Title of Regulation: 18VAC90-26. Regulations for Nurse Aide Education Programs (amending 18VAC90-26-10, 18VAC90-26-20, 18VAC90-26-30, 18VAC90-26-50, 18VAC90-26-70).

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

Public Hearing Information:

February 22, 2023 - 9 a.m. - Department of Health Professions, Perimeter Center, 9960 Mayland Drive, Conference Center 201, Board Room 3, Henrico, Virginia 23233

Public Comment Deadline: March 1, 2023.

Effective Date: March 16, 2023.

Agency Contact: Jay P. Douglas, R.N., Executive Director, Board of Nursing, 9960 Mayland Drive, Suite 300, Henrico, VA 23233, telephone (804) 367-4520, FAX (804) 527-4455, or email jay.douglas@dhp.virginia.gov.

Basis: Regulations are promulgated under the general authority of § 54.1-2400 of the Code of Virginia, which provides the Board of Nursing the authority to promulgate regulations to administer the regulatory system. The specific authority for the board to regulate nurse aide education programs is found in § 54.1-3028.1 of the Code of Virginia.

Purpose: The purpose of this regulatory action is to ensure nurse aide programs are able to continue providing education to students in a timely manner and in a manner that protects the public health by ensuring students receive appropriate clinical training by qualified instructors. Nurse aide education programs have struggled to place nurse aide students in nursing home facilities given the restrictions that have been in place for several years due to the COVID-19 pandemic. In addition, programs have had difficulty in obtaining and retaining qualified personnel to teach in nurse aide education programs. The regulatory action is to allow other qualified health professionals to serve as instructors to nurse aide students as well as provide increased latitude that accounts for the newer nursing workforce.

Rationale for Using Fast-Track Rulemaking Process: The changes, which are deemed to be noncontroversial, were specifically prompted by a petition for rulemaking that requested that the board (i) amend the regulation that currently limit the locations nurse aide program training can occur and who could provide training and (ii) review the regulation to search for potential changes that could improve training, the accessibility of training, and the ability of nurse aide education programs to hire qualified instructional personnel. Board staff also reviewed the regulation for lack of clarity, particularly among roles of instructional personnel and maintenance of program records.

Substance: The board is amending (i) 18VAC90-26-10 to provide definitions of "clinical setting" and "direct client care" and to specify that the acronym "NNAAP" stands for "National Nurse Aide Assessment Program"; (ii) 18VAC90-26-20 to clarify that a nurse aide education program must implement a board-approved curriculum to maintain approval and to ensure that students employed by or with an offer of employment by a facility are not charged a fee by the education program; (iii) 18VAC90-26-30 to clarify and further define roles and decrease requirements for the program coordinator, primary instructor, and other instructional personnel; (iv) 18VAC90-26-50 to include a requirement that educational programs retain documentation listed in the section for two years following a site or survey visit and to eliminate the restriction on the number of hours of clinical instruction that may be provided outside of a geriatric care facility; and (v) 18VAC90-26-70 to require that programs that have not held classes for a period of one year notify the board.

Issues: The advantages to the public include nurse aide programs that can produce more and better trained nurse aides, retain more qualified instructors, and provide nurse aides with clinical training that matches the reality of nurse aide practice in the Commonwealth. There are no disadvantages to the public. There are no advantages or disadvantages to the agency or the Commonwealth.

Department of Planning and Budget's Economic Impact Analysis:

The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Code of Virginia (Code) and Executive Order 19. The analysis presented represents DPB's best estimate of these economic impacts.¹

Summary of the Proposed Amendments to Regulation. In response to a petition for rulemaking and following a review of this regulation, the Board of Nursing (Board) proposes to (i) allow nurse aide training to occur outside of a nursing home facility; (ii) allow the program coordinator or the primary instructor, but not both, to be a non-registered nurse; (iii) remove requirements for geriatric care experience for registered nurse or licensed practical nurse instructors; (iv) allow instructional personnel from other health professions to supplement the primary instructor, and to also reduce the two year experience requirement for a licensed practical nurse acting as other instructional personnel to one year; (v) specify that program documentation be maintained for two years following each site visit; and (vi) require notification if a program has been inactive for a year.

