The definitions in RCW 18.88A.020 and in this section apply throughout this chapter unless the context clearly requires otherwise.

(1) "Asynchronous" means online learning of classroom or theory content that allows students to view and participate with online instructional materials within a flexible, but defined time period and does not include a live video lecture component.

(2) "Clinical" means students' in-facility experiences providing care in accordance with the nursing assistant scope of practice under the supervision of an approved instructor for the training program. Students who opt to complete clinical requirements through the nursing assistant-registered work pathway may be supervised by a licensed nurse as described in subsection (8)(b) of this section.

(3) "Commission" means the Washington state nursing care quality assurance commission.

(4) "Common curriculum" means the curriculum framework provided by the commission for use by all programs. The curriculum framework includes materials for nine basic units and integrates three specialty trainings (developmental disabilities, mental health, and dementia) as directed by the legislature. The common curriculum supports students' development of a holistic, person-centered care approach.

(5) "Competency evaluation" means the measurement of an individual's knowledge and skills as related to safe, competent performance of one's professional role. A formal, state-required competency evaluation is required for certification as a nursing assistant or for a certification endorsement as a medication assistant.

(6) "Corrective action" means the necessary steps a nursing assistant training program must take to address identified deficiencies in or violations of program standards.

(7) "Corrective action designation" means a classification added by the commission to a nursing assistant training program's approval status when deficiencies in or violations of program standards exist. Corrective action designations are described in WAC 246-841A-470 and include: Full approval with plan of correction; full approval with plan of correction and technical assistance; and conditional approval.

(8) "Direct patient care" means implementing all aspects of the nursing process with patients through hands-on, face-to-face contact by a licensed nurse. The nursing process consists of assessment, diagnosis, planning, implementation, and evaluation.

(9) "Direct supervision" means:

(a) For nursing assistant and medication assistant students in clinical: An approved instructor is always on-site to ensure appropriate care assignments, supervise, teach, and evaluate performance while the students are providing care.

(b) For nursing assistant-registered employees using the nursing assistant-registered work pathway for clinical credit in a nursing assistant training program: A licensed nurse is always on-site to supervise and evaluate competency for all tasks assigned and care to be provided.

(c) For medication assistants employed in a nursing home: The licensed registered nurse who directs medication administration and commission-approved treatments to a medication assistant is on-site, immediately accessible in person, and has assessed the residents prior to performance of these duties.

(10) "Good standing" means:

(a) For a nursing assistant training program: The program has operated for at least one year and has full approval status with no corrective action designation as identified in WAC 246-841A-470.

(b) Regarding the status of an individual's license or credential: The license or credential is not currently subject to any sanction, terms, conditions or restrictions required by formal or informal discipline or an agreement to practice with conditions under chapter 18.130 RCW, the Uniform Disciplinary Act.

(11) "Holistic care" means care of the whole person by supporting the person's human needs within one's professional scope of practice. Human needs include physiological, safety, love and belonging, self-esteem, and self-actualization needs.

(12) "Home care aide-certified" means any person certified under chapter 18.88B RCW.

(13) "Hybrid program" means online learning replaces a portion of face-to-face classroom or theory instruction with web-based online learning (e.g., video lectures, online discussions, or activities).

(14) "Learning management system" means a software application for the administration, documentation, tracking, reporting, automation and delivery of educational courses, training programs, or learning and development programs.

(15) "Live online" (also called "synchronous") means online classroom theory learning where students are required to log in at a specific time and participate in real-time activities in the virtual classroom with a live instructor.

(16) "Medical assistant-certified" means a person certified under chapter 18.360 RCW.

(17) "Medication assistant" means a nursing assistant-certified with a medication assistant endorsement issued under chapter 18.88A RCW who is authorized to administer certain medications and perform certain treatments in a nursing home under the supervision of a registered nurse.

(18) "Nursing assistant(s)" includes both nursing assistants-registered and nursing assistants-certified.

(19) "Nursing assistant-certified" means any person certified under chapter 18.88A RCW.

(20) "Nursing assistant-registered" means any person registered under chapter 18.88A RCW.

(21) "Nursing home" means any facility licensed under chapter 18.51 RCW.

(22) "Pass rates" means the averaged percentage of students who successfully meet the standard for the state certification examination on their first attempt, measured annually for all programs individually and in aggregate.

(23) "Prescriber-ordered treatments" means drugs or care tasks ordered by a practitioner who is authorized by law or rule in the state of Washington to prescribe drugs or treatments.

(24) "Program standards" means:

(a) Requirements as stated in this chapter;

(b) Policies, procedures, and program materials and forms developed by the commission in support of implementation and compliance with this chapter and state and federal laws;

(c) Demonstration of current and accurate information in program teaching, materials, and communications regarding federal and state laws and regulations pertaining to:

(i) Nursing assistant training, testing, and certification requirements;

(ii) Nursing assistant scope of practice and practice standards; and

(iii) Nursing assistant professional conduct requirements; and

(d) Compliance with applicable state and federal laws.

(25) "Technical assistance" means aid by the commission to support the program in its efforts to meet program standards. Technical assistance sessions are scheduled for a designated time period. They may occur by phone, virtual meeting, or in-person. As examples, technical assistance may include:

(a) Review of program activities and processes in relation to program standards;

(b) Review of program standards with explanations and examples relevant to the program;

(c) Introduction to approaches or resources that may be helpful to the program; or

(d) A written summary of technical assistance provided and requirements for the program to meet program standards.

(26) "Technical support" relates to students in hybrid programs with asynchronous online elements and means timely assistance by the training program to correct technical difficulties with access to online training program materials or use of those materials. Technical support is provided as part of the overall training program with no additional costs to students for technical support needs.

Competencies and standards of practice are statements of knowledge, skills, and behaviors. They are written as descriptions of observable, measurable actions. All nursing assistant competencies are performed under the direction and supervision of a licensed registered nurse or licensed practical nurse as required by RCW 18.88A.030. The following competencies are considered standards of practice for both nursing assistant-certified and nursing assistant-registered:

(1) The nursing assistant role and knowledge of rules and regulations.

(a) A nursing assistant demonstrates competency in providing holistic, person-centered care that supports the human needs of diverse individuals. The nursing assistant:

(i) Identifies the holistic needs of clients or residents.

(ii) Provides care to support holistic needs in accordance with nursing assistant competencies and clients' or residents' plans of care.

(iii) Provides person-centered care by adjusting care approaches to accommodate the unique needs and preferences of clients or residents.

(b) A nursing assistant demonstrates knowledge of and can explain the practical implications of the laws and regulations which affect nursing assistant practice including, but not limited to:

(i) Mandatory reporting procedures related to client or resident abuse, neglect, abandonment, and exploitation (chapters 74.34 RCW and 246-16 WAC, and WAC 246-841A-720);

(ii) Scope of practice;

(iii) Opportunities for expanding scope:

(A) Nurse delegation; and

(B) Medication assistant certification endorsement;

(iv) Workers right to know (chapter 49.70 RCW);

(v) The Uniform Disciplinary Act (chapter 18.130 RCW);

(vi) Omnibus Budget Reconciliation Act (OBRA);

(vii) Medicare and medicaid.

(2) Client or resident rights and promotion of independence. A nursing assistant demonstrates behavior which maintains and respects clients' or residents' rights and promotes independence, regardless of race, religion, lifestyle, sexual orientation, gender identity, disease process, or ability to pay. A nursing assistant:

(a) Recognizes that clients or residents have the right to participate in decisions about their care.

(b) Recognizes and respects each client's or resident's need for privacy and confidentiality.

(c) Promotes and respects clients' or residents' rights to make personal choices to accommodate their needs.

(d) Reports clients' or residents' concerns and gives assistance with resolving grievances and disputes.

(e) Provides assistance to clients or residents in getting to and participating in activities.

(f) Respects the property of clients or residents and employer and does not take equipment, material, property, or medications for the nursing assistant's or another's use or benefit. A nursing assistant may not solicit, accept or borrow money, material, or property from a client or resident for the nursing assistant's or another's use or benefit.

(g) Promotes clients' or residents' right to be free from abuse, mistreatment, and neglect.

(h) Intervenes appropriately on a client's or resident's behalf when abuse, mistreatment, or neglect is observed.

(i) Complies with mandatory reporting requirements by reporting to the department of health and the department of social and health services instances of neglect, abuse, exploitation, or abandonment.

(j) Participates in the plan of care regarding the use of restraints in accordance with current professional standards.

(3) Communication and interpersonal skills. A nursing assistant uses communication and interpersonal skills effectively to function as a member of the nursing team. A nursing assistant:

(a) Reads, writes, speaks, and understands English at the level necessary for performing duties of the nursing assistant.

(b) Listens and responds to verbal and nonverbal communication in an appropriate manner.

