Nursing Assistant Training Program

PURPOSE: The Omnibus Nursing Home Act mandates in section 198.082, RSMo, that nursing assistants employed in skilled nursing and intermediate care facilities complete an approved training program. This rule gives information regarding the purpose of the training program, required objectives and curriculum content, designates what is the approved course curriculum, and indicates the training locations and testing which are required for a program to be considered approved. (1) Definitions. For the purpose of this rule, the following definitions shall apply: (A) Association—means the Missouri Health Care Association, the Missouri Association of Nursing Home Administrators, Leading Age Missouri, or Missouri Hospital Association; (B) Basic course—means the seventy-five (75) hours of instructional training, the one hundred (100) hours of supervised on-the-job training, and the final examination of the nursing assistant training course; (C) Certifying agency—means an association, Career Center school, comprehensive high school, community college, or four- (4-) year institution of higher learning approved by the department; (D) Challenge the final examination— means taking the final examination of the basic course without taking the entire basic course; (E) Department—means the Missouri Department of Health and Senior Services; (F) Hospital—means any licensed hospital as defined in section 197.020, RSMo; (G) Missouri Veterans’ Home—means any facilities established and maintained as a Missouri Veterans’ Home as defined in section 42.002, RSMo; (H) Nursing Assistant Clinical Supervisor Workshop—means the training course approved by the department and conducted by a certifying agency to prepare clinical supervisors to learn the methodology of teaching the supervised on-the-job training component of the nursing assistant training program; (I) Nursing Assistant Instructor Workshop— means a training course approved by the department and conducted by a certifying agency to prepare instructors to learn the methodology of teaching the nursing assistant training program; (J) Program—means the nursing assistant training program as required by section 198.082, RSMo; (K) Registered Nurse Instructor Trainer— means a registered nurse (RN) approved by a certifying agency to teach the Nursing Assistant Instructor Workshop and the Nursing Assistant Clinical Supervisor Workshop to prepare instructors and clinical supervisors to teach the nursing assistant training program; and (L) Training agency—means an organization approved by the department which sponsors the approved nursing assistant training program. (2) The purpose of the program shall be to prepare individuals for employment as a certified nursing assistant (CNA). The program shall be designed to teach skills in resident care which will qualify individuals to perform uncomplicated nursing procedures and to assist licensed practical nurses (LPNs) or RNs in direct resident care. (3) All aspects of the program included in this rule (that is, qualified instructor, clinical supervisor, course curriculum, training agency, certifying agency, supervised on-the-job training, testing, and student qualifications) shall be met in order for a program to be considered as approved. (4) Basic Course Requirements. The program shall consist of a basic course that includes, at a minimum, the following: (A) Seventy-five (75) hours of instructional training in the curricula identified in section (5) of this rule; (B) One hundred (100) hours of supervised on-the-job training (clinical practice) in an approved laboratory or other setting in which the student demonstrates knowledge while performing tasks on an individual under the supervision of a LPN or RN; and (C) A final examination. (5) Curricula Content. (A) Until August 31, 2021, a training agency identified in paragraphs (9)(A)1., (9)(A)2., and (9)(A)6. of this rule, shall teach the basic course and utilize either the content outlined in paragraphs (5)(A)1. and 2. or (5)(B)1. and 2. This basic course includes the following: 1. Curriculum content of the program shall include procedures and instructions on basic nursing skills in the following areas: basic hygiene techniques; bedmaking; personal care of residents; food service; charting; safety measures (including fire/safety and disaster preparedness and infection control); basic preventative and restorative care and procedures; basic observation procedures, such as weighing and measuring; communication skills; methods of handling and caring for mentally confused residents; residents’ rights; ethical and legal responsibilities; death and dying; and mental health and social needs; and 2. The course curriculum as outlined in the manual entitled The Nurse Assistant in a Long-Term Care Facility, produced by the Instructional Materials Laboratory, University of Missouri-Columbia, revised November 2001, catalogue number 50-5061S shall be considered an approved course curriculum. Other manuals and course material may be used to supplement the curriculum. Instructors shall use the companion instructor’s guide, catalogue number 50-5061-I. (B) A training agency identified in paragraphs (9)(A)3.–5. of this rule, shall teach the basic course content outlined in paragraphs (5)(B)1. and 2. by August 31, 2021, a training agency identified paragraphs (9)(A)1., (9)(A)2., and (9)(A)6. of this rule, shall transition and begin teaching the basic course content outlined in paragraphs (5)(B)1. and 2. This basic course includes the following: 1. The curriculum content shall include the required seventy-five (75) hours of instructional training and covers all of the following areas: A. Communication and interpersonal skills; B. Infection control; C. Safety/emergency procedures, including the Heimlich maneuver; D. Promoting residents’ independence; E. Respecting residents’ rights; F. Basic nursing skills including, but not limited to— (I) Taking and recording vital signs; (II) Measuring and recording height and weight; (III) Caring for the residents’ environment; (IV) Recognizing abnormal changes in body functioning and the importance of reporting such changes to a supervisor; and (V) Caring for residents when death is imminent; G. Personal care skills including, but not limited to— (I) Bathing; (II) Grooming, including mouth care; (III) Dressing; (IV) Toileting; (V) Assisting with eating and hydration; (VI) Proper feeding techniques; (VII) Skin care; and (VIII) Transfers, positioning, and turning; H. Mental health and social service needs including, but not limited to— (I) Modifying nursing assistant’s behavior in response to resident’s behavior; (II) Awareness of developmental tasks associated with the aging process; (III) How to respond to resident behavior; (IV) Allowing the residents to make personal choices, providing and reinforcing other behavior consistent with the resident’s dignity; and (V) Utilizing the resident’s family as a source of emotional support; I. Care of cognitively impaired residents including, but not limited to— (I) Techniques for addressing the unique needs and behaviors of individuals with dementia (Alzheimer’s and others); (II) Communicating with cognitively impaired residents; (III) Understanding the behavior of cognitively impaired residents; (IV) Appropriate responses to the behavior of cognitively impaired residents; and (V) Methods of reducing the effects of cognitive impairments; J. Basic restorative services including, but not limited to— (I) Training the resident in self-care according to the resident’s abilities; (II) The use of assistive devices in transferring, ambulation, eating, and dressing; (III) Maintenance of range of motion; (IV) Proper turning and positioning in bed and chair; (V) Bowel and bladder training; and (VI) Care and use of prosthetic and orthotic devices; K. Residents’ rights including, but not limited to— (I) Providing privacy and maintenance of confidentiality; (II) Promoting the residents’ right to make personal choices to accommodate their needs; (III) Giving assistance in resolving grievances and disputes; (IV) Providing needed assistance in getting to and participating in resident and family groups and other activities; (V) Maintaining care and security of residents’ personal possessions; (VI) Promoting the residents’ right to be