subsection A of 18VAC90-26-50;

e. Perform other activities necessary to comply with subsection B of 18VAC90-26-20; and

f. Ensure that students do not perform services for which they have not received instruction and been found proficient by the instructor.

C. Other instructional personnel.

1. Instructional personnel who assist the primary instructor in providing classroom or clinical supervision shall be registered nurses or licensed practical nurses.

a. A registered nurse shall:

(1) Hold a current, unrestricted Virginia license as a registered nurse; and

(2) Have had at least one year of direct patient care experience as a registered nurse.

b. A licensed practical nurse shall:

(1) Hold a current, unrestricted Virginia license as a practical nurse;

(2) Hold a high school diploma or equivalent;

(3) Have been graduated from a state-approved practical nursing program; and

(4) Have had at least two years of direct patient care experience as a licensed practical nurse.

2. Responsibilities. Other instructional personnel shall provide instruction under the supervision of the primary instructor.

D. Prior to being assigned to teach the nurse aide education program, all instructional personnel shall demonstrate competence to teach adults by one of the following:

1. Satisfactory completion of a course in teaching adults that includes:

a. Basic principles of adult learning;

b. Teaching methods and tools for adult learners; and

c. Evaluation strategies and measurement tools for assessing the learning outcomes; or

2. Have experience in teaching adults or high school students.

E. To meet planned program objectives, the program may, under the direct, onsite supervision of the primary instructor, use other persons who have expertise in specific topics and have had at least one year of experience in their field.

F. When students are giving direct care to clients in clinical areas, instructional personnel must be on site solely to supervise the students. The ratio of students to each instructor shall not exceed 10 students to one instructor.

18VAC90-26-40. Requirements for the curriculum.

A. Curriculum content. The curriculum shall include, but shall not be limited to, classroom and clinical instruction in the following:

1. Initial core curriculum. Prior to the direct contact with a nursing facility client, a student shall have completed a total of at least 24 hours of instruction. Sixteen of those hours shall be in the following five areas:

a. Communication and interpersonal skills.

b. Infection control.

c. Safety and emergency procedures, including dealing with obstructed airways and fall prevention.

d. Promoting client independence.

e. Respecting clients' rights.

2. Basic skills.

a. Recognizing changes in body functioning and the importance of reporting such changes to a supervisor.

b. Measuring and recording routine vital signs.

c. Measuring and recording height and weight.

d. Caring for the client's environment.

e. Measuring and recording fluid and food intake and output.

f. Performing basic emergency measures.

g. Caring for a client when death is imminent.

3. Personal care skills.

a. Bathing and oral hygiene.

b. Grooming.

c. Dressing.

d. Toileting.

e. Assisting with eating and hydration, including proper feeding techniques.

f. Caring for skin, to include prevention of pressure ulcers.

g. Transfer, positioning, and turning.

4. Individual client's needs, including mental health and social service needs.

a. Modifying the aide's behavior in response to the behavior of clients.

b. Identifying developmental tasks associated with the aging process.

c. Demonstrating principles of behavior management by reinforcing appropriate behavior and causing inappropriate behavior to be reduced or eliminated.

d. Demonstrating skills supporting age-appropriate behavior by allowing the client to make personal choices, and by providing and reinforcing other behavior consistent with the client's dignity.

e. Utilizing the client's family or concerned others as a source of emotional support.

f. Responding appropriately to the client's behavior including, but not limited to, aggressive behavior and language.

g. Providing appropriate clinical care to the aged and disabled.

h. Providing culturally sensitive care.

5. Care of the cognitively or sensory (visual and auditory) impaired client.

a. Using techniques for addressing the unique needs and behaviors of individuals with dementia (Alzheimer's and others).

b. Communicating with cognitively or sensory impaired clients.

c. Demonstrating an understanding of and responding appropriately to the behavior of cognitively or sensory impaired clients.

d. Using methods to reduce the effects of cognitive impairment.

6. Skills for basic restorative services.

a. Using assistive devices in transferring, ambulation, eating, and dressing.

b. Maintaining range of motion.

c. Turning and positioning, both in bed and chair.

d. Bowel and bladder training.

e. Caring for and using prosthetic and orthotic devices.

f. Teaching the client in self-care according to the client's abilities as directed by a supervisor.

7. Clients' rights.

a. Providing privacy and maintaining confidentiality.

b. Promoting the client's right to make personal choices to accommodate individual needs.

c. Giving assistance in resolving grievances and disputes.

d. Providing assistance necessary to participate in client and family groups and other activities.

e. Maintaining care and security of the client's personal possessions.

f. Promoting the client's rights to be free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate staff.

g. Avoiding the need for restraints in accordance with current professional standards.

8. Legal and regulatory aspects of practice as a certified nurse aide including, but not limited to, consequences of abuse, neglect, misappropriation of client property, and unprofessional conduct.

9. Occupational health and safety measures.

10. Appropriate management of conflict.

B. Unit objectives.

1. Objectives for each unit of instruction shall be stated in behavioral terms that are measurable.

2. Objectives shall be reviewed with the students at the beginning of each unit.

C. Curriculum changes. Changes in curriculum shall be approved by the board prior to implementation and shall be submitted at the time of the onsite visit or with the report submitted by the program coordinator in the intervening year.

18VAC90-26-50. Other program requirements.