(c) Recognizes how one's own behavior influences a client's or resident's behavior and uses resources for obtaining assistance in understanding the client's or resident's behavior.

(d) Adjusts one's own behavior to accommodate clients' or residents' physical or mental limitations.

(e) Uses terminology accepted in the health care setting to appropriately record and report observations, actions, and pertinent information accurately and timely.

(f) Is able to explain policies and procedures before and during care of clients or residents.

(4) Infection control. A nursing assistant uses standard and transmission-based precautions to prevent the spread of microorganisms. A nursing assistant:

(a) Uses principles of medical asepsis and demonstrates infection control techniques and standard and transmission-based precautions including, but not limited to:

(i) Demonstrates effective handwashing methods.

(ii) Identifies different types of personal protective equipment (PPE) and demonstrates how and when to use each.

(b) Explains how disease-causing microorganisms are spread.

(c) Explains transmission of bloodborne pathogens.

(d) Demonstrates knowledge of cleaning agents and methods which destroy microorganisms on surfaces.

(5) Safety and emergency procedures. A nursing assistant demonstrates the ability to identify and implement safety and emergency procedures, including the Heimlich maneuver. A nursing assistant:

(a) Provides an environment with adequate ventilation, warmth, light, and quiet.

(b) Promotes a clean, orderly, and safe environment including equipment for a client or resident.

(c) Identifies and uses measures for accident prevention.

(d) Demonstrates principles of good body mechanics for self and clients or residents, using the safest and most efficient methods to lift and move clients, residents, and heavy items.

(e) Demonstrates proper use of protective devices in the care of clients or residents.

(f) Demonstrates knowledge of and follows fire and disaster procedures.

(g) Identifies and demonstrates principles of health and sanitation in food service.

(h) Demonstrates the proper use and storage of cleaning agents and other potentially hazardous materials.

(6) Basic nursing skills. A nursing assistant demonstrates basic technical skills which facilitate an optimal level of functioning for clients or residents, recognizing individual, cultural, and religious diversity. A nursing assistant:

(a) Demonstrates proficiency in cardiopulmonary resuscitation (CPR) and can perform CPR independently.

(b) Takes and records vital signs.

(c) Measures and records height and weight.

(d) Measures and records fluid and food intake and output.

(e) Recognizes normal body functions, deviations from normal body functions and the importance of reporting deviations in a timely manner to a supervising nurse.

(f) Recognizes, responds to, and reports clients' or residents' emotional, social, cultural, and mental health needs.

(g) Recognizes, responds to, and reports problems in clients' or residents' environment to ensure safety and comfort of clients.

(h) Participates in care planning and the nursing reporting process.

(7) Basic restorative services. The nursing assistant incorporates principles and skills in providing restorative care. A nursing assistant:

(a) Demonstrates knowledge and skill in using assistive devices in ambulation, transferring, eating, and dressing.

(b) Demonstrates knowledge and skill in the maintenance of range of motion.

(c) Demonstrates proper techniques for turning, positioning, and repositioning clients or residents in a bed and chair.

(d) Demonstrates proper techniques for transferring and ambulating clients or residents.

(e) Demonstrates knowledge about methods for meeting the elimination needs of clients or residents.

(f) Demonstrates knowledge and skill for the use and care of prosthetic devices by clients or residents.

(g) Uses basic restorative services by training clients or residents in self-care according to their capabilities.

(8) Personal care. A nursing assistant demonstrates basic personal care skills. A nursing assistant:

(a) Assists clients or residents with bathing, oral care, and skin care.

(b) Assists clients or residents with grooming and dressing.

(c) Provides toileting assistance to clients or residents.

(d) Assists clients or residents with eating and hydration.

(e) Uses proper oral feeding techniques.

(9) Life transitions. A nursing assistant demonstrates the ability to support the care needs of clients or residents during life transitions with competency in the following areas:

(a) Uses basic procedures for admitting, transferring, and discharging clients or residents and maintains professional boundaries.

(b) Applies knowledge of psychosocial and mental health considerations during life transitions. Examples include, but are not limited to:

(i) Human responses to stress and stressors;

(ii) Stages of psychosocial development across the lifespan; and

(iii) Human responses to grief and loss.

(c) Demonstrates ability to support clients' or residents' holistic needs at the end of life.

(d) Demonstrates knowledge of legal documents affecting care and the nursing assistant role in using the documents:

(i) Advance directives (living wills, durable power of attorney);

(ii) Portable orders for life sustaining treatment (POLST);

(iii) Do not resuscitate (DNR).

(e) Demonstrates the ability to provide postmortem care with respect for clients' or residents' rights and sensitivity to the grieving process of their loved ones.

(f) Demonstrates awareness of the need for self-care and support in response to grief and loss.

(10) Care of clients or residents with developmental disabilities. A nursing assistant demonstrates basic care of clients or residents with developmental disabilities. In accordance with developmental disability specialty training (WAC 388-112A-0430), a nursing assistant:

(a) Demonstrates a basic understanding of developmental disabilities and awareness of the unique needs of residents with developmental disabilities.

(b) Promotes and supports a resident's self-determination.

(c) Provides culturally compassionate and individualized care by utilizing a basic understanding of each client or resident and each client's or resident's history, experience, and cultural beliefs.

(d) Uses person-centered and interactive planning when working with clients or residents with developmental disabilities.

(e) Uses a problem-solving approach and positive support principles when dealing with challenging behaviors.

(f) Supports clients or residents experiencing a crisis and gets assistance when needed.

(g) Promotes and protects the legal and resident rights of clients or residents with developmental disabilities.

(11) Mental health and social service needs. A nursing assistant demonstrates the ability to identify psychosocial needs of clients or residents based upon awareness of the developmental and age specific processes. A nursing assistant:

(a) Addresses individual behavioral needs of the client or resident.

(b) Knows the developmental tasks associated with the developmental and age specific processes.

(c) Allows the client or resident to make personal choices but provides and reinforces behaviors consistent with the client's or resident's dignity.

(d) Is sensitive and supportive and responds to the emotional needs of the clients or residents and their sources of emotional support.

(e) Applies the knowledge, skills, and behaviors from mental health specialty training in the care of residents and clients (WAC 388-112A-0450).

(12) Care of clients or residents with cognitive impairment. A nursing assistant demonstrates basic care of clients or residents with cognitive impairment. A nursing assistant:

(a) Uses techniques for addressing the unique needs and behaviors of individuals with cognitive impairment including Alzheimer's, dementia, delirium, developmental disabilities, mental illnesses, and other conditions.

(b) Communicates with clients or residents with cognitive impairment in a manner appropriate to their needs.

(c) Demonstrates sensitivity to the behavior of clients or residents with cognitive impairment.

(d) Appropriately responds to the behavior of clients or residents with cognitive impairment.

(1) Nursing assistants work in health care facilities as identified in RCW 18.88A.020. These include nursing homes, hospitals, hospice care facilities, and agencies and home health agencies.

(2) In addition, nursing assistants may work for other entities delivering health care services where licensed nurses supervise nursing assistants performing within the nursing assistant scope. Examples include, but are not limited to: Adult family homes, assisted living communities, residential treatment facilities, and correctional facilities.

(3) Nursing assistant students shall apply for a nursing assistant registration within three days of hire at a nursing home. Students working as nursing assistants-registered in a nursing home must become certified within the timeline required by federal regulations.

(4) Nursing assistant students shall meet other registration and certification timelines as required by the care setting.

In addition to the competencies identified in WAC 246-841A-400, nursing assistants may perform additional delegated tasks under the supervision of a registered nurse in accordance with RCW 18.79.260.

(1) RCW 18.79.260 addresses general requirements for registered nurse delegation as well as requirements specific to certain care entities and settings, including home health or hospice agencies and community-based or in-home care settings, as defined in the statute.

(2) General requirements for registered nursing delegation that apply in all care settings include:

(a) In accordance with RCW 18.79.260 (3)(f), registered nurse delegation may include glucose monitoring and testing as a general allowance, including in hospitals and nursing homes.

(b) Delegated nursing care tasks described in this section are only for the specific patient receiving delegation.

(c) A nursing assistant may consent or refuse to consent to perform a delegated nursing care task. The nursing assistant is responsible for their own actions with the decision to consent or refuse to consent and the performance of the delegated nursing care task.

(d) Nursing assistants shall not accept delegation of, or perform, the following nursing care tasks:

(i) Administration of medication by injection, except for insulin injections as authorized in RCW 18.79.260 (3)(e);

(ii) Sterile procedures;

(iii) Central line maintenance;

(iv) Except as authorized in RCW 18.79.260 (3)(e) and (f), piercing or severing of tissues and acts requiring substantial skill; and

(v) Acts requiring nursing judgment.

