Nursing Assistants, Medication Aides, and the Approval of Nursing Assistant and Medication Aide Training Programs (216-RICR-40-05-22)


216-RICR-40-05-22 ACTIVE RULE

22.1 Authority

These regulations are promulgated pursuant to the authority conferred under R.I. Gen. Laws § 23-17.9-14, and are established for the purpose of defining the minimum standards for the training, competency, evaluation, and licensing of nursing assistants and medication aides; and adopting unified standards for nursing assistants and medication aides to ensure safe and adequate care to individuals receiving health care services from nursing assistants and medication aides within the State.

22.2 Incorporated Materials

These regulations hereby adopt and incorporate 42 C.F.R. § 483.152 (2017) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these rules and regulations.

22.3 Definitions

A. Wherever used in these rules and regulations the following terms shall be construed as follows:

1. "Abuse" means any assault or battery as defined in R.I. Gen. Laws Chapter 11-5, R.I. Gen. Laws § 11-37-1, or any conduct which harms or is likely to harm a patient, or intentionally engaging in a pattern of harassing conduct which causes or is likely to cause emotional or psychological harm to the patient, including, but not limited to, ridiculing or demeaning a patient, making derogatory remarks to a patient, cursing directed towards a patient, and threatening to inflict physical or emotional harm on a patient, except when the conduct is a part of the care and treatment and in furtherance of the health and safety of the patient.

2. "Act" means R.I. Gen. Laws Chapter 23-17.9.

3. “Adult day services program” means a community-based group program, licensed by the Department in accordance with the provisions of R.I. Gen. Laws § 23-1-52, designed to meet the biopsychosocial needs of adults with impairments through individual plans of care.

4. "Approval" means the process whereby the Director or designee evaluates and grants official recognition to a nursing assistant or medication aide training program based on the requirements of this Part.

5. "Assisted living residence" means a publicly or privately operated residence licensed under the provisions of R.I. Gen. Laws Chapter 23-17.4.

6. “Complicated feeding” means the feeding of patients with complex medical needs and the feeding of patients that require feeding tubes or parenteral/intravenous feedings.

7. “Department” means the Rhode Island Department of Health.

8. "Director" means the Director of the Rhode Island Department of Health or designee.

9. "Health care facility" means a provider as defined by R.I. Gen. Laws § 23-17-2(8).

10. “Long term care services” means a set of health care, personal care and social services required by persons who lack some degree of functional capacity (e.g., chronically ill, aged, disabled), who are living in an institution on a long-term basis or at home. The term may refer to long-term institutional care such as care provided in nursing homes, adult day care services, and assisted living residences, or to ambulatory services such as home health care.

11. “Medication aide” means a nursing assistant who has had additional training in the administration of medications and is licensed with the Department as a medication aide.

12. "Medication aide training program" means an organized course of classroom instruction and clinical training, approved by the Director, designed to prepare individuals to function as assistants to licensed nurses in the administration of medication.

13. “Medication aide exam” means an examination approved by the Director that tests the ability of a person to perform the skills and exercise the judgment necessary to carry out the duties of a medication aide.

14. "Neglect" means the intentional failure to provide treatment, care, goods and services necessary to maintain the health and safety of a patient, or the intentional failure to carry out a plan of treatment or care prescribed by a patient’s physician, or the intentional failure to report a patient’s health problems or changes in health conditions to an immediate supervisor or licensed nurse, or the intentional lack of attention to the physical needs of a patient including, but not limited to, toileting, bathing, meals, and safety. Provided, however, no person shall be considered neglected for the sole reason that he or she relies on or is being furnished with treatment in accordance with the tenets and teachings of a well-recognized church or denomination by a duly-accredited practitioner thereof.

15. "Nursing assistant" means a paraprofessional who holds a Rhode Island license pursuant to the provisions of the Act and this Part, and who is trained to give personal care and related health care and assistance based on his or her level of preparation to individuals who are sick, disabled, dependent, or infirm, and who are patients at or are receiving services from health care facilities or agencies.

16. "Nursing assistant examination" means an examination approved by the Director that includes a written and practical component that tests the ability of a person to perform the skills and exercise the judgment that is necessary to carry out the duties of a nursing assistant as defined in these regulations.

17. "Nursing assistant training program" means an organized course of classroom instruction and practical training, approved by the Director, designed to prepare individuals to function as nursing assistants.

18. "Nursing service agency" means any person, firm, partnership or corporation doing business within the State of Rhode Island that supplies, on a temporary basis, licensed nursing assistants to a hospital, nursing home, private home, or other health care facility licensed under R.I. Gen. Laws Chapter 23-17.7.1 and the rules and regulations for Licensing Nursing Service Agencies (Subchapter 10 Part 10 of this Chapter).

19. "Patient" means client and resident.

20. “Registry” means the Department's licensure database that provides a mechanism to verify the status of a nursing assistant’s license.

21. "Supervision" means the provision of guidance for the accomplishment of a nursing assistant activity by a supervisor who is a nurse, physician, or other appropriate health professional who is duly licensed and/or certified as required by law.

a. "Direct supervision" means supervision provided by a supervisor who is and remains on the premises, in the building, while the nursing assistant is performing his or her duties, and evaluates the performance of the nursing assistant and medication aide.

b. "Indirect supervision" means supervision provided by a supervisor who is not on the premises while the nursing assistant is performing his or her duties, but who is responsible for the assignment of duties and evaluation of the performance of the nursing assistant.