Background. Some of the proposed changes were specifically prompted by a petition for rulemaking² and others resulted from staff efforts to identify potential changes that could improve training, the accessibility of training, and the ability of nurse aide education programs to hire qualified instructional personnel. According to the Board, nurse aide education programs have struggled to place their students in nursing home facilities given the restrictions that have been in place for several years due to the COVID-19 pandemic.³ In addition, programs have had difficulty in obtaining and retaining qualified personnel to teach in nurse aide education programs. In order to address these issues, the Board proposes amendments to this regulation as discussed.

Estimated Benefits and Costs. One of the proposed amendments would allow nurse aide training to occur outside of a nursing home facility. Currently, nurse aide education programs are required to provide skills training experience in a "nursing facility" specifically. Additionally, there is a limitation that only five of the 40 hours of direct client care training may occur outside of geriatric long-term care facilities. However, due to the COVID-19 pandemic and the associated restrictions on who can enter in these facilities, the education programs have struggled to comply with this requirement, which probably prompted the petition for rulemaking.⁴ The Board proposes to allow skills training to occur in a "clinical setting" which is broader than the nursing facility. This proposed change would broaden the types of facilities where training can occur and should provide additional options to the education programs and their students.

The Board also proposes to change the requirements for program coordinators, primary instructors, and other instructional personnel in a way to make the requirements less restrictive. Currently, both the program coordinator and primary instructor must hold a license as a registered nurse. Under the proposed amendments, only the program coordinator or primary instructor would be required to hold a license as a registered nurse. This would allow training programs to be in compliance even if they only had a single registered nurse (acting as either the coordinator or as the primary instructor) as opposed to having to have two registered nurses on staff. Also, the requirement for direct client care experience in geriatric services for registered nurse or licensed practical nurse instructors would be removed, thereby allowing additional experience from other clinical settings. Similarly, this change would provide some relief to the training programs by expanding the pool of potential trainers. Additionally, the requirements for other instructional personnel who supplement the primary instructor would be amended to permit health professionals other than registered nurses and licensed practical nurses to become instructors. Currently, the other instructional personnel that support the primary instructor are required to be either a registered nurse or a licensed practical nurse. Moreover, the proposal would reduce the two-year experience requirement for a licensed practical nurse as other instructional personnel to one year. Again, these changes open the possibility of other health professionals supplementing the primary instructor, expand the pool of individuals who may be hired to help the primary instructor, and provide some relief to the training programs.

The common theme in the proposed changes is a shift from the emphasis on the type of education and experience gained in a nursing facility setting to that gained in other settings such as assisted living facilities, home care, and hospitals. Nursing facility care is probably more intensive overall compared to other settings, but allowing additional settings would offer additional educational and training opportunities and may thereby increase the pool of available instructors.⁵ In addition, not all nurse aides actually obtain employment in a nursing home. This leads to overinvestment in this aspect of nursing aide education and training for those who may never work in a nursing facility. Under the proposed changes, the education and experience provided to nursing aides may more closely align with their actual work experience after graduation and thereby improve the allocation of scarce resources.

One of the remaining proposed changes would specify that documentation be maintained for two years following a site or survey visit. Currently, the language requires records to be maintained but does not state for how long. Specifying the recordkeeping requirements will assist the Board in its oversight responsibilities and ensure the programs have clarity about the Board's expectations. The proposed duration of two years may be more or less than what an individual program may already be doing, and thus may extend or shorten the duration compared to their current practice. To the extent that these programs already maintain the required documentation, any extension or shortening would not introduce significant costs or benefits, but data is not available on the industry's current record keeping practices.

Finally, the Board proposes to require a program that has not held classes for one year to notify the Board of the program's inactivity. The Board states that this change is necessary because under the current regulatory language, there is a requirement to place the program's approval on inactive status if a program is inactive for one year. However, there is currently no reporting requirement for the education programs. This leads the Board to discover program closures well after the program has been inactive for one year. Thus, this change would help provide timely and accurate information to the Board in so far as which programs should be designated as inactive.

Businesses and Other Entities Affected. This regulation affects nurse aide education programs and their students. There are currently 236 nurse aide programs in Virginia. The Board does not track or regulate students, so an estimate of the number of students that would be affected is not available. The Board reports that there were 3,767 students undergoing testing for certification as a nurse aide in 2021, but that number is not comprehensive as many students do not participate in testing because they are able to work without certification. No nurse aide program or students appear to be disproportionately affected.