(3) RCW 18.79.260 (3)(e) defines specific requirements for registered nurse delegation in community-based or in-home care settings. WAC 246-840-910 through 246-840-970 provide additional applicable requirements for compliance. Before performing any delegated task in these care settings:

(a) Nursing assistants-registered must show evidence as required by the department of social and health services of successful completion of both the basic caregiver training and designated nurse delegation core training from the department of social and health services to the registered nurse delegator.

(b) Nursing assistants-certified must show the registered nurse delegator evidence as required by the department of social and health services of successful completion of required nurse delegation core training. The training is provided by the department of social and health services.

(c) All nursing assistants registered and certified who may be completing insulin injections must show to the registered nurse delegator evidence as required by the department of social and health services of successful completion of nurse delegation special focus on diabetes training.

(d) All nursing assistants must meet any additional training requirements identified by the commission. Any exceptions to additional training requirements must comply with RCW 18.79.260 (3)(e)(v).

Nursing assistants-certified with the required experience, training, and successful completion of competency evaluation as described in WAC 246-841A-586 through 246-841A-595 may apply for a medication assistant certification endorsement.

This endorsement expands the scope of the nursing assistant-certified working in a nursing home setting, allowing the nursing assistant-certified to perform certain medication administration tasks and prescriber ordered treatments under the direct supervision of a designated registered nurse.

(1) This chapter addresses four types of nursing assistant training programs:

(a) Traditional nursing assistant training programs, which provide the complete training required for competency evaluation and career entry as a nursing assistant-certified.

(b) Home care aide-certified alternative training programs, which recognize prior training and certification as a home care aide and provide the additional education required to qualify for competency evaluation and career progression to a nursing assistant-certified.

(c) Medical assistant-certified alternative training programs, which recognize prior training and certification as a medical assistant and provide the additional education required to qualify for competency evaluation and career progression to a nursing assistant-certified.

(d) Medication assistant certification endorsement training, which provides the additional education required of experienced nursing assistants-certified to qualify for competency evaluation to earn a medication assistant endorsement.

(2) The requirements for initial and ongoing approval of nursing assistant training programs (described in WAC 246-841A-420 through 246-841A-460) and for corrective actions for nursing assistant training programs (described in WAC 246-841A-465 through 246-841A-490) apply to all training program types unless exceptions are specifically noted in this chapter:

(a) Exceptions for home care aide-certified alternative programs are noted in WAC 246-841A-545.

(b) Exceptions for medical assistant-certified alternative programs are noted in WAC 246-841A-550.

(c) Exceptions for medication assistant certification endorsement programs are noted in WAC 246-841A-590.

The commission reviews and approves nursing assistant training programs to ensure preparation for safe practice of nursing assistants by requiring nursing assistant training programs to meet minimum standards.

To qualify as a nursing assistant training program for initial and ongoing approval, an applicant must:

(1) Attend an online orientation provided by the commission prior to submission of an application;

(2) Submit a completed application packet provided by the commission. The completed packet will reflect how the training program will meet program standards on an ongoing basis. The packet will include forms and instructions for submitting required materials which include, but are not limited to:

(a) Owner identification and contact information, business name, and physical address;

(b) Documentation demonstrating the program director and instructor(s) meet all qualifying criteria as stated in WAC 246-841A-430. Required documentation includes:

(i) Verification that the program director and instructor(s) have successfully completed a course in adult instruction as required by WAC 246-841A-430 (2)(a) or have demonstrated one year of experience teaching adults.

(ii) Verification that the program director and instructor(s) who teach the specialty class units (mental health, dementia, and developmental disabilities) have successfully completed coursework in the subjects prior to instructing students as required by WAC 246-841A-430 (6)(g);

(c) Contractual agreements related to providing training. For any program that uses another facility to provide clinical training, contractual agreements include an affiliation agreement between the training program and the facility. The affiliation agreement must describe how the program will provide clinical experience in the facility, making it clear that students will be supervised at all times, taught, and evaluated by an approved instructor who meets the requirements under this chapter. The agreement must specify the rights and responsibilities of both parties, students, and clients or residents;

(d) A student enrollment agreement that the training program will provide to each student for review, discussion, and signature prior to beginning the course. The training program retains a signed copy in each student's file. The student agreement must include:

(i) A statement that specifies the student's rights and responsibilities, including those listed in the clinical affiliation agreement;

(ii) A general description of the program and the program components (classroom, skills lab, and clinical), including the number of hours and length of time required to complete the program;

(iii) The program's policies relevant to students, including all criteria required to pass the course and criteria that may be cause for immediate dismissal or failure;

(iv) A statement that the student has received the class schedule and access to common curriculum materials for students as provided by the commission;

(v) The following statement regarding the right to file a complaint with the commission with concerns about the training program: "Student complaints about this nursing assistant training program can be filed with the nursing care quality assurance commission." The current web page link for filing a complaint must be included with the statement;

(e) An implementation plan for teaching the common curriculum using a format and instructions provided by the commission. Implementation information must include:

(i) The outline of materials for assigned study for each unit, including text readings, videos, and other resources. The main text resource must have a publication date within the last five years;

(ii) Presentations and active discussion of content;

(iii) A variety of activities to reinforce and apply knowledge and concepts, including activities provided in the common curriculum;

(iv) Skills practice to integrate theory with skills, including use of skills checklists which match the state exam;

(v) Plans for evaluation to measure student learning and competency; and

(vi) Plans for conducting and supervising clinical experiences;

(f) A description of classroom and skills lab facilities with photographs demonstrating adequate space, equipment, and supplies available to provide the training program in accordance with this chapter;

(g) Verification that the nursing assistant training program or school is approved to operate in the state of Washington by:

(i) The state board for community and technical colleges for college programs;

(ii) The superintendent of public instruction for high schools and skills center programs;

(iii) The workforce training and education coordinating board for private vocational schools; or

(iv) The department of social and health services for nursing home programs. For purposes of this chapter: Lack of a department of social and health services sanction signifies department of social and health services approval; a current sanction with no department of social and health services waiver to conduct training signifies nonapproval;

(h) A declaration of compliance with all program standards signed by:

(i) Program owner or administrator; and

(ii) Program director, if different from owner or administrator;

(3) Submit all application items in one submission and respond to requests for more information or clarification regarding the program's application submission. Failure to submit a completed application packet or respond to request for more information or clarification within 90 days may result in closure of the application;

(4) Agree to in-person or online site visits by the commission on request or, when applicable per WAC 246-841A-465(2) and 246-841A-470 (2)(c)(v), unannounced site visits by the commission. Examples of activities a site visit may include are:

(a) Observation of classroom, skills lab, and clinical teaching;

(b) A review of the program facilities, equipment, supplies, documentation, and files related to the program with the potential need to make copies or take photos of them;

(c) Access to student names and contact information;

(d) Interviews with the program owner(s), program director, instructor(s), other support staff, clinical site personnel, and students;

(e) A review of facilities, equipment, supplies, and staff at clinical affiliation sites;

(5) Comply with all program standards;

(6) For each class taught, implement the common curriculum as developed and described in materials provided by the commission;

(7) Submit all program change requests on forms provided by the commission and receive approval prior to implementation of the change. Notify other approving agencies of changes prior to implementing the change(s). Program changes include, but are not limited to:

(a) Program owner(s);

(b) Program director;

(c) Instructor(s);

(d) Program location;

(e) Program curriculum plan as approved;

(f) Program curriculum hours; and

(g) Program schedule pattern;

(8) Comply with changes in program standards;

(9) Participate in and complete the program renewal process every two years. Failure to renew by the designated deadline results in lapse of approval.

The commission will grant initial approval status for one year to a nursing assistant training program applicant demonstrating the ability to meet program standards.

(1) The commission will monitor the nursing assistant training program for the first year and then complete a program evaluation to verify the program has continued to meet program standards. Following the program evaluation, the commission may:

(a) Change the program's status to full approval if program standards have been met consistently; or

(b) Extend a program's initial approval for up to one additional year with an evaluation at the end of the second year to verify program standards have been met consistently; or

(c) Withdraw initial approval if a nursing assistant training program demonstrates deficiencies in or violations of program standards.

(2) A nursing assistant training program with initial approval status is subject to announced and unannounced site visits by the commission.

The commission will grant full approval status to initially approved nursing assistant training programs demonstrating they have consistently met program standards during the initial approval period.

(1) Existing nursing assistant training programs with full approval status retain full approval status on the date these rules take effect.

(2) Existing nursing assistant training programs with conditional approval status retain conditional approval status on the date these rules take effect.

(3) Existing nursing assistant training programs are subject to approval status changes under the rules of this chapter upon the effective date.

(1) The program director must hold an active license in good standing as a registered nurse (RN) in the state of Washington.

(a) The commission may deny or withdraw a program director's approval if there is or has been any action taken against the director which disqualifies them from working with vulnerable populations.

