Texas caregiver training: orientation, competency and supervision

Competency for PAS attendants

The PAS standards in §558.404 tie competency to the tasks the supervisor assigns. Personal assistance services "may be performed by an unlicensed person who is at least 18 years of age and has demonstrated competency, when competency cannot be determined through education and experience, to perform the tasks assigned by the supervisor." (§558.404(c)). The same subsection allows younger workers in limited cases: "An unlicensed person who is under 18 years of age, is a high school graduate or is enrolled in a vocational educational program, and has demonstrated competency to perform the tasks assigned by the supervisor, may perform personal assistance services."

Two points follow from the wording. Competency is tied to the tasks the supervisor assigns, so an attendant may be competent for some tasks and not yet for others. And where education or experience already shows competency, the rule does not ask for a separate demonstration; by our reading, you should still record that decision, because your training policies must ensure a demonstration of competency whenever education, license, certification or experience cannot show it (§558.245(b)(2)(B)), and a record shows which route you used.

What the rule leaves to you

We found no test, pass mark or form for showing a PAS attendant’s competency in Chapter 558, apart from the g-tube program below (home health aides have their own evaluation under §558.701), and we have not found an HHSC form for it. CareRulebook’s manual has the supervisor decide, task by task, whether the attendant’s education, license, certification or experience shows competency; if it does not, the supervisor watches the attendant do the task, in practice or with a client while the supervisor is present, and records the task, the date, the result and the supervisor’s name. That method is the manual’s, not HHSC’s.

Staff who serve children need more: "Services provided to pediatric clients must be provided by staff who have been instructed and have demonstrated competency in the care of pediatric clients" (§558.245(b)(9)).

Supervision of attendants

On top of the staffing policies, a PAS agency "must adopt and enforce a written policy addressing the supervision of personnel with input from the client or family on the frequency of supervision." (§558.404(g)). "Supervision of personnel must be in accordance with the agency's policies and applicable State laws and rules, including rules adopted by the Texas Board of Nursing in 22 TAC Chapter 225." (§558.404(g)(1))

• Who supervises. "A supervisor must be a licensed nurse or have completed two years of full-time study at an accredited college or university." A high school diploma or GED plus one year of full-time supervisory work in a health care facility, agency or community-based agency can stand in for each year of college (§558.404(g)(2)). In a client managed attendant care program funded by HHSC or the former Department of Assistive and Rehabilitative Services, the client does not have to meet that standard (§558.404(g)(3)).
• How often. By our reading, §558.404 sets no fixed visit frequency for PAS; it leaves frequency to your policy, with input from the client or family. Where an RN delegates a task, the RN must "determine, in consultation with the client or the client's responsible adult, the level of supervision and frequency of supervisory visits required" (22 TAC §225.9(a)(3)).
• Records. The PAS client file holds "documentation of determination of services based on an on-site visit by the supervisor where services will be primarily delivered and records of supervisory visits, if applicable" (§558.404(f)(1)), and each individualized service plan includes a plan of supervision (§558.404(f)(2)(F)).

CareRulebook’s manual covers this in Policy 5.2 (Supervision of personnel). The supervisor’s role in the client’s service plan is on required policies.

RN delegation, and the separate g-tube program

Personal assistance services can include, among other tasks, "health-related tasks provided by unlicensed personnel that may be delegated by an RN, or that an RN determines do not require delegation, in accordance with the agency's written policy adopted, implemented, and enforced to ensure compliance with the rules adopted by the Texas Board of Nursing in 22 TAC Chapter 225" (§558.404(d)(2)). Where an RN delegates, the Board of Nursing’s rules set the competency check.

• Before delegating, the RN must "verify the experience and competency of the unlicensed person to perform the task, including the unlicensed person's ability to recognize and inform the RN of client changes related to the task. The RN must have either: (A) instructed the unlicensed person in the delegated task; or (B) verified the unlicensed person's competency to perform the nursing task based on personal knowledge of the training, education, experience and/or certification/permit of the unlicensed person." (22 TAC §225.9(a)(2))
• On paper. "The competency of the unlicensed person to whom the nursing task is delegated must be adequately documented." (§225.9(c))
• While the task is done. "The RN or another RN qualified to supervise the unlicensed person shall be available, in person or by telecommunications when the unlicensed person is performing the task." (§225.9(b))

HHSC’s FAQ puts it this way: "The RN is responsible for the supervision and evaluation of competency of the unlicensed personnel to whom the delegation is provided. Documentation of delegation is also required." (HCSSA FAQ p. 16). That is HHSC guidance, not rule text. Some health maintenance activities need no delegation when an RN finds that all of the Board’s conditions are met. One is that "the client is willing and able to train the unlicensed person in the proper performance of the HMA", or that the client’s responsible adult can train them and is present for the task, or has watched the person do it at least once and stays immediately reachable (22 TAC §225.8(a)(2)). The RN’s side is in CareRulebook’s Policy 5.3 (RN delegation of health-related tasks).

