The North Carolina Nurse Aide

Jesse Goodman, Acting Chief Operating OfficerNorth Carolina Division of Health Service Regulation

February 25, 2010

§ 131E-255. Nurse Aide Registry

(a) Pursuant to 42 U.S.C. § 1395i-3(e) and 42U.S.C. § 1396r(e), the Department shallestablish and maintain a registry containing thenames of all nurse aides working in nursingfacilities in North Carolina. The Department shallinclude in the nurse aide registry any findings bythe Department of neglect of a resident in anursing facility or abuse of a resident in a nursingfacility or misappropriation of the property of aresident in a nursing facility by a nurse aide.

Overview

• Nurse aide is federally defined – Any individualproviding nursing or nursing-related services toresidents in a facility who is not a licensed healthprofessional, a registered dietitian, or someonewho volunteers to provide such services withoutpay. 42CFR483.75(e)

• Other names used among various groupsinclude CNA, certified nurse aide, nursingassistant.

• Nurse aides must hold a current listing on theNC Nurse Aide I Registry.

NC and Federal Requirementsfor Nurse Aide I Registry Listing

• Successfully complete either a state-approvedNurse Aide I Training and CompetencyEvaluation Program or a state-approved NurseAide Competency Evaluation Program (42 CFR483 Subpart B 483.75(e); 42 CFR 483 SubpartD 483.150-158)

• May renew by working a minimum of 8 hoursduring every 24 months as long as the work is 1)for pay, 2) as a nurse aide, and 3) supervised bya registered nurse

• Active Nurse Aides FY 08-09 - 110,726

Registry Verifications

• Before allowing an individual to serve as anurse aide, a skilled nursing facility mustreceive registry verification that theindividual has met competency evaluationrequirements.42 CFR 483, Subpart B 483.75, 42 CFR 483.13 (c)(1)(ii)(B)

• Verification confirmations given inFY 08-09 – 650,279

Federal Requirements forNurse Aide I Training (NAT)

Programs42CFR483.151-152

• State must review and approve ordisapprove NAT programs upon request

• State must withdraw programs that do notmeet applicable requirements

• Approval good for 2 years

Source: 42CFR483.152

Federally Required Contentfor Nurse Aide I Training Programs

• Communication skills,infection control,safety/emergencyprocedures

• Promoting residents’independence andrights

• Basics nursing skills

• Personal care skills

• Mental health andsocial service needs

• Care of cognitivelyimpaired residents

• Basic restorativeservices

Nurse Aide I Model Curriculum

• Developed in 1997 by DHSR in responseto the federal regulations

• Updated in 2002; continued to reflectfederal requirements, updatedskills/procedures

• Research and stakeholder feedbackbegan in 2009 to prepare for next revision

Representatives from the followingstakeholder groups were involved incurriculum development:

• NC State Board ofNursing

• Nurse Aide Registry &Certification Sections ofthe Division of HealthService Regulation

• NC Health Care FacilitiesAssociation

• Beverly Enterprises - StarMount Villa

• Mayview ConvalescentCenter

• NC Association for HomeCare, Inc.

• NC Nurses Association

• NC Community CollegeSystem Office

• NC Hospital Association

North Carolina State-approved NurseAide I Training Programs:

• Include all content required by federalgovernment.

• Follow extensive curriculum developed byNorth Carolina or follow the North Carolinacurricular requirements (www.ncnar.org).

• Require student proficiency in 69 skills.

*includes community college,licensed proprietary schools,hospitals, & nursing facilities

NC state-approved* programs follow orexceed federal requirements:

Minimum Total - 75

Requirement includes at least16 hours of supervised

practical training (simulatedlab or clinical experience)

Federal Curricular HourlyRequirements for Nurse Aide I

Training

Average Total – 142

Average hours supervisedsimulated lab – 48

Average hours of clinicalexperience - 43

State-Approved ProgramAverages

(data sampled)

Other Training Programs

Anecdotalinformation reveals$200 - $800,depending on lengthof class

Varies, no minimum;anecdotal informationreveals range of a fewhours to one day toseveral classes; manyknown as “fast track”classes

Varies, no minimum classroomcontent; anecdotal informationreveals “test prep” type classesfocusing on 25 testing skillsrather than content/skillsrequired in state-approvedtraining

Non-approved,unlicensed, privateclasses/courses &schools

Free to enrollees180-360 (40 clinicalhours)