(b) Directing a nursing assistant training program constitutes the practice of nursing. Any unprofessional conduct by a program director, as defined in the Uniform Disciplinary Act, chapter 18.130 RCW, may subject the program director to license discipline under that act.

(2)(a) The program director must have completed a training course on adult instruction or have demonstrated one year of experience teaching adults. Acceptable experience does not include teaching patients. A program director working exclusively in a secondary or postsecondary educational setting is exempt from this requirement.

(b) The training course on adult instruction must provide instruction in:

(i) Understanding the adult learner;

(ii) Techniques for teaching adults;

(iii) Classroom methods for teaching adults;

(iv) Audio visual techniques for teaching adults.

(3) The program director must attend an online orientation provided by the commission within 30 days of approval as program director.

(4) The program director will have a minimum of three years of experience as an RN, of which at least one year will be in direct patient care.

(5) If the program director will also be acting as an instructor, the program director must meet the requirements for instructional staff.

(6) Program director responsibilities:

(a) Implement the common curriculum as developed and described in materials provided by the commission and in accordance with the requirements of WAC 246-841A-440. The program director is responsible for all classroom and clinical training content and instruction;

(b) Ensure compliance with and assume responsibility for meeting the training program requirements of this chapter;

(c) Ensure that all student clinical training is directly supervised:

(i) For instructor-led clinical training provided by the program, direct supervision means that an approved instructor is always on-site to supervise, teach, and evaluate performance while the students are providing care.

(ii) For clinical training provided through the nursing assistant-registered work pathway described in WAC 246-841A-440(8), direct supervision means the program director requires the student to provide verifiable documentation of supervision and competency evaluation by a supervising licensed nurse prior to awarding clinical training credit. To receive clinical training credit, students must provide documentation on the verification form provided by the commission. The student must also provide evidence of at least 40 hours of work in the role of a nursing assistant;

(d) Ensure that the clinical instructor has no concurrent duties during the time he or she is instructing students;

(e) Create and maintain an environment conducive to teaching and learning;

(f) Select and supervise all instructors involved in the course, including clinical instructors and guest lecturers;

(g) Ensure the instructor(s) teaching specialty units on the topics of mental health, dementia, and developmental disabilities are approved to teach the units prior to teaching them. For the instructor to receive approval, the program director will:

(i) Verify the instructor has completed a class on adult instruction as identified in subsection (2)(b) of this section. Acceptable experience does not include teaching patients. An instructor working exclusively in a secondary or postsecondary educational setting is exempt from this requirement.

(ii) Verify the instructor(s) has completed the corresponding specialty class(es) for the unit(s) they will teach. The mental health and dementia specialty classes must be the complete curriculum approved by the department of social and health services; the developmental disabilities specialty class must be the complete curriculum provided by the developmental disabilities administration of the department of social and health services.

(iii) Submit documentation with an instructor application to the commission;

(h) Ensure teaching of specialty units on mental health, dementia, and developmental disabilities occurs only as components of the complete nursing assistant training program. Unless expressly approved by the department of social and health services to provide stand-alone specialty classes on the specialty topics, a nursing assistant training program is only authorized to provide specialty units as components of the overall nursing assistant training program;

(i) Ensure that students are not asked to, nor allowed to, perform any clinical skill with residents or clients until first demonstrating the skill satisfactorily to an instructor;

(j) Provide students with instruction regarding the nursing assistant-registered work pathway as described in WAC 246-841A-440(8), including supervision and documentation requirements;

(k) Ensure evaluation of professional knowledge, skills, and behaviors of students before verifying completion of the course;

(l) Without delay upon successful completion of course requirements:

(i) Provide students a certificate of completion on a form provided by the commission.

(ii) Provide verification of each student's eligibility to take the state exam. Verification is to be provided in accordance with the established procedure provided to program directors by the commission;

(m) Communicate directly with the commission in all matters regarding the program.

(7) The program director may select instructional staff to assist in the teaching of the course.

(a) Instructional staff must teach in their area of expertise.

(b) Instructional staff must have a minimum of:

(i) One year of verifiable paid or unpaid work experience as a licensed nurse within the past three years providing direct patient care for the elderly or chronically ill of any age; or

(ii) Three years of verifiable paid experience as a licensed nurse at any time providing direct patient care for the elderly or chronically ill of any age and verifiable paid or unpaid work experience as a licensed nurse in any role for at least one of the last three years.

(c) A clinical instructor providing care to patients with staff or students is considered a provider of direct patient care.

(d) Instructional staff must complete a training course on adult instruction as described in subsection (2)(b) of this section or have demonstrated one year of experience teaching adults. Instructional staff working exclusively in a secondary or postsecondary educational setting are exempt from this requirement.

(i) Instructional staff who will teach the specialty units of curriculum on the topics of mental health, dementia, or developmental disabilities, must also demonstrate successful completion of those courses described in (g) of this subsection prior to teaching them.

(ii) Instructional staff must hold an active Washington state license to practice as a registered or licensed practical nurse, in good standing. The commission may deny or withdraw an instructor's approval if there is or has been any action taken against the instructor which disqualifies them from working with vulnerable populations.

(iii) Instructional staff may assist the program director in development of curricula, teaching modalities, and evaluation.

(iv) Instructional staff will always be under the supervision of the program director.

(v) A guest lecturer or individual with expertise in a specific course unit may be used in the classroom setting for teaching within that unit without commission approval, following the program director's review of the currency and relevance of content in relation to unit objectives. Guest lecturers must hold a license, certificate, or registration in good standing in their field of expertise. The allowance for a guest lecturer does not apply to the specialty units of the common curriculum on the topics of mental health, dementia, or developmental disabilities. The specialty units must be taught by a program instructor specifically approved by the commission to teach the specialty units as described in subsection (6)(g) of this section.

(1) Common curriculum. Approved programs must implement the common curriculum as developed and described in materials provided by the commission in accordance with the transition timelines established by the commission in (a) through (c) of this subsection. The common curriculum includes the complete specialty curricula on the topics of developmental disabilities, mental health, and dementia as developed by the department of social and health services.

(a) Approved programs must apply for approval to implement the first nine units of the common curriculum within six months of the effective date of these rules and begin implementation by September 1, 2024.

(b) Until they transition to the common curriculum, approved programs may continue to implement their existing curriculum as approved under previous rules; however, subsections (5) through (8) of this section are effective with the effective date of these rules.

(c) Approved programs must implement the specialty curricula as units 10, 11, and 12 of the common curriculum for all students graduating on or after September 1, 2025.

(2) Implementing the common curriculum. Implementing the common curriculum as developed and described in materials provided by the commission includes, but is not limited to:

(a) Interactive presentation and discussion of content for each unit and activity that provides students with an opportunity to reinforce learning and apply knowledge. The program will demonstrate use of a variety of activities across units. Examples include, but are not limited to:

(i) Written assignments;

(ii) Responding to videos shown or assigned;

(iii) Small group exercises;

(iv) Role play;

(v) Student presentations; and

(vi) Team or game-type learning activities.

(b) Instructor demonstration of each unit's lab skills followed by students' practice of the skills under the supervision of an approved instructor who provides guidance and evaluation in real time.

(c) A clinical training opportunity for students to successfully demonstrate the core competencies of a nursing assistant through integration of professional knowledge, skills, and behaviors gained in class and skills lab.

(d) Evaluation to measure each student's level of competency achievement in each part of the training program (classroom theory, skills lab, and clinical) and overall.

(3) Correlation of classroom and clinical teaching. When implementing the common curriculum, programs will ensure clinical teaching is closely correlated with classroom theory teaching to support students' integration of professional knowledge and behaviors with manual skills.

(a) For skills lab training, close correlation means skills included in each unit of the common curriculum are taught together with the unit's classroom theory.

(b) For clinical training, close correlation means clinical training occurs as part of the planned, continuous flow of the class immediately following completion of classroom theory and skills lab. When there are delays in the start of clinical training, as allowed by the program's policies, the program will reverify and document student competency to participate safely in clinical training prior to a student's participation.

(4) Program hours. The program director will determine the amount of time required in the curriculum to achieve the objectives. The time designated may vary with characteristics of the learners and teaching or learning variables, but the program must provide a minimum of 138 training hours total, with a minimum of 66 hours of classroom theory, a minimum of 32 hours of skills lab, and a minimum of 40 hours of clinical training.

(a) These hours include 32 hours of classroom training on the specialty topics of developmental disabilities (16 hours), mental health (eight hours), and dementia (eight hours). Training programs must incorporate the complete curriculum for each specialty topic as developed by department of social and health services. Requirements for providing and instructing specialty curricula as part of a nursing assistant training program are found in WAC 246-841A-430 (g) and (h).

(i) If a student has already taken one or more of the specialty topics, the program director may excuse the student from repeating the topic(s) when they provide documentation of successful completion.

(ii) Only the specialty classes developed specifically by the department of social and health services qualify for acceptable training to excuse students from specialty topic(s).

