---
kind: "range"
citation: "42 C.F.R. §§ 483.151–483.154"
title: "42"
from: "483.151"
to: "483.154"
count: 3
url: "https://uscodex.org/cfr/42/483.151..483.154"
---

# §483.151. State review and approval of nurse aide training and competency evaluation programs.

- (a) **State review and administration.**
  - (1) **The State—**
    - (i) Must specify any nurse aide training and competency evaluation programs that the State approves as meeting the requirements of [§ 483.152](/cfr/42/483.152.md) and/or competency evaluations programs that the State approves as meeting the requirements of [§ 483.154](/cfr/42/483.154.md); and
    - (ii) May choose to offer a nurse aide training and competency evaluation program that meets the requirements of [§ 483.152](/cfr/42/483.152.md) and/or a competency evaluation program that meets the requirements of [§ 483.154](/cfr/42/483.154.md).
  - (2) If the State does not choose to offer a nurse aide training and competency evaluation program or competency evaluation program, the State must review and approve or disapprove nurse aide training and competency evaluation programs and nurse aide competency evaluation programs upon request.
  - (3) The State survey agency must in the course of all surveys, determine whether the nurse aide training and competency evaluation requirements of §§ [483.35(c)](/cfr/42/483.35.md?p=c) and [(d)](/cfr/42/483.35.md?p=d) and [483.95(g)](/cfr/42/483.95.md?p=g) are met.
- (b) **Requirements for approval of programs.**
  - (1) Before the State approves a nurse aide training and competency evaluation program or competency evaluation program, the State must—
    - (i) Determine whether the nurse aide training and competency evaluation program meets the course requirements of [§ 483.152](/cfr/42/483.152.md):
    - (ii) Determine whether the nurse aide competency evaluation program meets the requirements of [§ 483.154](/cfr/42/483.154.md); and
    - (iii) **In all reviews other than the initial review, visit the entity providing the program.**
  - (2) The State may not approve a nurse aide training and competency evaluation program or competency evaluation program offered by or in a facility which, in the previous two years—
    - (i) In the case of a skilled nursing facility, has operated under a waiver under section 1819(b)(4)(C)(ii)(II) of the Act;
    - (ii) In the case of a nursing facility, has operated under a waiver under section 1919(b)(4)(C)(ii) of the Act that was granted on the basis of a demonstration that the facility is unable to provide nursing care required under section 1919(b)(4)(C)(i) of the Act for a period in excess of 48 hours per week;
    - (iii) Has been subject to an extended (or partial extended) survey under sections 1819(g)(2)(B)(i) or 1919(g)(2)(B)(i) of the Act;
    - (iv) Has been assessed a civil money penalty described in [section 1819(h)(2)(B)(ii)](/cfr/42/1819.md?p=h-2-B-ii) of 1919(h)(2)(A)(ii) of the Act of not less than $5,000 as adjusted annually under [45 CFR part 102](/cfr/45/part102.md); or
    - (v) Has been subject to a remedy described in [sections 1819(h)(2)(B)](/cfr/42/1819.md?p=h-2-B) (i) or (iii), 1819(h)(4), 1919(h)(1)(B)(i), or 1919(h)(2)(A) (i), (iii) or (iv) of the Act.
  - (3) A State may not, until two years since the assessment of the penalty (or penalties) has elapsed, approve a nurse aide training and competency evaluation program or competency evaluation program offered by or in a facility that, within the two-year period beginning October 1, 1988—
    - (i) Had its participation terminated under title XVIII of the Act or under the State plan under title XIX of the Act;
    - (ii) Was subject to a denial of payment under title XVIII or title XIX;
    - (iii) Was assessed a civil money penalty of not less than $5,000 as adjusted annually under [45 CFR part 102](/cfr/45/part102.md) for deficiencies in nursing facility standards;
    - (iv) Operated under temporary management appointed to oversee the operation of the facility and to ensure the health and safety of its residents; or
    - (v) **Pursuant to State action, was closed or had its residents transferred.**
- (c) **Waiver of disapproval of nurse aide training programs.**
  - (1) A facility may request that CMS waive the disapproval of its nurse aide training program when the facility has been assessed a civil money penalty of not less than $5,000 as adjusted annually under [45 CFR part 102](/cfr/45/part102.md) if the civil money penalty was not related to the quality of care furnished to residents in the facility.
  - (2) For purposes of this provision, “quality of care furnished to residents” means the direct hands-on care and treatment that a health care professional or direct care staff furnished to a resident.
  - (3) Any waiver of disapproval of a nurse aide training program does not waive any requirement upon the facility to pay any civil money penalty.
- (d) **Time frame for acting on a request for approval.** The State must, within 90 days of the date of a request under [paragraph (a)(3)](#a-3) of this section or receipt of additional information from the requester—
  - (1) Advise the requester whether or not the program has been approved; or
  - (2) **Request additional information form the requesting entity.**
- (e) **Duration of approval.** The State may not grant approval of a nurse aide training and competency evaluation program for a period longer than 2 years. A program must notify the State and the State must review that program when there are substantive changes made to that program within the 2-year period.
- (f) **Withdrawal of approval.**
  - (1) The State must withdraw approval of a nurse aide training and competency evaluation program or nurse aide competency evaluation program offered by or in a facility described in [paragraph (b)(2)](#b-2) of this section.
  - (2) The State may withdraw approval of a nurse aide training and competency evaluation program or nurse aide competency evaluation program if the State determines that any of the applicable requirements of [§ 483.152](/cfr/42/483.152.md) or [§ 483.154](/cfr/42/483.154.md) are not met by the program.
  - (3) The State must withdraw approval of a nurse aide training and competency evaluation program or a nurse aide competency evaluation program if the entity providing the program refuses to permit unannounced visits by the State.
  - (4) If a State withdraws approval of a nurse aide training and competency evaluation program or competency evaluation program—
    - (i) The State must notify the program in writing, indicating the reason(s) for withdrawal of approval of the program.
    - (ii) Students who have started a training and competency evaluation program from which approval has been withdrawn must be allowed to complete the course.