22.4 Levels of Nursing Assistants

A. Pursuant to R.I. Gen. Laws § 23-17.9-2(3), the Director of the Rhode Island Department of Health hereby establishes the following levels of nursing assistants:

1. Nursing Assistant. A nursing assistant is a paraprofessional trained to provide personal care and related health care and assistance to individuals who are sick, disabled, or infirm, and who are residents of or receiving services from health care facilities or agencies licensed by the state, and holds a license as a nursing assistant issued by the Department.

2. Medication Aide. A medication aide is a nursing assistant who has had additional training in the administration of medication, and holds a license as a medication aide issued by the Department.

22.5 General Requirements: Nursing Assistants and Medication Aides

A. No person shall be employed in this state as a nursing assistant or medication aide unless he or she holds a license as a nursing assistant in accordance with the provisions of the Act and this Part.

B. No person shall assume the title of “nursing assistant” or such similar title or use any abbreviations or any other words, letters, signs, figures, or devices to indicate that the individual using same is a nursing assistant as set forth in these regulations, unless he or she holds a license as a nursing assistant issued by the Department. The only abbreviation that a nursing assistant may use in this state is "N.A."

C. All nursing assistants and medication aides shall assess patient pain in accordance with the “Rules and Regulations Related to Pain Assessment” promulgated by the Department of Health.

D. All nursing assistants and medication aides must notify the Department of all changes of home address and all changes of employment within ten (10) days of any such change. Failure to provide notice will result in sanctions.

22.5.1 Supervision

A. Nursing assistants must be supervised by a licensed nurse, physician, or other appropriate health professional who is duly licensed and/or certified as required by law. The type of supervision, either direct or indirect, shall be determined by the licensed health care facility as defined in R.I. Gen. Laws § 23-17-2(8). Provided, however, those duties listed in § 22.12.1(B) of this Part shall be discharged only under direct supervision of a licensed nurse, physician, or other appropriate health professional who is duly licensed and/or certified as required by law.

B. A medication aide must be supervised by a licensed nurse, physician, or other appropriate health professional who is duly licensed and/or certified as required by law. The type of supervision, either direct or indirect, shall be determined by the licensed health care facility as defined in R.I. Gen. Laws § 23-17-2(8), provided, however, those duties listed in § 22.12.1(B) of this Part shall be discharged only under direct supervision of a licensed nurse, physician, or other appropriate health professional who is duly licensed and/or certified as required by law.

C. For the first three (3) months of employment, a licensed nurse designated by the health care facility, adult day services program, or assisted living residence, as appropriate, shall conduct and document monthly evaluations (in accordance with the evaluation checklist on the Department website) of a medication aide who administers medication. After the first three (3) months, the evaluation shall be conducted no less than quarterly. Copies of said evaluations shall be placed in the medication aides’ personnel records.

D. Persons who are actively enrolled in a bachelor of science program in nursing, associate degree program in nursing, accredited licensed practical nursing program, or registered nurse course of study in a National League for Nursing Accrediting Commission, Inc., or a Commission on Collegiate Nursing Education (CCNE) accredited nursing program, and have completed two (2) clinical courses, including a Fundamentals of Nursing course, and who provide written documentation from the clinical supervisor indicating that the student is prepared to serve as a nursing assistant, are exempt from completing a Nursing Assistant Training Program and from sitting for the National Nurse Assistant Assessment Program Skills portion.

22.5.2 General Requirements: Medication Aides

A. Persons licensed by the Department as medication aides may administer medications, as provided in this Part, in nursing facilities, adult day services programs, and assisted living residences.

B. Medication Aides may not administer medications to patients who reside at home.

C. In accordance with R.I. Gen. Laws § 23-17.9-2(3), a medication aide license may be issued to any person who meets the requirements established under the Act and this Part.

D. No person may serve as a medication aide without holding a valid medication aide license issued by the Department.

E. A medication aide applicant shall be required to furnish such information as the Department may prescribe, and simultaneously with the filing of said application, shall pay to the Department the required non-refundable fee as set forth in the rules and regulations pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

F. All licenses issued to medication aides shall be valid for a period of two (2) years and shall expire on the same date as the medication aide’s nursing assistant license.

G. A medication aide shall wear a name tag that indicates the aide's name and the appropriate license designation.

22.5.3 Qualifications for Applicants

A. An applicant seeking a license as a Nursing Assistant must demonstrate:

1. Successful completion of a department-approved nursing assistant training program; or be actively enrolled in a nursing program in accordance with § 22.5.1(D) of this Part; and

2. Successful completion of the required nursing assistant examination; or

3. Possession of a current license as a nursing assistant in good standing in another state or jurisdiction that includes successful completion of a state-approved training program that meets or exceeds RI Nursing Assistant training program requirements, and successful completion of a State approved nursing assistant exam, and provides documentation of the equivalent of three (3) months of full-time work experience as a nursing assistant; or

4. Successful completion of a one hundred (100) hour state-approved training program in another state or jurisdiction that includes a minimum of twenty (20) hours of practical clinical training under supervision, and successful completion of a nursing assistant examination.

B. An applicant seeking License as a Medication Aide shall:

1. Possess an active license as a nursing assistant in Rhode Island;

2. Be a high-school graduate or the equivalent;

3. Not have been convicted of any felony for crimes involving controlled substances (subject to waiver by the Department upon presentation of satisfactory evidence that such conviction does not impair the ability of the person to conduct the duties of a medication aide without endangering public health and safety);

4. Provide proof of successful completion of a Department-approved medication aide training program defined in this Part.

5. Pass the Medication Aide Certification Exam.

C. Duties and Responsibilities of a Medication Aide

1. A medication aide may perform only those tasks and duties for which he or she has been trained and for which there is documentation of proof of proficiency, as determined by his or her supervisor, but in no case shall those tasks and duties exceed what is permitted by regulation, law, scope of practice, or as set forth in § 22.12.3 of this Part.