(iii) For students who are excused, programs must retain documentation of a student's previous specialty training in the student's file.

(b) Training to orient the student to the health care facility and facility policies and procedures is required, but must not be included in the minimum clinical training hours required.

(5) Classroom theory teaching and learning. Classroom theory teaching and learning may be conducted through the following modalities:

(a) An in-person format in a classroom space approved by the commission;

(b) A live online format.

(i) Prior to implementation, the program must apply to the commission for approval to use a live online format on a form provided by the commission.

(ii) At no time will the ratio of students to instructor exceed 20 students to one instructor in a live online class;

(c) An online or hybrid format that includes asynchronous online elements.

(i) Prior to implementation, the program must apply to the commission for approval to use this online format on a form provided by the commission.

(ii) The program must provide the commission with access to all online programming from both the instructor and the student user views including, but not limited to: Lessons, assignments, quizzes and tests, discussion boards, tools for instructor monitoring of student progress and interacting with students, evaluation mechanisms, and electronic gradebook.

(iii) The student-to-instructor ratio for an online or hybrid program with asynchronous learning elements must not exceed one instructor to 30 students.

(iv) Except for high school programs with a 10-month calendar, the entire program must be completed by students within three months.

(v) For initial and ongoing approval, the program must demonstrate how it meets the standards for online education as established by the commission. The standards require the program to demonstrate:

(A) Evidence of ability to provide online training or online educational programs successfully (i.e., a history of success, institutional support, external review, and certification by a commission-approved quality assurance organization).

(B) Correlation between the curriculum and text readings for the course.

(C) Instructor interaction with and support of students during the classroom theory portion of the class and throughout the entire class.

(D) Close correlation of the teaching and learning of classroom theory with teaching and learning in skills lab and clinical.

(E) The direct supervision role of an approved instructor in the classroom theory, skills lab, and clinical portions of the class.

(F) Student selection process, including entry requirements for the program.

(G) Provision of a live online or in-person orientation for all students prior to beginning the program. The orientation will include information about program requirements and policies, time schedule, appropriate online conduct, and how to navigate the learning management system and program content. The orientation hours may not be included in the minimum required program hours.

(H) An academic-based assignment related to the course outcome in the first week of class for the purpose of reporting attendance.

(I) For each unit, at least one asynchronous online discussion related to a unit outcome that allows instructor feedback, student interaction, and a rubric for grading participation.

(J) Facilitation of students' ability to meet independently in a study group.

(K) The opportunity for robust and individualized instructor feedback for students needing to improve grades or requiring further instruction. This does not include computer-generated feedback.

(L) An organized schedule of classroom theory, skills lab, and clinical activities with paced deadlines to support time management and successful course completion provided to the students.

(M) Ensuring the identity of each student completing online examinations and security measures throughout the examination.

(N) Adequate technical support to the website and to students, including provisions for: Reliability; privacy; security; addressing technical difficulties; assuring back-up of data; services and training for students to use the website and program; and student technical support services.

(O) Evidence of meeting requirements for all nursing assistant training programs as described in this chapter.

(6) Skills lab teaching and learning. Skills lab teaching and learning will be conducted in-person in a commission-approved skills lab.

(7) Clinical teaching and learning: Instructor-led clinical in a care facility. The program shall provide instructor-led clinical training in a care facility for all students completing the program. Instructor-led clinical training means the program must provide a commission-approved instructor who conducts and supervises a coordinated clinical training experience in a nursing home or other care facility where students have an opportunity to safely demonstrate competency in the role of a nursing assistant caring for a variety of individuals with diverse care needs.

(a) The clinical instructor must be on-site with students at all times to supervise, teach, and evaluate performance.

(b) The clinical instructor must have no concurrent duties during the student clinical experience.

(c) The ratio of students to instructor must not exceed 10 students to one instructor in the clinical setting.

(d) Students cannot perform any clinical skill with clients or residents until first satisfactorily demonstrating the skill to an approved instructor.

(e) Students must wear name tags clearly identifying them as students at all times.

(8) Clinical teaching and learning: Nursing assistant-registered work pathway. In accordance with the program's established policies, the program retains authority to allow students who choose to do so, on a case-by-case basis, to complete their clinical training hours by working as a nursing assistant-registered in a care facility under the supervision of a licensed nurse. To meet qualifying standards to count as clinical hours' credit, the nursing assistant-registered employment experience must:

(a) Be completed following successful completion of required classroom theory and skills lab hours;

(b) Be completed in a time frame comparable to that of classmates who complete through instructor-led clinical training as established by the program's schedule and completion policies;

(c) Be performed under a pending or active nursing assistant-registered credential during enrollment in the class;

(d) Include a background check prior to contact with clients or residents;

(e) Occur in a care facility where a licensed nurse is present to provide direct supervision and verify competency for care provided throughout the clinical experience; the supervising nurse may not be a friend or relative;

(f) Include opportunities for the student to successfully demonstrate the competencies of a nursing assistant as identified in WAC 246-841A-400;

(g) Include care of clients or residents who are not friends or relatives;

(h) Be documented on a form provided by the commission and available on file at the training program along with formal documentation of the number of hours worked; and

(i) Be verifiable with the care facility.

(1) Classroom, skills lab, and clinical facilities used by the program must provide adequate space, lighting, comfort, privacy, safety, and cleanliness for effective teaching and learning.

(2) Adequate classroom resources, such as a white board or other writing device, audio-visual materials, and written materials must be available. Audio-visual materials include a computer with internet and projection capability in order to access and implement the common curriculum.

(3) Online classrooms used by the program must provide browser-based platforms and mixed media capability such as captioning, video, and audio-text to enhance accessibility. Online classrooms must have a method for providing private and secure methods of evaluation, submitting grades, and providing feedback.

(4) The program must provide the equipment and supplies necessary to teach skills lab and allow students to practice and gain competency as nursing assistants in accordance with WAC 246-841A-400.

(a) A list of required equipment and supplies for all nursing assistant training programs is provided by the commission.

(b) The program will maintain the safety and proper working condition of equipment and supplies.

(c) The program will ensure that equipment and supplies used by the program reflect current practice and are sufficient in quantity for effective teaching and learning for students.

(1) The program must establish and maintain a file for each student enrolled and demonstrate measures for safe, secure storage of all paper and electronic files. Each student's file must include:

(a) Dates of enrollment, attendance, and completion of the program, including multiple attempts to successfully complete the program;

(b) A record of the student's performance in relationship to all passing criteria for the class, including: Quizzes, tests, and other required assignments; evaluation of skills lab performance; and evaluation of clinical performance.

(i) Skills lab evaluations use a checklist that shows the skills evaluated, the date(s) of skills evaluation, the printed name(s), signature(s), and date(s) of evaluating instructor(s);

(ii) Clinical evaluations document performance in relation to each student's competency as a nursing assistant as identified in WAC 246-841A-400;

(c) Documentation of successful completion of the course, or documentation of the course outcome.

(2) Each student file must be maintained by the program for a period of five years. The program must provide copies of each student's file documents to the student on request, within two business days.

(3) The program director will provide verification of students' successful completion of the training program for testing and certification without delay once requirements are met. Verification is to be provided in accordance with the established procedures and format provided to program directors by the commission.

(4) For programs based in a health care facility, verification of program completion and the application for state testing will not be withheld from a student who has successfully met the requirements of the program. Successful completion will be determined by the training program director separately from other employer issues.

Students who successfully complete an approved nursing assistant training program or the equivalent in an approved nursing education program may apply to take the state certification exam (also called competency evaluation). The competency evaluation includes a knowledge exam and a skills exam. Students must pass both exams before their certification application can be processed.

(1) Training programs will communicate accurate information about the state certification exam to students and share written and video resources including, but not limited to:

(a) Testing service provider's website and how to access it. This includes the testing handbook, practice tests, and steps to register for the exam.

(b) The commission's website and how to access it. This includes information to help students navigate through training, testing, and certification.

(c) The department of health website and how to access it. This includes steps to apply for nursing assistant registration and certification.

(2) The commission will monitor all training programs' pass rates on the state certification exam. The program standard for pass rates is:

(a) At least 80 percent of first-time test-takers pass the knowledge portion of the examination; and

(b) At least 80 percent of first-time test-takers pass the skills portion of the examination.

(1) To be eligible to apply for nursing assistant-certified, a traditional program or nursing education program student must:

(a) Have successfully completed a Washington state-approved training program as outlined in WAC 246-841A-440 or the equivalent in an approved nursing education program; and

(b) Have successfully completed a competency evaluation.

(2) An applicant for nursing assistant-certified must submit to the department:

(a) A completed application for nursing assistant-certified;

(b) Proof of training from an approved traditional nursing assistant training program or an approved nursing education program; and

(c) Applicable fees as required in WAC 246-841A-990.