# §483.152. Requirements for approval of a nurse aide training and competency evaluation program.

- (a) For a nurse aide training and competency evaluation program to be approved by the State, it must, at a minimum—
  - (1) Consist of no less than 75 clock hours of training;
  - (2) Include at least the subjects specified in [paragraph (b)](#b) of this section;
  - (3) **Include at least 16 hours of supervised practical training.** Supervised practical training means training in a laboratory or other setting in which the trainee demonstrates knowledge while performing tasks on an individual under the direct supervision of a registered nurse or a licensed practical nurse;
  - (4) **Ensure that—**
    - (i) Students do not perform any services for which they have not trained and been found proficient by the instructor; and
    - (ii) Students who are providing services to residents are under the general supervision of a licensed nurse or a registered nurse;
  - (5) Meet the following requirements for instructors who train nurse aides;
    - (i) The training of nurse aides must be performed by or under the general supervision of a registered nurse who possesses a minimum of 2 years of nursing experience, at least 1 year of which must be in the provision of long term care facility services;
    - (ii) Instructors must have completed a course in teaching adults or have experience in teaching adults or supervising nurse aides;
    - (iii) In a facility-based program, the training of nurse aides may be performed under the general supervision of the director of nursing for the facility who is prohibited from performing the actual training; and
    - (iv) Other personnel from the health professions may supplement the instructor, including, but not limited to, registered nurses, licensed practical/vocational nurses, pharmacists, dietitians, social workers, sanitarians, fire safety experts, nursing home administrators, gerontologists, psychologists, physical and occupational therapists, activities specialists, speech/language/hearing therapists, and resident rights experts. Supplemental personnel must have at least 1 year of experience in their fields;
  - (6) Contain competency evaluation procedures specified in [§ 483.154](/cfr/42/483.154.md).
- (b) The curriculum of the nurse aide training program must include—
  - (1) At least a total of 16 hours of training in the following areas prior to any direct contact with a resident:
    - (i) Communication and interpersonal skills;
    - (ii) Infection control;
    - (iii) Safety/emergency procedures, including the Heimlich maneuver;
    - (iv) Promoting residents' independence; and
    - (v) **Respecting residents' rights.**
  - (2) Basic nursing skills;
    - (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.**
  - (3) **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.**
  - (4) **Mental health and social service needs—**
    - (i) Modifying aide's behavior in response to residents' behavior;
    - (ii) Awareness of developmental tasks associated with the aging process;
    - (iii) How to respond to resident behavior;
    - (iv) Allowing the resident to make personal choices, providing and reinforcing other behavior consistent with the resident's dignity; and
    - (v) **Using the resident's family as a source of emotional support.**
  - (5) **Care of cognitively impaired residents—**
    - (i) Techniques for addressing the unique needs and behaviors of individual 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.**
  - (6) **Basic restorative services—**
    - (i) Training the resident in self care according to the resident's abilities;
    - (ii) 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.**
  - (7) **Residents' Rights.**
    - (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 resident's right to be free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate facility staff;
    - (vii) **Avoiding the need for restraints in accordance with current professional standards.**
- (c) **Prohibition of charges.**
  - (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program (including any fees for textbooks or other required course materials).
  - (2) If an individual who is not employed, or does not have an offer to be employed, as a nurse aide becomes employed by, or receives an offer of employment from, a facility not later than 12 months after completing a nurse aide training and competency evaluation program, the State must provide for the reimbursement of costs incurred in completing the program on a pro rata basis during the period in which the individual is employed as a nurse aide.

