Title of Regulation: 18VAC90-26. Regulations for Nurse Aide Education Programs (amending 18VAC90-26-10 through 18VAC90-26-70; adding 18VAC90-26-80, 18VAC90-26-90).

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

Public Hearing Information:

October 14, 2020 - 11:30 a.m. - WebEx - The hearing will be conducted during an electronic board meeting. The link and instructions to join the meeting will be on the agenda on the Virginia Regulatory Town Hall (www.townhall.virginia.gov).

Public Comment Deadline: November 13, 2020.

Agency Contact: Jay P. Douglas, R.N., Executive Director, Board of Nursing, 9960 Mayland Drive, Suite 300, Richmond, 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 statutory authority for approval of nurse aide education programs is found in § 54.1-3005 of the Code of Virginia.

Purpose: Certified nurse aides often provide care to the most vulnerable of our citizens in long-term care, home health, and other health care settings. The workgroup convened in 2016 to review and standardize curriculum found that persons who train nurse aides need to be better trained themselves, that additional topics need to be taught in the educational programs, and that students need a sufficient number of hours of clinical training to be prepared to pass the examination and practice safely. Amendments are recommended to improve the training of nurse aides so they can be competent in their skills and knowledge to protect the health and safety of patients in their care.

Substance: As a result of periodic review of 18VAC90-26, the board adopted amendments to clarify and update regulations for approval of nurse aide education programs. Substantive changes include: (i) a requirement that all clinical sites must be within 50 miles of the educational program or have board approval (current policy of the board); (ii) a requirement for the certificate of completion to include specific information on the name of the program, the approval number from the board, and the signature of the primary instructor or program coordinator; (iii) a requirement for the primary instructor that states that while onsite to instruct students, that person cannot assume other duties within the school (such as serving as the school nurse and teaching the certified nurse aide course simultaneously); (iv) a requirement for nurse aide education programs to follow the board-approved curriculum with the addition of training in mental health and substance abuse; (v) a refresher course every three years for instructors to remain qualified to teach the nurse aide curriculum; (vi) a change in the length of program to add 20 hours, from 120 to 140, with 20 hours specifically designated for skills acquisition; and (vii) two new sections, 18VAC90-26-80 and 18VAC90-26-90, to move the provision of 18VAC90-25-130 and 18VAC90-25-140 (advanced nurse aide education programs) to 18VAC90-26 so that all regulatory requirements for nurse aide education are included in one chapter.

Issues: The primary advantage of the regulatory changes is greater competency among certified nurse aides who have challenges in working with a vulnerable population of patients. There could also be an advantage to nurse aide students if instructors are better trained and more knowledgeable and there is more time in the curriculum for developing clinical skills, which together might improve their opportunity to pass the required examination. The disadvantage of the regulatory changes may be an increase in the number of hours, which may necessitate a modest increase in staff in some situations.

There are no advantages or disadvantages to the agency or the Commonwealth.

Department of Planning and Budget's Economic Impact Analysis:

A change in the minimum length of program to add 20 hours, an increase from 120 to 140 hours, with 20 hours specifically designated for skills acquisition is also being proposed. The nurse aide programs are offered by community colleges, high schools, proprietary (for profit) schools, and nursing homes/hospitals. The data provided by DHP on the number of programs with their current hours is presented in the table below by type of program.

The data indicate that 144 programs (63%) out of 227 already meet the proposed minimum program length and would not likely be affected from this change. Programs with fewer than 140 hours would face additional costs in terms of instructional or support personnel needing to be paid for the additional hours of work, and any other costs that may arise from additional hours. DHP believes that there are 500‑600 instructors statewide. The students in those programs would also have to allocate more of their time toward completing training and may have a delayed graduation date. These anticipated impacts would be proportional to the number of hours needed to reach the 140 hours for the 52 (23%) programs that currently provide between 120 and 140 hours (the hours needed for this group may vary from 1‑20 hours, depending on the program). The remaining 31 (14%) programs would face the full additional cost as they are meeting only the minimum hours currently required.