free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate facility staff; and (VII) Avoiding the need for restraints in accordance with current professional standards; and 2. The basic course shall be taught using current published instruction material(s) that are no more than ten (10) years old. The material(s) shall include current standards of practice for nursing assistants. Other course materials that contain current standards of practice in healthcare and are no more than ten (10) years old may be used to supplement the curriculum. (6) Student Enrollment and Qualifications. (A) Any individual who is employable by an intermediate care facility (ICF) or skilled nursing facility (SNF) to be involved in direct resident care shall be eligible to enroll in a training agency’s nursing assistant training program if— 1. The individual is at least eighteen (18) years of age and employable. Employable shall mean that the individual is not listed on the department’s Employee Disqualification List (EDL) and has not been convicted or entered a plea of guilty to a misdemeanor or felony charge which includes any suspended imposition of sentence, any suspended execution of sentence or any period of probation or parole in this state or any other state which if committed in Missouri would be a class A or B felony violation of Chapters 565, 566, or 569, RSMo, or any violation of subsection 198.070.3, RSMo, or section 568.020, RSMo, unless a good cause waiver has been granted by the department; or 2. The individual is at least sixteen (16) years of age providing he or she is— A. Currently enrolled in a secondary school health services occupation program or a cooperative work education program of an area vocational technical school or comprehensive high school; B. Placed for work experience in an ICF, SNF, hospital, Missouri Veterans’ Home, or a hospital-based nursing facility or hospital-based skilled nursing facility by that program; C. Not listed on the department’s EDL and has not been convicted or entered a plea of guilty to a misdemeanor or felony charge which includes any suspended imposition of sentence, any suspended execution of sentence, or any period of probation or parole in this state or any other state which if committed in Missouri would be a class A or B felony violation of Chapters 565, 566, or 569, RSMo, or any violation of subsection 198.070.3, RSMo, or section 568.020, RSMo, unless a good cause waiver has been granted by the department; and D. Under the direct supervision of an instructor or clinical supervisor, or both, while completing the clinical portion of the course. (B) Prior to any direct contact with a resident, a student enrolled in the basic course in a Medicare or Medicaid certified facility shall complete sixteen (16) of the required seventy-five (75) hours of instructional training in communication and interpersonal skills; infection control; safety/emergency procedures, including the Heimlich maneuver; promoting residents’ independence; and respecting residents’ rights. (C) If a student drops the basic course, the student may re-enroll in a course within six (6) months and make up the course material missed without retaking the entire basic course after presenting proof of attendance and materials covered in the original class. (D) A student shall not perform any services for which the student has not been trained nor found proficient by the instructor and/or clinical supervisor. (E) A student who received instructional training from the basic course content outlined in paragraphs (5)(B)1. and 2. of this rule, shall register with the department approved third party test administrator upon successful completion of the seventy-five (75) hours of instructional training and one hundred (100) hours of supervised on-the-job training. (7) Employees of a Long-Term Care (LTC) Facility. Each CNA hired to work in an ICF or SNF after January 1, 1980, shall have successfully completed a nursing assistant training program approved by the department or shall enroll in and begin the first available approved training program which is scheduled to commence within ninety (90) days of the date of the CNAs employment and which shall be completed within four (4) months of employment. (8) Final Examination Challenge. (A) Individuals eligible to challenge the final examination, includes— 1. Individuals who were enrolled in a RN or LPN nursing education program for at least four (4) months and successfully completed a course on the fundamentals of nursing, including clinical hours within the last five (5) years; 2. Individuals currently enrolled in a RN or LPN nursing education program and who have successfully completed a course on the fundamentals of nursing, including clinical hours; 3. RN or LPN nursing licensure candidates who have failed state licensure examinations within the last five (5) years; 4. Individuals who have met the requirements of unlicensed assistive personnel contained in 19 CSR 30-20.125; 5. Individuals trained by a hospital as nursing assistants or psychiatric aides who have completed the following: A. One hundred (100) hours of supervised on-the-job training in an ICF, SNF, hospital, Missouri Veterans’ Home, or hospitalbased nursing facility or hospital-based skilled nursing facility; and B. Instruction that covers the basic course content outlined in paragraphs (5)(B)1. and 2. of this rule; 6. Any other persons whose background, education, and training in gerontology and health occupations includes components of the basic course content outlined in paragraphs (5)(B)1. and 2. may be allowed to challenge the final examination after taking those portions of the course as determined to be necessary based on evaluation of their credentials by the Section for Long-Term Care Regulation, Health Education Unit; 7. A CNA who is listed as inactive for less than five (5) years on the Missouri Certified Nurse Assistant Registry and cannot provide the required employment documentation in accordance with section (18) of this rule; and 8. Individuals who have successfully completed a nursing program outside the United States within the last five (5) years or who have obtained a nursing license outside the United States. (B) Individuals who are certified and active on another state’s nurse aide registry shall not be required to challenge the final examination. The individual shall submit, in writing to the department, a request to be added to the Missouri Certified Nurse Assistant Registry. At a minimum, the request shall include: the individual’s legal name; Social Security number; current address; telephone number; email address, if applicable; and proof of their current certified nursing assistant certificate. The department will respond in writing, either approving or denying the request to be added to the registry. (C) Individuals identified as eligible to challenge the final examination in paragraphs (8)(A)1.-7., shall submit a request in writing to the department and enclose, at a minimum, the following information: legal name; Social Security number; current address and telephone number; email address, as applicable; and transcripts. The department will respond in writing, either approving or denying the request to challenge the final examination. If approved, the department shall provide a list of individuals eligible to take the examination to the department approved third party test administrator. (D) Individuals identified in paragraph (8)(A)8., shall submit a request in writing to the department to take the final examination and enclose, at a minimum, the following information: legal name; Social Security number; current address and telephone number; email address, as applicable; a copy of the out-of-country license or certificate translated to English; a copy of the school transcript translated to English; and a copy of the out-of-country criminal background check translated to English. The department will respond in writing, either approving or denying the request to challenge the final examination. If approved, the department shall provide a list of individuals eligible to take the examination to the department approved third party test administrator. (E) Those individuals permitted to challenge shall take the final examination within one hundred twenty (120) calendar days of the department notification. Permission