The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.⁶ An adverse impact is indicated if there is any increase in net cost or reduction in net revenue for any entity, even if the benefits exceed the costs for all entities combined. As noted, the proposed changes generally allow education and training opportunities available from settings other than nursing facilities be utilized. The remaining changes regarding specification of two years in records maintenance and notification of inactive status do not appear to have the potential to pose significant costs. Thus, no adverse impact is indicated.

Small Businesses⁷ Affected.⁸ No data are available to assess whether the education programs meet the definition of a small business.

Localities⁹ Affected.¹⁰ The proposed amendments do not disproportionally affect any particular localities and do not introduce costs for local governments.

Projected Impact on Employment. The proposed amendments are expected to expand the pool of instructors educational programs can hire from which is essentially an increase in the available supply of potential instructors. Such a flexibility may allow them to maintain or expand the size of their programs. Thus, an increase in the number of instructors hired by the programs may be expected or a potential decrease may be avoided. However, since at least some of these instructors may hold jobs elsewhere currently, the impact on total employment may not be large.

Effected on the Use and Value of Private Property. The proposed changes that allow utilization of education and experience available in settings other than nursing facilities provide additional opportunities to the programs in terms of where they can provide training and who they can hire as instructors. These flexibilities should provide some cost avoidances and improve their asset values.

The proposed amendments do not affect real estate development costs.

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¹Section 2.2-4007.04 of the Code of Virginia requires that such economic impact analyses determine the public benefits and costs of the proposed amendments. Further the analysis should include but not be limited to: (1) the projected number of businesses or other entities to whom the proposed regulatory action would apply, (2) the identity of any localities and types of businesses or other entities particularly affected, (3) the projected number of persons and employment positions to be affected, (4) the projected costs to affected businesses or entities to implement or comply with the regulation, and (5) the impact on the use and value of private property.

²https://townhall.virginia.gov/l/viewpetition.cfm?petitionid=356.

³See page 1 at https://townhall.virginia.gov/l/GetFile.cfm?File=27\5929\9569\AgencyStatement_DHP_9569_v1.pdf.

⁴Arguably even before the pandemic, the U.S. Supreme Court's ruling on June 22, 1999, in Olmstead v. L.C. which requires that individuals with disabilities be served in the most integrated settings possible has resulted in moving many nursing home residents into community based programs severely restricting nursing home services growth over two decades and thereby educational and training opportunities available through them.

⁵One of the comments states "COVID has created an issue with interacting with patient in a long term setting and to be honest it does not give you a lot of diversity of the type of patients that you will encounter. By engaging in the same routine care of patients, CNAs can become stagnant in their skills and quite frankly that is dangerous for our long term care population. I have seen this first hand. Also, I do have hospital experience as a CNA, which is most of my professional career. The hospital setting gives you the ability to see different patients on a routine basis and allows the chance to use different skills daily making the CNA well rounded. Additionally, the CNA has the ability to learn new skills that she would necessarily not be able to learn in the long term care setting. Personally, I was able to learn to do bladder scanners on patients." See https://townhall.virginia.gov/l/ViewComments.cfm?commentid=119235.

⁶Pursuant to § 2.2-4007.04 D: In the event this economic impact analysis reveals that the proposed regulation would have an adverse economic impact on businesses or would impose a significant adverse economic impact on a locality, business, or entity particularly affected, the Department of Planning and Budget shall advise the Joint Commission on Administrative Rules, the House Committee on Appropriations, and the Senate Committee on Finance. Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation.

⁷Pursuant to § 2.2-4007.04, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

⁸If the proposed regulatory action may have an adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include: (1) an identification and estimate of the number of small businesses subject to the proposed regulation, (2) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the proposed regulation, including the type of professional skills necessary for preparing required reports and other documents, (3) a statement of the probable effect of the proposed regulation on affected small businesses, and (4) a description of any less intrusive or less costly alternative methods of achieving the purpose of the proposed regulation. Additionally, pursuant to § 2.2-4007.1 of the Code of Virginia, if there is a finding that a proposed regulation may have an adverse impact on small business, the Joint Commission on Administrative Rules shall be notified.

⁹"Locality" can refer to either local governments or the locations in the Commonwealth where the activities relevant to the regulatory change are most likely to occur.