Between the different types of programs, proprietary schools appear to be the ones that would need to expend relatively more than others; 31 programs would have to increase their hours by a portion (1‑19 hours) and 12 would have increase their hours by 20. This particular change has a delayed effective date; affected programs would have two years to adjust schedules and plan for the personnel and other costs once the change becomes final. It is more than likely that the programs would pass at least a portion of these additional costs to their students, leading to an increase in tuition. The expected benefit is having more nurse aides pass the competency examination and becoming more qualified in their skills.

The workgroup found out that trainers at high schools often were assuming other duties (such as serving as the school nurse) concurrently while on site to instruct students. The Board proposes to prohibit simultaneously assuming other duties within the school. This amendment may necessitate scheduling changes to make sure trainers can focus undistracted entirely on training, or if the scheduling could not address the conflict hiring of additional personnel to handle those other duties.

Additionally, the Board proposes a requirement for the certificate of completion to include specific information on the name of the program, the approval number from the Board, and the signature of the primary instructor or program coordinator as well as a requirement that all clinical sites must be within 50 miles of the educational program or have Board approval (current policy of the Board). DHP has indicated that some of the programs, especially those owned by individuals, do not issue a certificate of completion to their graduates. The fifth change is intended to address that deficiency. The sixth change is to prevent programs imposing unreasonable burdens on their students if the clinical site is too far away. However, the proposal allows programs to obtain a waiver in cases where there is no clinical site within the 50-mile radius.

Overall, the Board believes the benefits of more specific training for instructors and more hours in skills acquisition would result in an increase in passage rates on the skills portion of the national competency examination. In turn, the Board believes this will increase the number of CNAs, and the quality of the training they receive, which will respond to the growing needs of the Commonwealth and its most vulnerable members. There would also be a benefit to nurse aide students if their instructors are better trained and more knowledgeable, and the curriculum has additional time devoted to developing clinical skills, which would in turn improve their chances of passing the certification exam. The expected costs include an increase in the number of hours which would likely necessitate changes in scheduling, an increase in the staff time needed to ensure an ongoing program operation, an increase in the time needed for CNAs to complete the program, a possible delay in graduation, and a likely tuition increase.

Businesses and Other Entities Affected. The proposed amendments apply to nurse aide programs currently offered by 44 community colleges, 77 high schools, 72 proprietary (for profit) schools, and 34 nursing homes/hospitals. 144 programs already meet the most significant proposed change, an increase from 120 to 140 training hours; accordingly, they and their students would likely be the least affected. 52 programs would have to increase their hours by less than 20 and they and their students would be more affected. 31 programs would have to increase their training hours by 20 hours and their students would likely be the most affected. To the extent programs cannot pass all of the additional compliance costs to their students, an adverse impact would be indicated for them. Similarly, an adverse impact would be indicated for students to the extent the costs of compliance (e.g., additional time to complete training, delays in graduation, increase in tuition) exceed the benefits to them (e.g., higher exam pass rates).

Similarly, train-the-trainer programs (indirectly) and the trainers themselves would be affected as there would be a minimum 12 hours of initial coursework and a required refresher course every three years. The Board indicates train-the-trainer programs are available in the marketplace and there are 500-600 trainers.

Additionally, high schools and community colleges generally receive state and local funding. Therefore, there may be some fiscal impact on the state and/or local governments depending on the particular effect on the programs in a given locality.

Small Businesses² Affected:

Types and Estimated Number of Small Businesses Affected. DHP has no information on which programs are small businesses. However, it is probable that at least some of the proprietary schools and some of the train-the trainer programs would fall under the small business category.

