105 CMR 156.00 — The training of nurses' aides in long-term care facilities

105 CMR: DEPARTMENT OF PUBLIC HEALTH

105 CMR 156.000: THE TRAINING OF NURSE AIDES IN LONG-TERM CARE FACILITIES

Section 156.010: 156.020: 156.100: 156.110: 156.120: 156.200: 156.210: 156.220: 156.230: 156.300: 156.310: 156.400: 156.500: 156.600:

105 CMR 156.00 The training of nurses' aides in long-term care facilities

156.010 156.020:

156.010: 156.020: Scope and Applicability Definitions Responsibilities of the Facility Staffing Ratios Nurse Aides Required to Take Training Courses Approval of Training Providers Responsibilities of Training Providers Qualifications of the Primary Instructor Responsibilities of the Primary Instructor Minimum Curriculum Standards Approval of Curriculum Documentation of Completed Training Competency Evaluation Severability Scope and Applicability 105 CMR 156.000 applies to all long-term care facilities licensed pursuant to 105 CMR 153.000: Licensure Procedure and Suitability Requirements for Long-term Care Facilities that employ nurse aides, all nurse aides working in long-term care facilities, and all nurse aide training programs. Definitions Commissioner. The Commissioner of Public Health or his or her designee. Contact Hour. 50 consecutive classroom minutes of instruction in accordance with 244 CMR 5.04(1): Amount. Department. The Massachusetts Department of Public Health. Document of Completion. The form prescribed by the Department that records when an individual has successfully completed a nurse aide training course or equivalency evaluation. Long-term Care Facility or Facility. A nursing home or rest home licensed pursuant to 105 CMR 150.000: Licensing of Long-term Care Facilities. Minimum Standard Curriculum. The minimum requirements for a nurse aides training course as prescribed by the Department. Module. A single section of the minimum standard curriculum. Nurse Aide. Any individual who provides nursing care under the supervision of a nurse in a long-term care facility. Nurse Aide includes permanent, temporary, full-time and part-time personnel employed by a long-term care facility and temporary agency personnel employed by a long-term care facility. Nurse aide excludes individuals employed as responsible persons as defined in 105 CMR 150.001: Definitions, registered nurses, licensed practical nurses and volunteers.

105 CMR: DEPARTMENT OF PUBLIC HEALTH Nursing Care. Therapeutic or convalescent care provided by nurses or individuals assisting nurses in long-term care facilities. Primary Instructor. An individual who meets the requirements of 105 CMR 156.220 who is responsible for providing the nurse aide training. Registry. Nurse aide registry as established in accordance with M.G.L. c. 111, § 72J.

105 CMR: DEPARTMENT OF PUBLIC HEALTH

156.020 continued

156.020: continued Training. Clinical and/or classroom instruction to deliver the minimum standard curriculum. Training Provider. The organization or individual using a curriculum approved by the Department, providing the facilities for and maintaining the records of a nurse aides training course. 155.100: Responsibilities of the Facility (A) Any long-term care facility that hires a nurse aide shall ensure the nurse aide completes the nurse aide training within 90 days of commencing employment unless: (1) The facility verifies through the Registry, as established in accordance with M.G.L. c. 111, § 72J, the individual has a current certification as a nurse aide; or (2) The facility documents the individual is exempt from completing training as a nurse aide subsequent to beginning employment because: (a) The individual is currently certified as a nurse aide in another state, as verified through that state's nurse aide registry; (b) The individual has successfully completed a nurse aide training program in another state that has been approved by that state under 42 CFR 483.151; or (c) The individual has successfully completed a clinical course in an approved school of nursing, in accordance with 244 CMR 6.00: Approval of Nursing Education Programs and the General Conduct Thereof, which included hands on care skills as specified in the minimum standard curriculum. (B) A long-term care facility shall not continue to employ any individual as a nurse aide for more than four months after commencing employment unless the facility verifies through the Registry that the individual has current certification as a nurse aide. (C) A facility shall ensure that all nurse aides employed through temporary nursing agencies to provide care to the facility's residents meet the training and certification requirements pursuant to 105 CMR 156.100 through: (1) a written agreement with the temporary nursing agency that the agency will provide only nurse aides trained in conformity with 105 CMR 156.100; or (2) Verification by the facility prior to employment at the facility, that such nurse aides meet the training and certification requirements of 105 CMR 156.100. (D) The facility shall ensure nurse aides perform only those tasks for which they have been trained and for which they have successfully demonstrated their ability to correctly perform these tasks.