D. License Application

1. Nursing Assistants

a. Application for a Rhode Island license as a nursing assistant shall be made on forms provided by the Department.

b. Such application must be accompanied by the following:

(1) Documented evidence of completion of a Department-approved nursing assistant training program;

(2) Documented evidence of successful completion of the required nursing assistant examination;

(3) The non-refundable processing fee in accordance with R.I. Gen. Laws § 23-17.9-5 and as set forth in the rules and regulations pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

(4) If the nursing assistant is employed by a health care facility at the time of application and is continuously employed by the same facility for six (6) months after the license is issued, the fee required pursuant to R.I. Gen. Laws § 23-17.9-5 shall be directly refunded to the applicant by the facility or agency.

(5) Full Bureau of Criminal Investigation (BCI) check from the Rhode Island Attorney General’s Office;

(6) If seeking registration under the provisions of § 22.5.3(A)(3) of this Part, the applicant shall submit proof of an active license in good standing from the state or jurisdiction, written documentation from an employer attesting to no less than the equivalent of three (3) months of full-time work experience as a nursing assistant, as well as the items required in §§ 22.5.3(D)(1)(b)((1)) through ((3)) of this Part.

(7) If seeking registration under the provisions of § 22.5.3(A)(4) of this Part, the applicant shall submit written documentation of successful completion of a one hundred (100) hour state-approved training program (including the minimum of twenty (20) hours of practical clinical training under supervision) completed in another state or jurisdiction as well as the items required in §§ 22.5.3(D)(1)(b)((2)) and ((3)) of this Part.

2. Medication Aides

a. Application for a Rhode Island license as a medication aide shall be made on forms provided by the Department.

b. Such application must be accompanied by the following:

(1) Documented evidence of completion of a Department-approved medication aide training program including a signed statement from the clinical supervisor or licensed nurse.

(2) The non-refundable application fee as set forth in the rules and regulations pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title); and

(3) Full Bureau of Criminal Investigation (BCI) check from the Rhode Island Attorney General’s Office.

22.5.4 Licensure by Examination: Nursing Assistants

A. The nursing assistant written and practical examinations shall be selected and approved by the Director or designee.

B. All applicants shall be required to successfully complete the nursing assistant examinations within a period of one (1) year from the date that the applicant began the nursing assistant training program. If more than one year has passed, the nursing assistant applicant shall be required to complete the nursing assistant training program again.

C. Nursing assistant applicants shall be given three (3) opportunities to successfully complete both the written and practical components of the nursing assistant examinations. After three (3) unsuccessful attempts to complete the nursing assistant examinations, the nursing assistant shall be required to repeat the nursing assistant training program.

D. Applicants for initial licensure as a nursing assistant by examination who have completed a nursing assistant training program in accordance with this Part, may be issued a one hundred twenty (120) day Temporary Permit authorizing the applicant to work under direct supervision of a licensed nurse or physician until the applicant has passed all required portions of the National Nursing Assistant Assessment Program.

E. No extensions of the one hundred twenty (120) day Temporary Permit shall be allowed.

22.5.5 Issuance and Renewal of License and Fee

A. The Department shall issue to applicants who have satisfactorily met the license requirements of this Part a license as a nursing assistant and/or medication aide. Unless suspended or revoked, this license shall expire biennially (every two (2) years) on June 30 of every other year following the date of issuance of the original registration.

B. Every nursing assistant and/or medication aide who wishes to renew his or her license shall file a renewal application with the Department together with the renewal fee as set forth in the rules and regulations pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title) before June 15.

C. Upon receipt of such renewal application and payment of the fee, the Department shall renew the license effective July 1, and expiring June 30, two (2) years later unless the license is suspended or revoked.

D. Any nursing assistant and/or medication aide whose license lapses for a period of less than two (2) years may be reinstated by the Department upon submission of an application and payment of the renewal fee(s) as set forth in the rules and regulations pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title), unless the registration has been suspended or revoked.

E. A nursing assistant seeking renewal shall have been employed as a nursing assistant for at least eight (8) hours within the prior twenty-four (24) months and have completed 12 hours of in-service training per year at the facility where employed; or have successfully completed a nursing assistant training program and passed the exam for licensure within the past twenty-four (24) months.

F. A medication aide seeking renewal shall have been employed as a medication aide for at least eight (8) hours within the prior twenty-four (24) months and submit proof of 4 Continuing Education Units; or have completed a medication aide training program and have passed the Medication Assistant Certification Exam within the past twenty-four (24) months.

G. A nursing assistant applicant seeking renewal shall have been employed as a nursing assistant in:

1. A Rhode Island-licensed health care facility licensed under the provisions of R.I. Gen. Laws Chapter 23-17;

2. An assisted living residence licensed under the provisions of R.I. Gen. Laws Chapter 23-17.4;

3. An adult day services program licensed under the provisions of R.I. Gen. Laws § 23-1-52; or

4. Employed by a nursing service agency licensed under the provisions of R.I. Gen. Laws § 23-17.7.1-1.

5. Private duty employment does not meet this employment requirement.

H. A medication aide applicant seeking renewal shall have been employed as a medication aide in:

1. A Rhode Island-licensed nursing facility licensed under the provisions of R.I. Gen. Laws § 23-17-1;

2. An assisted living residence licensed under the provisions of R.I. Gen. Laws Chapter 23-17.4; or

3. An adult day services program licensed under the provisions of R.I. Gen. Laws § 23-1-52.

I. Any nursing assistant and/or medication aide whose license lapses for a period of two (2) years or longer, and who cannot provide proof of employment in accordance with §§ 22.5.5(G) and (H) of this Part, shall be required to successfully complete the nursing assistant training and/or medication aide training program, and all required examinations, prior to being reinstated as a nursing assistant and/or medication aide.

