19 CSR 30-84.010 - Nursing Assistant Training Program
PURPOSE: This amendment updates and adds requirements
for the basic course curricula content and adds requirements for update
training for instructors. Clarifies student requirements and who is eligible to
challenge the final examination. Clarifies requirements for employees of a
long-term care facility. Updates instructor/clinical supervisor/student ratios.
Adds requirements for a RN Instructor Trainer. Revises requirements to allow
for a
(1) Definitions. For the purpose of this
rule, the following definitions shall apply:
(A) Association-means the Missouri Health
Care Association, the Missouri Association of Nursing Home Administrators,
Leading Age Missouri, or Missouri Hospital Association;
(B) Basic course -means the seventy-five (75) hours of
instructional training, the one hundred (100) hours of supervised on-the-job
training, and the final examination of the nursing assistant training
course;
(C) Certifying agency
-means an long-term care (LTC) association, Career Center school, comprehensive
high school, community college, or four- (4-) year institution of higher
learning approved by the department ;
(D) Challenge the final examination -means taking the
final examination of the basic course without taking the entire basic
course;
(E) Department -means the
Missouri Department of Health and Senior Services;
(F) Hospital-means any licensed hospital as
defined in section
197.020,
RSMo;
(G) Missouri Veterans'
Home-means any facilities established and maintained as a Missouri Veterans'
Home as defined in section
42.002, RSMo;
(H) Nursing Assistant Clinical
Supervisor Workshop-means the training course approved by the department and
conducted by a certifying agency to prepare clinical supervisors to learn the
methodology of teaching the supervised on-the-job training component of the
nursing assistant training program;
(I) Nursing Assistant Instructor
Workshop-means a training course approved by the department and conducted by a
certifying agency to prepare instructors to learn the methodology of teaching
the nursing assistant training program;
(J) Program-means the nursing assistant
training program as required by section
198.082,
RSMo;
(K) Registered Nurse
Instructor Trainer-means a registered nurse (RN) approved by a certifying
agency to teach the Nursing Assistant Instructor Workshop and the Nursing
Assistant Clinical Supervisor Workshop to prepare instructors and clinical
supervisors to teach the nursing assistant training program; and
(L) Training agency-means an organization
approved by the department which sponsors the approved nursing assistant
training program.
(2)
The purpose of the program shall be to prepare individuals for employment as a
certified nursing assistant (CNA). The program shall be designed to teach
skills in resident care which will qualify individuals to perform uncomplicated
nursing procedures and to assist licensed practical nurses (LPNs) or RNs in
direct resident care.
(3) All
aspects of the program included in this rule (that is, qualified instructor,
clinical supervisor, course curriculum, training agency, certifying agency,
supervised on-the-job training, testing, and student qualifications) shall be
met in order for a program to be considered as approved.
(4) Basic Course Requirements. The program
shall consist of a basic course that includes, at a minimum , the following:
(A) Seventy-five (75) hours of instructional
training in the curricula identified in section (5) of this rule;
(B) One hundred (100) hours of supervised
on-the-job training (clinical practice) in an approved laboratory or other
setting in which the student demonstrates knowledge while performing tasks on
an individual under the supervision of a LPN or RN; and
(C) A final examination.
(5) Curricula Content.
(A) Until August 31, 2021, a training agency
identified in paragraphs (9)(A)1., (9)(A)2., and (9)(A)6. of this rule, shall
teach the basic course and utilize either the content outlined in paragraphs
(5)(A)1. and 2. or (5)(B)1. and 2. This basic course includes the following:
1. Curriculum content of the program shall
include procedures and instructions on basic nursing skills in the following
areas: basic hygiene techniques; bedmaking; personal care of residents; food
service; charting; safety measures (including fire/safety and disaster
preparedness and infection control); basic preventative and restorative care
and procedures; basic observation procedures, such as weighing and measuring;
communication skills; methods of handling and caring for mentally confused
residents; residents' rights; ethical and legal responsibilities; death and
dying; and mental health and social needs; and
2. The course curriculum as outlined in the manual
entitled The Nurse Assistant in a Long-Term Care Facility, produced by the
Instructional Materials Laboratory, University of Missouri-Columbia, revised
November 2001, catalogue number 50-5061-S shall be considered an approved
course curriculum. Other manuals and course material may be used to supplement
the curriculum. Instructors shall use the companion instructor's guide,
catalogue number 50-5061-I.
(B) A training agency identified in
paragraphs (9)(A)3.-5. of this rule, shall teach the basic course content
outlined in paragraphs (5)(B)1. and 2. by August 31, 2021, a training agency
identified paragraphs (9)(A)1., (9)(A)2., and (9)(A)6. of this rule, shall
transition and begin teaching the basic course content outlined in paragraphs
(5)(B)1. and 2. This basic course includes the following:
1. The curriculum content shall include the
required seventy-five (75) hours of instructional training and covers all of
the following areas:
A. Communication and
interpersonal skills;
B. Infection
control;
C. Safety/emergency
procedures, including the Heimlich maneuver;
D. Promoting residents'
independence;
E. Respecting
residents' rights;
F. Basic nursing
skills including, but not limited to-
(I)
Taking and recording vital signs;
(II) Measuring and recording height and
weight;
(III) Caring for the
residents' environment;
(IV)
Recognizing abnormal changes in body functioning and the importance of
reporting such changes to a supervisor; and
(V) Caring for residents when death is
imminent;
G. Personal
care skills including, but not limited to-
(I)
Bathing;
(II) Grooming, including
mouth care;
(III)
Dressing;
(IV) Toileting;
(V) Assisting with eating and
hydration;
(VI) Proper feeding
techniques;
(VII) Skin care;
and
(VIII) Transfers, positioning,
and turning;
H. Mental
health and social service needs including, but not limited to-
(I) Modifying nursing assistant's behavior in
response to resident's behavior;
(II) Awareness of developmental tasks
associated with the aging process;
(III) How to respond to resident
behavior;
(IV) Allowing the
residents to make personal choices, providing and reinforcing other behavior
consistent with the resident's dignity; and
(V) Utilizing the resident's family as a
source of emotional support;
I. Care of cognitively impaired residents
including, but not limited to-
(I) Techniques
for addressing the unique needs and behaviors of individuals with dementia
(Alzheimer's and others);
(II)
Communicating with cognitively impaired residents;
(III) Understanding the behavior of
cognitively impaired residents;
(IV) Appropriate responses to the behavior of
cognitively impaired residents; and
(V) Methods of reducing the effects of
cognitive impairments;
J. Basic restorative services including, but
not limited to-
(I) Training the resident in
self-care according to the resident's abilities;
(II) The use of assistive devices in
transferring, ambulation, eating, and dressing;
(III) Maintenance of range of
motion;
(IV) Proper turning and
positioning in bed and chair;
(V)
Bowel and bladder training; and
(VI) Care and use of prosthetic and orthotic
devices;
K. Residents'
rights including, but not limited to-
(I)
Providing privacy and maintenance of confidentiality;
(II) Promoting the residents' right to make
personal choices to accommodate their needs;
(III) Giving assistance in resolving
grievances and disputes;
(IV)
Providing needed assistance in getting to and participating in resident and
family groups and other activities;
(V) Maintaining care and security of
residents' personal possessions;
(VI) Promoting the residents' right to be
free from abuse, mistreatment, and neglect and the need to report any instances
of such treatment to appropriate facility staff; and
(VII) Avoiding the need for restraints in
accordance with current professional standards; and
2. The basic course
shall be taught using current published instruction material(s) that are no
more than ten (10) years old. The material(s) shall include current standards
of practice for nursing assistants. Other course materials that contain current
standards of practice in healthcare and are no more than ten (10) years old may
be used to supplement the curriculum.
(6) Student Enrollment and Qualifications.
(A) Any individual who is employable by an
intermediate care facility (ICF) or skilled nursing facility (SNF) to be
involved in direct resident care shall be eligible to enroll in a training
agency's nursing assistant training program if-
1. The individual is at least eighteen (18)
years of age and employable. Employable shall mean that the individual is not
listed on the department 's Employee Disqualification List (EDL) and has not
been convicted or entered a plea of guilty to a misdemeanor or felony charge
which includes any suspended imposition of sentence, any suspended execution of
sentence or any period of probation or parole in this state or any other state
which if committed in Missouri would be a class A or B felony violation of
Chapters 565, 566, or 569, RSMo, or any violation of subsection 198.070.3,
RSMo, or section
568.020, RSMo,
unless a good cause waiver has been granted by the department ; or
2. The individual is at least sixteen (16)
years of age providing he or she is-
A.
Currently enrolled in a secondary school health services occupation program or
a cooperative work education program of an area vocational technical school or
comprehensive high school;
B.
Placed for work experience in an ICF, SNF, hospital, Missouri Veterans' Home,
or a hospital-based nursing facility or hospital-based skilled nursing facility
by that program;
C. Not listed on
the department 's EDL and has not been convicted or entered a plea of guilty to
a misdemeanor or felony charge which includes any suspended imposition of
sentence, any suspended execution of sentence, or any period of probation or
parole in this state or any other state which if committed in Missouri would be
a class A or B felony violation of Chapters 565, 566, or 569, RSMo, or any
violation of subsection 198.070.3, RSMo, or section
568.020, RSMo,
unless a good cause waiver has been granted by the department ; and
D. Under the direct supervision of an
instructor or clinical supervisor, or both, while completing the clinical
portion of the course.