Covers state curriculum withinhealth science courses

NC Public High Schools(Memorandum ofUnderstanding between NCDepartment of PublicInstruction and NC Division of

Health Service Regulation)

No additional cost toenrollees

Point which approvedschool’s curriculummeets all federal andstate requirements forNurse Aide I training

Covers state curriculum withinnursing courses

NC Schools of Nursing(Memorandum ofUnderstanding between NCBoard of Nursing (BON) andNC Division of Health Service

Regulation)

$150 (plus books +various fees)

Varies –approximately 27hours

Reviews basic nurse aideknowledge and skills (forpreviously listed aides & out-of-state aides)

Nurse Aide I Refreshercourses (taught atcommunity colleges and

licensed proprietary schools)

AverageTraining Cost

HoursContentType

Types and Numbers ofState-approved NA I Training

Programs

110Schools of Nursing

162Community Colleges

212High Schools

0Hospitals

1Adult Care Homes

3Mental Health-State

12Nursing Homes

20Proprietary Schools

Number of Stateapprovedprograms

School type

Federal Requirements forCompetency Evaluation

(42CFR483.154)

• Choice of written or oral exam

• All course requirements in 42CFR483.152addressed

• Demonstration of randomly drawn skills

• Skills performed in a lab setting comparableto setting of aide employment

• Evaluator is an RN with experience caring forelderly or chronically ill of any age

• Individual has 3 chances to take the exam

North Carolina CompetencyEvaluation Guidelines include:

• All federal guidelines/requirements.

• Required training or re-training in a state-approved program for any tester failingcompetency evaluation three times, beforere-testing a fourth time.

NC Nurse Aide Competency Exam

• Administered by Pearson VUE, anationally and internationally recognizedleading provider of assessment services toregulatory agencies and nationalassociations

• Uses the National Nurse AideAssessment Program (NNAAP),developed and owned by the NationalCouncil of State Boards of Nursing, Inc.

NNAAP Exam• National exam which measures minimal competence of

entry-level nurse aides in their knowledge, skills, andabilities

• Written (also available as oral English and oral Spanish)and skills (performance) component

• Skills component: candidates must successfully completefive (5) randomly selected skills within 30 minutes

• Candidate cost to take exam - $96

• Exam is legally defensible

• Candidates who fail three times are required to completestate-approved training in order to continue testing

• Number of tests administered FY 2008-09 – 23,829(number includes repeaters)

98 98 9792

81

7469

63

50

55

60

65

70

75

80

85

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95

100

105

Gro

up1

Gro

up2

Gro

up3

Gro

up4

Pe

rcen

tp

ass

ing

Written Skills

Group 1: State-approved training

Group 2:Refreshers

Group 3: MOUSchools (HS/SON)

Group 4: Test-out/Non-approvedtraining

Passing Rates Percentages (%)

by Type Tested (6/1/08 – 12/31/09)

Federal Requirements forNurse Aide Inservice Training

• The skilled care facility must complete aperformance review of every nurse aide at leastonce every 12 months, and must provide regularinservice education based on the outcome ofthese reviews.

• The inservice training must be sufficient toensure the continuing competence of nurseaides, but must be no less than 12 hours peryear and based on performance review andspecial needs of residents. 42CFR483(e)(8)

In response to the federal regulations,the agency developed ContinuingEducation Modules to assist facilities inmeeting the inservice requirements.Topics include:

• A More Empathic You

• AdvancedCommunication

• Being Part of a Team

• Fecal Impaction andHydration

• Infection Control

• Me, Myself and I

• Prevention ofpressure ulcers

• Principles of AdultLearning

The agency continues to workcollaboratively with numerousprofessional and industry stakeholders:

• North Carolina Board ofNursing

• National Council for StateBoards of Nursing

• NC Division of Aging

• Direct Care WorkersAssociation

• NC-NOVA

• NC Department of PublicInstruction

• NC Community CollegeSystem Offices ofProprietary Schools &Continuing Education

• NC Health Care FacilitiesAssociation

Nurse Aides - Supply & Demand(Bureau of Labor Statistics, US Department of Labor - http://www.projectionscentral.com/lt_search.aspx)

48,340

13,900

27,860

6,580

Demand

(numberneeded)