J. A nursing assistant applicant seeking renewal shall attest that he or she has been employed within the previous twenty-four (24) months when completing the online renewal form. Renewal applicants are subject to audit and must retain proof of completion of in-service hours and/or Continuing Education Units for a three (3) year period.

K. Continuing Education Requirements: Medication Aides

1. Every medication aide seeking renewal of a license under the provisions of the Act and this Part shall provide satisfactory evidence to the Department that in the preceding two (2) years the licensee has completed four (4) required continuing education hours as established in this section.

2. Continuing education hours related to medication administration will be accepted by the Board for course work that has been presented, accepted, or approved by recognized professional nursing organizations, schools of pharmacy, health care facilities, employing organizations, or other professional organization, labor organization, or accrediting agency as may be approved by the Board.

3. At the time of license renewal, each medication aide will be required to attest to the completion of the above continuing education requirements.

4. It shall be the sole responsibility of the individual medication aide to obtain documentation (e.g., course descriptions, proof of attendance) from the sponsoring organization, agency, or institution of his or her participation in a continuing education program and/or activity. These documents shall be retained by each licensee for no less than three (3) years and are subject to random audit by the Department.

5. Failure to produce satisfactory documentation of completion of the requirements of this section, upon request by the Board, constitutes grounds for disciplinary action under the provisions of the Act.

L. Removal of Name from Nurse Aide Registry

1. In the case of a finding of unprofessional conduct, as defined in this Part, a nursing assistant may petition the Department in writing to have his or her record of discipline removed from the registry upon a determination by the Department that the employment and personal history of the nursing assistant does not reflect a pattern of unprofessional conduct; and the conduct involved in the original finding was a singular occurrence.

2. A nursing assistant shall submit a written petition to:

Rhode Island Department of Health

Nursing Assistant Advisory Board

3 Capitol Hill, Room 104

Providence, RI 02908

3. Such petition shall request that the nursing assistant’s offense be removed from the registry in accordance with the criteria stated in § 22.5.5(L)(1) of this Part.

4. The nursing assistant’s name and record of discipline shall remain on the registry for a period of two (2) years from the date on which the name was placed on the registry after which time the name may be removed if the petitioner’s request is granted by the Department.

M. Reinstatement of Nursing Assistant License

1. A nursing assistant who has been licensed in Rhode Island in good standing, has let his/her license lapse, and has been working as a nursing assistant in another state or jurisdiction within the two (2) years immediately preceding the application for reinstatement and has completed 12 hours of in-service per 12 month period, may apply for reinstatement upon submission of the following:

a. Photocopy of active license/registration from the state or jurisdiction where employed as a nursing assistant;

b. Reinstatement processing fee as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title);

c. Attestation of employment as a Nursing Assistant for eight (8) hours within the past two (2) years (license must be current at the time of employment) in a nursing home, hospital, home care agency, assisted living residence, adult day services program, or employed by a nursing service agency;

d. Attestation of completion of 12 hours per 12-month period of in-service training;

e. Verification from current state of licensure that the applicant for reinstatement is and has been in good standing in that jurisdiction.

22.6 Denial, Revocation or Suspension of Registration: Nursing Assistants and Medication Aides

A. Pursuant to R.I. Gen. Laws §§ 23-17.9-8 and 23-17.9-9, and upon a decision after a hearing as provided in accordance with the Rhode Island Administrative Procedures Act and the Rules and Regulations Pertaining to Practices and Procedures Before the Rhode Island Department of Health (Part 10-05-4 of this Title), the Department may deny, suspend, or revoke a license issued under this Part, or may reprimand, censure, or otherwise discipline an individual who has been found guilty of violations of the Act or this Part in any of the following cases:

1. Upon proof of any of the cases stated in R.I. Gen. Laws §§ 23-17.9-8(1) through 23-17.9-8(5)

2. Upon proof that the nursing assistant or medication aide has engaged in unprofessional conduct including, but not limited to, departure from, or failure to conform to, the standards of acceptable and prevailing practice;

3. Upon proof that the nursing assistant or medication aide has, without the patient’s consent, taken a photograph or made an audio or video recording of a patient, or has uploaded a photograph, audio or video recording of a patient to the internet, or who has disseminated a photograph, audio or video recording of a patient in any manner;

4. Upon proof that the nursing assistant or medication aide abandoned a patient or failed to appear for scheduled employment;

5. Upon proof that the nursing assistant or medication aide has engaged in any form of abuse as defined in this Part;

6. Upon proof that the nursing assistant or medication aide has participated in a physical or financial relationship with a patient. Consent of the patient shall not constitute a defense against the violation of § 22.6(A)(10) of this Part.

7. Upon proof that the nursing assistant or medication aide failed to provide the Department of a change of home address or change of employment within ten (10) days of any such change.

22.7 Requirements Pertaining to Nursing Assistant Training Programs

22.7.1 Application for and Approval of Training Programs

A. Approval of training programs shall be granted for two (2) years, if the program is found to meet the requirements of this Part, and such approval may be renewed biennially unless approval has been sooner revoked or suspended.