A. Records.

1. Each nurse aide education program shall develop and maintain an individual record of major skills taught and the date of performance by the student. At the completion of the nurse aide education program, the program shall provide each nurse aide with a copy of this record and a certificate of completion from the program.

2. A record of the reports of graduates' performance on the approved competency evaluation program shall be maintained.

3. A record that documents the disposition of complaints against the program shall be maintained.

B. Student identification. The nurse aide students shall wear identification that clearly distinguishes them as a "nurse aide student."

C. Length of program.

1. The program shall be at least 120 clock hours in length.

2. The program shall provide for at least 24 hours of instruction prior to direct contact of a student with a nursing facility client.

3. Skills training in clinical settings shall be at least 40 hours of providing direct client care. Five of the clinical hours may be in a setting other than a nursing home. Hours of observation shall not be included in the required 40 hours of skills training.

4. Employment orientation to facilities used in the education program must not be included in the 120 hours allotted for the program.

D. Classroom facilities. The nurse aide education program shall provide facilities that meet federal and state requirements including:

1. Comfortable temperatures.

2. Clean and safe conditions.

3. Adequate lighting.

4. Adequate space to accommodate all students.

5. Instructional technology and equipment needed for simulating client care.

18VAC90-26-60. Requirements for continued approval.

A. Program review.

1. Each nurse aide education program shall be reviewed annually either by a visit on site by an agent of the board or by a written program evaluation. Each program shall be reviewed by an onsite visit at least every two years following initial review or whenever deemed necessary by the board to ensure continued compliance.

2. The program coordinator shall prepare and submit a program evaluation report on a form provided by the board in the intervening year that an onsite review is not conducted.

B. Decision on continued approval.

1. The board shall receive and review the report of the onsite visit or program evaluation report and may grant continued approval, place a program on conditional approval or deny continued approval.

a. Granting continued approval. A nurse aide education program shall continue to be approved provided the requirements set forth in subsection B of 18VAC90-26-20 are maintained.

b. Placing a program on conditional approval. If the board determines that a nurse aide education program has not filed its program evaluation report or is not maintaining the requirements of subsection B of 18VAC90-26-20, as evidenced by the onsite report, the board may place the program on conditional approval and the program provider shall be given a reasonable period of time to correct the identified deficiencies. The program may request, within 30 days of the mailing of a decision on conditional approval, an informal conference to be convened in accordance with § 2.2-4019 of the Code of Virginia.

(1) The board shall receive and review reports of progress toward correcting identified deficiencies. When a final report is received at the end of the specified time showing corrections of deficiencies, the board may grant continued approval.

(2) If the program provider fails to correct the identified deficiencies within the time specified by the board, a committee may recommend withdrawing approval following an informal conference held in accordance with § 2.2-4019 of the Code of Virginia.

(3) If the recommendation to withdraw approval following an informal conference is accepted by the board or a panel thereof, no further action will be required unless the program requests a formal hearing.

(4) The program provider may request a formal hearing before the board or a panel thereof pursuant to § 2.2-4020 and subdivision 11 of § 54.1-2400 of the Code of Virginia if it objects to any action of the board relating to conditional approval.

c. Denying continued approval. If the board determines that a nurse aide education program is not maintaining the requirements of subsection B of 18VAC90-26-20, an informal conference will be convened in accordance with § 2.2-4019 of the Code of Virginia. If the recommendation to withdraw approval following an informal conference is accepted by the board or a panel thereof, no further action will be required unless the program requests a formal hearing.

2. If the decision of the board or a panel thereof following a formal hearing is to withdraw approval or continue on conditional approval with terms or conditions, the program shall be advised of the right to appeal the decision to the appropriate circuit court in accordance with § 2.2-4026 of the Code of Virginia and Part 2A of the Rules of the Supreme Court of Virginia.

18VAC90-26-70. Interruption or closing of a program.

A. Interruption of program.

1. When a program provider does not hold classes for a period of one year, the program shall be placed on inactive status and shall not be subject to compliance with subsection B of 18VAC90-26-20 for the specified time.

2. Unless the program provider notifies the board that it intends to admit students, the program will be considered closed at the end of the inactive period and be subject to the requirements of subsection B of this section.

3. If the program provider does not hold classes for two consecutive years, the program shall be considered closed and shall be subject to the requirements of subsection B of this section.

B. Closing of a nurse aide education program. When a nurse aide education program closes, the program provider shall:

1. Notify the board of the date of closing.

2. Submit to the board a list of all graduates with the date of graduation of each.

NOTICE: The following forms used in administering the regulation were filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form with a hyperlink to access it. The forms are also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia 23219.

FORMS (18VAC90-26)

Application to Establish Nurse Aide Education Program (rev. 7/11)

Nurse Aide Education Program - Program Evaluation Report (rev. 8/07)

Nurse Aide Education Program - On-Site Review Report (rev. 8/07)

Application to Establish an Advanced Certification Nurse Aide Education Program (rev. 8/07)

Advanced Certification Nurse Aide Education Program - Program Evaluation Report (rev. 8/08)

Advanced Certification Nurse Aide Education Program - On-Site Review Report (rev. 8/07)

Request for Statistical Information (rev. 6/08)

VA.R. Doc. No. R14-3553; Filed December 18, 2013, 9:13 a.m.