Costs and Other Effects. The proposed amendments would increase compliance costs for small proprietary schools. Some programs would need to increase the length of their training by up to 20 hours. An adverse economic impact³ on small affected programs is indicated to the extent they cannot pass a portion of their costs to the students because there do not appear to be any offsetting direct benefits to these small businesses. Similarly, some of the train-the trainer programs are believed to offer shorter than proposed 12 hour initial trainer coursework and may have to make scheduling changes or add more staff. To the extent increased costs to them are not passed on to the trainers, an adverse impact would be indicated.

Alternative Method that Minimizes Adverse Impact. There are no clear alternative methods that both reduce adverse impact on proprietary and train-the-trainer programs and meet the intended policy goals.

Localities⁴ Affected.⁵ The proposed amendments potentially affect programs in all 132 localities. The increased costs on high schools may have fiscal implications for the locality they are in. Accordingly, some local funds may be required. Consequently, an adverse economic impact⁶ on localities would be indicated to the extent affected high school programs necessitate additional local funding because there do not appear to be any offsetting direct benefits to these local governments.

Projected Impact on Employment. The proposed amendments would increase the demand for trainers and/or program support staff, but also may reduce supply of nurse aides as they would be spending more time in classroom and may choose to work fewer hours during the duration of their training. The net impact on total employment is not clear.

Effects on the Use and Value of Private Property. The additional compliance costs placed on programs would have a negative impact on the asset values of 72 private proprietary schools and 34 nursing homes/hospitals to the extent they cannot pass a portion of the costs to their students. Consequently, the asset value of some these firms may be reduced. The proposed amendments do not affect real estate development costs.

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¹https://townhall.virginia.gov/l/ViewPReview.cfm?PRid=1636

²Pursuant to § 2.2-4007.04 of the Code of Virginia, 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."

³Adverse 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.

⁴"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.

⁵§ 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

⁶Adverse 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.

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

Summary:

As a result of periodic review of 18VAC90-26, the proposed amendments clarify and update the regulation for approval of nurse aide education programs, including (i) requiring instructors to have minimum of 12 hours of coursework and to take a refresher course every three years, (ii) requiring nurse aide education programs to follow the board-approved curriculum with the addition of training in mental health and substance abuse, (iii) increasing the length of program to 140 hours, (iv) prohibiting the primary instructors at schools from assuming other duties within the school while onsite to instruct students, (v) requiring the certificate of completion to include specific information, and (vi) requiring that all clinical sites must be within 50 miles of the educational program or have board approval.

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.

"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.

"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.

"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 an 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. Initial approval 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 and length as approved by the board and 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 that has not been subject to penalty or penalties 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. The use of a nursing facility in Virginia located 50 miles or more from the school shall require board approval.

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

g. 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. Completion and submission of biennial onsite 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 on any nurse aide student who, on the date on which the nurse aide 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, but not be limited to, 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 certificate of completion as specified in 18VAVC90-26-50.

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

A. 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 in a nursing facility based program may be the director of nursing services. The director of nursing services may shall assume the administrative responsibility and accountability for the nurse aide education program but shall not engage in the actual classroom and clinical teaching.

3. The primary instructor may be the program coordinator in any nurse aide education program.

4. 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. 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 who holds a current, unrestricted license in Virginia or a multistate licensure privilege; 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 facility services. Such Other experience may include, but not be limited to, 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. Experience should include varied responsibilities, such as direct client care, supervision, and education.

2. Responsibilities. The primary instructor is responsible for the teaching and evaluation of students and, in addition, shall not assume other duties while instructing or supervising students. The primary instructor shall:

a. Participate in the planning of each learning experience;

b. Ensure that course objectives are accomplished met;

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 by the instructor.

C. Other instructional personnel.

1. Instructional personnel who assist the primary instructor in providing classroom or clinical supervision 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 patient client geriatric long-term 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) Hold a high school diploma or equivalent;

(3) Have been graduated from a state-approved practical nursing program; and

(4) Have had at least two years of direct patient client geriatric long-term care experience as a licensed practical nurse.