B. Any person desiring to conduct a training program for the preparation of individuals to provide nursing assistant services shall apply to the Department for approval by submitting a completed application on forms provided by the Department accompanied by documentation pertaining to no less than the following:

1. Evidence of support and fiscal administration accountability;

2. Sources and locations of potential students, faculty, classrooms, conference rooms, clinical laboratory for practical experience and other resources;

3. Names and qualifications of instructors;

4. Copy of the curriculum including provisions for the practical experience;

5. Written statements of purpose, philosophy and objectives;

6. Organization with clearly defined authorities and responsibilities and a chart showing the relationships and channels of communication of the program to other agencies, programs, etc.;

7. Practical experiences related to areas of instruction of the didactic segment of the program; and

8. Written policies and procedures pertaining to the nursing assistant training program.

C. The application fee for a training program certification shall be as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title). Any nursing assistant training program within a facility administered and operated by the state of Rhode Island shall be exempt from this fee.

1. Nursing Assistant Training program sites that are not inspected by the Board within four (4) weeks of approval by the Board, will be inspected by the Department.

D. Standards for Nursing Assistant Training Program Approval

1. The nursing assistant training program shall consist of no less than one hundred twenty (120) clock hours including no less than forty (40) hours of practical training integrated with the classroom topics and under supervision in accordance with the definition of “supervision” in § 22.3(A)(21) of this Part.

2. A nursing assistant training program conducted in a health care facility shall be completed within ninety (90) days.

3. Paperwork required for a candidate to sit for the Nursing Assistant Training Program Exam must be submitted to the Department by the Nursing Assistant Training Program within four (4) weeks of program completion.

4. The course of instruction shall be designed to prepare students to perform all the nursing assistant duties listed in § 22.12.1 of this Part. At least sixteen (16) hours of classroom instruction shall be required prior to a trainee's direct involvement with patients. Such instruction shall be consistent with the curriculum outline of § 22.12.2 of this Part.

E. Personnel

1. Program Coordinator

a. Each nursing assistant training program shall have a coordinator who shall be responsible for the management of the instructional and practical portions of the program. The program coordinator must be a registered nurse with a minimum of two (2) years of nursing experience, one (1) of which must be in the provision of long term care services; and must have documented evidence of teaching and/or appropriate supervisory experience. Directors of nursing in nursing facilities are prohibited from performing actual training, but may supervise clinical training.

2. Instructors

a. Competent resource personnel from various areas of the health field may participate as program instructors at the discretion of the program coordinator. Such personnel may include: licensed registered nurses (RNs)/practical nurses (LPNs) with one (1) year of nursing experience, dietitians; pharmacists; or physical therapists. Instructors shall have completed a course in teaching adults or have experience in teaching adults, or supervising nursing assistants, and shall have at least one (1) year of experience in their respective fields.

F. Policies and Procedures

1. Each nursing assistant training program shall have available for students written policies pertaining to no less than the following:

a. Admission, re-admission, retention, dismissal and course completion requirements;

b. The identification of the resource facilities for the practical experience in a long-term care or appropriate acute care facility;

c. The supervision requirement of nursing assistants in all settings in accordance with the definition of “supervision” in this Part; and

d. Such other provisions as may be deemed appropriate.

e. Licensed Nursing Assistant training programs shall submit all required documentation for students who have successfully completed a nursing assistant training program within one (1) month to the Department or shall be subject to disciplinary action in accordance with § 22.10.1 of this Part.

G. Resources and Facilities

1. Each nursing assistant training program shall have resources/facilities consistent with the philosophy, purposes, objectives and policies of the nursing assistant program. Such resources/facilities shall include no less than:

a. Classroom, offices, and conference rooms accessible to and adequate for the number of students;

b. Sufficient instructional materials to meet the needs of students and instructor, including clinical supplies;

c. Furnishings of appropriate size and numbers as may be required for the instructional program and for the number of students;

d. An adequate number of service resources to provide the kinds of practical learning experiences as required to meet the curriculum objectives;

e. Adequate financial support to implement and operate the nursing assistant program;

f. Compliance with all applicable licensing laws and regulatory requirements.

H. Curriculum

1. The objectives of the nursing assistant training program shall be consistent with 42 C.F.R. § 483.152 incorporated at § 22.2 of this Part and the curriculum outline of § 22.12.2 of this Part and shall promote the provision of quality health care services by nursing assistants who are able to perform competently the duties listed in § 22.12.1 of this Part.

I. Evaluation of Curriculum

1. A systematic plan for on-going evaluation of the curriculum shall be established and include evaluation provisions pertaining to no less than:

a. The implementation of the curriculum design;

b. The relationship of the curriculum to current needs of patients in health care facilities and current standards of practice;

c. Revisions and/or modifications of curriculum as may be necessary based on evaluation data and/or other federal and state requirements.

J. Examinations

1. An examination shall be administered that tests the knowledge and competency of a person to carry out the duties of a nursing assistant as defined in these regulations.

2. The nursing assistant program shall determine a person’s skill, knowledge levels, and competency through a manual skills (practical) examination. Such examination shall test no less than the following:

a. Communication and interpersonal skills;

b. Infection control;

c. Safety emergency procedures;

d. Promotion of patients' independence;

e. Respecting patients' rights;

f. Basic nursing skills;

g. Mental health/social service needs;

h. Care of cognitively impaired patients;

i. Basic restorative services.

3. In addition, the nursing assistant program shall test specific manual skills as set forth in § 22.12.1 of this Part. Where appropriate, skills demonstration shall be performed on a real patient, or "pseudo-patient," but shall not be performed on a mannequin.

K. Standards for Medication Aide Training Program Approval

1. Medication aide training programs shall be offered by a college or university that is approved by an appropriate accrediting authority. Correspondence courses and on-line learning programs shall not be approved.

2. Approval of a medication aide training program shall be granted for two (2) years, if the program is found to meet the requirements of this Part, and such approval may be renewed biennially unless approval has been sooner revoked or suspended.