¹⁰ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency's Response to Economic Impact Analysis: The Board of Nursing concurs with the economic impact analysis of the Department of Planning and Budget.

Summary:

As a result of a petition for rulemaking and following a review of the regulations governing nurse aide education programs, the amendments (i) allow nurse aide training to occur outside of a nursing home facility focusing on geriatric care; (ii) update requirements of the program coordinator, primary instructor, and other instructional personnel to clarify roles and duties of each; (iii) remove requirements for geriatric care experience for registered nurse and licensed practical nurse instructors and allow instructional personnel from other health professions to supplement the primary instructor; (iv) require program documentation be maintained for two years following each site visit; and (v) update procedures for program closures.

18VAC90-26-10. Definitions.

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

"Approval" means the process by which the board evaluates and grants official recognition to a nurse aide education program.

"Board" means the Virginia Board of Nursing.

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

"Clinical setting" means a location in which clinical practice occurs in a setting comparable to those in which the practice of a nurse aide may occur.

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

"Conditional approval" means the time-limited status that results when a board-approved nurse aide education program has failed to maintain requirements as set forth in this chapter.

"Direct client care" means nurse aide care provided to patients or clients in a clinical setting supervised by a qualified instructor.

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

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

"NNAAP" means National Nurse Aide Assessment Program.

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

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

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

"Site visit" means a focused onsite review of the nurse aide education program by board staff for the purpose of evaluating program components, such as the physical location (skills lab, classrooms, learning resources) for obtaining program approval, change of location, or verification of noncompliance with this chapter or in response to a complaint.

"Survey visit" means a comprehensive onsite review of the nurse aide education program by board staff for the purpose of granting continued program approval. The survey visit includes the program's completion of a self-evaluation report prior to the visit as well as a board staff review of all program resources, including skills lab, classrooms, learning resources, and clinical facilities, and other components to ensure compliance with this chapter. Meetings with administration, instructional personnel, and students will occur on an as-needed basis.

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

A. Establishing a nurse aide education program.

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

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

3. Approval may be granted when all documentation of the program's compliance with requirements as set forth in subsection B of this section has been submitted and deemed satisfactory to the board and a site visit has been conducted. Advertisement of the program is authorized only after board approval has been granted.

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

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

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

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

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

a. Curriculum content as approved by the board and Implementation of the board approved curriculum as set forth in subsection A of 18VAC90-26-40 and subsection C of 18VAC90-26-50.

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

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

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

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

f. The use of a nursing facility clinical setting in Virginia located 50 miles or more from the school shall require board approval.

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

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

h. i. Completion and submission of biennial survey visit review reports and program evaluation reports as requested by the board within a timeframe specified by the board.

2. Impose no fee for any portion of the program, including any fees for textbooks or other required course materials, on any nurse aide student who, on the date on which the student begins the program, is either employed or has an offer of employment from a nursing facility.

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

4. Report all substantive changes in subdivision 1 of this subsection within 10 days of the change to the board to include a change in the program coordinator, primary instructor, program ownership, physical location of the program, or licensure status of the clinical facility.

5. Provide each student with a copy of his the student's certificate of completion as specified in 18VAVC90-26-50 18VAC90-26-50.

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

A. The program coordinator or primary instructor shall:

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

2. Have two years of experience as a registered nurse and at least one year of direct client care or supervisory experience in the provision of long-term care services. Experiences may include employment in a nurse aide education program or employment in, or supervision of nursing students in, a nursing facility or unit, geriatrics department, chronic care hospital, home care, or other long-term care setting.

B. Program coordinator.

1. Each program shall have a program coordinator who must be a registered nurse who holds a current, unrestricted license in Virginia or a multistate licensure privilege. 2. The program coordinator shall assume the administrative responsibility and accountability for the nurse aide education program and shall:

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

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

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

3. 2. The primary instructor may be the program coordinator in any nurse aide education program, except in a nursing facility-based program.

4. 3. The director of nursing services in a nursing facility-based program may serve as the program coordinator but shall not simultaneously engage in the actual classroom, skills laboratory, or clinical teaching while serving as the director of nursing services.