(B) Prior to any direct contact with a
resident, a student enrolled in the basic course in a Medicare or Medicaid
certified facility shall complete sixteen (16) of the required seventy-five
(75) hours of instructional training in communication and interpersonal skills;
infection control; safety/emergency procedures, including the Heimlich
maneuver; promoting residents' independence; and respecting residents'
rights.
(C) If a student drops the
basic course, the student may reenroll in a course within six (6) months and
make up the course material missed without retaking the entire basic course
after presenting proof of attendance and materials covered in the original
class.
(D) A student shall not
perform any services for which the student has not been trained nor found
proficient by the instructor and/or clinical supervisor.
(E) A student who received instructional
training from the basic course content outlined in paragraphs (5)(B)1. and 2.
of this rule, shall register with the department approved third party test
administrator upon successful completion of the seventy-five (75) hours of
instructional training and one hundred (100) hours of supervised on-the-job
training.
(7) Employees
of a Long-Term Care (LTC) Facility. Each CNA hired to work in an ICF or SNF
after January 1, 1980, shall have successfully completed a nursing assistant
training program approved by the department or shall enroll in and begin the
first available approved training program which is scheduled to commence within
ninety (90) days of the date of the CNAs employment and which shall be
completed within four (4) months of employment.
(8) Final Examination Challenge.
(A) Individuals eligible to challenge the
final examination, includes-
1. Individuals
who were enrolled in a RN or LPN nursing education program for at least four
(4) months and successfully completed a course on the fundamentals of nursing,
including clinical hours within the last five (5) years;
2. Individuals currently enrolled in a RN or
LPN nursing education program and who have successfully completed a course on
the fundamentals of nursing, including clinical hours;
3. RN or LPN nursing licensure candidates who
have failed state licensure examinations within the last five (5)
years;
4. Individuals who have met
the requirements of unlicensed assistive personnel contained in
19 CSR
30-20.125;
5. Individuals trained by a hospital as
nursing assistants or psychiatric aides who have completed the following:
A. One hundred (100) hours of supervised
on-the-job training in an ICF, SNF, hospital, Missouri Veterans' Home, or
hospital-based nursing facility or hospital-based skilled nursing facility;
and
B. Instruction that covers the
basic course content outlined in paragraphs (5)(B)1. and 2. of this
rule;
6. Any other
persons whose background, education, and training in gerontology and health
occupations includes components of the basic course content outlined in
paragraphs (5)(B)1. and 2. may be allowed to challenge the final examination
after taking those portions of the course as determined to be necessary based
on evaluation of their credentials by the Section for LongTerm Care Regulation,
Health Education Unit;
7. A CNA who
is listed as inactive for less than five (5) years on the Missouri Certified
Nurse Assistant Registry and cannot provide the required employment
documentation in accordance with section (18) of this rule; and
8. Individuals who have successfully
completed a nursing program outside the United States within the last five (5)
years or who have obtained a nursing license outside the United
States.
(B) Individuals
who are certified and active on another state's nurse aide registry shall not
be required to challenge the final examination. The individual shall submit, in
writing to the department , a request to be added to the Missouri Certified
Nurse Assistant Registry. At a minimum, the request shall include: the
individual's legal name; Social Security number; current address; telephone
number; email address, if applicable; and proof of their current certified
nursing assistant certificate. The department will respond in writing, either
approving or denying the request to be added to the registry.
(C) Individuals identified as eligible to
challenge the final examination in paragraphs (8)(A)1.-7., shall submit a
request in writing to the department and enclose, at a minimum, the following
information: legal name; Social Security number; current address and telephone
number; email address, as applicable; and transcripts. The department will
respond in writing, either approving or denying the request to challenge the
final examination. If approved, the department shall provide a list of
individuals eligible to take the examination to the department approved third
party test administrator.
(D)
Individuals identified in paragraph (8)(A)8., shall submit a request in writing
to the department to take the final examination and enclose, at a minimum, the
following information: legal name; Social Security number; current address and
telephone number; email address, as applicable; a copy of the out-of-coun-try
license or certificate translated to English; a copy of the school transcript
translated to English; and a copy of the out-ofcountry criminal background
check translated to English. The department will respond in writing, either
approving or denying the request to challenge the final examination. If
approved, the department shall provide a list of individuals eligible to take
the examination to the department approved third party test
administrator.
(E) Those
individuals permitted to challenge shall take the final examination within one
hundred twenty (120) calendar days of the department notification. Permission
letters not utilized within the one hundred twenty- (120-) day period shall be
considered invalid and reapplication for permission to challenge shall be made
to the department .
(F) If an
individual fails the final examination after one (1) attempt, he or she shall
successfully complete basic course in its entirety.
(9) Training Agency Responsibilities.
(A) The following entities are eligible to
apply to the department to be an approved training agency::
1. Career Center schools and comprehensive
high schools approved by the Missouri Department of Elementary and Secondary
Education (DESE) that offer health service occupation programs which have a
practice classroom and equipment used in delivering health care. There shall be
a signed written agreement of cooperation with one (1) or more ICFs, SNFs,
hospitals, Missouri Veterans' Homes, or hospital-based nursing facilities or
hospital-based skilled nursing facilities in their vicinity for the one hundred
(100) hours of supervised on-the-job training component of the basic
course;
2. Public community
colleges, public colleges and universities, proprietary schools, or private
agencies approved by the Missouri Department of Higher Education and Workforce
Development (MDHEWD) or accredited by a recognized accrediting agency or
association on the list published by the Secretary of the United States
Department of Education, pursuant to the Higher Education Act of 1965, the
Higher Education Opportunity Act 2008 (
Public
Law 110-315 ), and the Veterans' Readjustment
Assistance Act which have a practice laboratory with one (1) or more bed units
and equipment used in delivering health care and have a signed written
agreement of cooperation with one (1) or more ICFs, SNFs, hospitals, Missouri
Veterans' Homes, or hospital-based nursing facilities or hospitalbased skilled
nursing facilities in their vicinity for the one hundred (100) hours of
supervised on-the-job training component of the basic course;
3. Associations as defined in section (1) of
this rule. There shall be a signed written agreement of cooperation with an
ICF, SNF, hospital, Missouri Veterans' Home, or a hospital-based nursing
facility or hospital-based skilled nursing facility to provide the one hundred
(100) hours of supervised on-the-job training;
4. A licensed ICF, SNF, or a hospital-based nursing
facility or hospital-based skilled nursing facility. There shall be a signed
written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans'
Home, or a hospital-based nursing facility or hospitalbased skilled nursing
facility if the one hundred (100) hours of supervised on-the-job training is
not provided on-site;
5. Licensed
hospitals. There shall be a signed written agreement of cooperation with an
ICF, SNF, hospital, Missouri Veterans' Home, or a hospital-based nursing
facility or hospital-based skilled nursing facility if the one hundred (100)
hours of supervised on-the-job training is not provided on site; or
6. Missouri Veterans' Homes. There shall be a
signed written agreement of cooperation with an ICF, SNF, hospital, Missouri
Veterans' Home, or a hospital-based nursing facility or hospital-based skilled
nursing facility if the one hundred (100) hours of supervised on-the-job
training is not provided on site.
(B) Organizations identified in paragraphs
(9)(A)1.-6. which want to be approved by the department to teach the program
shall submit to the department form DHSS-DRL-2469 (08-20), Application for
Approval as a Nursing Assistant Training Agency, included herein.
(C) In order to be approved, the applicant
shall have a designated location which contains sufficient space, equipment,
and teaching aids to meet the course objectives and accommodate the maximum
number of students allowed. The instructor and each student shall be provided
with the required curricula content and instructional material(s) for the basic
course identified in section (5) of this rule.
(D) Any ICF or SNF which has received a Class
I notice of noncompliance related to administration and resident care from the
department in the two- (2-) year period prior to application for approval shall
not be eligible for approval . If this notice is issued after approval, the
approval shall be withdrawn by the department within ninety (90) calendar days
and the certifying agencies shall be notified of the withdrawal of approval.
Students already enrolled in the basic course may complete the course if a
notice is issued after the basic course has begun.
(E) An ICF or SNF whose approval has been
withdrawn for a Class I notice of noncompliance related to administration and
resident care may request in writing to the department for an exception to
train and test nursing assistants. This written request shall include, at a
minimum, the following information:
1. The
training site name, and training site number, address, telephone and fax
number, and email address as applicable;
2. Administrator's name and facility
operator's name and address;
3.
Sponsoring training site name, sponsoring training site number, sponsoring
training site's instructor's name, instructor's Social Security number, and
email address as applicable;
4. The
exit date of the noncompliance interview for each deficiency of a Class I in
the areas of administration and resident care requirements in
19 CSR
30-85.042; reason(s) for noncompliance; explanation of
efforts in locating another training agency within a reasonable distance (at
least one-half (1/2) hour travel time each way from the facility);
and
5. A student roster for each
class. The student roster shall include each student's name; student's address
and telephone number; student's Social Security number; and the student's email
address, as applicable; class begin date; number of students completed;
instructor's name and telephone number; instructor's license number;
instructor's Social Security number; instructor's employer; and the
instructor's email address, as applicable.