letters not utilized within the one hundred twenty- (120-) day period shall be considered invalid and reapplication for permission to challenge shall be made to the department. (F) If an individual fails the final examination after one (1) attempt, he or she shall successfully complete basic course in its entirety. (9) Training Agency Responsibilities. (A) The following entities are eligible to apply to the department to be an approved training agency: 1. Career Center schools and comprehensive high schools approved by the Missouri Department of Elementary and Secondary Education (DESE) that offer health service occupation programs which have a practice classroom and equipment used in delivering health care. There shall be a signed written agreement of cooperation with one (1) or more ICFs, SNFs, hospitals, Missouri Veterans’ Homes, or hospital-based nursing facilities or hospital-based skilled nursing facilities in their vicinity for the one hundred (100) hours of supervised on-the-job training component of the basic course; 2. Public community colleges, public colleges and universities, proprietary schools, or private agencies approved by the Missouri Department of Higher Education and Workforce Development (MDHEWD) or accredited by a recognized accrediting agency or association on the list published by the Secretary of the United States Department of Education, pursuant to the Higher Education Act of 1965, the Higher Education Opportunity Act 2008 (Public Law 110-315), and the Veterans’ Readjustment Assistance Act which have a practice laboratory with one (1) or more bed units and equipment used in delivering health care and have a signed written agreement of cooperation with one (1) or more ICFs, SNFs, hospitals, Missouri Veterans’ Homes, or hospital-based nursing facilities or hospital-based skilled nursing facilities in their vicinity for the one hundred (100) hours of supervised on-the-job training component of the basic course; 3. Associations as defined in section (1) of this rule. There shall be a signed written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans’ Home, or a hospital-based nursing facility or hospital-based skilled nursing facility to provide the one hundred (100) hours of supervised on-the-job training; 4. A licensed ICF, SNF, or a hospitalbased nursing facility or hospital-based skilled nursing facility. There shall be a signed written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans’ Home, or a hospital-based nursing facility or hospital-based skilled nursing facility if the one hundred (100) hours of supervised onthe-job training is not provided on-site; 5. Licensed hospitals. There shall be a signed written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans’ Home, or a hospital-based nursing facility or hospital-based skilled nursing facility if the one hundred (100) hours of supervised onthe-job training is not provided on site; or 6. Missouri Veterans’ Homes. There shall be a signed written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans’ Home, or a hospital-based nursing facility or hospital-based skilled nursing facility if the one hundred (100) hours of supervised on-the-job training is not provided on site. (B) Organizations identified in paragraphs (9)(A)1.-6. which want to be approved by the department to teach the program shall submit to the department form DHSS-DRL-2469 (08-20), Application for Approval as a Nursing Assistant Training Agency, included herein. (C) In order to be approved, the applicant shall have a designated location which contains sufficient space, equipment, and teaching aids to meet the course objectives and accommodate the maximum number of students allowed. The instructor and each student shall be provided with the required curricula content and instructional material(s) for the basic course identified in section (5) of this rule. (D) Any ICF or SNF which has received a Class I notice of noncompliance related to administration and resident care from the department in the two- (2-) year period prior to application for approval shall not be eligible for approval. If this notice is issued after approval, the approval shall be withdrawn by the department within ninety (90) calendar days and the certifying agencies shall be notified of the withdrawal of approval. Students already enrolled in the basic course may complete the course if a notice is issued after the basic course has begun. (E) An ICF or SNF whose approval has been withdrawn for a Class I notice of noncompliance related to administration and resident care may request in writing to the department for an exception to train and test nursing assistants. This written request shall include, at a minimum, the following information: 1. The training site name, and training site number, address, telephone and fax number, and email address as applicable; 2. Administrator’s name and facility operator’s name and address; 3. Sponsoring training site name, sponsoring training site number, sponsoring training site’s instructor’s name, instructor’s Social Security number, and email address as applicable; 4. The exit date of the noncompliance interview for each deficiency of a Class I in the areas of administration and resident care requirements in 19 CSR 30-85.042; reason(s) for noncompliance; explanation of efforts in locating another training agency within a reasonable distance (at least one-half (1⁄2) hour travel time each way from the facility); and 5. A student roster for each class. The student roster shall include each student’s name; student’s address and telephone number; student’s Social Security number; and the student’s email address, as applicable; class begin date; number of students completed; instructor’s name and telephone number; instructor’s license number; instructor’s Social Security number; instructor’s employer; and the instructor’s email address, as applicable. (F) The department shall make an on-site inspection of each training agency’s premises within two (2) years of approval and every two (2) years following to determine the adequacy of space; equipment and supplies; and, if clinical training is not done on-site, verify that there is a current copy of a signed written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans’ Home, or a hospital-based nursing facility or hospital-based skilled nursing facility for the clinical portion of the course. (G) Upon receipt of the completed form DHSS-DRL-2469 (08-20), Application for Approval as a Nursing Assistant Training Agency, the department shall notify the applicant in writing within ninety (90) calendar days of approval or disapproval. If disapproved, the reasons why shall be given. (H) Training agencies shall be approved for a two- (2-) year period and shall submit a new application for approval thirty (30) calendar days prior to the expiration of approval. (I) The training agency shall be responsible for obtaining an approved instructor and providing training materials for each student. If an instructor is not employed by the training agency, there shall be a signed written agreement of cooperation between the training agency and the instructor. (J) The training agency shall be responsible for obtaining an approved clinical supervisor. If a clinical supervisor is not employed by a training agency, there shall be a signed written agreement of cooperation between the training agency and the clinical supervisor. (K) If the training agency is not a licensed ICF or SNF, the agency shall have a signed written agreement of cooperation currently in effect with an ICF, SNF, hospital, Missouri Veterans’ Home, or a hospital-based nursing facility or hospital-based skilled nursing facility where the one hundred (100) hours of supervised on-the-job training shall be conducted. (L) In the event that a qualified instructor for the basic course did not sign records of a student who successfully completed the program, without justification or due to resignation from his or her position, the administrator or designee of the training agency shall validate the training by signature. (M) Evidence of successful completion of the basic course shall be documented prior to a student taking the final examination and shall include: 1. Class schedules and form MO 5802473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B, included herein