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

D. Prior to being assigned to teach the 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 a course in teaching adults at least 12 hours of coursework that includes:

a. Basic principles of adult learning;

b. Teaching methods and tools for adult learners; and

c. Evaluation strategies and measurement tools for assessing the 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 experience in teaching adults or high school students:

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. 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.

F. 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.

18VAC90-26-40. Requirements for the curriculum.

A. Curriculum content. The curriculum shall include, but shall not be limited to, classroom, skills laboratory, and clinical instruction in the following:

1. Initial core curriculum. Prior to the direct contact with a nursing facility client, a student shall have completed a total of at least 24 hours of instruction. Sixteen of those hours shall be in the following five areas:

a. Communication and interpersonal skills.

b. Infection control.

c. Safety and emergency procedures, including dealing with obstructed airways and fall prevention.

d. Promoting client independence.

e. Respecting clients' rights.

2. Basic skills.

a. Recognizing changes in body functioning and the importance of reporting such changes to a supervisor.

b. Measuring and recording routine vital signs.

c. Measuring and recording height and weight.

d. Caring for the client's environment.

e. Measuring and recording fluid and food intake and output.

f. Performing basic emergency measures.

g. Caring for a client when death is imminent.

3. Personal care skills.

a. Bathing and oral hygiene.

b. Grooming.

c. Dressing.

d. Toileting.

e. Assisting with eating and hydration, including proper feeding techniques.

f. Caring for skin, to include prevention of pressure ulcers.

g. Transfer, positioning, and turning.

4. Individual client's needs, including mental health and social service needs.

a. Modifying the nurse aide's behavior in response to the behavior of clients.

b. Identifying developmental tasks associated with the aging process.

c. Demonstrating principles of behavior management by reinforcing appropriate behavior and causing inappropriate behavior to be reduced or eliminated.

d. Demonstrating skills supporting age-appropriate behavior by allowing the client to make personal choices, and by providing and reinforcing other behavior consistent with the client's dignity.

e. Utilizing the client's family or concerned others as a source of emotional support.

f. Responding appropriately to the client's behavior including, but not limited to, aggressive behavior and language.

g. Providing appropriate clinical care to the aged and disabled.

h. Providing culturally sensitive care.

5. Care of the cognitively or sensory (visual and auditory) impaired client.

a. Using techniques for addressing the unique needs and behaviors of individuals with dementia (Alzheimer's and others).

b. Communicating with cognitively or sensory impaired clients.

c. Demonstrating an understanding of and responding appropriately to the behavior of cognitively or sensory impaired clients.

d. Using methods to reduce the effects of cognitive impairment.

6. Skills for basic restorative services.

a. Using assistive devices in transferring, ambulation, eating, and dressing.

b. Maintaining range of motion.

c. Turning and positioning, both in bed and chair.

d. Bowel and bladder training.

e. Caring for and using prosthetic and orthotic devices.

f. Teaching the client in self-care according to the client's abilities as directed by a supervisor.

7. Clients' rights.

a. Providing privacy and maintaining confidentiality.

b. Promoting the client's right to make personal choices to accommodate individual needs.

c. Giving assistance in resolving grievances and disputes.

d. Providing assistance necessary to participate in client and family groups and other activities.

e. Maintaining care and security of the client's personal possessions.

f. Promoting the client's rights to be free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate staff.

g. Avoiding the need for restraints in accordance with current professional standards.

8. Legal and regulatory aspects of practice as a certified nurse aide including, but not limited to, consequences of abuse, neglect, misappropriation of client property, and unprofessional conduct as set forth in § 54.1-3007 of the Code of Virginia and 18VAC90-25-100.

9. Occupational health and safety measures.

10. Appropriate management of conflict.

11. Observational and reporting techniques.

12. Substance abuse and opioid misuse.

B. Unit objectives.

1. Objectives for each unit of instruction shall be stated in behavioral terms that are measurable.

2. Objectives shall be reviewed with the students at the beginning of each unit.

C. Curriculum changes. Changes in curriculum shall be approved by the board prior to implementation and shall be submitted at the time of the onsite visit or with the report submitted by the program coordinator in the intervening year.