3. Training programs for medication aides that are approved by the Department shall include the following components:

a. Require written documentation for entry into the medication aide training program from a director of nursing or an administrator at an adult day services program, nursing facility, or assisted living residence licensed in Rhode Island;

b. A minimum of forty-five (45) hours of classroom instruction in a medication administration training program that includes theoretical and practical instruction;

c. Skills demonstration, performed within one (1) year of successful completion of the medication aide training program, under the supervision of a registered nurse and approval of a registered nurse in the employing facility;

d. Written guidelines, policies, and procedures that define the specific tasks the medication aide shall be expected to perform;

e. A stipulation of how the medication aide's competency is to be assessed (i.e., examination and practicum).

L. Curriculum for a Department-approved Training Program for Medication Aides

1. Training programs for medication aides that are approved by the Department shall include, but not be limited to, the following course content:

a. Legal constraints;

b. Dose forms;

c. Laxatives, vitamins, cold and cough remedies, and other over-the-counter drugs;

d. Psychiatric medications;

e. Antidiabetic and antiemetic drugs;

f. Asthma and chronic obstructive pulmonary disease (COPD);

g. Hormones (including steroids);

h. Antibiotics;

i. Systems of measurement and medical abbreviations;

j. Anti-Parkinson drugs and muscle relaxers;

k. Cardiac drugs;

l. Seizures and pain;

m. Communication techniques;

n. Security and safety of drugs;

o. Glossary of terms;

p. Drug orders;

q. Over-the-counter and legend medications;

r. Common side effects of drugs;

s. Drug administration preparation;

t. Prescribers;

u. Directions for use;

v. Commonly-used abbreviations and symbols;

w. Number of dosage units;

x. Strengths and systems of measurement;

y. Routes of administration;

z. Frequency of administration;

aa. Interpreting directions for use;

bb. Infection control procedures;

cc. Patient instruction;

dd. Calculations and conversions;

ee. Administration of topical medications;

ff. Patient monitoring of health indicators;

gg. “Five rights” of medication administration: right patient, right drug, right dose, right time, and right route of administration;

hh. Proper documentation in patient medication records;

ii. Accurate administration of the appropriate quantity of drug product.

M. Personnel for a Department-approved Training Program for Medication Aides

1. All instructors in a Department-approved training program for medication aides shall be licensed pharmacists (R.Ph) with no less than a bachelor’s degree in pharmacy. Provided, however, pharmacist instructors may engage competent resource personnel from other health fields, such as nursing, to deliver discrete lectures in their area(s) of expertise.

2. Instructors shall have completed a course in teaching adults or have experience in teaching adults and shall have at least one (1) year of experience in their respective fields.

22.8 Denial or Revocation of Approval/Termination of Program

A. If the Department determines that an approved nursing assistant training program does not meet the requirements of this Part, the Department shall notify, in writing, the institution and/or agency or such other training program of a proposed pending action to deny or revoke the approval of the program and the institution and/or agency shall be given an opportunity for a prompt and fair hearing in accordance with the provisions of § 22.11 of this Part.

B. Any nursing assistant training program that terminates, for whatever reason, shall make provisions for the appropriate storage of its students' records to ensure future accessibility to the training program data for a minimum of five (5) years after the date of termination.

1. Provisions shall be made for the completion of the nursing assistant training program for any individual who has begun a program, if, for whatever reason, the training program terminates.

22.9 Advisory Board

A. Within the Department there shall be established an Advisory Board which shall meet at least once a year and shall consist of eleven (11) members:

1. Five (5) of whom shall be registered nurses,

2. One (1) of whom shall be a nursing assistant,

3. Two (2) of whom shall be administrators of health care facilities,

4. One (1) of whom shall be a public member, and

5. Two (2) of whom shall be licensed practical nurses.

B. All Board members shall be currently licensed in Rhode Island, where required, and shall be actively working in his/her profession.

C. Members of the Advisory Board shall be appointed by the Director: three (3) to serve for one (1) year; four (4) to serve for two (2) years; and four (4) to serve for three (3) years. No member shall be appointed for more than two (2) consecutive full terms. A member appointed for less than a full term (originally, or to fill a vacancy) may serve two (2) full terms in addition to that part of a full term, and a former member shall again be eligible for appointment after a period of one (1) or more years passes.

D. Successors to members of the Advisory Board whose terms expire shall be appointed in such year by the Director to hold office for three (3) years or until their respective successors are appointed.

E. The Director may remove any member of the Advisory Board for neglect of duty or incompetency and may fill vacancies that occur for any purpose for the remainder of the unexpired term.

F. Functions of the Advisory Board

1. The Advisory Board shall serve in an advisory capacity to the Director in matters pertaining to the registration of nursing assistants, medication aides and the practice of nursing assistants and medication aides. The Advisory Board shall advise the Director on such matters as policies affecting examination, qualifications, issuance and renewal, denial or revocation of licenses, and the development of rules and regulations.

22.10 Violations and Penalties

Any person who violates the statutory or regulatory provisions of this Part shall be subject to the disciplinary provisions of this Part and as set forth in R.I. Gen. Laws § 23-17.9-9.

22.11 Rules Governing Practices and Procedures

All hearings and reviews as may be required under the provisions of R.I. Gen. Laws Chapters 23-17.9 and 42-35 shall be conducted in accordance with the provisions of the Rules and Regulations Pertaining to Practices and Procedures before the Rhode Island Department of Health (Part 10-05-4 of this Title).

22.12 Duties and Training Program Curriculum

22.12.1 Duties of Nursing Assistants

A. A nursing assistant duly registered in this state may discharge the following duties under supervision as described in this Part.

