Maryland caregiver training: seven topics, a skills demonstration and dementia hours

Skills assessment and demonstration

Two rules meet here. Screening includes "Completion of a skills assessment and demonstration before client referral" (COMAR 10.07.05.10B(1)(i)), and one of the 23 written policy items is "Skill assessments of all employees and contractors" (.08B(1)(b)(ii)). OHCQ’s application asks you to point to that policy by document and page; the full list is on Maryland RSA policies and procedures.

For delegated nursing tasks, the Board of Nursing’s rule adds its own step: before delegating a nursing task, the nurse assesses the client, then either instructs the caregiver in the task or verifies their competency, supervises it and evaluates how it is done. The nursing model must include a way to re-evaluate the competency of those the nurse delegates to. (COMAR 10.27.11.03D-E)

What the rules leave to you

The rules set no form, no pass mark and no list of skills, and OHCQ has not published one. CareRulebook’s manual has the registered nurse watch each caregiver perform each hands-on task on training equipment or with a colleague acting as the client, never for the first time on a client; a caregiver does for clients only the tasks marked competent, and the nurse re-checks each caregiver once a year (Policy 3.2). The yearly re-check and the pass standard are the manual’s choices, not OHCQ’s. How a new agency’s only nurse should show their own skills is on our list of questions for OHCQ.

The registered nurse’s part in training

• Oversight. "For clients who require skilled services or assistance with the activities of daily living, an agency shall have a registered nurse to provide oversight for" the care plan, delegation, supervision and training (COMAR 10.07.05.12E(1)).
• Training and retraining. The RN shall also "participate in training and retraining the individuals who will provide the care, when indicated" (.12B(2)(c)).
• The caregiver level. The RN decides whether the client requires a certified nursing assistant or whether someone who is not certified may give the care (.12B(2)(b)).
• Dementia training. It may be given by the supervisory staff member responsible for developing plans of care and assigning staff (Health-General §19-4A-03.1(c)(2)), which in most RSAs is the RN.

More on the nurse’s role, visits and delegation is on the registered nurse in a Maryland RSA.

Dementia training: the statute’s hours

• Within 45 days of starting, each person on the direct care or supervisory staff is trained by, at a minimum, "providing 3 hours of online or in–person training regarding dementia", covering an overview of Alzheimer’s disease and dementia, person-centered care, the assessment and care planning process, activities of daily living, and dementia-related behaviors and communication (Health-General §19-4A-03.1(c)(1)(i)).
• Every calendar year, each of them "receives 2 hours of online or in–person continuing education training regarding Alzheimer’s disease and dementia each calendar year" (§19-4A-03.1(c)(1)(ii)).
• Who counts. Direct care staff and supervisory staff, where "“supervisory staff” means an individual who supervises direct care staff in the individual’s clinical role" (§19-4A-03.1(a)). An RSA that only provides durable medical equipment is outside the section (§19-4A-03.1(b)).
• Exemptions. The initial 3 hours are not needed for someone with 24 consecutive months of dementia care experience who holds a completion certificate; the yearly 2 hours are not needed if done in the past 12 months. (§19-4A-03.1(d))
• Certificates and records. Whoever gives the training issues a certificate of completion; the RSA keeps records of the type of training each person received. The training may be given by the supervisory staff member who develops plans of care. (§19-4A-03.1(c)(2), (e)-(f))

The duty came from Chapter 487 of 2021 and has applied since July 1, 2022 (Chapter 487 of 2021). It is in the statute, not in COMAR 10.07.05, but OHCQ’s trainer checklist already lists it (checklist item 9). When the dementia duty passed in 2021, MDH estimated a baseline increase in RSA provider rates of $0.25 per hourly unit to account for the new training. (fiscal note, HB 141 (2021))

What the statute leaves open

It does not say whether the first 3 hours count toward the 2 hours for the calendar year in which they are given. By our reading they do, and CareRulebook’s manual counts them that way. It also does not say whether an outside dementia course needs OHCQ’s approval like other outside training. Both are on our list of questions for OHCQ. Our suggestion: finish a caregiver’s dementia training before assigning them to a client living with dementia, even though the law allows 45 days.

