North Carolina caregiver training: competency shown, not hours counted

Competency, shown by demonstration

Rule .1110 sets the core duty for every in-home caregiver (13J .1110):

• Documented. "Each agency shall document that its in-home caregivers are competent to perform client care tasks or activities that they are assigned."
• Demonstrated. "Meeting competency includes a demonstration of tasks to the health care practitioner."
• Only demonstrated tasks. Caregivers not subject to occupational licensing laws, such as in-home aides, are only assigned client care activities they have demonstrated competency in, and the agency keeps the documentation (.1110(b)).
• Method in your policy. Personnel records hold the verification of competencies for every skill an employee’s assigned tasks need, and "The method of verification shall be defined in agency policy." (.1003(f)(9))

DHSR explains what counts: "The competencies of In-Home Caregivers must be verified by a demonstration. Demonstration means the action or process of showing the proof of competency by performing the task or activity being assigned." (FAQ 57) It also says the RN "validates the competency of In-Home Caregivers (other RN’s, LPN, In-Home Aides, Nurse Aides)" (FAQ 45). The RN’s role for in-home aides →

DHSR’s Initial Survey Checklist lists a "Competency verification, skills validation/checklist policy" among the personnel policies it reviews before licensing (DHSR checklist). All 32 checklist items →

How CareRulebook’s manual does it

Policy 4.2 (Competency verification and skills checklist) has the RN supervisor watch each task performed in full, in a client’s home with consent or in a practice setting, and record the date, the result and their signature on an in-home aide skills checklist. A written or verbal test alone does not count, and an aide is not assigned a task until it is marked competent. That method is the manual’s, written to meet .1003(f)(9); We found no DHSR form.

The RN’s six core skills, for aides not on the registry

"For in-home aides not listed on the nurse aide registry, personnel records shall include verification of core competencies by a registered nurse" "that includes the following core personal care skills for in-home aides hired after April 1, 2009:" (13J .1003(g))

1. Assisting with Mobility including ambulation, transfers and bed mobility
2. Assisting with Bath/Shower
3. Assisting with Toileting
4. Assisting with Dressing
5. Assisting with Eating
6. Assisting with continence needs

The rule names a registered nurse for this check, and DHSR’s personnel record review lists "Competency Verification" among the items it expects (DHSR checklist p. 2). The six-skill list is written for aides hired after April 1, 2009; by our reading, the general duty in .1110 to document competency by demonstration still applies to every in-home caregiver.

Extensive or limited assistance: when the Nurse Aide Registry applies

The plan of care states the level of help the client needs for each activity of daily living, and that decides whether the aide must be listed (13J .1107(b)):

• Extensive assistance: "If the client's plan of care requires the in-home aide to provide extensive assistance, the in-home aide shall be listed on the Nurse Aide Registry". Extensive assistance means a client is totally dependent, or needs hands-on help more than half the time while performing part of an activity, and meets one of three criteria, one being that the client "needs an in-home aide to perform at least one task at the nurse aide II level" (.0901(7)).
• Limited assistance: "if the client's plan of care requires the in-home aide to provide only limited assistance, the in-home aide is not required to be listed on the Nurse Aide Registry". Limited assistance is hands-on care, such as guided maneuvering of limbs, needed half the time or less during the activity (.0901(18)). Those not on the registry need the RN’s six-skill verification above (for aides hired after April 1, 2009).

DHSR notes that "In-home aides are sometimes referred to as PCAs (personal care assistants), NA I or NA II (nurse aides), or UAP (unlicensed assistive personnel)." (FAQ 52) Checking the registries at hire is covered on caregiver background checks.

One more layer applies only to some agencies: those in the Home and Community Care Block Grant or Social Services Block Grant through the Division of Aging and Adult Services must also follow the in-home aide service level rules in 10A NCAC 06A and 06X (13J .1107(g)). We have not reviewed those rules, so check them if you take block grant clients.

Companion, sitter and respite staff

If your home care agency also provides these services, their staff do non-hands-on work. The rules define it as "basic home management tasks, shopping, meal preparation, transportation, companion services, socialization, medication reminders, and other services that do not require the service provider to use "hands-on care" as defined in Rule .0901 of this Subchapter and which do not require training or verification of skills by a Registered Nurse" (13J .1501(2)).

• Competency, documented. "Each agency shall have documentation that its companion and sitters are competent to perform client care tasks or activities to which they are assigned." (.1504(1))
• A supervisor named in your policy. "Such individuals shall perform delegated activities under the supervision of a supervisor designated by agency policy for the services assigned." (.1504(1))
• Supervision. The supervisor contacts the client every three months and visits at least every six months, and at least once a year while the companion or sitter is in the home (.1504(2)).

The orientation and in-service policies in .1003(d) are agency-wide personnel policies, and DHSR’s personnel record review table includes a companion sitter column (DHSR checklist p. 2). CareRulebook’s manual reads that table as asking for proof of orientation, bloodborne pathogen training and competency verification for companion, sitter and respite staff too, and keeps them in each of their files. In CareRulebook’s manual, they demonstrate their tasks to the companion, sitter and respite supervisor, by our reading of .1501(2). Rule .1504 also applies .1110 (.1504), which speaks of demonstration to the health care practitioner (.1110(a), (b)), so ask DHSR if you are unsure.