G-tube feedings: a set program

G-tube feedings come in under §558.404(d)(3), health-related tasks that are not the practice of professional nursing, not under RN delegation (§558.404(h)). For g-tube work, Chapter 558 spells out a full training program. Tube feedings and medication through a permanently placed g-tube may be done by an unlicensed person "only after successful completion of the training and competency program and procedures" in §558.404(h) (§558.404(h)):

• "The training and competency program for the performance of g-tube feedings by an unlicensed person must be taught by an RN, physician, physician assistant (PA), or qualified trainer." ((h)(1))
• The competency evaluation includes "a score of 100 percent on a written multiple-choice test that consists of situational questions" ((h)(3)(A)), a skills checklist and a documented demonstration by the trainee ((h)(3)(B)-(C)).
• For qualified trainers: "Documentation of competency to perform, train, and teach must be maintained in the employee's or contractor's file. Competency must be evaluated and documented annually by an RN, physician, or PA." ((h)(1)(C))
• "The supervisor of the delivery of these services must have successfully completed a training and competency program outlined in paragraphs (2) and (3) of this subsection or be a qualified trainer." ((h)(4))

If your attendants do not do g-tube tasks, this program does not apply, and CareRulebook’s manual says so.

Other training the rules set

• Emergency plan. "An agency must orient and train employees, volunteers, and contractors about their responsibilities in the agency’s emergency preparedness and response plan." (§558.256(i))
• Infection control. Chapter 558 requires written infection control policies (§558.285). HHSC’s FAQ adds: "Providers should adopt, implement, and enforce their policies and procedures, and ensure staff are trained accordingly." (HCSSA FAQ p. 19)
• Health information privacy. Texas’s medical records privacy law says "An employee of a covered entity must complete training described by Subsection (a) not later than the 90th day after the date the employee is hired by the covered entity." The training covers state and federal law on protected health information, as your employees need it for their duties (§181.101(a)). The employee signs a completion statement, kept until its sixth anniversary (Tex. Health & Safety Code §181.101(b), (d)). By our reading, a home care agency that handles client health information is a covered entity under §181.001(b)(2), and the chapter’s exemption for "an employer" (§181.051) covers an employer in that role, not a provider holding client records.
• Abuse, neglect and exploitation. Today’s rule requires a written reporting policy (§558.249(b)). We found no separate training duty in the current section; the proposed new §558.251 would add one (below). CareRulebook’s manual suggests the training now, as Recommended practice.

Records and yearly evaluations

Each personnel record must include, among other items, "(3) verification of license, permits, references, job experience, and educational requirements, as conducted by the agency to verify qualifications for each position accepted; (4) performance evaluations and disciplinary actions; (5) the signed statement about compliance with agency policies required by §558.245(b)(10)" (§558.246(a)(3)-(5)). Two of these show up in HHSC’s FY 2025 list of the ten most-cited Chapter 558 violations in its “Home Health Agencies” table, which covers all license categories, including PAS (it lists PAS service plan citations under §558.404):

• "The agency failed to include verification of license, permits, reference(s), job experience, or educational requirements to verify qualifications for each position a person accepted in its personnel records." 70 citations, rank 7 (HHSC FY 2025 report, p. 159).
• "The agency failed to include performance evaluations and disciplinary actions in its personnel records." 61 citations, rank 10 (p. 159).

Section 558.246 does not name training or competency records. By our reading, a written record is how you show a surveyor that your training and competency policy was followed, so CareRulebook’s manual keeps them in the personnel record. HHSC’s FAQ gives an example of an agency being held to its own policy, about driver’s licenses: "if the agency’s policy states that a copy of the driver’s license will be included in the personnel record, the agency must follow its policy and include a copy of the employee’s driver’s license." (HCSSA FAQ p. 13). By our reading the same applies to training: if your policy promises a topic or a timetable, do it and record it.

The Nurse Aide Registry and the Employee Misconduct Registry

For a PAS agency, both registries are mainly part of hiring checks, not training. They touch training in three places:

• Registry searches are not training records. You must search the Nurse Aide Registry and the Employee Misconduct Registry before hiring an unlicensed applicant or before their first face-to-face client contact (§558.247(a)(3)), and HHSC has also required a SEMARC search since August 3, 2026 (PL 2026-10). By our reading, a clear search shows the person is not barred; it does not show they are competent for your tasks.
• Information about the misconduct registry. "The agency must provide written information about the EMR to an unlicensed employee" (§558.247(a)(4)), and the personnel record holds documentation that they received it (§558.246(a)(6)(B)). CareRulebook’s manual has the administrator give it and record the date in the personnel record.
• Nurse aides. To be listed on the registry, a nurse aide must complete at least 100 hours of approved course work and a competency evaluation, and must renew every two years with at least 24 hours of in-service education (HSC §250.0035). For a licensed home health agency, registry listing with no findings is one route to qualify as a home health aide (§558.701(a)(6)).

The checks themselves, the yearly re-check and SEMARC are on Texas caregiver background checks.

What Texas licensing rules do not require of PAS attendants

• Set hours or a general curriculum. We found no hour minimum and no general curriculum for PAS attendants in Chapter 558; the rules set duties and competency, not course length (§558.245(b)(2)). The one set program is for g-tube tasks (§558.404(h), above).
• Nurse aide certification. Not a PAS requirement under §558.404(c); see the table above.
• A TB test. HHSC: "There is no regulatory requirement for a HCSSA to conduct employee TB screenings." HHSC adds that TB is a notifiable condition: your infection control policy should say how you report a positive case to the local health entity, and HHSC encourages following CDC guidelines (HCSSA FAQ p. 19).
• CPR or first aid certification. We found no CPR or first aid requirement for PAS attendants in Chapter 558. If your own policy promises it, follow it and record it (see records).

Medicaid programs and managed care contracts can add their own attendant requirements; we have not checked those here. HHSC’s FAQ says HCSSAs that "participate in Medicare or contract for Medicaid or other programs must also follow applicable federal regulations, applicable state program rules and contracts, and policy guidance for their contracted programs" (HCSSA FAQ p. 1).