156.110 Staffing Ratios

156.110: Staffing Ratios Nurse aides participating in orientation and in classroom/clinical instruction pursuant to 105 CMR 156.000 may not be counted in the staffing ratios for ancillary personnel as prescribed in 105 CMR 150.007: Nursing Services. Nurse aides who have been trained to perform some of the tasks required in the minimum standard curriculum and have successfully demonstrated their ability to perform these tasks may be counted in staffing ratios when they perform these tasks. 155.120: Nurse Aides Required to Take Training Course (A) The long-term care facility must ensure that a nurse aide providing care at the facility are

105 CMR: DEPARTMENT OF PUBLIC HEALTH

trained in accordance with 105 CMR 156.100. (B) An individual whose certification as a nurse aide has lapsed, and who has not been employed by either a long-term care facility or a temporary nursing agency as a nurse aide or licensed nurse at a long-term care facility at some point in the two years prior to re-commencing employment as a nurse aide shall be considered a new employee, and is required to repeat training and obtain certification as a nurse aide in accordance with 105 CMR 156.100.

105 CMR: DEPARTMENT OF PUBLIC HEALTH

156.200 Approval of Training Providers

156.200: Approval of Training Providers (A) A training provider shall not offer nurse aide training, or advertise that it provides nurse aides' training, without current approval from the Department to operate a nurse aide training program. (B) Applications for approval as a nurse aide training provider shall be made to the Department in the format prescribed by the Department, and submitted at least 60 days prior to the proposed commencement of training. (C) A nurse aide training program operated by a vocational high school, a community college, or any other training entity shall obtain all necessary approvals from other appropriate regulatory agencies, in addition to approval from the Department, prior to offering nurse aide training or advertising itself as a nurse aide training provider. (D) Upon a determination by the Department that an application for approval to operate a nurse aide training program is complete, and the applicant is in compliance with the requirements for training providers, the Department shall issue its approval to the applicant to operate as a nurse aide training provider for a period of not more than two years. (E) A nurse aide training provider must notify the Department at least 30 days in advance of any substantive changes to its program, and obtain approval from the Department prior to initiating a new training course. (F) A nurse aide training provider must file an application for renewal of approval as a training provider in the format specified by the Department at least 60 days prior to the expiration of its current approval period. (G) An applicant approved or re-approved as a nurse aide training provider for two years must submit documentation updating its status as a training provider in the format prescribed by the Department one year after receiving approval or re-approval as a training provider. (H) The Department may withdraw its approval of a nurse aide training provider that fails to comply with the requirements for nurse aide training programs in 105 CMR 156.000 or at 42 CFR 483; and must withdraw its approval of a nurse aide training provider under the conditions specified in 42 CFR 483.151. In the event of withdrawal of approval by the Department, students who have started training with a training provider for which approval has been withdrawn will be allowed to complete the course.

156.210 Responsibilities of Training Providers

156.210: Responsibilities of Training Providers (A) Nurse aides training providers shall: (1) employ, or have written arrangements with, a primary instructor who meets the qualifications specified in 105 CMR 156.210; (2) provide, or have written arrangements to provide, appropriate facilities for classroom instruction and for clinical instruction in a level II or III long-term care facility; (3) offer a curriculum that has been approved by the Department; and (4) ensure that appropriate equipment is available for training in accordance with guidelines issued by the Department. (B) Examples of training providers include but are not limited tovocational high schools, community colleges, long-term care facilities, and temporary nursing agencies.

105 CMR: DEPARTMENT OF PUBLIC HEALTH

(C) The training provider shall submit a curriculum proposal for approval by the Department as specified in 105 CMR 156.310. (D) The training provider shall maintain the following documentation for each course offered and shall make it available for inspection by the Department upon request: (1) curriculum outline and record of dates on which courses were taught; (2) notification of approval by the Department; (3) daily attendance roster;

105 CMR: DEPARTMENT OF PUBLIC HEALTH

156.210 continued

156.210: continued (4) name and resume of each instructor showing he or she meets the requirements specified in 105 CMR 156.220; (5) copies of all documents of completion issued by the training provider; and (6) copies of all evaluation forms completed by the training provider.