B. C. Primary instructor.

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

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

b. Have two years of experience as a registered nurse within the previous five years and at least one year of direct client care or supervisory experience in the provision of geriatric long-term care services. Other experience may include employment in a nurse aide education program or employment in or supervision of nursing students in a nursing facility or unit, geriatrics department, chronic care hospital, home care, or other long-term care setting. 2. Responsibilities. The primary instructor is responsible for the teaching majority of instruction and evaluation of students and shall not assume other duties while instructing or supervising students. A program may request an exception to the restriction on assumption of other duties. The executive director of the board shall be authorized to make the decision on requests for exception or may refer to an informal fact-finding committee for consideration as needed.

The primary instructor shall:

a. Participate in the planning of each learning experience;

b. Ensure that course objectives are met; and

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

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

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

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

C. D. Other instructional personnel.

1. Instructional Other instructional personnel from the health professions with at least one year of experience in their field may supplement the primary instructor in the classroom setting.

2. Other instructional personnel who assist the primary instructor in providing classroom or clinical supervision instruction shall be registered nurses or licensed practical nurses.

a. A registered nurse shall:

(1) Hold a current, unrestricted Virginia license or multistate licensure privilege as a registered nurse; and

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

b. A licensed practical nurse shall:

(1) Hold a current, unrestricted Virginia license or multistate licensure privilege as a practical nurse; and

(2) Have had at least two years one year of direct client geriatric care experience as a licensed practical nurse.

2. Responsibilities. 3. Other instructional personnel shall provide instruction under the supervision of the primary instructor.

D. E. Prior to being assigned to teach in a nurse aide education program, all instructional personnel shall demonstrate competence to teach adults or high school students by one of the following:

1. Satisfactory completion of at least 12 hours of coursework that includes:

a. Basic principles of adult learning;

b. Teaching methods and tools for adult learners;

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

d. Review of current regulations for nurse aide education programs;

e. Review of the board-approved nurse aide curriculum content; and

f. Review of the skills evaluated on the board-approved nurse aide certification examination; or

2. Have:

a. Experience in teaching the curriculum content and skills evaluated on the board-approved nurse aide certification examination to adults or high school students; and

b. Knowledge of current regulations for nurse aides and nurse aide education programs.

E. F. In order to remain qualified to teach the nurse aide curriculum, instructional personnel shall complete a refresher course every three years that includes a review of regulations for nurse aides and nurse aide education programs and the skills evaluated on the board-approved nurse aide certification examination.

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

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

18VAC90-26-50. Other program requirements.

A. Records. Original documentation shall be maintained for a period of two years following each site or survey visit, to include:

1. Each nurse aide education program shall develop and maintain an individual record of major skills taught and the date of performance by the student. At the completion of the nurse aide education program, the program shall provide each nurse aide with a copy of this record and a certificate of completion from the program, which includes the name of the program, the board approval number, date of program completion, and the signature of the primary instructor or program coordinator.

2. A record of the graduates' performance on the state-approved nurse aide certification examination (the National Nurse Aide Assessment Program or NNAAP) shall be maintained.

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

B. Student identification. The nurse aide students shall wear identification that clearly distinguishes them as a "nurse aide student." Name identification on a badge shall follow the policy of the facility in which the nurse aide student is practicing clinical skills.

C. Length of program.

1. By May 12, 2023, the program shall be at least 140 clock hours in length, at least 20 hours of which shall be specifically designated for skills acquisition in the laboratory setting.

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

3. Clinical training in clinical settings shall be at least 40 hours of providing direct client care. Five of the clinical hours may be in a setting other than a geriatric long-term care facility. Hours of observation shall not be included in the required 40 hours of skills clinical training.

4. Time spent in employment orientation to facilities used in the education program must not be included in the 140 hours allotted for the program.

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

1. Comfortable temperatures.

2. Clean and safe conditions.

3. Adequate lighting.

4. Adequate space to accommodate all students.

5. Current instructional technology and equipment needed for simulating client care.

6. Equipment and supplies sufficient for the size of the student cohort.

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

A. Interruption of program

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

2. At any time during the year after the program is placed on inactive status, the program provider may request that the board return the program to active status by providing a list of the admitted student cohort and start date.

3. If the program provider does not hold classes for two consecutive years, the program shall be considered closed and shall be subject to the requirements of subsection B of this section. In the event that a program desires to reopen after closure, submission of a new program approval application shall be required.

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

1. Notify the board of the date of closing.

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