(F) The department shall make an on-site inspection of
each training agency's premises within two (2) years of approval and every two
(2) years following to determine the adequacy of space; equipment and supplies;
and, if clinical training is not done on-site, verify that there is a current
copy of a signed written agreement of cooperation with an ICF, SNF, hospital,
Missouri Veterans' Home, or a hospital-based nursing facility or hospital-based
skilled nursing facility for the clinical portion of the course.
(G) Upon receipt of the completed form
DHSS-DRL-2469 (08-20), Application for Approval as a Nursing Assistant Training
Agency, the department shall notify the applicant in writing within ninety (90)
calendar days of approval or disapproval. If disapproved, the reasons why shall
be given.
(H) Training agencies
shall be approved for a two- (2-) year period and shall submit a new
application for approval thirty (30) calendar days prior to the expiration of
approval.
(I) The training agency
shall be responsible for obtaining an approved instructor and providing
training materials for each student. If an instructor is not employed by the
training agency, there shall be a signed written agreement of cooperation
between the training agency and the instructor.
(J) The training agency shall be responsible
for obtaining an approved clinical supervisor. If a clinical supervisor is not
employed by a training agency, there shall be a signed written agreement of
cooperation between the training agency and the clinical supervisor.
(K) If the training agency is not a licensed
ICF or SNF, the agency shall have a signed written agreement of cooperation
currently in effect with an ICF, SNF, hospital, Missouri Veterans' Home, or a
hospital-based nursing facility or hospital-based skilled nursing facility
where the one hundred (100) hours of supervised on-the-job training shall be
conducted.
(L) In the event that a
qualified instructor for the basic course did not sign records of a student who
successfully completed the program, without justification or due to resignation
from his or her position, the administrator or designee of the training agency
shall validate the training by signature.
(M) Evidence of successful completion of the
basic course shall be documented prior to a student taking the final
examination and shall include:
1. Class
schedules and form MO 580-2473 (12-07) Certified Nurse Assistant Competency
Score Sheet (For Use Only With The 2001 Manual) Appendix A/B, included herein
for training agencies using the basic course content outlined in paragraphs
(5)(A)1. and 2. of this rule; or
2.
Class schedules and form DHSS-DRL-111 (08-20), Classroom and On-the-Job
Training Record, included herein for training agencies using the basic course
content outlined in paragraphs (5)(B)1. and 2. of this rule.
(N) The training agency shall
ensure that all applicable portions of appropriate forms identified in
paragraphs (9)(M)1. and 2. of this rule are complete and shall provide a copy
to the student within seven (7) calendar days of successful completion of the
seventy-five (75) hours of instructional training and one hundred (100) hours
of supervised on-the-job training.
(O) The training agency shall maintain
records for a minimum of two (2) years for those individuals who have completed
the basic course.
(10)
Certifying Agency Responsibilities.
(A) In
order for a certifying agency to be approved by the department , the agency
shall have a signed written agreement of cooperation with the department which
shall be renewable every five (5) years.
(B) Certifying agencies that provide the
Nursing Assistant Instructor Workshop and the Nursing Assistant Clinical
Supervisor Workshop shall complete the following responsibilities:
1. Verify eligibility requirements for the
participants enrolled in the Nursing Assistant Instructor Workshop and the
Nursing Assistant Clinical Supervisor Workshop;
2. Provide qualified Registered Nurse
Instructor Trainers to teach the applicable workshop(s);
3. Issue the applicable workshop
certificate(s) to participants upon successful completion; and
4. Within seven (7) calendar days of issuing
the workshop certificate, provide a listing of approved instructors and
clinical supervisors to the department that includes: the name of workshop
completed; participant's legal name, address, and telephone number; email
address, as applicable; Social Security number; and date of birth.
(C) Certifying agencies that
provide the four (4) hour instructor update training shall comply with the
requirements in section (16) of this rule.
(D) Maintain accurate and complete records
for a period of at least two (2) years.
(11) Instructor and Clinical Supervisor/Stu-dent
Ratios. During the required one hundred (100) hours of supervised on-the-job
training, the training agency's instructor and clinical supervisor/student
ratio shall be a maximum of one to fifteen (1:15).
(12) Qualifications of Instructors, Clinical
Supervisors, and Examiners
(A) Instructor.
1. An instructor shall be currently licensed
as a RN in Missouri or shall hold a current temporary permit from the Missouri
State Board of Nursing or shall hold a multi-state or single state RN license
from a jurisdiction that is party to the Nurse Licensure Compact. The licensee
shall not be subject of current disciplinary action, such as censure,
probation, suspension, or revocation.
2. An instructor shall not be listed on the
department 's EDL.
3. An individual
that has been previously disqualified as an instructor shall not function as an
instructor unless he or she receives written approval from the
department .
4. An instructor shall
have had, at a minimum, two (2) years of nursing experience and at least one
(1) year of experience in the provision of long-term care facility services in
the last ten (10) years. Other personnel from the health professions may assist
the instructor; however, they shall have at least one (1) year of experience in
their field.
5. An instructor
shall successfully complete a Nursing Assistant Instructor Workshop by a
certifying agency using qualified instructors. The department shall issue a
letter of approval to the qualified instructor after the individual has
successfully completed the workshop. The department shall maintain a list of
approved instructors.
6. An
instructor shall be responsible to teach the seventy-five (75) hours of
instructional training for the basic course and a minimum of sixteen (16) of
the one hundred (100) hours of supervised onthe-job training in accordance with
the requirements contained in this rule.
7. The instructor teaching the seventy-five
(75) hours of instructional training and/or sixteen (16) of the one hundred
(100) hours of supervised on-the-job training for the basic course shall
complete and sign all applicable portions of either form MO 580-2473 (12-07)
Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001
Manual) Appendix A/B for training agencies using the basic course content
outlined in paragraphs (5)(A)1. and 2. or form DHSS-DRL-111 (08-20), Classroom
and On-the-Job Training Record for training agencies using the basic course
content outlined in paragraphs (5)(B)1. and 2. for each student participating
in the program.
8. An instructor
shall provide to the student within seven (7) calendar days of successful
completion of the seventy-five (75) hours of instructional training and one
hundred (100) hours of supervised on-the-job training, either completed form MO
580-2473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only
With The 2001 Manual) Appendix A/B for training agencies using the basic course
content outlined in paragraphs (5)(A)1. and 2. or form DHSS-DRL-111 (08-20),
Classroom and On-the-Job Training Record for training agencies using the basic
course content outlined in paragraphs (5)(B)1. and 2.
9. If the course is not completed, records
and documentation regarding the completed portions shall be provided by the
instructor to the student, if requested, and to the training agency.
(B) Clinical Supervisor
(On-the-Job Supervisor).
1. The clinical
supervisor shall be currently licensed as a RN or LPN in Missouri or hold a
current temporary permit from the Missouri Board of Nursing or shall hold a
multi-state or single state RN or LPN license from a jurisdiction that is party
to the Nurse Licensure Compact. The licensee shall not be subject of current
disciplinary action such as censure, probation, suspension, or
revocation.
2. A clinical
supervisor shall not be listed on the department 's EDL.
3. An individual that has been previously
disqualified as a clinical supervisor shall not function as a clinical
supervisor unless he or she receives written approval from the
department .
4. The clinical
supervisor, if not currently employed by an ICF, SNF, hospital, or Missouri
Veterans' Home, shall have at least one (1) year of licensed nursing
experience. The clinical supervisor shall be currently employed by the approved
training agency facility where the students are performing their duties or by
the training agency conducting the program.
5. A clinical supervisor shall successfully
complete a Nursing Assistant Clinical Supervisor Workshop by a certifying
agency using qualified instructors. The department shall issue a letter of
approval to the qualified clinical supervisor after the individual has
successfully completed the workshop. The department shall maintain a list of
approved clinical supervisors.
6.
The clinical supervisor shall be on the facility premises in which the students
are performing their duties while the students are completing the on-the-job
component of their training and shall directly assist the students in their
training and observe their skills when checking their competencies.
7. A clinical supervisor shall be responsible
to supervise eighty-four (84) of the one hundred (100) hours of supervised
on-the-job training in accordance with the requirements contained in this
rule.
8. The clinical supervisor(s)
shall complete and sign all applicable portions of form MO 580-2473 (12-07)
Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001
Manual) Appendix A/B for training agencies using the basic course content
outlined in paragraphs (5)(A)1. and 2. or form DHSS-DRL-111 (08-20), Classroom
and On-the-Job Training Record for training agencies using the basic course
content outlined in paragraphs (5)(B)1. and 2. for each student participating
in the program.
(C)
Examiner.
1. An examiner using the
department 's testing materials for the basic course content outlined in
paragraphs (5)(A)1. and 2. of this rule shall be-
A. A RN currently licensed in Missouri or
shall hold a current temporary permit from the Missouri State Board of Nursing,
or shall hold a multi-state or single state RN license from a jurisdiction that
is party to the Nurse Licensure Compact and shall not be currently subject of
disciplinary action such as censure, probation, suspension, or
revocation.
B. The examiner shall
have taught a similar course or shall be qualified to teach a similar course;
but shall not have been the instructor of the students being examined; and
shall not be employed by the operator whose students are being examined. The
examiner shall be specifically approved by the department to administer final
examinations of the state-approved nurse assistant training curriculum and
shall have signed an agreement with the department to protect and keep secure
the final examinations.