for training agencies using the basic course content outlined in paragraphs (5)(A)1. and 2. of this rule; or 2. Class schedules and form DHSSDRL-111 (08-20), Classroom and On-the-Job Training Record, included herein for training agencies using the basic course content outlined in paragraphs (5)(B)1. and 2. of this rule. (N) The training agency shall ensure that all applicable portions of appropriate forms identified in paragraphs (9)(M)1. and 2. of this rule are complete and shall provide a copy to the student within seven (7) calendar days of successful completion of the seventy-five (75) hours of instructional training and one hundred (100) hours of supervised on-the-job training. (O) The training agency shall maintain records for a minimum of two (2) years for those individuals who have completed the basic course. (10) Certifying Agency Responsibilities. (A) In order for a certifying agency to be approved by the department, the agency shall have a signed written agreement of cooperation with the department which shall be renewable every five (5) years. (B) Certifying agencies that provide the Nursing Assistant Instructor Workshop and the Nursing Assistant Clinical Supervisor Workshop shall complete the following responsibilities: 1. Verify eligibility requirements for the participants enrolled in the Nursing Assistant Instructor Workshop and the Nursing Assistant Clinical Supervisor Workshop; 2. Provide qualified Registered Nurse Instructor Trainers to teach the applicable workshop(s); 3. Issue the applicable workshop certificate(s) to participants upon successful completion; and 4. Within seven (7) calendar days of issuing the workshop certificate, provide a listing of approved instructors and clinical supervisors to the department that includes: the name of workshop completed; participant’s legal name, address, and telephone number; email address, as applicable; Social Security number; and date of birth. (C) Certifying agencies that provide the four (4) hour instructor update training shall comply with the requirements in section (16) of this rule. (D) Maintain accurate and complete records for a period of at least two (2) years. (11) Instructor and Clinical Supervisor/Student Ratios. During the required one hundred (100) hours of supervised on-the-job training, the training agency’s instructor and clinical supervisor/student ratio shall be a maximum of one to fifteen (1:15). (12) Qualifications of Instructors, Clinical Supervisors, and Examiners. (A) Instructor. 1. An instructor shall be currently licensed as a RN in Missouri or shall hold a current temporary permit from the Missouri State Board of Nursing or shall hold a multistate or single state RN license from a jurisdiction that is party to the Nurse Licensure Compact. The licensee shall not be subject of current disciplinary action, such as censure, probation, suspension, or revocation. 2. An instructor shall not be listed on the department’s EDL. 3. An individual that has been previously disqualified as an instructor shall not function as an instructor unless he or she receives written approval from the department. 4. An instructor shall have had, at a minimum, two (2) years of nursing experience and at least one (1) year of experience in the provision of long-term care facility services in the last ten (10) years. Other personnel from the health professions may assist the instructor; however, they shall have at least one (1) year of experience in their field. 5. An instructor shall successfully complete a Nursing Assistant Instructor Workshop by a certifying agency using qualified instructors. The department shall issue a letter of approval to the qualified instructor after the individual has successfully completed the workshop. The department shall maintain a list of approved instructors. 6. An instructor shall be responsible to teach the seventy-five (75) hours of instructional training for the basic course and a minimum of sixteen (16) of the one hundred (100) hours of supervised on-the-job training in accordance with the requirements contained in this rule. 7. The instructor teaching the seventyfive (75) hours of instructional training and/or sixteen (16) of the one hundred (100) hours of supervised on-the-job training for the basic course shall complete and sign all applicable portions of either form MO 5802473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B for training agencies using the basic course content outlined in paragraphs (5)(A)1. and 2. or form DHSS-DRL-111 (08-20), Classroom and Onthe-Job Training Record for training agencies using the basic course content outlined in paragraphs (5)(B)1. and 2. for each student participating in the program. 8. An instructor shall provide to the student within seven (7) calendar days of successful completion of the seventy-five (75) hours of instructional training and one hundred (100) hours of supervised on-the-job training, either completed form MO 5802473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B for training agencies using the basic course content outlined in paragraphs (5)(A)1. and 2. or form DHSS-DRL-111 (08-20), Classroom and Onthe-Job Training Record for training agencies using the basic course content outlined in paragraphs (5)(B)1. and 2. 9. If the course is not completed, records and documentation regarding the completed portions shall be provided by the instructor to the student, if requested, and to the training agency. (B) Clinical Supervisor (On-the-Job Supervisor). 1. The clinical supervisor shall be currently licensed as a RN or LPN in Missouri or hold a current temporary permit from the Missouri Board of Nursing or shall hold a multi-state or single state RN or LPN license from a jurisdiction that is party to the Nurse Licensure Compact. The licensee shall not be subject of current disciplinary action such as censure, probation, suspension, or revocation. 2. A clinical supervisor shall not be listed on the department’s EDL. 3. An individual that has been previously disqualified as a clinical supervisor shall not function as a clinical supervisor unless he or she receives written approval from the department. 4. The clinical supervisor, if not currently employed by an ICF, SNF, hospital, or Missouri Veterans’ Home, shall have at least one (1) year of licensed nursing experience. The clinical supervisor shall be currently employed by the approved training agency facility where the students are performing their duties or by the training agency conducting the program. 5. A clinical supervisor shall successfully complete a Nursing Assistant Clinical Supervisor Workshop by a certifying agency using qualified instructors. The department shall issue a letter of approval to the qualified clinical supervisor after the individual has successfully completed the workshop. The department shall maintain a list of approved clinical supervisors. 6. The clinical supervisor shall be on the facility premises in which the students are performing their duties while the students are completing the on-the-job component of their training and shall directly assist the students in their training and observe their skills when checking their competencies. 7. A clinical supervisor shall be responsible to supervise eighty-four (84) of the one hundred (100) hours of supervised on-the-job training in accordance with the requirements contained in this rule. 8. The clinical supervisor(s) shall complete and sign all applicable portions of form MO 580-2473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B for training agencies using the basic course content outlined in paragraphs (5)(A)1. and 2. or form DHSS-DRL-111 (08-20), Classroom and On-the-Job Training Record for training agencies using the basic course content outlined in paragraphs (5)(B)1. and 2. for each student participating in the program. (C) Examiner. 