# §483.154. Nurse aide competency evaluation.

- (a) **Notification to Individual.** The State must advise in advance any individual who takes the competency evaluation that a record of the successful completion of the evaluation will be included in the State's nurse aid registry.
- (b) **Content of the competency evaluation program—**
  - (1) **Written or oral examinations.** The competency evaluation must—
    - (i) Allow an aide to choose between a written and an oral examination;
    - (ii) Address each course requirement specified in [§ 483.152(b)](/cfr/42/483.152.md?p=b);
    - (iii) Be developed from a pool of test questions, only a portion of which is used in any one examination;
    - (iv) Use a system that prevents disclosure of both the pool of questions and the individual competency evaluations; and
    - (v) If oral, must be read from a prepared text in a neutral manner.
  - (2) **Demonstration of skills.** The skills demonstration must consist of a demonstration of randomly selected items drawn from a pool consisting of the tasks generally performed by nurse aides. This pool of skills must include all of the personal care skills listed in [§ 483.152(b)(3)](/cfr/42/483.152.md?p=b-3).
- (c) **Administration of the competency evaluation.**
  - (1) The competency examination must be administered and evaluated only by—
    - (i) The State directly; or
    - (ii) A State approved entity which is neither a skilled nursing facility that participates in Medicare nor a nursing facility that participates in Medicaid.
  - (2) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide competency evaluation program may be charged for any portion of the program.
  - (3) If an individual who is not employed, or does not have an offer to be employed, as a nurse aide becomes employed by, or receives an offer of employment from, a facility not later than 12 months after completing a nurse aide competency evaluation program, the State must provide for the reimbursement of costs incurred in completing the program on a pro rata basis during the period in which the individual is employed as a nurse aide.
  - (4) The skills demonstration part of the evaluation must be—
    - (i) Performed in a facility or laboratory setting comparable to the setting in which the individual will function as a nurse aide; and
    - (ii) Administered and evaluated by a registered nurse with at least one year's experience in providing care for the elderly or the chronically ill of any age.
- (d) **Facility proctoring of the competency evaluation.**
  - (1) The competency evaluation may, at the nurse aide's option, be conducted at the facility in which the nurse aide is or will be employed unless the facility is described in [§ 483.151(b)(2)](/cfr/42/483.151.md?p=b-2).
  - (2) The State may permit the competency evaluation to be proctored by facility personnel if the State finds that the procedure adopted by the facility assures that the competency evaluation program—
    - (i) Is secure from tampering;
    - (ii) Is standardized and scored by a testing, educational, or other organization approved by the State; and
    - (iii) **Requires no scoring by facility personnel.**
  - (3) The State must retract the right to proctor nurse aide competency evaluations from facilities in which the State finds any evidence of impropriety, including evidence of tampering by facility staff.
- (e) **Successful completion of the competency evaluation program.**
  - (1) The State must establish a standard for satisfactory completion of the competency evaluation. To complete the competency evaluation successfully an individual must pass both the written or oral examination and the skills demonstration.
  - (2) A record of successful completion of the competency evaluation must be included in the nurse aide registry provided in [§ 483.156](/cfr/42/483.156.md) within 30 days of the date if the individual is found to be competent.
- (f) **Unsuccessful completion of the competency evaluation program.**
  - (1) If the individual does not complete the evaluation satisfactorily, the individual must be advised—
    - (i) Of the areas which he or she; did not pass; and
    - (ii) **That he or she has at least three opportunities to take the evaluation.**
  - (2) The State may impose a maximum upon the number of times an individual upon the number of times an individual may attempt to complete the competency evaluation successfully, but the maximum may be no less than three.