2. Causes for Disqualification. A person shall not be
allowed to be an examiner if it is found that he or she-
A. Knowingly acted or omitted any duty in a
manner which would materially or adversely affect the health, safety, welfare,
or property of a resident;
B.
Defrauded a training agency or student by taking payment and not completing a
course, not administering the final examination as required, or not being
on-site while students are being trained;
C. Failed to teach, examine, or clinically supervise
in accordance with 19 CSR 30-84.010, or taught students from the state test,
changed answers on the state test, lost test booklets, or recorded false
information on test materials or test booklets of the program; or
D. Failed to send documentation of a
completed course to a certifying agency within thirty (30) days.
3. Notification of
Disqualification.
A. The department shall
notify the individual that he or she is no longer eligible to be an
examiner.
B. The department shall
notify all approved training and certifying agencies if it has been determined
that an individual is no longer considered an approved examiner and that
person's name shall be removed from the lists maintained by the department of
approved examiners.
C. To be
reinstated as a state-approved examiner the individual shall submit a request
in writing to the department stating the reasons why reinstatement is
warranted. The department shall respond in writing to the request.
(13)
Instructor and Clinical Supervisor Disqualification Criteria.
(A) Causes for Disqualification. The
department may disqualify an individual as an instructor or clinical supervisor
if it is found the individual failed to follow the requirements in section (12)
of this rule or-
1. Knowingly acted or
omitted any duty in a manner which would materially or adversely affect the
health, safety, welfare, or property of a resident;
2. Defrauded a training agency or student by
taking payment and not completing a course or not being on-site while students
are being trained;
3. Failed to
teach or clinically supervise in accordance with the regulations contained in
this rule, or provide false information to the department ; or
4. Is disqualified as a RN Test Observer by
the department approved third party test administrator.
(B) Notification of Disqualification.
1. The department shall notify the individual
that he or she is no longer eligible to be an instructor or clinical
supervisor.
2. The department shall
notify all certifying agencies if it has been determined that an individual is
no longer considered an approved instructor or clinical supervisor and that
person's name shall be removed from the lists maintained by the department of
approved instructors or clinical supervisors.
3. To be reinstated as an approved instructor
or clinical supervisor, the individual shall submit a request in writing to the
department stating the reasons why reinstatement is warranted. The department
shall respond in writing to the request.
(14) Training and Certifying Agency
Disqualification Criteria.
(A) Causes for
Disqualification. The department may disqualify a training agency or certifying
agency if it is found that an agency failed to follow the requirements in
section (9) for a training agency or section (10) for a certifying agency of
this rule or-
1. Defrauded a student by
taking payment and not ensuring the seventy five (75) hours instructional
training or on-the-job training were completed as required by this rule; or
2. Failed to maintain approval from
MDHEWD or DESE, if applicable
(15) Registered Nurse Instructor Trainer
Responsibilities.
(A) The RN Instructor
Trainer shall be currently licensed as a RN in Missouri or shall hold a current
temporary permit from the Missouri State Board of Nursing or shall hold a
multi-state or single state RN license from a jurisdiction that is party to the
Nurse Licensure Compact. The RN Instructor Trainer shall not be subject of
current disciplinary action, such as censure, probation, suspension, or
revocation and shall not be listed on the department 's EDL.
(B) The RN Instructor Trainer shall also be,
at a minimum, an approved nursing assistant instructor.
(C) The RN Instructor Trainer shall be
employed or contracted by a certifying agency to instruct the Nursing Assistant
Instructor Workshop, Nursing Assistant Clinical Supervisor Workshop, and the
Instructor Update Training.
(16) Instructor Update Training.
(A) The instructor shall attend a four (4)
hour update training provided by a certifying agency every five (5) years. This
update training shall include, at a minimum, the following:
1. Instruction on how to complete form
DHSS-DRL-111 (0820), Classroom and On-the-Job Training Record;
2. Instruction on the fundamentals of adult
learning;
3. Instruction in at
least one (1) area regarding standards of practice in long term care such as
pressure ulcer prevention, dining practices, or resident rights
issues;
4. Instruction on providing
care for cognitively impaired residents;
5. Review of the Nursing Assistant Training
Program regulations contained in 19 CSR 30-84.010; and
6. Review of the administration and resident
care requirements contained in
19 CSR
30-85.042.
(B) The certifying agency shall provide a
list of the instructors that complete the update training to the department
within seven (7) calendar days of completion of the training.
(C) Any instructor who has not completed the
required four (4) hour update training by August 31, 2022, and every five (5)
years thereafter shall be removed from the department -approved list of
instructors. If removed from the department 's list, the instructor shall attend
and successfully complete the Nursing Assistant Instructor Workshop in order to
be reinstated to act as an instructor.
(17) Final Examination Testing.
(A) In order to be eligible for testing, a
student shall have either completed the following:
1. Seventy-five (75) hours of instructional
training and the one hundred (100) hours of supervised on-the-job training
offered by a training agency. The student shall pass a minimum of three (3)
written or oral tests throughout the course with an eighty percent (80%) score
or better on each test in order to be eligible to take the final examination.
Each test shall consist of a minimum of fifteen (15) questions; or
2. Possess an approval letter from the
department granting approval to challenge the final examination.
(B) If the course content
outlined in paragraphs (5)(A)1. and 2. of this rule is used for teaching the
basic course, the final examination shall be conducted by an approved examiner
who may be assisted by the instructor using the following procedures:
1. The instructor will select an LTC resident
to participate in the testing process and obtain approval for this activity
from the resident
2. The examiner
shall verify the eligibility of the students by reviewing form MO 580-2473
(12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The
2001 Manual) Appendix A/B to establish that the student has completed the
approved training program or possesses an approval letter from the department
granting approval to challenge the final examination;
3. The student shall successfully complete at
least nine (9) procedures under the observation of the instructor or a facility
licensed nurse and examiner
A. The nine (9)
procedures shall always include a type of bath, vital signs (temperature,
pulse, respirations, and blood pressure), transfer techniques, feeding
techniques, dressing and grooming, skin care, active or passive, range of
motion to upper and lower extremities (unless contraindicated by a physician's
order), and handwashing and gloving from the standardized curriculum.
B. The remainder shall be selected according
to the resident's care needs at the time of day that testing occurs.
C. The evaluation of the student shall
include communication and interaction with the resident, provision of privacy,
work habits, appearance, conduct, and reporting and recording skills;
4. The student shall successfully
answer forty (40) out of fifty (50) oral or written questions presented by the
examiner based on the standardized curriculum and selected from a specific test
pool of questions which are safeguarded by the department ;
5. The examiner who uses the basic course
content outlined in paragraphs (5)(A)1. and 2. of the basic course for the
final examination shall notify the department and obtain different examinations
to be administered each time; and
6. The examiner who uses the basic course
content outlined in paragraphs (5)(A)1. and 2. of the basic course for the
final examination shall conduct the following:
A. Complete and sign form MO 580-2473 (12-07)
Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001
Manual) Appendix A/B and the final examination score sheet which shall include
scores and comments. The examiner shall advise the individual that successful
completion of the evaluation will result in the addition of his/her name to the
CNA Registry;
B. After scoring, the
examiner shall return all test materials, test booklets, answer sheets, and any
appendices to the department . The examiner shall also provide the training
agency with documentation of the student's test scores; and
C. A copy of the student's final record
sheets shall be provided to the student (except for the answer sheets). If the
course is not completed, records and documentation regarding the portions
completed shall be provided to the student, if requested, and to the training
agency.
(C)
If the basic course content outlined in paragraphs (5)(B)1. and 2. of this
rule, is used to teach the course, testing shall comply with the following:
1. The instructor shall verify the
eligibility of the students by reviewing form DHSS-DRL-111 (08-20), Classroom
and On-the-Job Training Record, to establish that the student has completed the
approved program;
2. The final
examination shall be conducted by the department approved third party test
administrator and a fee will be assessed for each examination;
3. The student shall successfully complete an
examination proctored by the department approved third party test
administrator. The student shall achieve a passing score of at least eighty
percent (80%); and
4. The student
shall successfully complete the skills evaluation portion of the examination
proctored by the department approved third party test administrator. The
student shall achieve a score of one hundred percent (100%).
(D) Any individual who fails the
final examination, except those who have been permitted to challenge the
examination, shall have the opportunity to retake the examination twice within
ninety (90) calendar days of the initial examination. If the individual fails
the final examination a third time, the entire basic course shall be retaken
before another examination can be given.
(E) Any individual who is employed by a LTC facility
and required by section
198.082,
RSMo, to enroll in the program, but who has been permitted to challenge the
final examination and who fails the examination, must immediately re-enroll in
and begin study in the next available basic course. The individual shall
complete the basic course within four (4) months of employment.
(18) CNA Registry.
(A) If the CNA passes the final examination,
the individual's name shall be placed on the CNA active registry.
(B) CNAs shall submit documentation (e.g.,
pay stubs, W-2, letter from employer, etc.) of work in nursing or nursing
related services for at least one (1) day (e.g. eight (8) hours) within each
twenty-four- (24-) consecutive month period to maintain active status.
Documentation shall be submitted to the department approved third party test
administrator and a fee will be assessed for each renewal.