1. An examiner using the department’s testing materials for the basic course content outlined in paragraphs (5)(A)1. and 2. of this rule shall be— A. A RN currently licensed in Missouri or shall hold a current temporary permit from the Missouri State Board of Nursing, or shall hold a multi-state or single state RN license from a jurisdiction that is party to the Nurse Licensure Compact and shall not be currently subject of disciplinary action such as censure, probation, suspension, or revocation. B. The examiner shall have taught a similar course or shall be qualified to teach a similar course; but shall not have been the instructor of the students being examined; and shall not be employed by the operator whose students are being examined. The examiner shall be specifically approved by the department to administer final examinations of the state-approved nurse assistant training curriculum and shall have signed an agreement with the department to protect and keep secure the final examinations. 2. Causes for Disqualification. A person shall not be allowed to be an examiner if it is found that he or she— A. Knowingly acted or omitted any duty in a manner which would materially or adversely affect the health, safety, welfare, or property of a resident; B. Defrauded a training agency or student by taking payment and not completing a course, not administering the final examination as required, or not being on-site while students are being trained; C. Failed to teach, examine, or clinically supervise in accordance with 19 CSR 30-84.010, or taught students from the state test, changed answers on the state test, lost test booklets, or recorded false information on test materials or test booklets of the program; or D. Failed to send documentation of a completed course to a certifying agency within thirty (30) days. 3. Notification of Disqualification. A. The department shall notify the individual that he or she is no longer eligible to be an examiner. B. The department shall notify all approved training and certifying agencies if it has been determined that an individual is no longer considered an approved examiner and that person’s name shall be removed from the lists maintained by the department of approved examiners. C. To be reinstated as a stateapproved examiner the individual shall submit a request in writing to the department stating the reasons why reinstatement is warranted. The department shall respond in writing to the request. (13) Instructor and Clinical Supervisor Disqualification Criteria. (A) Causes for Disqualification. The department may disqualify an individual as an instructor or clinical supervisor if it is found the individual failed to follow the requirements in section (12) of this rule or— 1. Knowingly acted or omitted any duty in a manner which would materially or adversely affect the health, safety, welfare, or property of a resident; 2. Defrauded a training agency or student by taking payment and not completing a course or not being on-site while students are being trained; 3. Failed to teach or clinically supervise in accordance with the regulations contained in this rule, or provide false information to the department; or 4. Is disqualified as a RN Test Observer by the department approved third party test administrator. (B) Notification of Disqualification. 1. The department shall notify the individual that he or she is no longer eligible to be an instructor or clinical supervisor. 2. The department shall notify all certifying agencies if it has been determined that an individual is no longer considered an approved instructor or clinical supervisor and that person’s name shall be removed from the lists maintained by the department of approved instructors or clinical supervisors. 3. To be reinstated as an approved instructor or clinical supervisor, the individual shall submit a request in writing to the department stating the reasons why reinstatement is warranted. The department shall respond in writing to the request. (14) Training and Certifying Agency Disqualification Criteria. (A) Causes for Disqualification. The department may disqualify a training agency or certifying agency if it is found that an agency failed to follow the requirements in section (9) for a training agency or section (10) for a certifying agency of this rule or— 1. Defrauded a student by taking payment and not ensuring the seventy five (75) hours instructional training or on-the-job training were completed as required by this rule; or 2. Failed to maintain approval from MDHEWD or DESE, if applicable. (B) Notification of Disqualification. 1. The department shall notify the agency that he or she is no longer eligible to be a training agency or certifying agency. 2. To be reinstated as a training agency or certifying agency, the agency shall submit a request in writing to the department stating the reasons why reinstatement is warranted. The department shall respond in writing to the request. (15) Registered Nurse Instructor Trainer Responsibilities. (A) The RN Instructor Trainer shall be currently licensed as a RN in Missouri or shall hold a current temporary permit from the Missouri State Board of Nursing or shall hold a multi-state or single state RN license from a jurisdiction that is party to the Nurse Licensure Compact. The RN Instructor Trainer shall not be subject of current disciplinary action, such as censure, probation, suspension, or revocation and shall not be listed on the department’s EDL. (B) The RN Instructor Trainer shall also be, at a minimum, an approved nursing assistant instructor. (C) The RN Instructor Trainer shall be employed or contracted by a certifying agency to instruct the Nursing Assistant Instructor Workshop, Nursing Assistant Clinical Supervisor Workshop, and the Instructor Update Training. (16) Instructor Update Training. (A) The instructor shall attend a four (4) hour update training provided by a certifying agency every five (5) years. This update training shall include, at a minimum, the following: 1. Instruction on how to complete form DHSS-DRL-111 (08-20), Classroom and Onthe-Job Training Record; 2. Instruction on the fundamentals of adult learning; 3. Instruction in at least one (1) area regarding standards of practice in long term care such as pressure ulcer prevention, dining practices, or resident rights issues; 4. Instruction on providing care for cognitively impaired residents; 5. Review of the Nursing Assistant Training Program regulations contained in 19 CSR 30-84.010; and 6. Review of the administration and resident care requirements contained in 19 CSR 30-85.042. (B) The certifying agency shall provide a list of the instructors that complete the update training to the department within seven (7) calendar days of completion of the training. (C) Any instructor who has not completed the required four (4) hour update training by August 31, 2022, and every five (5) years thereafter shall be removed from the department-approved list of instructors. If removed from the department’s list, the instructor shall attend and successfully complete the Nursing Assistant Instructor Workshop in order to be reinstated to act as an instructor. (17) Final Examination Testing. (A) In order to be eligible for testing, a student shall have either completed the following: 1. Seventy-five (75) hours of instructional training and the one hundred (100) hours of supervised on-the-job training offered by a training agency. The student shall pass a minimum of three (3) written or oral tests throughout the course with an eighty percent (80%) score or better on each test in order to be eligible to take the final examination. Each test shall consist of a minimum of fifteen (15) questions; or 2. Possess an approval letter from the department granting approval to challenge the final examination. (B) If the course content outlined in paragraphs (5)(A)1. and 2. of this rule is used for teaching the basic course, the final examination shall be conducted by an approved examiner who may be assisted by the instructor using the following procedures: 1. The instructor will select an LTC resident to participate in the testing process and obtain approval for this activity from the resident; 2. The examiner shall verify the eligibility of the students by reviewing form MO 580-2473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B to establish that the student has completed the approved training program or possesses an approval letter from the department granting approval to challenge the final examination; 3. The student shall successfully complete at least nine (9) procedures under the observation of the instructor or a facility licensed nurse and examiner. A. The nine (9) procedures shall always include a type of bath, vital signs (temperature, pulse, respirations, and blood pressure), transfer techniques, feeding