The commission may investigate complaints of alleged deficiencies or violations relating to this chapter. The commission:

(1) Will notify the program director in writing within 10 business days when a complaint investigation is opened.

(a) Failure by the program director to cooperate with an investigation may result in disciplinary action against the program director's license as a registered nurse in the state of Washington in accordance with the Uniform Disciplinary Act, chapter 18.130 RCW.

(b) Failure to cooperate with an investigation may result in withdrawal of program approval by the commission.

(2) May conduct announced or unannounced site visits to training programs in the course of investigating complaints. Site visits may include, but are not limited to:

(a) Observation of classroom, skills lab, and clinical teaching;

(b) A review of the program facilities, equipment, supplies, documentation, and files related to the program. The commission may make copies of documentation or take photos;

(c) Access to student names and contact information;

(d) Interviews with the program owner(s), program director, instructor(s), other support staff, clinical site personnel, and students;

(e) A review of facilities, equipment, supplies, and staff at clinical affiliation sites.

(3) Will notify the program director of the outcome in writing when the complaint investigation process is complete. Outcomes may include:

(a) Closing the complaint with no action; or

(b) Specifying deficiencies or violations and, as applicable, providing notification of the commission's intent to add a corrective action designation to the program's full approval status or change the program's approval status which may include:

(i) Requirements for corrective action steps by the program;

(ii) Withdrawal of program approval; or

(iii) Immediate suspension of program approval for immediate threat to public health and safety.

(1) The commission may add a corrective action designation to a training program's full approval status when deficiencies in or violations of program standards exist. Corrective action designations are organized to provide progressive steps for corrective action to meet program standards and restore full approval status.

(2) Corrective action designations include:

(a) Full approval with plan of correction:

(i) The program develops, implements, and evaluates an initial plan of correction using a format provided by the commission.

(ii) The commission staff may provide one formal technical assistance session to a program on request.

(b) Full approval with plan of correction and technical assistance:

(i) The program develops, implements, and evaluates an adjusted plan of correction when program standards are not met or violations persist after implementation of the first plan of correction or if the first plan of correction was not fully implemented.

(ii) The commission may require the program to participate in one technical assistance session as part of the plan of correction.

(iii) The commission may require a directed plan of correction, which means the commission stipulates some or all aspects of the plan of correction.

(c) Conditional approval:

(i) The commission may change a program's approval status to conditional if the program fails to fully implement the plan of correction or if deficiencies in or violations of program standards persist with implementation of plans of correction.

(ii) The commission will establish in writing additional specific conditions with which the program must comply.

(iii) The commission may require the program to participate in one technical assistance session with commission staff as a condition.

(iv) The program has a responsibility to seek external sources of technical assistance other than commission staff if additional support is needed to meet conditions.

(v) The commission may conduct announced or unannounced site visits to monitor a program on conditional approval. Failure to cooperate with site visits may result in withdrawal of approval by the commission.

(3) The commission will reevaluate a program's corrective action designation in accordance with a timeline established and provided by the commission at the time the program is notified in writing of the designation.

(4) With reevaluation, the commission may:

(a) Remove a corrective action designation if program standards are consistently met;

(b) Change the corrective action designation to a higher designation with improvement toward meeting standards;

(c) Change the corrective action designation to lower designation if standards are not met; for programs with a conditional approval designation, this means withdrawal of approval in accordance with WAC 246-841A-475;

(d) Extend a corrective action designation if more time and evaluation are needed to determine program standards are being met consistently.

(1) The commission may withdraw a program's approval status when any condition of the program's conditional approval status is not met or the program's deficiencies in or violations of program standards persist with implementation of corrective efforts. When a program's approval status is withdrawn, the program shall submit an action plan for closure to the commission providing options for current students to complete the program. The action plan must be submitted within 10 business days of the withdrawal of approval. The commission must review and act on the action plan within 10 business days of receipt of the action plan.

(2) Program approval may be immediately suspended and withdrawn when continued operation of the program presents an immediate danger to the public health, safety, or welfare in accordance with the Administrative Procedure Act (APA), RCW 34.05.479, and chapter 246-11 WAC. If students are in progress to complete the program at time of suspension, the commission will coordinate with the dual approving agency and other training programs to identify options to support students' training completion.

(3) Program approval may be withdrawn if the program:

(a) Has no approved program director at the time of program renewal; or

(b) Has no first-time test-takers for a period of two years; or

(c) Is no longer approved by the appropriate agency providing dual approval. Agencies providing dual approval include:

(i) The office of the superintendent of public instruction for high school and skill center programs;

(ii) The state board of community and technical colleges for college programs;

(iii) The workforce training and education coordinating board for private vocational schools; or

(iv) The department of social and health services for nursing home programs.

A current department of social and health services sanction on a nursing home with no waiver granted by the department of social and health services to conduct training means the nursing home training program is no longer approved by the department of social and health services.

When a nursing assistant training program's approval has been denied or withdrawn or had its approval status changed to conditional by the commission, the program shall have the right to a hearing to appeal the commission's decision according to the provisions of: Chapters 18.88A and 34.05 RCW, the Administrative Procedure Act; and chapter 246-11 WAC.

When an approved program plans to close, it shall notify the commission in writing, stating the reason and the date of intended closing.

(1) The program shall notify the commission in writing at least 30 days in advance and complete all current class(es) in session prior to closing.

(2) In the event of an emergency or unexpected event which renders the program inoperable, the program will ensure a transition plan for students to complete their training.

After a program's approval is withdrawn, the program may be eligible to reapply for initial approval in accordance with certain timelines:

(1) The commission will withdraw approval when the training program loses approval by the office of the superintendent of public instruction, state board of community and technical colleges, workforce training board, or department of social and health services. The program may reapply immediately for initial approval upon regaining approval by the office of the superintendent of public instruction, state board of community and technical colleges, workforce training board, or department of social and health services.

(2) When approval lapses for failure to renew, the program may reapply for initial approval after 90 days. If the program reapplies, receives initial approval, and does not renew a second time, the program may not reapply for initial approval for at least one year.

(3) When approval is withdrawn due to no first-time test-takers within a period of two years, the program may reapply for initial approval six months after notification of withdrawal. If the program reapplies, receives initial approval and has no first-time test-takers again at its one-year program evaluation, the commission may withdraw program approval, and the program may not reapply for initial approval for at least one year after notification of withdrawal.

(4) If the commission withdraws a program's initial or conditional status, the program may reapply for initial approval after one year if it can demonstrate meeting program standards and evidence that the basis for the commission's withdrawal of approval no longer exists.

(5) A program with initial or conditional approval status withdrawn twice by the commission may not reapply for initial approval for at least two years after the date of the second withdrawal.

(6) A program application that includes the same program owner, program director, or instructor(s) from a previous program which had approval withdrawn may be considered by the commission as a reapplication from the previous program, subject to the regulations in this chapter; this applies even if the program has a new name or is operated by a different corporate entity.

Alternative training programs for home care aide-certified and medical assistant-certified recognize relevant training; provide opportunity for recruitment and career progression in nursing; and maintain a single standard for competency as a nursing assistant.

(1) The alternative program provides additional training, including clinical training, on topics not addressed in the specified training for certification as a home care aide or medical assistant, that will meet the requirements necessary to take the nursing assistant-certified competency evaluation.

(2) Successful completion of an approved alternative program may allow the home care aide-certified and medical assistant-certified to meet requirements to complete a competency evaluation. Successful completion of the competency evaluation may allow an applicant who is a home care aide-certified or medical assistant-certified to become a nursing assistant-certified.

(1) A student who takes a home care aide-certified alternative program must be a home care aide-certified prior to beginning the program. Home care aide-certified means any person certified under chapter 18.88B RCW.

(2) A student who takes a medical assistant-certified alternative program must be a medical assistant-certified prior to beginning the program and hold a current certification from one of the certifying organizations in WAC 246-827-0200(2), as defined in chapter 18.88A RCW.

The commission approves home care aide-certified alternative training programs that meet approval requirements. These programs may enroll individuals credentialed as home care aides-certified under chapter 18.88B RCW. Successful completion allows them to apply to take the state exam evaluating competency for nursing assistant certification.

(1) An alternative program shall:

(a) Meet the requirements for initial and ongoing approval of nursing assistant training programs in this chapter except for the following differences:

(i) The program must implement the common curriculum designed specifically for home care aide-certified alternative programs, as developed and described in materials provided by the commission in accordance with the transition timelines established by the commission in WAC 246-841A-440 (1)(a) through (c).

(ii) The program must provide the minimum required training hours designed specifically for home care aide-certified alternative programs.

(A) The minimum required training hours are: Sixty-eight hours total, with a minimum of 49 hours of classroom theory, a minimum of 13 hours of skills lab, and a minimum of six hours of clinical training.