18VAC90-26-50. Other program requirements.

A. Records.

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 reports of graduates' performance on the approved competency evaluation program 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. The By (insert a the date two years from effective date of the regulation), the program shall be at least 120 140 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 nursing facility client.

3. Skills 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 nursing home a geriatric long-term care facility. Hours of observation shall not be included in the required 40 hours of skills training.

4. Employment Time spent in employment orientation to facilities used in the education program must not be included in the 120 140 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. Instructional Current instructional technology and equipment needed for simulating client care.

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

18VAC90-26-60. Requirements for continued approval.

A. Program review.

1. Each nurse aide education program shall be reviewed annually either by a survey visit on site by an agent of the board or by a written program evaluation. Each program shall be reviewed by an onsite a survey visit at least every two years following initial review or by a site visit whenever deemed necessary by the board to ensure continued compliance.

2. The program coordinator shall prepare and submit a program evaluation report on a form provided by the board in the intervening year that an onsite review a survey visit is not conducted.

3. Any additional information needed to evaluate a program's compliance with regulations of the board must be submitted within a timeframe specified by the board.

B. Decision on continued Continued, conditional, or withdrawal of approval.

1. The board shall receive and review the report of the onsite survey visit or program evaluation report and may grant continued approval, place a program on conditional approval, or deny continued withdraw approval.

a. Granting continued approval. A nurse aide education program shall continue to be approved provided the requirements set forth in subsection B of 18VAC90-26-20 are maintained.

b. Placing a program on conditional approval. If the board determines that a nurse aide education program (i) has not filed its biennial survey visit or program evaluation report; (ii) is unresponsive or uncooperative in the scheduling of the survey or site visit; or (iii) is not maintaining the requirements of subsection B of 18VAC90-26-20, as evidenced by the onsite survey visit or program evaluation report, the board may place the program on conditional approval and the program provider shall be given a reasonable period of time to correct the identified deficiencies. Within 30 days of the mailing of a decision on conditional approval, The the program may request, within 30 days of the mailing of a decision on conditional approval, an informal conference to be convened in accordance with § 2.2-4019 of the Code of Virginia.

(1) The board shall receive and review reports of progress toward correcting identified deficiencies. When a final report is received at the end of the specified time showing corrections of deficiencies, the board may grant continued approval.

(2) If the program provider fails to correct the identified deficiencies within the time specified by the board, a committee the board may recommend withdrawing approval following an informal conference held in accordance with § 2.2-4019 of the Code of Virginia withdraw approval.

c. Withdrawing approval.

(3) If the recommendation to withdraw approval following an informal conference is accepted by the board or a panel thereof, no further action will be required unless the program requests a formal hearing.

(1) If the board determines that a nurse aide education program is not maintaining the requirements of subsection B of 18VAC90-26-20, an informal conference will be convened in accordance with § 2.2-4019 of the Code of Virginia. If the recommendation to withdraw approval following an informal conference is accepted by the board or a panel thereof, no further action will be required unless the program requests a formal hearing.

(4) (2) The program provider may request a formal hearing before the board or a panel thereof pursuant to § 2.2-4020 and subdivision 11 of § 54.1-2400 of the Code of Virginia if it objects to any action of the board relating to conditional withdrawal of approval.

c. Denying continued approval. If the board determines that a nurse aide education program is not maintaining the requirements of subsection B of 18VAC90-26-20, an informal conference will be convened in accordance with § 2.2-4019 of the Code of Virginia. If the recommendation to withdraw approval following an informal conference is accepted by the board or a panel thereof, no further action will be required unless the program requests a formal hearing.

2. If the decision of the board or a panel thereof following a formal hearing is to withdraw approval or continue on conditional approval with terms or conditions, 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.

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 be placed on inactive status and shall not be subject to compliance with subsection B of 18VAC90-26-20 for the specified time.