A business mainly providing companion, sitter or respite care (alone or with homemaker services) is a home assistance services provider, which needs its own license (G.S. 131E-136(1b)-(1c), 131E-138(a)). We have not confirmed which rules DHSR applies to that license, so this page does not describe its training.

Orientation and in-service education

• Written policies. "Written policies shall be established and implemented which include personnel record content, orientation and in-service education." (13J .1003(d)) DHSR’s checklist lists an in-service training policy and an orientation policy among the personnel policies (DHSR checklist).
• Hours. We found none in the rule. DHSR says the policy should specify the number of in-service hours employees must complete (FAQ 54).
• Records. "Records on the subject of in-service education and attendance shall be maintained by the agency and retained as set out in Paragraph (f) of this Rule." (.1003(d)) That paragraph keeps personnel records for at least one year after employment ends (.1003(f)). DHSR’s personnel record review lists proof of orientation (DHSR checklist p. 2).
• Client rights. The home care clients’ bill of rights says "Each agency shall provide appropriate training to implement this Part." (G.S. 131E-144.5)
• Only trained duties. "Individuals shall be assigned only to duties for which they are trained and competent to perform and when applicable for which they are licensed." (.1003(e))

CareRulebook’s manual asks you for the yearly in-service hours (it suggests 12, which is our default, not a state number) and writes them into Policy 4.1, with an orientation topic list covering client rights, complaints, confidentiality, registry reporting, infection control, emergencies, the no smoking rule and, for aides, the plan of care, supervision and the limits of their duties. The topic list and the timing before the first assignment are the manual’s choices.

Bloodborne pathogen training

Personnel records for hands-on care employees include "airborne and bloodborne pathogen training for hands on care employees, including annual updates" (13J .1003(f)(6)). 13J incorporates the federal OSHA standard (29 CFR 1910), which adds when: "Such training must be provided at no cost to the employee and during working hours." It is given at the time of initial assignment to tasks where occupational exposure may take place, and at least annually after that (29 CFR 1910.1030(g)(2)).

DHSR’s checklist lists a "Blood borne pathogen policy (include training and updates) required for all in-home caregivers" (DHSR checklist) and proof of the training in personnel records (p. 2). In CareRulebook’s manual the training is in Policy 4.1 and the exposure control plan in Policy 7.2 (Bloodborne pathogens exposure control plan).

Nurse Aide I and the registry, for context

The Nurse Aide I credential is run outside the home care license, under 10A NCAC 13O. "To be eligible to be listed on the NC Nurse Aide I Registry by the Health Care Personnel Education and Credentialing Section, a person shall:" pass a Nurse Aide I training program approved by the Department and the state’s Nurse Aide I competency exam, or be approved by reciprocity from another state (13O .0301(a)), with some exceptions to the training program, such as former military medical corpsmen and retired nurses (13O .0301(k)). The exam is administered only by the Department or its contracted testing agent, and a candidate may take it at most three times before retaking a training program (13O .0301(g), (j)).

DHSR’s FAQ adds that "The North Carolina Board of Nursing lists tasks for NA I and IIs and has a criterion for responsibilities of the nurse regarding delegation to NA I & IIs, and unlicensed assistive personnel." (FAQ 53) We have not saved the Board of Nursing’s task lists or the Nurse Aide I program’s course length, so check those with the Board and the Department. For your agency, the license rule that matters is .1107(b): a registry listing when the plan of care requires extensive assistance.

Medicaid personal care services training, for context

Only if you bill NC Medicaid for personal care services (PCS). Policy 3L is a Medicaid coverage policy, not a licensing rule, and it adds to the 13J duties above:

• Aide qualifications. "PCS Aides shall be a high school graduates or equivalent; or Eighteen (18) years of age or older." (Policy 3L, 6.1.1)
• Training topics. Aide personnel records must document training in beneficiary rights, confidentiality, personal care skills for the five ADLs, accidents and incidents, recognizing and reporting abuse and neglect, and infection control, plus dementia training or experience for aides serving beneficiaries with hours under Session Law 2013-306. (6.1.2)
• Staff development. Medicaid PCS providers give new in-home aides and other employees an orientation covering the state home care rules and Policy 3L, run ongoing staff development, provide competency training and evaluate aides’ competencies, and keep records of orientation and training. (7.10 d)
• Nurse aide tasks. Under Policy 3L, in-home aides may do Nurse Aide I and Nurse Aide II tasks when they meet the training, competency evaluation and other qualifications in 21 NCAC 36.0403 (the Board of Nursing’s rules) and the tasks are on the beneficiary’s service plan. (6.1.6 a)
• EVV. Staff are trained on the electronic visit verification system, with written documentation of initial and at least annual training in each employee’s file (7.4).
• The aide file. An individual file on every in-home aide documents training, background checks and competency evaluations, and shows the aide is supervised (7.10 c).

CareRulebook’s manual is written to the licensing rules. It does not include Policy 3L’s Medicaid requirements, apart from noting that a PCS service plan cannot replace the plan of care. Becoming a Medicaid PCS provider →