techniques, dressing and grooming, skin care, active or passive, range of motion to upper and lower extremities (unless contraindicated by a physician’s order), and handwashing and gloving from the standardized curriculum. B. The remainder shall be selected according to the resident’s care needs at the time of day that testing occurs. C. The evaluation of the student shall include communication and interaction with the resident, provision of privacy, work habits, appearance, conduct, and reporting and recording skills; 4. The student shall successfully answer forty (40) out of fifty (50) oral or written questions presented by the examiner based on the standardized curriculum and selected from a specific test pool of questions which are safeguarded by the department; 5. The examiner who uses the basic course content outlined in paragraphs (5)(A)1. and 2. of the basic course for the final examination shall notify the department and obtain different examinations to be administered each time; and 6. The examiner who uses the basic course content outlined in paragraphs (5)(A)1. and 2. of the basic course for the final examination shall conduct the following: A. Complete and sign form MO 5802473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B and the final examination score sheet which shall include scores and comments. The examiner shall advise the individual that successful completion of the evaluation will result in the addition of his/her name to the CNA Registry; B. After scoring, the examiner shall return all test materials, test booklets, answer sheets, and any appendices to the department. The examiner shall also provide the training agency with documentation of the student’s test scores; and C. A copy of the student’s final record sheets shall be provided to the student (except for the answer sheets). If the course is not completed, records and documentation regarding the portions completed shall be provided to the student, if requested, and to the training agency. (C) If the basic course content outlined in paragraphs (5)(B)1. and 2. of this rule, is used to teach the course, testing shall comply with the following: 1. The instructor shall verify the eligibility of the students by reviewing form DHSS-DRL-111 (08-20), Classroom and Onthe-Job Training Record, to establish that the student has completed the approved program; 2. The final examination shall be conducted by the department approved third party test administrator and a fee will be assessed for each examination; 3. The student shall successfully complete an examination proctored by the department approved third party test administrator. The student shall achieve a passing score of at least eighty percent (80%); and 4. The student shall successfully complete the skills evaluation portion of the examination proctored by the department approved third party test administrator. The student shall achieve a score of one hundred percent (100%). (D) Any individual who fails the final examination, except those who have been permitted to challenge the examination, shall have the opportunity to retake the examination twice within ninety (90) calendar days of the initial examination. If the individual fails the final examination a third time, the entire basic course shall be retaken before another examination can be given. (E) Any individual who is employed by a LTC facility and required by section 198.082, RSMo, to enroll in the program, but who has been permitted to challenge the final examination and who fails the examination, must immediately re-enroll in and begin study in the next available basic course. The individual shall complete the basic course within four (4) months of employment. (18) CNA Registry. (A) If the CNA passes the final examination, the individual’s name shall be placed on the CNA active registry. (B) CNAs shall submit documentation (e.g., pay stubs, W-2, letter from employer, etc.) of work in nursing or nursing related services for at least one (1) day (e.g. eight (8) hours) within each twenty-four- (24-) consecutive month period to maintain active status. Documentation shall be submitted to the department approved third party test administrator and a fee will be assessed for each renewal. (C) A CNA who has been inactive on the registry for less than five (5) years and cannot provide documentation (e.g., pay stubs, W-2, letter from employer, etc.) of work in nursing or nursing related services for at least one (1) day (e.g. eight (8) hours) within each twentyfour- (24-) consecutive month period shall challenge the final examination in accordance with section (8) of this rule before the CNA is reinstated to the active registry. (D) A CNA who has been inactive on the registry for more than five (5) years and cannot provide documentation (e.g., pay stubs, W-2, letter from employer, etc.) of work in nursing or nursing related services for at least one (1) day (e.g. eight (8) hours) within each twenty-four- (24-) consecutive month period is not eligible to challenge the final examination and shall successfully complete the entire basic course before the CNA is reinstated to the active registry. 1ST INSTRUCTOR SIGNATURE LICENSE NO. PRINTED LAST NAME 2ND INSTRUCTOR SIGNATURE LICENSE NO. PRINTED LAST NAME ADMINISTRATOR/DON SIGNATURE - 75 HOURS LICENSE NO. PRINTED LAST NAME CHARGE NURSE SIGNATURE - FACILITY VERIFICATION 84 HRS OJT COMPLETED LICENSE NO. PRINTED LAST NAME CHARGE NURSE SIGNATURE - FACILITY VERIFICATION 16 HRS COMPETENCY EVALUATION LICENSE NO. PRINTED LAST NAME CLINICAL SUPERVISOR - 84 HRS OJT LICENSE NO. PRINT LAST NAME CLINICAL SUPERVISOR - 84 HRS OJT LICENSE NO. PRINT LAST NAME CLINICAL SUPERVISOR - 16 HRS OJT LICENSE NO. PRINT LAST NAME CLINICAL SUPERVISOR - 16 HRS OJT LICENSE NO. PRINT LAST NAME 1ST EXAMINER SIGNATURE LICENSE NO. PRINT LAST NAME 2ND EXAMINER SIGNATURE LICENSE NO. PRINT LAST NAME STUDENT NAME (PLEASE PRINT) (LAST) (FIRST) (MIDDLE) (MAIDEN) SOCIAL SECURITY NO. HOME PHONE NO. PERMANENT ADDRESS (STREET) (CITY) (STATE) (ZIP) DATE OF BIRTH WORK PHONE NO. SITE NAME - 75 HRS CLASSROOM SITE NO. BEGIN DATE COMPLETE DATE ATTENDANCE MAKE-UP SITE NAME - 84 HRS/100 HRS* 84 100 SITE NO. BEGIN DATE COMPLETE DATE - 84 HRS/100 HRS SITE NAME - 16 HRS COMPETENCIES SITE NO. BEGIN DATE COMPLETE DATE 16 HRS. SITE NAME - WRITTEN/ORAL FINAL EXAM SITE NO. 1ST ATTEMPT BOOKLET NO. EXAM DATE WRITTEN ORAL SCORE SITE NAME - WRITTEN/ORAL FINAL EXAM SITE NO. 2ND ATTEMPT BOOKLET NO. EXAM DATE WRITTEN ORAL SCORE SITE NAME - WRITTEN/ORAL FINAL EXAM SITE NO. 3RD ATTEMPT BOOKLET NO. EXAM DATE WRITTEN ORAL SCORE SITE NAME - PRACTICUM EXAM SITE NO. 1ST ATTEMPT EXAM DATE SCORE SITE NAME - PRACTICUM EXAM SITE NO. 2ND ATTEMPT EXAM DATE SCORE SITE NAME - PRACTICUM EXAM SITE NO. 3RD ATTEMPT EXAM DATE SCORE MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES CERTIFIED NURSE ASSISTANT COMPETENCY SCORE SHEET (FOR USE ONLY WITH 2001 MANUAL) APPENDIX A MO 580-2473 (12-07) CLASS TEST SCORES 1. 2. 3. EACH SCORE MUST BE AT LEAST 80% (MUST BE COMPLETED BY INSTRUCTOR PRIOR TO EXAM) APPROVED FOR CERTIFICATION NOT APPROVED FOR CERTIFICATION Evaluation of procedures includes: knowledge, safety, encouraged self-help, work habits, student-resident interaction, organization, resident’s rights. Other procedures may be determined by resident’s needs. All procedures must be evaluated. Examiner advised individual that successful completion of the evaluation will result in the addition of his/her name to the state nursing assistant register. If you have been determined to have committed abuse, neglect or misappropriation of goods in a certified facility, a permanent federal marker will be placed against your name on the CNA register. You will NEVER AGAIN be allowed to work in a certified facility. STUDENT MUST INITIAL. PRACTICUM EXAM PROCEDURES 1. BATH 4. FEEDING TECHNIQUES 7. HANDWASHING 2. VITAL SIGNS 5. DRESSING AND GROOMING 8. GLOVING 3. TRANSFER TECHNIQUES 6. SKIN CARE 9. ACTIVE OR PASSIVE FOM TO  AND  EXTERMITIES PASS/FAIL PRACTICUM EXAM PROCEDURES PASS/FAIL PRACTICUM EXAM PROCEDURES PASS/FAIL 33. Assist resident to undress 34. Apply and remove elastic stockings 35. Give complete bed bath 36. Give tub bath 37. Give shower bath 38. Make an unoccupied bed 39. Make an occupied bed 40. Give back rub 41. Give stage 1 pressure ulcer care 42. Give peri care with catheter 43. Change a drainage bag 44. Empty a urinary drainage bag 45. Assist resident in using urinal 46. Assist resident in using bedpan 47. Give care of an uncomplicated established colostomy 48. Move resident to head of bed (two-person assist) 49. Turn resident to one side (3⁄4 turn) 50. Demonstrate one-person pivot transfer from bed to chair 51. Demonstrate one-person pivot transfer from chair to bed 52. Demonstrate two-person pivot transfer from chair to bed (resident able to assist) 53. Demonstrate two-person transfer with a mechanical lift to chair 54. Ambulate resident using a gait belt 55. Ambulate resident using a walker 56. Ambulate resident using a cane 57. Give range of motion exercises to neck and shoulders 58. Give range of motion exercises to elbow 59. Give range of motion exercises to wrist and fingers 60. Give range of motion exercises to hip and knee 61. Give range of motion exercises to ankle and toes 62. Measure weight of resident 63. Measure height of resident 64. Give post-mortem care APPENDIX A-B – INSTRUCTIONS: 1st. Column: List date of classroom instruction - 75 hours. 