Appendix PP of the State Operations Manual details the requirements for F947 (Required in-service training for nurse aides). To comply with this regulation, a facility’s nurse aide in-service training program must:
- Ensure competence of all nurse aides and address areas of weakness as determined in the nurse aide’s performance review and the facility assessment.
- Offer no less than twelve hours of in-service training per year.
- Include training on how to care for residents with cognitive impairments, dementia, and resident abuse prevention.
This article will highlight aspects of F726 (Nursing services) and F838 (Facility assessment) that intertwine with F947 (Required in-service training for nurse aides) and provide ideas and resources to assist facilities in complying with this regulation.
Nurse aide competency
Appendix PP describes competency as “a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.” F838 requires facilities to determine the competencies staff must have to care for and meet the needs of the residents. When making that determination, the facility is expected to identify the care and services it provides and then ensure that staff competencies align with that care. For example, if a facility provides in-house dialysis, the nurse aides caring for residents receiving that service would need to be competent not only in monitoring the resident pre- and post-dialysis, but also in executing the care-planned interventions, pertinent to their role, that address the resident’s dialysis needs. In contrast, a nurse aide working in memory care would require entirely different competencies more specifically related to executing care plans to meet the needs of residents with various forms of dementia.
When deciding what competencies are necessary, facilities must also consider the scope of practice in relation to the care and services provided by the facility. For example, the registered nurse’s scope of practice requires they assess residents when there is a change in condition. A nurse aide does not complete an assessment, as this is beyond their scope of practice; however, they must be competent to monitor residents for changes and report to the nurse to ensure a resident’s acute condition is addressed as early as possible.
AAPACN provides a nurse in-service training titled “Nurse Assessment: Acute Changes in Condition” and a nurse aide in-service training titled “Staying Alert for Acute Conditions.” These in-service materials, which also include a quiz, are examples of how content should be customized to the intended learner audience, as well as the different competency expectations for different roles.
The table below lists the competencies mentioned in Appendix PP, F726, that are necessary to care for residents’ needs. Note that this is not an all-inclusive list.
| Competencies | • Resident rights; • Person-centered care; • Communication; • Basic nursing skills; • Basic restorative services; • Skin and wound care; • Medication management; • Pain management; • Infection control; • Identification of changes in condition; • Cultural competency |
Facilities must also have in place a process to evaluate the staff competencies outlined in the facility assessment. Furthermore, F726 requires the facility to ensure nurse aides can demonstrate competency, meaning documentation of attendance or completion of training is not sufficient. The nurse aide must be able to apply the knowledge they gain during the in-service or training experience to the actual care of residents. One option to evaluate competency that nurse leaders can use is the Nursing Home Staff Competency Assessment, which identifies several areas of competency and provides a comprehensive assessment in the form of a multiple-choice test.
However, nurse leaders must be open to evaluating competency in many ways. A quiz or test may be sufficient, but the nurse leader must also recognize that a nurse aide may have difficulty taking a quiz or test. There can be many reasons for testing difficulties, but sensitivity to this is challenge is critical, because a poor grade may simply mean the nurse aide is not a good test taker; it does not necessarily communicate anything regarding their competency to fulfill the responsibilities of the role.
The table below lists the possible methods of evaluating competency mentioned in Appendix PP, F726.
| Evaluation | • Lecture with return demonstration for physical activities; • A pre- and post-test for documentation issues; • Demonstrated ability to use tools, devices, or equipment that were the subject of training and used to care for residents; • Reviewing adverse events that occurred as an indication of gaps in competency; or • Demonstrated ability to perform activities that is in the scope of practice an individual is licensed or certified to perform. |
Demonstration is clearly emphasized over testing to evaluate competency. While a quiz or test has value, the larger point of competency-based education programming is the evaluation of knowledge and skills practiced at the bedside.
Nurse leaders can make observations of the nurse aide demonstrating competency during rounds, impromptu encounters (e.g., when the nurse leader assists the nurse aide to provide incontinence care), and during scheduled periods of time, such as the window when the nurse aide’s performance evaluation is due. When it is not feasible or ideal to wait to observe a demonstration of competency during a real-time, real-life situation, the nurse leader can get creative and use role plays, case studies, and simulations. Mock codes and mock elopements are two examples of opportunities to evaluate for a demonstration of competencies related to resident safety.
Minimum of twelve hours of in-service training per year
Each nurse aide is required to complete a minimum of twelve hours of in-service training per year; however, nurse aides may require more than the twelve-hour minimum per year to ensure they are competent. One critical point the nurse leader must understand is that the year of in-service training starts with the employee’s hire date and not the calendar year. Although tracking this time can be cumbersome due to different hire dates for each nurse aide, having a methodical process in place can avert noncompliance.
To help with this process, AAPACN members can use the Nurse Aide (CNA) In-Service Training and Competency Tracker, a free member tool designed to assist the nurse leader to track training dates and the time each CNA completes, as well as the associated competencies the CNA achieves.
As the team develops its process, consider the following questions:
- How will the person responsible for tracking the CNA training time and competency know the new CNA’s hire date?
- Who will document completion of in-service training, including the time?
- Who will document the achievement of competency?
- If the person tracking and documenting in-service training and achievement of competency is different than the person providing the in-service training and evaluating competency, how will they communicate information that the other needs?
- How often and by whom will the CNA files be audited to ensure documented compliance with F947 is on target?
Training Topics: Abuse prevention and dementia
F947 specifies that training topics must include how to care for residents with cognitive impairments, dementia training, and resident abuse prevention training. To ensure nurse aides are competent in these areas, nurse leaders should understand that these areas require in-depth training over time rather than a one-time, brief in-service. In collaboration with subject matter experts, CMS developed a comprehensive training program called “CMS Hand in Hand: A Training Series for Nursing Homes,” commonly referred to as Hand in Hand. CMS states, “The mission of the Hand in Hand training is to provide nursing homes with a high-quality training program that emphasizes person-centered care in the care of persons with dementia and the prevention of abuse.” The training program includes videos and other training materials to deliver a high quality, engaging educational experience. Hand in Hand can be found on the Quality, Safety, & Education Portal, or QSEP website. Using public access, enter a search for Hand in Hand and links to the program will appear.
Summary
A well thought-out and implemented nurse aide training program is essential to maintain compliance with the regulations presented in this article. When nurse leaders utilize the resources available to them and develop their tracking process, they will not only have a robust training program, but will also be secure in the knowledge that the staff members caring for the facility’s residents are competent in what they do.
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