(C) A CNA who has been inactive on the
registry for less than five (5) years and cannot provide documentation (e.g.,
pay stubs, W-2, letter from employer, etc.) of work in nursing or nursing
related services for at least one (1) day (e.g. eight (8) hours) within each
twenty-four- (24-) consecutive month period shall challenge the final
examination in accordance with section (8) of this rule before the CNA is
reinstated to the active registry.
(D) A CNA who has been inactive on the
registry for more than five (5) years and cannot provide documentation (e.g.,
pay stubs, W-2, letter from employer, etc.) of work in nursing or nursing
related services for at least one (1) day (e.g. eight (8) hours) within each
twenty-four- (24-) consecutive month period is not eligible to challenge the
final examination and shall successfully complete the entire basic course
before the CNA is reinstated to the active registry.
MISSOURI
CERTIFIED NURSE ASSISTANT COMPETENCY SCORE SHEET (FOR USE ONLY WITH 2001 MANUAL)
APPENDIX A
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Appendix B
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Notes
*Original authority: 198.079, RSMo 1979 and 198.082, RSMo 1979, amended 1988.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
PURPOSE: This amendment updates and adds requirements for the basic course curricula content and adds requirements for update training for instructors. Clarifies student requirements and who is eligible to challenge the final examination. Clarifies requirements for employees of a long-term care facility. Updates instructor/clinical supervisor/student ratios. Adds requirements for a RN Instructor Trainer. Revises requirements to allow for a department approved third party proctor to administer the final examination test. Updates and adds requirements for training and certifying agencies. Clarifies and adds requirements for instructors and clinical supervisors. Updates definitions, removes redundancy, outdated language, and makes grammatical changes.
(1) Definitions. For the purpose of this rule, the following definitions shall apply:
(A) Association-means the Missouri Health Care Association, the Missouri Association of Nursing Home Administrators, Leading Age Missouri, or Missouri Hospital Association;
(B) Basic course -means the seventy-five (75) hours of instructional training, the one hundred (100) hours of supervised on-the-job training, and the final examination of the nursing assistant training course;
(C) Certifying agency -means an long-term care (LTC) association, Career Center school, comprehensive high school, community college, or four- (4-) year institution of higher learning approved by the department;
(D) Challenge the final examination -means taking the final examination of the basic course without taking the entire basic course;
(E) Department-means the Missouri Department of Health and Senior Services;
(F) Hospital-means any licensed hospital as defined in section 197.020, RSMo;
(G) Missouri Veterans' Home-means any facilities established and maintained as a Missouri Veterans' Home as defined in section 42.002, RSMo;
(H) Nursing Assistant Clinical Supervisor Workshop-means the training course approved by the department and conducted by a certifying agency to prepare clinical supervisors to learn the methodology of teaching the supervised on-the-job training component of the nursing assistant training program;
(I) Nursing Assistant Instructor Workshop-means a training course approved by the department and conducted by a certifying agency to prepare instructors to learn the methodology of teaching the nursing assistant training program;
(J) Program-means the nursing assistant training program as required by section 198.082, RSMo;
(K) Registered Nurse Instructor Trainer-means a registered nurse (RN) approved by a certifying agency to teach the Nursing Assistant Instructor Workshop and the Nursing Assistant Clinical Supervisor Workshop to prepare instructors and clinical supervisors to teach the nursing assistant training program; and
(L) Training agency-means an organization approved by the department which sponsors the approved nursing assistant training program.
(2) The purpose of the program shall be to prepare individuals for employment as a certified nursing assistant (CNA). The program shall be designed to teach skills in resident care which will qualify individuals to perform uncomplicated nursing procedures and to assist licensed practical nurses (LPNs) or RNs in direct resident care.
(3) All aspects of the program included in this rule (that is, qualified instructor, clinical supervisor, course curriculum, training agency, certifying agency, supervised on-the-job training, testing, and student qualifications) shall be met in order for a program to be considered as approved.
(4) Basic Course Requirements. The program shall consist of a basic course that includes, at a minimum , the following:
(A) Seventy-five (75) hours of instructional training in the curricula identified in section (5) of this rule;
(B) One hundred (100) hours of supervised on-the-job training (clinical practice) in an approved laboratory or other setting in which the student demonstrates knowledge while performing tasks on an individual under the supervision of a LPN or RN; and
(C) A final examination.
(5) Curricula Content.
(A) Until August 31, 2021, a training agency identified in paragraphs (9)(A)1., (9)(A)2., and (9)(A)6. of this rule, shall teach the basic course and utilize either the content outlined in paragraphs (5)(A)1. and 2. or (5)(B)1. and 2. This basic course includes the following:
1. Curriculum content of the program shall include procedures and instructions on basic nursing skills in the following areas: basic hygiene techniques; bedmaking; personal care of residents; food service; charting; safety measures (including fire/safety and disaster preparedness and infection control); basic preventative and restorative care and procedures; basic observation procedures, such as weighing and measuring; communication skills; methods of handling and caring for mentally confused residents; residents' rights; ethical and legal responsibilities; death and dying; and mental health and social needs; and
2. The course curriculum as outlined in the manual entitled The Nurse Assistant in a Long-Term Care Facility, produced by the Instructional Materials Laboratory, University of Missouri-Columbia, revised November 2001, catalogue number 50-5061-S shall be considered an approved course curriculum. Other manuals and course material may be used to supplement the curriculum. Instructors shall use the companion instructor's guide, catalogue number 50-5061-I.
(B) A training agency identified in paragraphs (9)(A)3.-5. of this rule, shall teach the basic course content outlined in paragraphs (5)(B)1. and 2. by August 31, 2021, a training agency identified paragraphs (9)(A)1., (9)(A)2., and (9)(A)6. of this rule, shall transition and begin teaching the basic course content outlined in paragraphs (5)(B)1. and 2. This basic course includes the following:
1. The curriculum content shall include the required seventy-five (75) hours of instructional training and covers all of the following areas:
A. Communication and interpersonal skills;
B. Infection control;
C. Safety/emergency procedures, including the Heimlich maneuver;
D. Promoting residents' independence;
E. Respecting residents' rights;
F. Basic nursing skills including, but not limited to-
(I) Taking and recording vital signs;
(II) Measuring and recording height and weight;
(III) Caring for the residents' environment;
(IV) Recognizing abnormal changes in body functioning and the importance of reporting such changes to a supervisor; and
(V) Caring for residents when death is imminent;
G. Personal care skills including, but not limited to-
(I) Bathing;
(II) Grooming, including mouth care;
(III) Dressing;
(IV) Toileting;
(V) Assisting with eating and hydration;
(VI) Proper feeding techniques;
(VII) Skin care; and
(VIII) Transfers, positioning, and turning;
H. Mental health and social service needs including, but not limited to-
(I) Modifying nursing assistant's behavior in response to resident's behavior;
(II) Awareness of developmental tasks associated with the aging process;
(III) How to respond to resident behavior;
(IV) Allowing the residents to make personal choices, providing and reinforcing other behavior consistent with the resident's dignity; and
(V) Utilizing the resident's family as a source of emotional support;
I. Care of cognitively impaired residents including, but not limited to-
(I) Techniques for addressing the unique needs and behaviors of individuals with dementia (Alzheimer's and others);
(II) Communicating with cognitively impaired residents;
(III) Understanding the behavior of cognitively impaired residents;
(IV) Appropriate responses to the behavior of cognitively impaired residents; and
(V) Methods of reducing the effects of cognitive impairments;
J. Basic restorative services including, but not limited to-
(I) Training the resident in self-care according to the resident's abilities;
(II) The use of assistive devices in transferring, ambulation, eating, and dressing;
(III) Maintenance of range of motion;
(IV) Proper turning and positioning in bed and chair;
(V) Bowel and bladder training; and
(VI) Care and use of prosthetic and orthotic devices;
K. Residents' rights including, but not limited to-
(I) Providing privacy and maintenance of confidentiality;
(II) Promoting the residents' right to make personal choices to accommodate their needs;
(III) Giving assistance in resolving grievances and disputes;
(IV) Providing needed assistance in getting to and participating in resident and family groups and other activities;
(V) Maintaining care and security of residents' personal possessions;
(VI) Promoting the residents' right to be free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate facility staff; and
(VII) Avoiding the need for restraints in accordance with current professional standards; and
2. The basic course shall be taught using current published instruction material(s) that are no more than ten (10) years old. The material(s) shall include current standards of practice for nursing assistants. Other course materials that contain current standards of practice in healthcare and are no more than ten (10) years old may be used to supplement the curriculum.
(6) Student Enrollment and Qualifications.
(A) Any individual who is employable by an intermediate care facility (ICF) or skilled nursing facility (SNF) to be involved in direct resident care shall be eligible to enroll in a training agency's nursing assistant training program if-
1. The individual is at least eighteen (18) years of age and employable. Employable shall mean that the individual is not listed on the department's Employee Disqualification List (EDL) and has not been convicted or entered a plea of guilty to a misdemeanor or felony charge which includes any suspended imposition of sentence, any suspended execution of sentence or any period of probation or parole in this state or any other state which if committed in Missouri would be a class A or B felony violation of Chapters 565, 566, or 569, RSMo, or any violation of subsection 198.070.3, RSMo, or section 568.020, RSMo, unless a good cause waiver has been granted by the department; or
2. The individual is at least sixteen (16) years of age providing he or she is-
A. Currently enrolled in a secondary school health services occupation program or a cooperative work education program of an area vocational technical school or comprehensive high school;
B. Placed for work experience in an ICF, SNF, hospital, Missouri Veterans' Home, or a hospital-based nursing facility or hospital-based skilled nursing facility by that program;
C. Not listed on the department's EDL and has not been convicted or entered a plea of guilty to a misdemeanor or felony charge which includes any suspended imposition of sentence, any suspended execution of sentence, or any period of probation or parole in this state or any other state which if committed in Missouri would be a class A or B felony violation of Chapters 565, 566, or 569, RSMo, or any violation of subsection 198.070.3, RSMo, or section 568.020, RSMo, unless a good cause waiver has been granted by the department; and
D. Under the direct supervision of an instructor or clinical supervisor, or both, while completing the clinical portion of the course.