2. Unless the program provider notifies the board that it intends to admit students, the program will be considered closed at the end of the inactive period and be subject to the requirements of subsection B of this section. 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.

18VAC90-26-80. Requirements for an approved advanced certification education program.

A. The advanced certification education program shall be approved by the Virginia Board of Nursing. An approved advanced certification education program shall also be an approved nurse aide education program as set forth in 18VAC90-26-20.

B. An advanced certification education program shall consist of a minimum of 140 hours, at least 20 hours of which shall be specifically designated for skills acquisition in the laboratory setting. There shall also be a minimum of 40 hours of clinical skills instruction in direct client care with onsite supervision by instructional personnel. When nurse aides are engaged in direct client care in the course of advanced certification training, the ratio shall not exceed 10 students to one instructor.

C. The instructional personnel in an approved advanced certification education program shall meet the requirements as set forth in 18VAC90-26-30.

D. The curricula of an approved advanced certification education program shall, at a minimum, meet the requirements of 18VAC90-26-40.

E. Each advanced certification program shall develop an individual record of major skills taught and the date of performance by the student. At the completion of the program, the program shall provide each nurse aide with a copy of this record and a certificate of completion, as specified in 18VAC90-26-50 A.

F. An advanced certification education program shall develop and submit to the board a competency evaluation based on the curriculum content required in 18VAC90-26-40. Such an evaluation shall include both a written test on the curriculum and an assessment of manual skills. A record of the reports of each graduate's performance on the nurse aide certification examination (the National Nurse Aide Assessment Program or NNAAP) shall be maintained for a minimum of three years.

G. Program review shall be in accordance with requirements of 18VAC90-26-60 and shall be conducted concurrently with the onsite review of the basic nurse aide education program. Loss of board approval for the basic nurse aide education program shall automatically result in the loss of approval for the advanced certification education program.

H. When an advanced certification education program closes, the program provider shall comply with 18VAC90-26-70 B.

18VAC90-26-90. Required curriculum content for an advanced certification education program.

A. In addition to the curriculum content specified in 18VAC90-26-40, an advanced certification education program shall include classroom, skills laboratory, and clinical instruction in the following curriculum:

1. Leadership and mentoring skills.

a. Principles of adult learning;

b. Learning styles;

c. Evaluation methods to assess learner knowledge;

d. Communication techniques and communication barriers; emphasizing cultural diversity of coworkers and clients;

e. Conflict management;

f. Precepting and mentoring new certified nurse aides;

g. Teamwork;

h. Contributing to care plan development and implementation;

i. Organizational responsibilities; and

j. Principles of documentation.

2. Care of the cognitively impaired client.

a. Signs and symptoms of dementia;

b. Concepts and techniques for addressing the unique needs and behaviors of individuals with dementia, including agitation, combativeness, sundown syndrome, wandering, and forgetfulness;

c. Basic concepts of communication with cognitively impaired clients, including techniques to reduce the effects of cognitive impairment;

d. Basic concepts of behavior management with cognitively impaired clients; and

e. Recognizing changes in the client's condition and reporting and documenting such changes.

3. Restorative care.

a. Anatomy and physiology with emphasis on the effects of aging;

b. Pathophysiology of common disorders of the elderly;

c. Measures to assist clients with common medical problems;

d. Recognizing changes in the client's condition and reporting and documenting such changes;

e. Concepts to maintain or improve client mobility and ability to perform activities of daily living; and

f. Rehabilitation procedures.

4. Wound care.

a. Prevention, identification and treatment of Stage I and Stage II pressure ulcers;

b. Positioning;

c. Sterile and clean technique;

d. Dressing changes;

e. Concepts of hydration;

f. Nutrition and weight loss; and

g. Recognizing changes in the client's condition and reporting and documenting such changes.

B. Written objectives for each unit of instruction shall be stated in behavioral terms that are measurable and shall be reviewed with the students at the beginning of each unit.