Outside trainers need OHCQ’s written approval

"Sources other than the agency may provide training, as approved in writing by the Office of Health Care Quality." (COMAR 10.07.05.11B) OHCQ’s RSA page puts it plainly: "If an outside trainer is used, that individual must have OHCQ’s approval prior to training." OHCQ says an outside trainer submits its training materials to OHCQ on an online form for review and approval. (OHCQ, RSAs that Use an Outside Trainer)

• What OHCQ checks. The trainer checklist has a Yes or No approval box for each topic, and notes that "a vendor is responsible for obtaining a copy of the current RSA regulations 10.07.05" and use them for the curriculum (OHCQ trainer checklist).
• Before you buy a course. Ask the vendor for OHCQ’s written approval of the exact course your staff will take, and keep a copy with your training records. By our reading, a course without it does not meet COMAR 10.07.05.11B, however good it is.
• CPR. The rule names CPR as a topic without a provider or renewal period. By our reading, a CPR course from a recognized provider meets that topic, but OHCQ has not said so in writing.

Certified or uncertified caregivers

Training is not the same as certification. Certified care is work that, for pay, only someone certified by the Board of Nursing may do (a certified medication technician, certified medicine aide or certified nursing assistant), and it includes nursing functions a registered nurse routinely delegates. (COMAR 10.07.05.02B(4))

• The default. An agency must provide or refer a certified caregiver to a client who needs one for activities of daily living, or who needs medication administration (COMAR 10.07.05.10E).
• When an uncertified caregiver may serve. A client who needs no help with activities of daily living; a client who "only requires assistance with activities of daily living and in the judgment of the supervising nurse, there are no predictable adverse health consequences"; or a client who signs a waiver of skilled services (.10D). The Board of Nursing’s rule matches the second case: "An unlicensed individual merely provides assistance with activities of daily living unless the client’s needs are such that adverse health consequences are predictable." (COMAR 10.27.11.05E(2))
• Occasional delegated tasks. A registered nurse or LPN may delegate a nursing task to an unlicensed person as long as it does not become a routine part of that person’s job. Routinely doing delegated nursing tasks for pay is what makes someone a nursing assistant, who must be certified. (Health Occupations §8-6A-02(c))
• Help with medication. A cognitively capable adult client (not a representative) may waive the agency’s recommendation of certified care for help with routine treatments or self-administration of medication, after a documented risk and benefit discussion. (COMAR 10.07.05.12D)

By our reading, an agency that uses uncertified aides needs its training, skills demonstration and the nurse’s documented judgment to carry more weight, because the certification process has not already tested those aides. How OHCQ expects the nurse’s judgment to be recorded is on our list of questions for OHCQ. More on medication limits is on medication in a Maryland RSA.

What the Maryland rules do not set

• Hours for the seven topics. The rule lists topics only (COMAR 10.07.05.11C). Dementia training is the only RSA training duty with hours in law.
• A state exam or certificate for uncertified aides. COMAR 10.07.05 asks the agency to train and assess them, not to have them certified, except where the client needs a certified caregiver (.10D-E).
• A yearly repeat of the seven topics. The rule sets none; OHCQ’s signalled update would add annual training. The RN retrains when indicated (.12B(2)(c)).
• A CPR provider or renewal period. Not in the rule yet (signalled).
• Training records in a set format. They go in the personnel file (.10B(2)), and dementia training needs certificates and a record of its type (§19-4A-03.1(e)-(f)); no form is prescribed.

Health and TB screening is a hiring step, not training (COMAR 10.07.05.10B(1)(c)); CareRulebook’s manual covers it in Policies 3.4 and 3.3.