1. Personal Care Skills

a. Assist with complicated feeding, hydration

b. Bed bath, tub bath, shower

c. Care of skin and back

d. Foot care, foot soak, applying foot lotion

e. Nail care

f. Oral hygiene

g. Shampoo hair (sink, tub, bed) comb/brush

h. Shave

2. Basic Nursing Skills

a. Application of dry heat and cold packs to intact skin

b. Sitz bath to intact skin for comfort measures and pain relief only

c. Application of topical over-the-counter (OTC) drugs to intact skin

d. Apply lamb's wool

e. Apply elastic stockings

f. Care of patients on precautions

g. Make an occupied, unoccupied bed

h. Measure intake and output

i. Reinforce simple non-sterile dressings

j. Remind patient to take medication

k. Care for a patient when death is imminent

l. Post-mortem care

m. Specimen collection

n. Apply condom catheter

o. Empty catheter bag, commode, urinal

p. Assist with ostomy appliance

q. Assist with commode, toilet, bedpans and urinals

r. Change urinary drainage bag, excluding any sterile procedures

s. Assist with bowel/bladder retraining

t. Report and record weight and height

u. Take and record vital signs (temperature, pulse, and respiration (TPR) and blood pressure)

3. Rehabilitation Skills

a. Ambulate

b. Encourage self-help

c. Positioning

d. Normal range of motion

e. Restraining and use of appropriate alternatives

f. Transfer from bed, wheel chair, chair, commode

g. Transfer using mechanical lift

h. Use of assistive devices in ambulation, eating and dressing

4. Environment

a. Care of patient environment

b. Handling of blood/body fluid spills

c. Clean patient care area

d. Do basic domestic chores (e.g., laundry, ironing, dishes, food preparation, where appropriate)

5. Recognition of and Reporting Signs and Symptoms

a. Infection

b. Redness

c. Swelling

d. Fever, chills

e. Drainage

6. Respiratory Problems

a. Shortness of breath

b. Rapid respirations

c. Cheyne-Stokes respirations

d. Cough

7. Cardiac Problems

a. Chest pains

b. Cyanosis lips/nails

c. Rapid pulse

8. GI/GU problems

a. Abdominal pain

b. Nausea

c. Vomiting blood

d. Urine/stool: difficulty urinating; diarrhea

9. Endocrine problems

a. Drowsiness

b. Thirst

c. Sweating

B. Duties Which a Nursing Assistant May Perform Under Direct Supervision:

1. Enema

2. Colostomy irrigation

3. Application of hot packs using moist heat device or heat lamp

4. In addition, nursing assistants may be assigned nursing duties beyond those listed in §§ 22.12.1(A) and (B) of this Part (but in no case may they may be assigned any of the duties excluded in § 22.12.1(C), so long as those duties are clearly delineated in facility policies. Documented evidence of training and competency evaluation for each additional duty permitted to be discharged shall be filed in the individual's personnel file.

C. Excluded from the Duties of a Nursing Assistant

1. A nursing assistant shall not perform functions that otherwise require a professional license, certification or registration by state law and shall not perform the following duties that include but are not limited to:

a. Sterile dressing application

b. Gastric lavage or gavage, including any tube feeding

c. Injections

d. Vaginal Irrigations

e. Cutting toenails or fingernails for diabetic

f. Cutting toenails

g. Giving advice on medical/nursing matters

h. Changing a Foley catheter

i. Tracheostomy tube care

j. Any treatment to non-intact skin

k. Oxygen application

D. Medications:

1. A nursing assistant may only remind a patient to take medication, unless the nursing assistant is licensed with the Department as a medication aide.

2. Medication aides shall not administer drugs or biologicals under any circumstances in an acute care setting, and shall not administer any Schedule II controlled substances.

22.12.2 Curriculum Outline Basic Nursing Assistant Training Program

A. Minimum requirement of:

1. 80 classroom hours

2. 40 hours of practical experience

B. Being A Nursing Assistant - Introduction

1. Function of the nursing assistant

a. In health care institutions

b. In the home

2. Working with the health care team

3. Ethical responsibilities

a. Accountability

b. Confidentiality

4. Policies and procedures

5. State rules and regulations related to the registration of nursing assistants

6. Communication and interpersonal skills

7. Infection control

8. Safety/emergency procedures

9. Promoting patients' independence

10. Respecting patients' rights

C. Basic Human Needs

1. Patients as human beings

a. Physical, emotional, spiritual and mental health needs of patients throughout the life cycle

b. Modifying the nursing assistant's behavior in response to patient's behavior

c. Identifying developmental tasks associated with the life cycle

d. Behavior management (reinforcement, reduction, elimination of behaviors)

e. Allowing maximum independence in relation to patient's ability

f. Working with the patient's family

D. Caring for Patients

1. Admission and discharge procedures

2. Personal care skills:

a. To include instruction relative to all those personal care duties outlined in § 22.12.1 of this Part, which a nursing assistant may discharge under supervision.