(B) Prior to any direct contact with a resident, a student enrolled in the basic course in a Medicare or Medicaid certified facility shall complete sixteen (16) of the required seventy-five (75) hours of instructional training in communication and interpersonal skills; infection control; safety/emergency procedures, including the Heimlich maneuver; promoting residents' independence; and respecting residents' rights.
(C) If a student drops the basic course, the student may reenroll in a course within six (6) months and make up the course material missed without retaking the entire basic course after presenting proof of attendance and materials covered in the original class.
(D) A student shall not perform any services for which the student has not been trained nor found proficient by the instructor and/or clinical supervisor.
(E) A student who received instructional training from the basic course content outlined in paragraphs (5)(B)1. and 2. of this rule, shall register with the department approved third party test administrator upon successful completion of the seventy-five (75) hours of instructional training and one hundred (100) hours of supervised on-the-job training.
(7) Employees of a Long-Term Care (LTC) Facility. Each CNA hired to work in an ICF or SNF after January 1, 1980, shall have successfully completed a nursing assistant training program approved by the department or shall enroll in and begin the first available approved training program which is scheduled to commence within ninety (90) days of the date of the CNAs employment and which shall be completed within four (4) months of employment.
(8) Final Examination Challenge.
(A) Individuals eligible to challenge the final examination, includes-
1. Individuals who were enrolled in a RN or LPN nursing education program for at least four (4) months and successfully completed a course on the fundamentals of nursing, including clinical hours within the last five (5) years;
2. Individuals currently enrolled in a RN or LPN nursing education program and who have successfully completed a course on the fundamentals of nursing, including clinical hours;
3. RN or LPN nursing licensure candidates who have failed state licensure examinations within the last five (5) years;
4. Individuals who have met the requirements of unlicensed assistive personnel contained in 19 CSR 30-20.125;
5. Individuals trained by a hospital as nursing assistants or psychiatric aides who have completed the following:
A. One hundred (100) hours of supervised on-the-job training in an ICF, SNF, hospital, Missouri Veterans' Home, or hospital-based nursing facility or hospital-based skilled nursing facility; and
B. Instruction that covers the basic course content outlined in paragraphs (5)(B)1. and 2. of this rule;
6. Any other persons whose background, education, and training in gerontology and health occupations includes components of the basic course content outlined in paragraphs (5)(B)1. and 2. may be allowed to challenge the final examination after taking those portions of the course as determined to be necessary based on evaluation of their credentials by the Section for LongTerm Care Regulation, Health Education Unit;
7. A CNA who is listed as inactive for less than five (5) years on the Missouri Certified Nurse Assistant Registry and cannot provide the required employment documentation in accordance with section (18) of this rule; and
8. Individuals who have successfully completed a nursing program outside the United States within the last five (5) years or who have obtained a nursing license outside the United States.
(B) Individuals who are certified and active on another state's nurse aide registry shall not be required to challenge the final examination. The individual shall submit, in writing to the department, a request to be added to the Missouri Certified Nurse Assistant Registry. At a minimum, the request shall include: the individual's legal name; Social Security number; current address; telephone number; email address, if applicable; and proof of their current certified nursing assistant certificate. The department will respond in writing, either approving or denying the request to be added to the registry.
(C) Individuals identified as eligible to challenge the final examination in paragraphs (8)(A)1.-7., shall submit a request in writing to the department and enclose, at a minimum, the following information: legal name; Social Security number; current address and telephone number; email address, as applicable; and transcripts. The department will respond in writing, either approving or denying the request to challenge the final examination. If approved, the department shall provide a list of individuals eligible to take the examination to the department approved third party test administrator.
(D) Individuals identified in paragraph (8)(A)8., shall submit a request in writing to the department to take the final examination and enclose, at a minimum, the following information: legal name; Social Security number; current address and telephone number; email address, as applicable; a copy of the out-of-coun-try license or certificate translated to English; a copy of the school transcript translated to English; and a copy of the out-ofcountry criminal background check translated to English. The department will respond in writing, either approving or denying the request to challenge the final examination. If approved, the department shall provide a list of individuals eligible to take the examination to the department approved third party test administrator.
(E) Those individuals permitted to challenge shall take the final examination within one hundred twenty (120) calendar days of the department notification. Permission letters not utilized within the one hundred twenty- (120-) day period shall be considered invalid and reapplication for permission to challenge shall be made to the department.
(F) If an individual fails the final examination after one (1) attempt, he or she shall successfully complete basic course in its entirety.
(9) Training Agency Responsibilities.
(A) The following entities are eligible to apply to the department to be an approved training agency::
1. Career Center schools and comprehensive high schools approved by the Missouri Department of Elementary and Secondary Education (DESE) that offer health service occupation programs which have a practice classroom and equipment used in delivering health care. There shall be a signed written agreement of cooperation with one (1) or more ICFs, SNFs, hospitals, Missouri Veterans' Homes, or hospital-based nursing facilities or hospital-based skilled nursing facilities in their vicinity for the one hundred (100) hours of supervised on-the-job training component of the basic course;
2. Public community colleges, public colleges and universities, proprietary schools, or private agencies approved by the Missouri Department of Higher Education and Workforce Development (MDHEWD) or accredited by a recognized accrediting agency or association on the list published by the Secretary of the United States Department of Education, pursuant to the Higher Education Act of 1965, the Higher Education Opportunity Act 2008 ( Public Law 110-315 ), and the Veterans' Readjustment Assistance Act which have a practice laboratory with one (1) or more bed units and equipment used in delivering health care and have a signed written agreement of cooperation with one (1) or more ICFs, SNFs, hospitals, Missouri Veterans' Homes, or hospital-based nursing facilities or hospitalbased skilled nursing facilities in their vicinity for the one hundred (100) hours of supervised on-the-job training component of the basic course;
3. Associations as defined in section (1) of this rule. There shall be a signed written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans' Home, or a hospital-based nursing facility or hospital-based skilled nursing facility to provide the one hundred (100) hours of supervised on-the-job training;
4. A licensed ICF, SNF, or a hospital-based nursing facility or hospital-based skilled nursing facility. There shall be a signed written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans' Home, or a hospital-based nursing facility or hospitalbased skilled nursing facility if the one hundred (100) hours of supervised on-the-job training is not provided on-site;
5. Licensed hospitals. There shall be a signed written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans' Home, or a hospital-based nursing facility or hospital-based skilled nursing facility if the one hundred (100) hours of supervised on-the-job training is not provided on site; or
6. Missouri Veterans' Homes. There shall be a signed written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans' Home, or a hospital-based nursing facility or hospital-based skilled nursing facility if the one hundred (100) hours of supervised on-the-job training is not provided on site.
(B) Organizations identified in paragraphs (9)(A)1.-6. which want to be approved by the department to teach the program shall submit to the department form DHSS-DRL-2469 (08-20), Application for Approval as a Nursing Assistant Training Agency, included herein.
(C) In order to be approved, the applicant shall have a designated location which contains sufficient space, equipment, and teaching aids to meet the course objectives and accommodate the maximum number of students allowed. The instructor and each student shall be provided with the required curricula content and instructional material(s) for the basic course identified in section (5) of this rule.
(D) Any ICF or SNF which has received a Class I notice of noncompliance related to administration and resident care from the department in the two- (2-) year period prior to application for approval shall not be eligible for approval . If this notice is issued after approval, the approval shall be withdrawn by the department within ninety (90) calendar days and the certifying agencies shall be notified of the withdrawal of approval. Students already enrolled in the basic course may complete the course if a notice is issued after the basic course has begun.
(E) An ICF or SNF whose approval has been withdrawn for a Class I notice of noncompliance related to administration and resident care may request in writing to the department for an exception to train and test nursing assistants. This written request shall include, at a minimum, the following information:
1. The training site name, and training site number, address, telephone and fax number, and email address as applicable;
2. Administrator's name and facility operator's name and address;
3. Sponsoring training site name, sponsoring training site number, sponsoring training site's instructor's name, instructor's Social Security number, and email address as applicable;
4. The exit date of the noncompliance interview for each deficiency of a Class I in the areas of administration and resident care requirements in 19 CSR 30-85.042; reason(s) for noncompliance; explanation of efforts in locating another training agency within a reasonable distance (at least one-half (½) hour travel time each way from the facility); and
5. A student roster for each class. The student roster shall include each student's name; student's address and telephone number; student's Social Security number; and the student's email address, as applicable; class begin date; number of students completed; instructor's name and telephone number; instructor's license number; instructor's Social Security number; instructor's employer; and the instructor's email address, as applicable.