2nd Column: Classroom instructor initials. 3rd Column: Date the competency evaluation (16 hrs - #1-#64 below) was completed in state approved training agency. 4th Column: Simulation must be done in white area and only if care issue NOT AVAILABLE in state approved training agency. 5th Column: Clinical Supervisor/Instructor must SIGN CORRESPONDING PINK SHEET THEN initial that the Nurse Assistant is competent in this skill and that the competency evaluation was completed on a ONE TO ONE RATIO IN A STATE APPROVED TRAINING AGENCY. COMPETENCY COMPETENCY DATE OF CLASSROOM INSTRUCTION INSTRUCTOR INITIALS DATE COMPETENCY ACHIEVED SIMULATION COMPETENCY EVALUATION CS/INSTRUCTOR INITIALS DATE OF CLASSROOM INSTRUCTION INSTRUCTOR INITIALS DATE COMPETENCY ACHIEVED SIMULATION COMPETENCY EVALUATION CS/INSTRUCTOR INITIALS 1. Take oral temperature 2. Take rectal temperature 3. Take axillary temperature 4. Count radial pulse 5. Count apical pulse 6. Count respirations 7. Measure blood pressure 8. Wash hands 9. Put on and remove daily care non-sterile gloves 10. Put on and remove mask 11. Put on and remove non-sterile gown 12. Feed helpless resident 13. Serve a food tray 14. Clear airway obstruction in conscious resident 15. Clear airway obstruction in unconscious resident 16. Thicken liquids 17. Distribute drinking water 18. Measure fluid intake 19. Measure fluid output 20. Shave with disposable razor 21. Shave with electric razor 22. Assist with oral hygiene 23. Administer oral hygiene to resident who is helpless/unconscious 24. Provide denture care 25. Give fingernail care 26. Give toenail care 27. Comb/brush hair 28. Give shampoo during tub bath/shower bath 29. Give bed shampoo 30. Give perineal care to male resident 31. Give perineal care to female resident 32. Assist resident to dress MO 580-2473 (12-07) PERSONAL COMPETENCY EVALUATION (PASSING SCORE REQUIRED ON ALL ITEMS PRIOR TO BEING ALLOWED TO TAKE FINAL EXAM) 65. Wears clean uniform, wears name tag and is free of body odor 66. Observes resident rights 67. Reports to work on time 68. Uses facility’s procedure for absenteeism 69. Completes assignments 70. Communicates well with others, is courteous 71. Incorporates acceptable techniques when caring for the confused resident, the mentally ill resident or the resident with unconventional behaviors. RATER NAME LICENSE NO. COMP. 72. Utilizes plan of care to meet resident’s needs 73. Maintains a safe environment for resident/self 74. Uses appropriate body mechanics 75. Reports & records pertinent information to appropriate personnel 76. Shows enthusiasm for learning 77. Applies critical thinking during class and clinical work. 78. Shows care and empathy while providing care. RATER NAME LICENSE NO. COMP. COMMENTS APPENDIX B STUDENT NAME - PLEASE PRINT (LAST) (FIRST) (MIDDLE) (MAIDEN) SOCIAL SECURITY NO. MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES DIVISION OF REGULATION AND LICENSURE SECTION FOR LONG-TERM CARE REGULATION CLASSROOM AND ON-THE-JOB TRAINING RECORD MO 580-3355 (9-2021) PAGE 1 OF 3 DHSS-DRL-111 (08-20) (12) 1ST INSTRUCTOR SIGNATURE - INSTRUCTIONAL HRS (12A) LICENSE NO. (12B) LAST NAME (13) 2ND INSTRUCTOR SIGNATURE - INSTRUCTIONAL HRS (13A) LICENSE NO. (13B) LAST NAME (14) ADMINISTRATOR/DIRECTOR OF NURSING (DON)/CEO SIGNATURE (14A) LICENSE NO. (14B) LAST NAME (15) CHARGE NURSE SIGNATURE - FACILITY VERIFICATION 84 HRS OJT COMPLETED (15A) LICENSE NO. (15B) LAST NAME (16) CHARGE NURSE SIGNATURE - FACILITY VERIFICATION 16 HRS OR 100 HRS OJT COMPLETED (16A) LICENSE NO. (16B) LAST NAME (17) 1ST INSTRUCTOR SIGNATURE - 16 HRS OJT (17A) LICENSE NO. (17B) LAST NAME (18) 2ND INSTRUCTOR SIGNATURE - 16 HRS OJT (18A) LICENSE NO. (18B) LAST NAME (19) CLINICAL SUPERVISOR SIGNATURE - 84 HRS OJT (19A) LICENSE NO. (19A) LAST NAME (20) CLINICAL SUPERVISOR SIGNATURE - 84 HRS OJT (20A) LICENSE NO. (20B) LAST NAME (1) STUDENT NAME (LAST, FIRST, MIDDLE) (2) FORMER NAMES USED (3) SOCIAL SECURITY NO. (4) STUDENT E-MAIL (5) STUDENT PERMANENT ADDRESS (STREET, CITY, STATE, ZIP) (6) DATE OF BIRTH (7) STUDENT PHONE NO. (8) APPROVED SITE NAME - 75 HRS INSTRUCTIONAL TRAINING (8A) SITE NO. (8B) BEGIN DATE (8C) COMPLETION DATE (8D) COMPLETED INSTRUCTIONAL TRAINING (9) APPROVED SITE NAME - 16 HRS OR 100 HRS ON-THE-JOB-TRAINING (OJT) (9A) SITE NO. (9B) BEGIN DATE (9C) COMPLETION DATE (9D) COMPLETED OJT HRS (10) APPROVED SITE NAME - 84 HRS OJT (10A) SITE NO. (10B) BEGIN DATE (10C) COMPLETION DATE 84 OJT HOURS (11) CLASS TEST SCORES 1. 2. 3. Each test score must be at least 80% (must be completed prior to final exam) (11A) APPROVED FOR FINAL EXAM (11B) NOT APPROVED FOR FINAL EXAM 35. Give complete bed bath 36. Give tub bath 37. Give shower bath 38. Make an unoccupied bed 39. Make an occupied bed 40. Give back rub 41. Give stage 1 pressure ulcer care & discuss prevention 42. Discuss pressure relieving devices 43. Reposition for pressure relief in bed 44. Reposition for pressure relief in chair 6XVSHQGUHVLGHQW·VKHHOV 46. Give perineal care with catheter 47. Change a drainage bag 48. Empty a urinary drainage bag 49. Assist resident in using urinal 50. Assist resident in using bedpan 51. Care of an uncomplicated established colostomy 52. Turn resident to one side (31⁄44 turn) 53. Move resident to head of bed (two-person assist) 54. Demonstrate one-person pivot transfer from bed to chair 55. Demonstrate one-person pivot transfer from chair to bed 56. Demonstrate two-person pivot transfer from chair to bed (resident can assist) 57. Demonstrate two-person transfer with a mechanical lift to chair 58. Ambulate resident using a gait belt 59. Ambulate resident using a walker 60. Ambulate resident using a cane 61. Range of Motion (ROM) exercises neck and shoulders 62. ROM exercises elbow 63. ROM exercises wrist/fingers 64. ROM exercises hip/knee 65. ROM exercises ankle/toes 66. Measure weight of resident 67. Measure height of resident 68. Give post-mortem care PG 2 – INSTRUCTIONS: 1st. Column: List date of 75 hours instructional training. 2nd Column: Classroom instructor initials. 3rd Column: Date the OJT evaluation was completed in state approved training agency. 4th Column: Simulation may be done only if care issue is not available in state approved training agency. 5th Column: Clinical Supervisor/Instructor must initial the student is competent in this skill and the competency evaluation was completed on a one to one ratio in a state approved training agency. NOTE: An instructor must provide at least 16 hours of the 100 hours OJT. SKILLS SKILLS DATE OF CLASSROOM INSTRUCTION DATE OF CLASSROOM INSTRUCTION INSTRUCTOR INITIALS INSTRUCTOR INITIALS DATE OJT ACHIEVED DATE OJT ACHIEVED SIMULATION SIMULATION OJT EVALUATION CS / INSTRUCTOR INITIALS OJT EVALUATION CS / INSTRUCTOR INITIALS 1. Take oral temperature 2. Take axillary temperature 3. Count radial pulse 4. Count apical pulse 5. Count respirations 6. Measure blood pressure 7. Wash hands 8. Put on/remove daily care non-sterile gloves 9. Put on/remove mask 10. Put on/remove non-sterile gown 11. Feed a resident that requires total assistance 12. Serve a food tray 13. Clear airway obstruction in conscious resident 14. Clear airway obstruction in unconscious resident 15. Thicken liquids 16. Distribute drinking water 17. Measure fluid intake 18. Measure fluid output 19. Shave with disposable razor 20. Shave with electric razor 21. Assist with oral hygiene 22. Administer oral hygiene to resident that requires assistance 23. Denture care 24. Fingernail care 25. Toenail care 26. Comb/brush hair 27. Shampoo tub bath/shower bath 28. Bed shampoo 29. Perineal care to male resident 30. Perineal care to female resident 31. Assist resident to dress 32. Changing a brief 33. Assist resident to undress 34. Apply and remove therapeutic stockings COMMENTS STUDENT NAME - (LAST, FIRST, MIDDLE) SOCIAL SECURITY NO. MO 580-3355 (9-2021) PAGE 2 OF 3 DHSS-DRL-111 (08-20) MO 580-3355 (9-2021) PAGE 3 OF 3 DHSS-DRL-111 (08-20) GUIDE TO CLASSROOM AND ON-THE-JOB TRAINING RECORD Guide for page 1 8. Name of approved training agency site where 75 hours of instructional training was conducted. 