(B) The minimum program hours include 32 hours of classroom theory training on the specialty topics of: Developmental disabilities (16 hours); mental health (eight hours); and dementia (eight hours).

(b) Be subject to corrective actions for nursing assistant training programs as described in WAC 246-841A-465 through 246-841A-490, when requirements are not met for initial and ongoing approval of nursing assistant training programs (WAC 246-841A-420 through 246-841A-460), including those specific to home care aide-certified alternative programs (WAC 246-841A-530 through 246-841A-555).

(c) Provide a subset of the content for traditional nursing assistant programs as identified in the common curriculum for the alternative program and reflecting the following competency areas found in WAC 246-841A-400:

(i) The nursing assistant role and knowledge of rules and regulations;

(ii) Resident rights and promotion of independence;

(iii) Communication and interpersonal skills;

(iv) Infection control;

(v) Safety and emergency procedures;

(vi) Basic nursing skills;

(vii) Basic restorative services;

(viii) Personal care;

(ix) Life transitions;

(x) Care of clients or residents with developmental disabilities (specialty curriculum);

(xi) Mental health and social service needs (specialty curriculum);

(xii) Care of clients or residents with cognitive impairment (specialty curriculum).

(2) The common curriculum for home care aide-certified alternative programs includes the complete specialty curricula on the topics of developmental disabilities, mental health, and dementia developed by the department of social and health services.

(a) For students who have not already taken the specialty classes, the training program must provide them as part of the class.

(b) For students who have already taken one or more of the specialty topics, the training program may excuse them from repeating the topic(s) when they provide documentation of successful completion.

(i) Only the specialty classes developed specifically by the department of social and health services qualify for acceptable training to excuse students from specialty topic(s).

(ii) For students who are excused, programs must retain a copy of documentation of a student's previous specialty training in the student's file.

(3) Training to orient the student to the health care facility and facility policies and procedures is required, but is not included in the minimum clinical training hours required.

The commission approves medical assistant-certified alternative training programs that meet approval requirements. These programs serve individuals credentialed as medical assistants-certified as defined in WAC 246-841A-535(2). Successful completion allows them to apply to take the state exam evaluating competency for nursing assistant certification.

(1) An alternative program shall:

(a) Meet the requirements for initial and ongoing approval of nursing assistant training programs in this chapter, except for the following differences:

(i) The program must implement the common curriculum designed specifically for medical assistant-certified alternative programs, as developed and described in materials provided by the commission in accordance with the transition timelines established by the commission in WAC 246-841A-440 (1)(a) through (c).

(ii) The program must provide the minimum required training hours designed specifically for medical assistant-certified alternative programs.

(A) The minimum required training hours are: Sixty-eight hours total, with a minimum of 48 hours of classroom theory, a minimum of 14 hours of skills lab, and a minimum of six hours of clinical training.

(B) The minimum program hours include 32 hours of classroom theory training on the specialty topics of: Developmental disabilities (16 hours); mental health (eight hours); and dementia (eight hours).

(b) Be subject to corrective actions for nursing assistant training programs as described in WAC 246-841A-465 through 246-841A-490, when requirements are not met for initial and ongoing approval of nursing assistant training programs (WAC 246-841A-420 through 246-841A-460), including those specific to medical assistant-certified alternative programs (WAC 246-841A-530 through 246-841A-555).

(c) Provide a subset of the content for traditional nursing assistant programs as identified in the common curriculum for the alternative program and reflecting the following competency areas found in WAC 246-841A-400:

(i) The nursing assistant role and knowledge of rules and regulations;

(ii) Resident rights and promotion of independence;

(iii) Communication and interpersonal skills;

(iv) Infection control;

(v) Safety and emergency procedures;

(vi) Basic nursing skills;

(vii) Basic restorative services;

(viii) Personal care;

(ix) Life transitions;

(x) Care of clients or residents with developmental disabilities (specialty curriculum);

(xi) Mental health and social service needs (specialty curriculum);

(xii) Care of clients or residents with cognitive impairment (specialty curriculum).

(2) The common curriculum for medical assistant-certified alternative programs includes the complete specialty curricula on the topics of developmental disabilities, mental health, and dementia developed by the department of social and health services.

(a) For students who have not already taken the specialty classes, the training program must provide them as part of the class.

(b) Training programs must follow the regulations in WAC 246-841A-430 and 246-841A-440 for incorporating and teaching specialty curricula.

(c) For students who have already taken one or more of the specialty topics, the training program may excuse them from repeating the topic(s) when they provide documentation of successful completion.

(i) Only the specialty classes developed specifically by the department of social and health services qualify for acceptable training to excuse students from specialty topic(s).

(ii) For students who are excused, programs must retain a copy of documentation of a student's previous specialty training in the student's file.

(3) Training to orient the student to the health care facility and facility policies and procedures is required, but is not included in the minimum clinical training hours required.

The program director of an alternative program is responsible for:

(1) Verifying home care aides-certified have an active home care aide-certified credential before admission to the alternative program.

(2) Verifying medical assistants have certification before admission to the alternative program.

(3) Assuring the alternative program meets program standards, including the requirements of this chapter and the requirements specific to home care aide-certified alternative programs in WAC 246-841A-545 and to medical assistant-certified programs in WAC 246-841A-550.

To be eligible to apply for nursing assistant certification, a graduate from an alternative program must:

(1) Be currently credentialed as a home care aide-certified under chapter 18.88B RCW; or

(2) Be a medical assistant-certified as defined in WAC 246-841A-535(2);

(3) Have completed a cardiopulmonary resuscitation course; and

(4) Have successfully completed the competency evaluation.

(1) An applicant for nursing assistant-certified who has successfully completed an approved alternative program as a home care aide-certified must submit to the department:

(a) A completed application for nursing assistant-certified;

(b) A copy of the certificate of completion from an approved alternative program for home care aides-certified;

(c) Documentation verifying current certification as a home care aide;

(d) Evidence of completion of a cardiopulmonary resuscitation course; and

(e) Applicable fees as required in WAC 246-841A-990.

(2) An applicant for nursing assistant-certified who successfully completed an approved alternative program as a medical assistant-certified must submit to the department:

(a) A completed application for nursing assistant-certified;

(b) A copy of certificate of completion from an approved alternative program for medical assistants-certified;

(c) An official transcript from the nationally accredited medical assistant program;

(d) Evidence of completion of an adult cardiopulmonary resuscitation course; and

(e) Applicable fees as required in WAC 246-841A-990.

WAC 246-841A-589 through 246-841A-595 apply to the endorsement of a nursing assistant-certified as a medication assistant. A nursing assistant-certified with a medication assistant endorsement administers medications and commission-approved treatments to residents in nursing homes under the direct supervision of a designated registered nurse.

Nothing in these rules requires a nursing home to employ a nursing assistant-certified with a medication assistant endorsement. A medication assistant's employer may limit or restrict the range of their employee's functions permitted in these rules, but may not expand those functions.

WAC 246-841A-589 through 246-841A-595 also apply to the approval of education and training programs and the competency evaluation for medication assistants.

Medication assistants are responsible and accountable for their specific functions.

(1) A medication assistant working in a nursing home shall only accept direction to perform medication administration and prescriber-ordered treatments from a designated registered nurse. A medication assistant may only administer medications or perform prescriber-ordered treatments that fall within the medication assistant's scope of practice, education, and demonstrated competency.

(2) It is the responsibility of the designated registered nurse to assess the individual needs of each resident and determine that the direction of medication administration or selected treatment tasks poses minimal risks to each resident. The designated registered nurse determines the frequency of resident assessments and decides the number and types of medications to be administered.

(3) The medication assistant under the direct supervision of a registered nurse in a nursing home, may:

(a) Administer over-the-counter medications;

(b) Administer legend drugs, except for chemotherapeutic agents and experimental drugs;

(c) Administer schedule IV and V medications orally, topically, and through inhalation;

(d) Perform simple prescriber-ordered treatments which include blood glucose monitoring, noncomplex clean dressing changes, pulse oximetry readings, and oxygen administration.

(4) The medication assistant shall accurately document the administration of medication and performance of treatments into the resident's medical records on facility-approved forms or format (e.g., electronic record).

(5) Performance of the tasks identified in subsection (1) of this section will be the sole work assignment to the medication assistant.

(6) A medication assistant may not perform the following tasks:

(a) Assessment of resident need for, or response to medication;

(b) Acceptance of telephone or verbal orders from prescribers;

(c) Conversion or calculation of drug dosages;

(d) Injection of any medications;

(e) Administration of chemotherapeutic agents and experimental drugs;

(f) Performance of any sterile task or treatment;

(g) Medication administration through a tube;

(h) Administration or participation in the handling, including counting or disposal of any schedule I, II, or III controlled substances;

(i) Participation in any handling, including counting or disposal of schedule IV and V controlled substances other than when administering these substances as authorized by subsection (3)(c) of this section;

(j) Performance of any task requiring nursing judgment, such as administration of as necessary or as needed (prn) medications.