43%160,600112,260Totals

76%32,25018,350Personal &Home Care

Aides

39%99,99072,130Home HealthAides

30%28,36021,780Nurse Aides

Percentchange

2016projections

2006employment

*Note: in NC, themajority of HomeHealth Aides,Personal andHome Care Aidesare also NurseAides

Nurse Aide I Employment Breakdown ReportSource: DHSR/Center for Aide Regulation and Education

2/10/10

111694TOTAL

3%2933Clinics (health dept, health clinics, MD

offices and dialysis centers)

6%6739Adult/Family Care Home

10%11097Not employed in health care

15%18060Hospital/Hospice/Mental Health

20%22432Nursing Homes

21%23909Other*

24%26524Home Health/Home Care (includes

nursing pools)

%Number EmployedEmployment Setting

*Other includes categories such as private duty, military/VA facilities, schools, Native American Indian Reservations,adult daycare, cardiac rehab & ambulatory surgery

Source: Employment BreakdownReport, Center for Aide

Regulation and Education

24%

21%

20%

16%

10%

6%3%

Home Health/Care

Other

Nursing Homes

Hosp/Hospice/MH

Not in health care

Adult/Family Care HomeHome

Clinic

Employment Settings for Nurse Aide I

Duties for Nurse Aide IJob duties approved by the Board of Nursing include, but arenot limited to, basic nursing tasks within the followingcategories:

• Personal Care (Activities of Daily Living)• Body Mechanics• Nutrition• Elimination• Safety• Special Procedures

The Registered Nurse is ultimately responsible fordetermining competence of the aide before delegatingnursing or nursing-related tasks.

Expanded Role of the Nurse Aide Iin North Carolina

22(2/12/09)

Learn new concepts tohelp older adults:dementia/challengingbehaviors, death/dying,stress management

• State-approved GeriatricAide course

• Must be listed on Nurse AideI Registry

GeriatricAide

(began in2009)

17,183(2/12/09)

Performs more complexnursing skillsemphasizing steriletechnique in elimination,oxygenation, nutrition

• Must be listed on Nurse AideI Registry

•BON approved course

•No substantiated findings

•Fee

Nurse AideII (managedby BON))

1889(2/12/09)

Performs technicalaspects of medicationadministration for certaintypes of medicines

• 24-hour Board of Nursing(BON) approved course

• State Med Aide Exam

MedicationAide

Number

Active

Duties (requires RNsupervision)

Listing RequirementsType

Health Care Personnel Registry Law

• Investigations of unlicensed health care workers began in 1992 withthe investigations of nurse aides working in nursing homes in theareas of abuse, neglect, and misappropriation of property of nursinghome residents - result of federal nursing home reform legislation(OBRA).

• GS 131E-256 expanded investigations & “findings” of the NurseAide I Registry; expanded types of reportable allegations and healthcare facilities reporting allegations and required names of individualsunder investigation for any reportable allegation to be listed on theregistry.

• In 1998, 1999, 2000, and 2008, expansions of the HCPR lawincreased the types of unlicensed health care personnel reportedand the types of health care facilities that must report allegations.

• “Health care personnel” was defined as any unlicensed staff of ahealth care facility that has direct access to residents, clients, ortheir property.

• Facilities must access the registry before hiring unlicensed staff.Most facilities, by rule, are prohibited from hiring individuals whohave findings.

The Health Care Personnel Registrycontains information about unlicensedhealth care workers for any of thefollowing allegations:

• Resident abuse

• Resident neglect

• Misappropriation of property (from aresident or facility)

• Diversion of resident of facility drugs

• Fraud against a resident or facility

The following types of facilities arerequired to report allegations:

• Adult Care Homes

• Hospitals

• Home Care Agencies

• Nursing Pools

• Hospices

• Nursing Facilities

• State-Operated Facilities

• Licensable Facilities formentally ill,developmental disabled,and substance abusers

• Multiunit AssistedHousing with Services

• Community-BasedProviders of Services forthe mentally ill,developmentallydisabled, and substanceabusers

• Agencies providing in-home aide servicesfunded through the Homeand Community CareBlock Grant Program

Pending Allegations andSubstantiated Findings on the

Health Care Personnel Registry

4,709506Total Number

367

PendingAllegations

3,491Total Individuals

SubstantiatedFindings

As of June 30, 2009

For additional information go toagency’s website for the Center forAide Regulation and Education at

www.ncnar.org