3. Basic nursing skills:

a. Taking and recording vital signs

b. Measuring and recording vital signs

c. Caring for patient's environment

d. Observing, reporting and documenting abnormal signs and symptoms of common diseases

e. Caring for patients when death is imminent

f. Specimen collection (urine, stool, sputum)

g. Heimlich maneuver

4. Basic Nutrition:

a. Food and nutrition

5. Fluid balance:

a. Intake and output

b. Maintaining proper hydration

E. Basic Restorative Services

1. Rehabilitation

a. Basic body mechanics

b. Anatomy/physiology

2. Training the patient in self-care, according to ability

3. Use of assistive devices in transferring, ambulation, eating and dressing

4. Maintenance of range of motion

5. Proper turning and positioning in bed and chair

6. Bowel and bladder training

7. Care and use of prosthetic and orthotic devices

F. Care of Patients with Specific Problems

1. The patient with cognitive impairment or other behavioral health conditions

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

b. Communicating with patients

c. Understanding behavior

d. Appropriate responses to behavior

e. Methods for reducing the effects of cognitive impairment

2. Care of patients with diseases of other body systems

a. Circulatory problems

b. Respiratory problems

c. Digestive system problems

d. Bowel and bladder problems

e. Musculoskeletal problems

f. Neurological problems

g. Endocrine problems

h. Skin problems

G. Patient’s Rights

1. Privacy/confidentiality

2. The right to personal choices

3. Giving assistance in resolving grievances and disputes

4. Maximizing participation in resident and family groups

5. Maintaining care and security of personal possessions/property

6. Providing care which maintains the patient free from abuse

7. Reporting abuse, mistreatment and neglect

8. The use of restraints; avoiding the use of restraints

H. Practical Training

1. Each student must satisfactorily complete twenty (20) hours of practical training under supervision and such practical experience shall be provided in a clinical setting for the practical application of nursing assistant duties as outlined in § 22.12.1 of this Part.

2. The practical training must be integrated with the didactic portion of the curriculum for a meaningful learning experience.

22.12.3 Duties of Medication Aides:

A. Medication aides shall consistently apply the community standard of care that includes but is not limited to:

1. Establish competency as a medication aide;

2. Maintain competency as a medication aide;

3. Perform within authorized duties;

4. Follow written instructions of a licensed health care professional authorized to prescribe medications within the scope of his/her practice and as transcribed in the medication administration record (MAR); and

5. Accurately record on the medication administration record (MAR) medications administered, medications withheld or refused, and the reason why a medication was withheld or refused.

B. A medication aide licensed in this state may discharge the following duties under supervision as described in this Part:

1. Under the supervision of a licensed nurse, medication aides may administer:

a. Oral, sublingual and buccal medications;

b. Eye medications;

c. Ear medications;

d. Nasal medications;

e. Rectal medications;

f. Vaginal medications;

g. Skin ointments, topical medications including patches and transdermal medications to intact skin only;

h. Premeasured medication delivered by aerosol/nebulizer; and

i. Medications delivered by metered hand-held inhalers.

2. Under the direct supervision of a licensed nurse, medication aides may apply oxygen.

C. Administration of PRN Medications

1. Medication aides may administer PRN medications to clients according to physician's, nurse practitioner's, or physician assistant’s orders.

2. Medication aides are not allowed to administer medications by the following routes:

a. Central lines;

b. Colostomy;

c. Intramuscular;

d. Intrathecal;

e. Intravenous;

f. Via any tubes (e.g., Nasogastric, gastrostomy)

g. Subcutaneous;

h. Intradermal;

i. Urethral;

j. Epidural; or

k. Endotrachea.

3. Medication aides are not allowed to administer the following kinds of medications:

a. Schedule II controlled substances;

b. Barium and other diagnostic contrast media; or

c. Chemotherapeutic agents, except oral maintenance chemotherapy.

4. Medication aides are not allowed to administer medication by medication pumps, including client-controlled analgesia.

5. Medication aides are not allowed to act as a preceptor to a student in a medication aide training program.





Title 216 Rhode Island Department of Health
Chapter 40 Professional Licensing and Facility Regulation
Subchapter 05 Professional Licensing
Part 22 Nursing Assistants, Medication Aides, and the Approval of Nursing Assistant and Medication Aide Training Programs (216-RICR-40-05-22)
Type of Filing Amendment
Regulation Status Active
Effective 07/12/2018

Regulation Authority :

R.I. Gen. Laws § § 23-17.9-14

Purpose and Reason :

In accordance with the Administrative Procedures Act, R.I. Gen. Laws Section 42-35-3(a)(1), the following is a concise statement regarding this rulemaking for Nursing Assistants, Medication Aides, and the Approval of Nursing Assistant and Medication Aide Training Programs (216-RICR-40-05-22). This amendment to the regulations updates definitions, establishes levels of nursing assistants, revises applicant qualifications, removes statutory reiteration, allows for temporary permitting of nursing assistants, augments the list of violations that are grounds for denial, suspension, or revocation of license, and removes superfluous language/sections that are more appropriate as guidance documents. In response to public comment, the definition of long term care services in § 22.3(A)(10) was revised to include adult day care services and assisted living residences. In response to public comment, the practical hourly requirement stated in § 22.12.2(A)(2) was revised to align with the requirements of § 22.7(D)(1), including the revision of practical hourly requirements from twenty (20) to forty (40) hours. In response to public comment, § 22.12.2(F)(1) was revised to state that it included other behavioral health conditions. During public comment, it was suggested that § 22.12.1(D)(1) be revised to allow nursing assistants to provide access to medications that are normally self-administered when an individual has a documented physical or visual impairment which interferes with the ability to do so independently. RIDOH has determined that this suggested revision will not be implemented because the regulations require that medication aides receive additional training in order to administer medications. During public comment, it was suggested that the oral hygiene curriculum in § 2.12 be strengthened. RIDOH has determined that this suggested revision will not be implemented because the current oral hygiene requirements are sufficient. In the development of this rule, consideration was given to: 1) alternative approaches; 2) overlap or duplication with other statutory and regulatory provisions; and 3) significant economic impact on small business. No alternative approach, duplication, or overlap was identified based on available information. RIDOH has determined that the benefits of this rule justify its costs.

There are no electronic rulemaking documents for rules filed prior to August 14, 2018. For rulemaking documents for rules filed prior to this date, please contact the appropriate agency's Rules Coordinator.