Tennessee caregiver training: seven areas before work, then every year

Basic competency in seven areas, before work

The licensee ensures and documents that "Individuals who provide personal support services demonstrate basic competency in the following skill/knowledge areas prior to beginning work with service recipients" (0940-05-38-.08(1)(a)):

1. Observing, reporting and documenting changes in the client’s daily living skills.
2. Abuse, neglect and exploitation: detection, reporting and prevention.
3. Client rights.
4. Universal health precautions, including infection control.
5. How to help clients with personal hygiene.
6. Client safety.
7. Emergency and disaster procedures, which at least include "emergency transportation, emergency medical care and staff coverage in such events" (.08(1)(a)7).

TDMHSAS puts this rule on its list of common PSSA deficiencies (PSSA slide 16); how TDMHSAS inspects is on Tennessee PSSA inspections. The rule asks for demonstrated competency, documented, not only attendance.

What the rule leaves to you

The rule sets no hours, no pass mark, no test and no form for showing competency, and TDMHSAS has not published one. CareRulebook’s manual trains each area, then checks it: questions or a short written quiz for the knowledge areas, and a watched demonstration for hand hygiene, gloves and help with personal hygiene, practised on another staff member or training equipment, never first on a client. Every line of the checklist is marked "competent" before the worker starts. That pass standard is the manual’s, not TDMHSAS’s.

If a worker comes with training from somewhere else, by our reading your agency still has to ensure and document their competency itself, so the manual runs its own checklist for everyone.

Training for each client

The licensee ensures and documents "Documented training specific to meeting individual service recipient needs in the areas of self-care, household management and community living, and methodologies for service delivery." (0940-05-38-.08(1)(d)). The rule does not say when; by our reading it belongs before a worker’s first visit to that client, and again when the client’s needs change.

CareRulebook’s manual has the individual responsible, or whoever assessed the client, go through the service plan with each assigned worker before the first visit: the tasks and how the client likes them done, routines and preferences, communication needs, risks such as falls, any equipment, the emergency contact and the alternate staffing plan, and anything the worker must not do. The worker and the trainer sign a client-specific training record. That is the manual’s method; the rule only asks that the training be specific to the client and documented.

The rule names three areas, self-care, household management and community living. Whether an agency that offers only some of those services must still train on all three is not stated; it is on our list of questions for TDMHSAS.

Training and evaluation every year

• Yearly training. "Individuals who provide personal support services receive training on job related topics at least annually" (0940-05-38-.08(1)(c)), documented under the opening words of .08(1). No hours, no topic list and no format are set.
• Yearly performance evaluation. Each personnel file holds "Annual performance evaluation reports evaluating, at a minimum, the ability of personal support services workers to provide daily supports to service recipients" (.07(1)(g)). TDMHSAS lists this among its common deficiencies (PSSA slide 15).

CareRulebook’s manual asks you to count the training year by calendar year or from each worker’s start date, and always covers infection control, abuse and neglect, client rights and emergency procedures each year, adding topics from the year’s incidents, complaints, client evaluations and any rule changes. That topic list is the manual’s choice of how to meet the rule. Policy 4.7 holds the yearly evaluation form, which draws on clients’ six-monthly evaluations, the consultation log and the training records.

Medication assistance training: a registered nurse

Medication assistance means "providing medication reminders and opening medication packaging, but does not mean giving the service recipient injections or any form of medication or medication administration" reserved for people authorized under Title 63, Chapter 7 (0940-05-38-.01(9)). If your workers give it, two rules apply:

• "Individuals who provide medication assistance receive documented training in medication assistance performed by, or under the general supervision of, a registered nurse and consistent with T.C.A. § 63-7-102" (.08(1)(b)).
• "Medication assistance training shall be provided to personal support services workers prior to providing assistance and training shall be documented in the personal support service worker’s record." (.06(1)(l)2).

TDMHSAS adds: "No. A PA cannot approve medication-assistance training." (PSSA slide 24). The RN-supervised training is on TDMHSAS’s common deficiency list (slide 14), and so is the client’s written authorization for medication assistance in the client record (.09(1)(n)).

The training should cover what medication assistance includes, in the rule’s seven examples, such as "Opening pill reminder box if the box is filled by the service recipient or authorized representative or licensed medical personnel practicing within the scope of their license" (.01(9)(a)-(g)), and what it does not: TDMHSAS lists filling medication planners, giving oral medications and applying ointments among the tasks not allowed under the PSSA license (slides 25-27); for staff with the medication administration certification below, it says to ask DDA’s certification program. Adding medicine to a nebulizer counts as medication administration (slide 23).

The rule also says the training must be consistent with T.C.A. 63-7-102. We could not save that statute, so we cannot tell you what it asks of the nurse or the curriculum; that is on our list of questions for a nurse and a Tennessee lawyer. How often to re-check competency is not stated either; CareRulebook’s manual suggests, as Recommended practice, that the nurse (or the person trained under the nurse’s supervision) watch each worker give medication assistance once a year. If you do not offer medication assistance, the PSSA rules require no nurse for training at all (.08(1)).

Lifts and gait belts: training first

Every agency needs a policy on "use of devices such as a hoyer lift or gait belt, after training, to assist the service recipient in getting out of or into bed, a chair, toilet or shower but not as part of a therapeutic regimen" (0940-05-38-.06(1)(n)). It is on TDMHSAS’s common deficiency list (PSSA slide 12).

The training record matters after an accident: "If the accident occurred during a transfer, provide a copy of the equipment training that the caregiver received." (PSSA slide 41). The rule sets no qualification for the person who trains. CareRulebook’s manual records each worker’s training on each device on a lift and gait belt training and competency record (Policy 2.10); if you do not use these devices, the policy says so and covers what workers do instead.

What Tennessee does not require

• A TB test. "Are PSSA workers/caregivers required to have a TB skin test? No. This is not a Licensure requirement." (PSSA slide 28)
• CPR certification. "Are PSSA workers/caregivers required to be certified in CPR? No. This is not a Licensure requirement." (slide 29) TDMHSAS adds that other entities you contract with may require either, so check your contracts.
• Set hours, a state curriculum or a certification. Chapter 0940-05-38 asks for competency, language skills and documented training, not a course length or a credential (0940-05-38-.08(1)).
• A nurse on staff. Only medication assistance training, and the optional education services, need a registered nurse (.01(6); .08(1)(b)).

Our suggestion: consider first aid and CPR training anyway. CareRulebook’s manual includes it as Recommended practice, labelled as not a TDMHSAS requirement.