8A. Site number of training agency where instructional training was conducted. 8B. Beginning date of instructional training (this date must pre-date any on the job training). 8C. Date instructional training was completed. 8D. Number of instructional training hours completed. 9. Name of approved long-term care (LTC) facility where student completed 16 or 100 hours of OJT. Note: If all 100 hours of OJT were completed in an approved LTC facility, boxes 10 through 10C may be left blank. 9A. Site number of approved LTC facility where student completed 16 or 100 hours of OJT. 9B. Date student began 16 or 100 hours of OJT in an approved LTC facility. 9C. Date student completed 16 or 100 hours of OJT in an approved LTC facility. 9D. Number of hours of the 16 or 100 hours of OJT the student completed. 10. Name of the approved LTC facility where student completed 84 hours of OJT. Note: An approved LTC facility that has been denied the ability to provide 100 hours of OJT due to enforcement issues may be able to provide only 84 hours of OJT. The other 16 hours of OJT must be completed in an approved/eligible facility. 10A. Site number of approved LTC facility where 84 hours of OJT was completed. 10B. Date 84 hours of OJT began. 10C. Date student completed 84 hours of OJT. 11. During the course of 175 hours of training, the student must take and pass at least WKUHHVDPSOHWHVWVZLWKDVFRUHRIDWOHDVWSULRUWRVLWWLQJIRUWKHÀQDOH[DP7KRVHWHVW scores shall be documented by the instructor at (11) 1., (11) 2., and (11) 3. 11A.\11B. Instructor checks applicable box if student has successfully met all required FULWHULDWRVLWIRUÀQDOH[DPRUIDLOHGWRVXFFHVVIXOO\FRPSOHWHDOOUHTXLUHGWRVLWIRUÀQDO exam. 12. 7KHVLJQDWXUHRIWKHÀUVWFODVVURRPLQVWUXFWRUVKDOOHQVXUHWKDWDOOWUDLQLQJUHTXLUHPHQWV are met according to 19 CSR 30-84.010 and that all portions of form DHSS-DRL-2473 is FRPSOHWH6LJQLQJLQGLFDWHVDOOWUDLQLQJZLWKWKHH[FHSWLRQRIWKHÀQDOH[DPKDVEHHQ completed. 12A.)LUVWLQVWUXFWRU·VQXUVHOLFHQVHQXPEHU 12B.)LUVWLQVWUXFWRU·VODVWQDPH 13. If applicable, signature of the second instructor who assisted with the instructional training, indicating he/she provided instructional training to the student. 13A.,IDSSOLFDEOHVHFRQGLQVWUXFWRU·VQXUVHOLFHQVHQXPEHU 13B.,IDSSOLFDEOHVHFRQGLQVWUXFWRU·VODVWQDPH 14. Signature of the Administrator, DON, or CEO of the approved LTC facility where 16 hours of OJT occurred. This signature is to acknowledge the CNA training occurred in the facility named in box #9. 14A.$GPLQLVWUDWRU'21RU&(2·VOLFHQVHQXPEHU 14B.$GPLQLVWUDWRU'21RU&(2·VODVWQDPH 15. Signature of charge nurse verifying the student was present in the LTC facility for 16 or 100 hours of OJT. 15A.&KDUJHQXUVH·VQXUVHOLFHQVHQXPEHU 15B. &KDUJHQXUVH·VODVWQDPH 16.&KDUJHQXUVH·VVLJQDWXUHYHULI\LQJWKDWWKHVWXGHQWZDVSUHVHQWLQWKHIDFLOLW\IRU hours of OJT (may be left blank if charge nurse signed for all 100 hours at #15.) 16A.&KDUJHQXUVH·VQXUVHOLFHQVHQXPEHU 16B.&KDUJHQXUVH·VODVWQDPH 17.6LJQDWXUHRIÀUVWLQVWUXFWRUZKRSURYLGHGDWOHDVWKRXUVRIKRXUV2-7LQDQ approved LTC facility. (These 16 hours of training may be shared between one or more instructors.) 17A.,QVWUXFWRU·VQXUVHOLFHQVHQXPEHU 17B. ,QVWUXFWRU·VODVWQDPH 18. If applicable, signature of second instructor who provided any portion of the 16 hours of 100 hours of OJT for the student in an approved LTC facility. 18A.,IDSSOLFDEOHWKHVHFRQGLQVWUXFWRU·VQXUVHOLFHQVHQXPEHU 18B.,IDSSOLFDEOHWKHVHFRQGLQVWUXFWRU·VODVWQDPH 19. Signature of clinical supervisor who supervised 84 hours of the OJT. 19A.&OLQLFDOVXSHUYLVRU·VQXUVHOLFHQVHQXPEHU 19B.&OLQLFDOVXSHUYLVRU·VODVWQDPH 20. If applicable, the signature of the second clinical supervisor who supervised any portion of 84 hours of OJT. 20A.,IDSSOLFDEOHWKHVHFRQGFOLQLFDOVXSHUYLVRU·VQXUVHOLFHQVHQXPEHU 20B.,IDSSOLFDEOHWKHVHFRQGFOLQLFDOVXSHUYLVRU·VODVWQDPH Guide for Page 2 $OOER[HVRQSDJHPXVWEHFRPSOHWHGSULRUWRWKHÀQDOH[DPZLWKWKHH[FHSWLRQRIWKH FRPPHQWVER[ZKLFKPD\EHÀOOHGRXWDVDSSURSULDWHWRWKHVWXGHQW All clinical supervisors and instructors who provided training and/or supervision must sign this form. If extra space is needed, signatures may be included in the comment section at the bottom of page 2. If the 75 hours of instructional training or 100 hours on-the-job hours are conducted at a different location other than at the above address - a current signed agreement shall be on file at the facility/agency. Provide the name, CNA training site number and address of the facility/ agency below: MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES DIVISION OF REGULATION AND LICENSURE SECTION FOR LONG-TERM CARE REGULATION APPLICATION FOR APPROVAL AS A NURSING ASSISTANT TRAINING AGENCY MO 580-2469 (5-2021) DHSS-DRL-2469 (8-20) DATE SUBMITTED FACILITY/SCHOOL NAME TRAINING AGENCY NO. LIST PREVIOUS FACILITY/SCHOOL NAMES PHYSICAL ADDRESS (STREET, CITY, STATE, ZIP CODE) TELEPHONE MAILING ADDRESS (STREET, CITY, STATE, ZIP CODE) FAX NUMBER ADMINISTRATOR/DIRECTOR DHSS APPROVED INSTRUCTOR(S) NAME LICENSE NUMBER TRAINING AGENCY/FACILITY CONTACT EMAIL ADDRESS PLEASE CHECK THE FOLLOWING IF APPLICABLE: DHSS LICENSED FACILITY (ICF/SNF) NON-FACILITY BASED HOSPITAL-BASED NF OR SNF * CAREER CENTER SCHOOL (PUBLIC) * CAREER CENTER SCHOOL (PRIVATE) HOSPITAL * COMPREHENSIVE HIGH SCHOOL MO VETERANS HOME * COMMUNITY OR 4-YEAR COLLEGE ASSOCIATION * PRIVATE AGENCY *Must be approved by Department of Secondary Education or Department of Higher Education NAME(S) AND NURSE LICENSE NUMBER(S) OF DHSS APPROVED CLINICAL SUPERVISOR(S) COMMENTS: ADMINISTRATOR/DIRECTOR SIGNATURE DATE The completed application form may be submitted by mail, fax to: 573-526-7656, or e-mail: cnaregistry@health.mo.gov. Mailing address: Missouri Department of Health and Senior Services, Section for Long-Term Care Regulation, Attn: Health Education Unit, PO Box 570, Jefferson City, MO 65102-0570 NEW APPLICATION RENEWAL APPLICATION REVISED APPLICATION AGENCY/FACILITY NAME CNA SITE NO. ADDRESS (STREET, CITY, STATE, ZIP CODE) DHSS APPROVED CERTIFYING AGENCY NAME What portions of the course will be conducted at the above address: 75 instructional training hours 100 On-The-Job Hrs What portions of the course will not be conducted at the above address: 75 instructional training hours 100 On-The-Job Hrs AUTHORITY: sections 198.009 and 198.079, RSMo 2016, and section 198.082, RSMo Supp. 2021.* This rule originally filed as 13 CSR 15-13.010. Original rule filed Aug. 13, 1982, effective Jan. 13, 1983. Amended: Filed March 10, 1983, effective June 11, 1983. Amended: Filed Sept. 12, 1984, effective Dec. 11, 1984. Amended: Filed Oct. 13, 1987, effective Jan. 29, 1988. Emergency amendment filed Dec. 16, 1988, effective Jan. 1, 1989, expired April 5, 1989. Amended: Filed Jan. 19, 1989, effective April 27, 1989. Amended: Filed June 16, 1992, effective Feb. 26, 1993. Amended: Filed May 26, 1998, effective Jan. 30, 1999. Moved to 19 CSR 30-84.010, effective Aug. 28, 2001. ** Emergency amendment filed June 14, 2021, effective June 28, 2021, expired Dec. 24, 2021. Amended: Filed June 14, 2021, effective Dec. 30, 2021. *Original authority: 198.009, RSMo 2016; 198.079, RSMo 1979; and 198.082, RSMo 1979, amended 1988. **Pursuant to Executive Order 21-07, 19 CSR 30-84.010, section (4), subsections (7)(C) and (7)(D), and paragraph (10)(C)1. was suspended from April 3, 2020 through August 31, 2021. Pursuant to Executive Order 21-09, 19 CSR 30-84.010, section (3), paragraph (5)(B)2., section (8), and paragraphs (9)(C)2., (10)(C)5., (10)(C)6., and (11)(B)4. was suspended from April 3, 2020 through December 31, 2021.