(F) The department shall make an on-site inspection of each training agency's premises within two (2) years of approval and every two (2) years following to determine the adequacy of space; equipment and supplies; and, if clinical training is not done on-site, verify that there is a current copy of a signed written agreement of cooperation with an ICF, SNF, hospital, Missouri Veterans' Home, or a hospital-based nursing facility or hospital-based skilled nursing facility for the clinical portion of the course.
(G) Upon receipt of the completed form DHSS-DRL-2469 (08-20), Application for Approval as a Nursing Assistant Training Agency, the department shall notify the applicant in writing within ninety (90) calendar days of approval or disapproval. If disapproved, the reasons why shall be given.
(H) Training agencies shall be approved for a two- (2-) year period and shall submit a new application for approval thirty (30) calendar days prior to the expiration of approval.
(I) The training agency shall be responsible for obtaining an approved instructor and providing training materials for each student. If an instructor is not employed by the training agency, there shall be a signed written agreement of cooperation between the training agency and the instructor.
(J) The training agency shall be responsible for obtaining an approved clinical supervisor. If a clinical supervisor is not employed by a training agency, there shall be a signed written agreement of cooperation between the training agency and the clinical supervisor.
(K) If the training agency is not a licensed ICF or SNF, the agency shall have a signed written agreement of cooperation currently in effect with an ICF, SNF, hospital, Missouri Veterans' Home, or a hospital-based nursing facility or hospital-based skilled nursing facility where the one hundred (100) hours of supervised on-the-job training shall be conducted.
(L) In the event that a qualified instructor for the basic course did not sign records of a student who successfully completed the program, without justification or due to resignation from his or her position, the administrator or designee of the training agency shall validate the training by signature.
(M) Evidence of successful completion of the basic course shall be documented prior to a student taking the final examination and shall include:
1. Class schedules and form MO 580-2473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B, included herein for training agencies using the basic course content outlined in paragraphs (5)(A)1. and 2. of this rule; or
2. Class schedules and form DHSS-DRL-111 (08-20), Classroom and On-the-Job Training Record, included herein for training agencies using the basic course content outlined in paragraphs (5)(B)1. and 2. of this rule.
(N) The training agency shall ensure that all applicable portions of appropriate forms identified in paragraphs (9)(M)1. and 2. of this rule are complete and shall provide a copy to the student within seven (7) calendar days of successful completion of the seventy-five (75) hours of instructional training and one hundred (100) hours of supervised on-the-job training.
(O) The training agency shall maintain records for a minimum of two (2) years for those individuals who have completed the basic course.
(10) Certifying Agency Responsibilities.
(A) In order for a certifying agency to be approved by the department, the agency shall have a signed written agreement of cooperation with the department which shall be renewable every five (5) years.
(B) Certifying agencies that provide the Nursing Assistant Instructor Workshop and the Nursing Assistant Clinical Supervisor Workshop shall complete the following responsibilities:
1. Verify eligibility requirements for the participants enrolled in the Nursing Assistant Instructor Workshop and the Nursing Assistant Clinical Supervisor Workshop;
2. Provide qualified Registered Nurse Instructor Trainers to teach the applicable workshop(s);
3. Issue the applicable workshop certificate(s) to participants upon successful completion; and
4. Within seven (7) calendar days of issuing the workshop certificate, provide a listing of approved instructors and clinical supervisors to the department that includes: the name of workshop completed; participant's legal name, address, and telephone number; email address, as applicable; Social Security number; and date of birth.
(C) Certifying agencies that provide the four (4) hour instructor update training shall comply with the requirements in section (16) of this rule.
(D) Maintain accurate and complete records for a period of at least two (2) years.
(11) Instructor and Clinical Supervisor/Stu-dent Ratios. During the required one hundred (100) hours of supervised on-the-job training, the training agency's instructor and clinical supervisor/student ratio shall be a maximum of one to fifteen (1:15).
(12) Qualifications of Instructors, Clinical Supervisors, and Examiners
(A) Instructor.
1. An instructor shall be currently licensed as a RN in Missouri or shall hold a current temporary permit from the Missouri State Board of Nursing or shall hold a multi-state or single state RN license from a jurisdiction that is party to the Nurse Licensure Compact. The licensee shall not be subject of current disciplinary action, such as censure, probation, suspension, or revocation.
2. An instructor shall not be listed on the department's EDL.
3. An individual that has been previously disqualified as an instructor shall not function as an instructor unless he or she receives written approval from the department.
4. An instructor shall have had, at a minimum, two (2) years of nursing experience and at least one (1) year of experience in the provision of long-term care facility services in the last ten (10) years. Other personnel from the health professions may assist the instructor; however, they shall have at least one (1) year of experience in their field.
5. An instructor shall successfully complete a Nursing Assistant Instructor Workshop by a certifying agency using qualified instructors. The department shall issue a letter of approval to the qualified instructor after the individual has successfully completed the workshop. The department shall maintain a list of approved instructors.
6. An instructor shall be responsible to teach the seventy-five (75) hours of instructional training for the basic course and a minimum of sixteen (16) of the one hundred (100) hours of supervised onthe-job training in accordance with the requirements contained in this rule.
7. The instructor teaching the seventy-five (75) hours of instructional training and/or sixteen (16) of the one hundred (100) hours of supervised on-the-job training for the basic course shall complete and sign all applicable portions of either form MO 580-2473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B for training agencies using the basic course content outlined in paragraphs (5)(A)1. and 2. or form DHSS-DRL-111 (08-20), Classroom and On-the-Job Training Record for training agencies using the basic course content outlined in paragraphs (5)(B)1. and 2. for each student participating in the program.
8. An instructor shall provide to the student within seven (7) calendar days of successful completion of the seventy-five (75) hours of instructional training and one hundred (100) hours of supervised on-the-job training, either completed form MO 580-2473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B for training agencies using the basic course content outlined in paragraphs (5)(A)1. and 2. or form DHSS-DRL-111 (08-20), Classroom and On-the-Job Training Record for training agencies using the basic course content outlined in paragraphs (5)(B)1. and 2.
9. If the course is not completed, records and documentation regarding the completed portions shall be provided by the instructor to the student, if requested, and to the training agency.
(B) Clinical Supervisor (On-the-Job Supervisor).
1. The clinical supervisor shall be currently licensed as a RN or LPN in Missouri or hold a current temporary permit from the Missouri Board of Nursing or shall hold a multi-state or single state RN or LPN license from a jurisdiction that is party to the Nurse Licensure Compact. The licensee shall not be subject of current disciplinary action such as censure, probation, suspension, or revocation.
2. A clinical supervisor shall not be listed on the department's EDL.
3. An individual that has been previously disqualified as a clinical supervisor shall not function as a clinical supervisor unless he or she receives written approval from the department.
4. The clinical supervisor, if not currently employed by an ICF, SNF, hospital, or Missouri Veterans' Home, shall have at least one (1) year of licensed nursing experience. The clinical supervisor shall be currently employed by the approved training agency facility where the students are performing their duties or by the training agency conducting the program.
5. A clinical supervisor shall successfully complete a Nursing Assistant Clinical Supervisor Workshop by a certifying agency using qualified instructors. The department shall issue a letter of approval to the qualified clinical supervisor after the individual has successfully completed the workshop. The department shall maintain a list of approved clinical supervisors.
6. The clinical supervisor shall be on the facility premises in which the students are performing their duties while the students are completing the on-the-job component of their training and shall directly assist the students in their training and observe their skills when checking their competencies.
7. A clinical supervisor shall be responsible to supervise eighty-four (84) of the one hundred (100) hours of supervised on-the-job training in accordance with the requirements contained in this rule.
8. The clinical supervisor(s) shall complete and sign all applicable portions of form MO 580-2473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B for training agencies using the basic course content outlined in paragraphs (5)(A)1. and 2. or form DHSS-DRL-111 (08-20), Classroom and On-the-Job Training Record for training agencies using the basic course content outlined in paragraphs (5)(B)1. and 2. for each student participating in the program.
(C) Examiner.
1. An examiner using the department's testing materials for the basic course content outlined in paragraphs (5)(A)1. and 2. of this rule shall be-
A. A RN currently licensed in Missouri or shall hold a current temporary permit from the Missouri State Board of Nursing, or shall hold a multi-state or single state RN license from a jurisdiction that is party to the Nurse Licensure Compact and shall not be currently subject of disciplinary action such as censure, probation, suspension, or revocation.
B. The examiner shall have taught a similar course or shall be qualified to teach a similar course; but shall not have been the instructor of the students being examined; and shall not be employed by the operator whose students are being examined. The examiner shall be specifically approved by the department to administer final examinations of the state-approved nurse assistant training curriculum and shall have signed an agreement with the department to protect and keep secure the final examinations.
2. Causes for Disqualification. A person shall not be allowed to be an examiner if it is found that he or she-
A. Knowingly acted or omitted any duty in a manner which would materially or adversely affect the health, safety, welfare, or property of a resident;
B. Defrauded a training agency or student by taking payment and not completing a course, not administering the final examination as required, or not being on-site while students are being trained;
C. Failed to teach, examine, or clinically supervise in accordance with 19 CSR 30-84.010, or taught students from the state test, changed answers on the state test, lost test booklets, or recorded false information on test materials or test booklets of the program; or
D. Failed to send documentation of a completed course to a certifying agency within thirty (30) days.
3. Notification of Disqualification.
A. The department shall notify the individual that he or she is no longer eligible to be an examiner.
B. The department shall notify all approved training and certifying agencies if it has been determined that an individual is no longer considered an approved examiner and that person's name shall be removed from the lists maintained by the department of approved examiners.