156.220 Qualifications of the Primary Instructor

156.220: Qualifications of the Primary Instructor (A) Primary instructors for nurse aides training courses must: (1) Be a registered nurse with current licensure with at least two years' nursing experience, one of which must have been in a level II or level III long-term care facility; and (2) Be able to effectively train students as demonstrated: (a) at least one year's experience in lesson planning, lesson delivery, student evaluation and remediation in a health care setting as an in-service coordinator, staff educator, or other health personnel instructor; or the equivalent of 24 contact hours in programs that meet continuing education standards currently set forth in 244 CMR 5.00: Continuing Education and that provide instruction in curriculum development, use of teaching strategies for adult learners and student evaluation; or (b) Meet all of the following qualifications:

1. A written agreement for consultation with a registered nurse who has the qualifications set forth in 105 CMR 156.220(A)(1) and (2);
2. Obtain such consultation prior to each course, midway through the course and at the end of the course prior to final evaluation. This consultation shall include lesson plans, teaching strategies, resource materials, evaluation procedures, and remediation methods;
3. Document the dates and recommendation of the consultations; and
4. Attend program(s) that meets continuing education standards set forth in 244 CMR 5.00: Continuing Education consisting of not less than 24 contact hours of adult education within the first year as instructor. (3) The Commissioner may waive the qualifications of the instructor imposed by 105 CMR 156.210(A)(2) upon finding that: (a) The proposed instructor has obtained sufficient experience in the care of long-term care residents and teaching adults how to provide such health care to ensure that he or she may train nurse aides to perform the objectives outlined in the minimum standard curriculum described in 105 CMR 156.000; and (b) The training provider provides to the Commissioner written documentation supporting the request for a waiver. (B) Other health care professionals such as dieticians, social workers, physical therapists, occupational therapists, and others may teach lessons or modules of a nurse aides training course.

156.230 Responsibilities of the Primary Instructor

156.230: Responsibilities of the Primary Instructor (A) The primary instructor shall prepare the curriculum that he or she will teach as specified in 105 CMR 156.300 and as prescribed in guidelines from the Department, or shall review the existing approved curriculum of the training program, and shall participate in the planning of each lesson, even if he or she does not teach that specific lesson. (B) The primary instructor shall evaluate each student to determine whether he or she has satisfactorily completed each module of nurse aides training and shall offer remediation for each student as needed.

105 CMR: DEPARTMENT OF PUBLIC HEALTH

(C) The primary instructor shall sign and issue a document of completion for each student upon satisfactory completion of the evaluation that is a part of a nurse aides training course as specified in 105 CMR 156.000. (D) The primary instructor shall ensure there is a minimum of one instructor for every 25 students in a classroom and a minimum of one instructor for every ten students in practice/ clinical sessions.

105 CMR: DEPARTMENT OF PUBLIC HEALTH

156.300 Minimum Curriculum Standards

156.300: Minimum Curriculum Standards (A) Each nurse aides training course shall be a minimum of 75 hours and shall include all modules of the minimum standard curriculum as prescribed in guidelines from the Department. (B) Curriculum organization and teaching strategies are at the discretion of the instructor. (C) Facilities requiring nurse aides to perform tasks not included in the minimum standard curriculum shall ensure nurse aides are trained to perform these tasks and have successfully demonstrated their ability to perform these tasks. Training for such tasks, including training for tasks related to special resident populations, shall be in addition to the minimum standard curriculum. (D) Facilities with special resident populations shall use the minimum standard curriculum for nurse aide training but may adapt content and clinical applications to the facility's specific resident population. Such adaptations shall continue to require that nurse aides master all objectives in the minimum standard curriculum. Such skills may be taught with attention to age or other considerations as the resident population dictates.

156.310 Approval of Curriculum

156.310: Approval of Curriculum (A) The training provider shall submit a proposed curriculum to the Department in a format specified by the Department. (1) The training provider shall submit the curriculum eight weeks prior to the start of the first course and every two years thereafter with the program's application for renewal of approval. (2) The training provider must submit any modifications of the curriculum to the Department for approval prior to the start of the course. (B) If the curriculum proposal is not approved, the training provider may revise and re-submit the proposed curriculum, and may not begin a nurse aides training course until the associated curriculum has been approved by the Department.

156.400 Documentation of Completed Training

156.400: Documentation of Completed Training (A) The training program shall issue to each student who successfully completes the nurse aide training program a documentation of completion in a format specified by the Department. (B) Facility administrators shall accept the document of completion as proof of meeting the training requirements set forth in 105 CMR 156.000.

156.500 Competency Evaluation

156.500: Competency Evaluation The Department shall conduct competency evaluations in accordance with the guidelines of the Department, consistent with federal standards for evaluating the competency of individuals completing nurse aide training as specified at 42 CFR 483.154.

156.600 Severability

156.600: Severability The provisions of 105 CMR 156.000 are severable. If any provision herein is declared unconstitutional or invalid by a court of competent jurisdiction, the validity of the remaining portions shall not be so affected.

105 CMR: DEPARTMENT OF PUBLIC HEALTH REGULATORY AUTHORITY 105 CMR 156.000: M.G.L. c. 111, § 72W.