C. To be reinstated as a state-approved examiner the individual shall submit a request in writing to the department stating the reasons why reinstatement is warranted. The department shall respond in writing to the request.
(13) Instructor and Clinical Supervisor Disqualification Criteria.
(A) Causes for Disqualification. The department may disqualify an individual as an instructor or clinical supervisor if it is found the individual failed to follow the requirements in section (12) of this rule or-
1. Knowingly acted or omitted any duty in a manner which would materially or adversely affect the health, safety, welfare, or property of a resident;
2. Defrauded a training agency or student by taking payment and not completing a course or not being on-site while students are being trained;
3. Failed to teach or clinically supervise in accordance with the regulations contained in this rule, or provide false information to the department; or
4. Is disqualified as a RN Test Observer by the department approved third party test administrator.
(B) Notification of Disqualification.
1. The department shall notify the individual that he or she is no longer eligible to be an instructor or clinical supervisor.
2. The department shall notify all certifying agencies if it has been determined that an individual is no longer considered an approved instructor or clinical supervisor and that person's name shall be removed from the lists maintained by the department of approved instructors or clinical supervisors.
3. To be reinstated as an approved instructor or clinical supervisor, the individual shall submit a request in writing to the department stating the reasons why reinstatement is warranted. The department shall respond in writing to the request.
(14) Training and Certifying Agency Disqualification Criteria.
(A) Causes for Disqualification. The department may disqualify a training agency or certifying agency if it is found that an agency failed to follow the requirements in section (9) for a training agency or section (10) for a certifying agency of this rule or-
1. Defrauded a student by taking payment and not ensuring the seventy five (75) hours instructional training or on-the-job training were completed as required by this rule; or
2. Failed to maintain approval from MDHEWD or DESE, if applicable
(15) Registered Nurse Instructor Trainer Responsibilities.
(A) The RN Instructor Trainer shall be currently licensed as a RN in Missouri or shall hold a current temporary permit from the Missouri State Board of Nursing or shall hold a multi-state or single state RN license from a jurisdiction that is party to the Nurse Licensure Compact. The RN Instructor Trainer shall not be subject of current disciplinary action, such as censure, probation, suspension, or revocation and shall not be listed on the department's EDL.
(B) The RN Instructor Trainer shall also be, at a minimum, an approved nursing assistant instructor.
(C) The RN Instructor Trainer shall be employed or contracted by a certifying agency to instruct the Nursing Assistant Instructor Workshop, Nursing Assistant Clinical Supervisor Workshop, and the Instructor Update Training.
(16) Instructor Update Training.
(A) The instructor shall attend a four (4) hour update training provided by a certifying agency every five (5) years. This update training shall include, at a minimum, the following:
1. Instruction on how to complete form DHSS-DRL-111 (0820), Classroom and On-the-Job Training Record;
2. Instruction on the fundamentals of adult learning;
3. Instruction in at least one (1) area regarding standards of practice in long term care such as pressure ulcer prevention, dining practices, or resident rights issues;
4. Instruction on providing care for cognitively impaired residents;
5. Review of the Nursing Assistant Training Program regulations contained in 19 CSR 30-84.010; and
6. Review of the administration and resident care requirements contained in 19 CSR 30-85.042.
(B) The certifying agency shall provide a list of the instructors that complete the update training to the department within seven (7) calendar days of completion of the training.
(C) Any instructor who has not completed the required four (4) hour update training by August 31, 2022, and every five (5) years thereafter shall be removed from the department-approved list of instructors. If removed from the department's list, the instructor shall attend and successfully complete the Nursing Assistant Instructor Workshop in order to be reinstated to act as an instructor.
(17) Final Examination Testing.
(A) In order to be eligible for testing, a student shall have either completed the following:
1. Seventy-five (75) hours of instructional training and the one hundred (100) hours of supervised on-the-job training offered by a training agency. The student shall pass a minimum of three (3) written or oral tests throughout the course with an eighty percent (80%) score or better on each test in order to be eligible to take the final examination. Each test shall consist of a minimum of fifteen (15) questions; or
2. Possess an approval letter from the department granting approval to challenge the final examination.
(B) If the course content outlined in paragraphs (5)(A)1. and 2. of this rule is used for teaching the basic course, the final examination shall be conducted by an approved examiner who may be assisted by the instructor using the following procedures:
1. The instructor will select an LTC resident to participate in the testing process and obtain approval for this activity from the resident
2. The examiner shall verify the eligibility of the students by reviewing form MO 580-2473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B to establish that the student has completed the approved training program or possesses an approval letter from the department granting approval to challenge the final examination;
3. The student shall successfully complete at least nine (9) procedures under the observation of the instructor or a facility licensed nurse and examiner
A. The nine (9) procedures shall always include a type of bath, vital signs (temperature, pulse, respirations, and blood pressure), transfer techniques, feeding techniques, dressing and grooming, skin care, active or passive, range of motion to upper and lower extremities (unless contraindicated by a physician's order), and handwashing and gloving from the standardized curriculum.
B. The remainder shall be selected according to the resident's care needs at the time of day that testing occurs.
C. The evaluation of the student shall include communication and interaction with the resident, provision of privacy, work habits, appearance, conduct, and reporting and recording skills;
4. The student shall successfully answer forty (40) out of fifty (50) oral or written questions presented by the examiner based on the standardized curriculum and selected from a specific test pool of questions which are safeguarded by the department;
5. The examiner who uses the basic course content outlined in paragraphs (5)(A)1. and 2. of the basic course for the final examination shall notify the department and obtain different examinations to be administered each time; and
6. The examiner who uses the basic course content outlined in paragraphs (5)(A)1. and 2. of the basic course for the final examination shall conduct the following:
A. Complete and sign form MO 580-2473 (12-07) Certified Nurse Assistant Competency Score Sheet (For Use Only With The 2001 Manual) Appendix A/B and the final examination score sheet which shall include scores and comments. The examiner shall advise the individual that successful completion of the evaluation will result in the addition of his/her name to the CNA Registry;
B. After scoring, the examiner shall return all test materials, test booklets, answer sheets, and any appendices to the department. The examiner shall also provide the training agency with documentation of the student's test scores; and
C. A copy of the student's final record sheets shall be provided to the student (except for the answer sheets). If the course is not completed, records and documentation regarding the portions completed shall be provided to the student, if requested, and to the training agency.
(C) If the basic course content outlined in paragraphs (5)(B)1. and 2. of this rule, is used to teach the course, testing shall comply with the following:
1. The instructor shall verify the eligibility of the students by reviewing form DHSS-DRL-111 (08-20), Classroom and On-the-Job Training Record, to establish that the student has completed the approved program;
2. The final examination shall be conducted by the department approved third party test administrator and a fee will be assessed for each examination;
3. The student shall successfully complete an examination proctored by the department approved third party test administrator. The student shall achieve a passing score of at least eighty percent (80%); and
4. The student shall successfully complete the skills evaluation portion of the examination proctored by the department approved third party test administrator. The student shall achieve a score of one hundred percent (100%).
(D) Any individual who fails the final examination, except those who have been permitted to challenge the examination, shall have the opportunity to retake the examination twice within ninety (90) calendar days of the initial examination. If the individual fails the final examination a third time, the entire basic course shall be retaken before another examination can be given.
(E) Any individual who is employed by a LTC facility and required by section 198.082, RSMo, to enroll in the program, but who has been permitted to challenge the final examination and who fails the examination, must immediately re-enroll in and begin study in the next available basic course. The individual shall complete the basic course within four (4) months of employment.
(18) CNA Registry.
(A) If the CNA passes the final examination, the individual's name shall be placed on the CNA active registry.
(B) CNAs shall submit documentation (e.g., pay stubs, W-2, letter from employer, etc.) of work in nursing or nursing related services for at least one (1) day (e.g. eight (8) hours) within each twenty-four- (24-) consecutive month period to maintain active status. Documentation shall be submitted to the department approved third party test administrator and a fee will be assessed for each renewal.
(C) A CNA who has been inactive on the registry for less than five (5) years and cannot provide documentation (e.g., pay stubs, W-2, letter from employer, etc.) of work in nursing or nursing related services for at least one (1) day (e.g. eight (8) hours) within each twenty-four- (24-) consecutive month period shall challenge the final examination in accordance with section (8) of this rule before the CNA is reinstated to the active registry.
(D) A CNA who has been inactive on the registry for more than five (5) years and cannot provide documentation (e.g., pay stubs, W-2, letter from employer, etc.) of work in nursing or nursing related services for at least one (1) day (e.g. eight (8) hours) within each twenty-four- (24-) consecutive month period is not eligible to challenge the final examination and shall successfully complete the entire basic course before the CNA is reinstated to the active registry.
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVIOES
CERTIFIED NURSE ASSISTANT COMPETENCY SCORE SHEET (FOR USE ONLY WITH 2001 MANUAL)
APPENDIX A
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Appendix B
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Notes
*Original authority: 198.079, RSMo 1979 and 198.082, RSMo 1979, amended 1988.