(1) A medication assistant certification endorsement training program must:

(a) Be a commission-approved nursing assistant certified training program in good standing, or a commission-approved nursing educational program in good standing; and

(b) Meet the requirements for initial and ongoing approval of nursing assistant training programs in this chapter except for the following differences:

(i) The program must implement as its common curriculum the complete medication assistant-certified model curriculum, as adopted and described in materials from the National Council of State Boards of Nursing;

(ii) The curriculum shall include training on the specific tasks that a medication assistant may and may not perform as listed in WAC 246-841A-589.

(iii) The education and training program may add to the required curriculum as stated in these rules but may not delete any content from the required curriculum.

(2) The program must provide the minimum required training hours designed specifically for medication assistant certification endorsement programs: One hundred hours total, with a minimum of 50 hours of classroom theory, a minimum of 10 hours of skills lab, and a minimum of 40 hours of clinical practicum.

(a) The training program will provide a minimum of 40 hours of directly supervised and progressive clinical experience in the administration of medications to residents in a nursing home.

(b) At no time will the ratio of students to instructor be allowed to exceed 10 students to one instructor during clinical.

(c) Instructional staff for the program must hold an active Washington state license in good standing as a registered nurse.

(d) The training program must include a sample lesson plan for one unit with its application to open a medication assistant certification endorsement program.

(e) The skills lab checklists and competency evaluation activities and documentation shall reflect the medication assistant scope as identified in the National Council of State Boards of Nursing model curriculum and WAC 246-841A-589.

(f) The following options for traditional and alternative training programs described in WAC 246-841A-420 through 246-841A-460 are not applicable for medication assistant certification endorsement programs:

(i) Nursing assistant-registered work pathway;

(ii) A live online teaching modality; or

(iii) Hybrid modalities with asynchronous teaching and learning activities counted as required classroom theory hours.

(g) The program director must attest to the student's successful completion of the course on commission-approved forms or electronic methods designed specifically for medication assistant certification endorsement programs.

(h) The standard to maintain an average annual student pass rate of 80 percent for first-time test-takers on the state's medication assistant competency evaluation applies to a knowledge exam only; psychomotor or skills competency evaluation for medication assistants is addressed by the training program.

(3) In addition to standard equipment and supplies required for nursing assistant training programs as described in WAC 246-841A-450, the program must provide equipment and supplies necessary for students to practice medication administration and prescriber-ordered treatments identified in the National Council of State Boards of Nursing medication assistant curriculum and WAC 246-841A-589. All equipment and supplies should reflect the current standard of nursing home practices. Required equipment and supplies include, but are not limited to:

(a) A medication cart;

(b) Professionally developed placebo medications that simulate actual medications in their appearance and packaging, enabling students to practice medication administration steps in the skills lab;

(c) A glucometer;

(d) A pulse oximeter; and

(e) Materials required to teach oxygen administration.

(4) Be subject to corrective actions for nursing assistant training programs as described in WAC 246-841A-465 through 246-841A-490, when requirements are not met for initial and ongoing approval of nursing assistant training programs (WAC 246-841A-420 through 246-841A-460), including those specific to medication assistant certification endorsement programs (WAC 246-841A-586 through 246-841A-595).

(1) Initial applicant requirements: Applicants for an initial medication assistant endorsement must meet the following requirements:

(a) Be credentialed as a nursing assistant-certified in good standing, under chapter 18.88A RCW;

(b) Successfully complete a commission-approved medication assistant education and training program, as described in WAC 246-841A-590 within the year immediately prior to the date of application;

(c) Complete at least 1,000 hours of work experience in a nursing home as a nursing assistant-certified within the year immediately prior to the date of application; and

(d) After completing the requirements in (a) through (c) of this subsection, the applicant must pass the commission-approved medication assistant competency evaluation.

(2) Application requirements for adding the medication assistant certification endorsement to a nursing assistant-certified credential:

(a) To add an initial medication assistant certification endorsement to a nursing assistant-certified credential, the nursing assistant-certified must submit to the department:

(i) An application on forms approved by the secretary of the department of health.

(ii) The applicable fees under WAC 246-841A-990.

(iii) Proof of completion of:

(A) A commission-approved medication assistant training program under WAC 246-841A-590; and

(B) Competency evaluation described under subsection (1) of this section; and

(iv) Employer documentation of work experience as required in subsection (1)(c) of this section.

(b) An applicant who is currently credentialed as a medication assistant in another state or jurisdiction may qualify for a medication assistant endorsement credential under this chapter. An applicant must submit to the department:

(i) An application on forms approved by the secretary of the department of health;

(ii) Written verification directly from the state or jurisdiction in which the applicant is credentialed, attesting that the applicant holds a credential in good standing substantially equivalent to the medication assistant endorsement credential in Washington;

(iii) Verification of completion of the required education substantially equivalent to the education requirements as described in WAC 246-841A-590(3);

(iv) Employer documentation of work experience as required in subsection (1)(c) of this section; and

(v) The applicable fees under WAC 246-841A-990.

(3) Renewal requirements: To renew a medication assistant certification endorsement credential, the medication assistant must have a current nursing assistant-certified credential in good standing and meet the requirements of WAC 246-12-030.

(4) Continuing competency requirements: A medication assistant shall meet the following requirements on an annual basis to coincide with renewal of their nursing assistant-certified credentials:

(a) Employer documentation of successful completion of 250 hours of employment as a medication assistant in a nursing home setting under the direct supervision of a registered nurse;

(b) Documentation of eight hours of continuing education specific to medications, medication administration, and performance of selected patient treatments. Continuing education hours must be obtained through a commission-approved medication education and training program as described in WAC 246-841A-590, continuing education programs approved by a professional association, or staff development programs offered in a nursing home. The education hours must directly relate to the medication assistant's role of medication administration and the performance of selected treatments.

(1) General violations of standards of practice for all nursing assistants. The following conduct may subject a nursing assistant to disciplinary action under the Uniform Disciplinary Act, chapter 18.130 RCW:

(a) Engaging in conduct described in RCW 18.130.180;

(b) Engaging in conduct such as, but not limited to:

(i) Failure to adhere and perform in accordance with standards of practice and competencies as stated in WAC 246-841A-400;

(ii) Performance of care activities beyond the nursing assistant scope of practice or regulations specific to the practice setting;

(iii) Performing or attempting to perform care tasks or procedures for which the nursing assistant lacks the appropriate knowledge, experience, and education and/or failing to obtain instruction, supervision and/or consultation for client or resident safety;

(iv) Failure to follow a client's or resident's care plan;

(v) Failure to report and document accurately and legibly the provision of care and other information pertinent to the care of a client or resident. Examples include, but are not limited to, a client's or resident's status; a change in status; observations of client's or resident's responses to care; progress; or a client's or resident's expressed concern;

(vi) Altering or destroying entries or making incorrect, illegible, or false entries in a client or resident record or an employer or employee record;

(vii) Failure to protect clients from unsafe practices or conditions, exploitation, abusive acts, neglect, or sexual misconduct as defined in WAC 246-16-100;

(viii) Violating the confidentiality or privacy of the client or resident, except where required by law or for the protection of the client or resident. These violations include taking or disseminating photos or videos of a client or resident by any means, including social media;

(ix) Providing care for a client or resident while impaired by alcohol or drugs;

(x) Providing care for a client or resident while affected by a mental, physical, or emotional condition to the extent that there is an undue risk of harm to self or others;

(xi) Abandoning a client or resident by leaving an assignment without transferring responsibilities to appropriate personnel or caregiver when the condition of the client or resident requires continued care;

(xii) Taking client's property for own or other's use or benefit. Soliciting, accepting, or borrowing money or property from clients;

(xiii) Conviction of a crime involving physical abuse or sexual abuse including convictions of any crime or plea of guilty, including crimes against persons as defined in RCW 43.43.830 and crimes involving the personal property of a client or resident, whether or not the crime relates to the nursing assistant role;

(xiv) Permitting another person to use the nursing assistant credential or using another person's credential;

(xv) Disclosing the contents of the nursing assistant credentialing examination or soliciting, accepting, or compiling information regarding the contents of any examination before, during, or after its administration; or

(xvi) Failure to follow the employer's or workplace policy and procedure for the wastage of medications.

(2) Additional standards of practice for nursing assistants working under registered nurse delegation. These nursing assistants may perform additional care tasks beyond those indicated in WAC 246-841A-400 through nursing assistant delegation by a registered nurse. Registered nurse delegation to nursing assistants is described in WAC 246-841A-405. The following conduct may subject a nursing assistant working under the delegation of a registered nurse to disciplinary action under the Uniform Disciplinary Act, chapter 18.130 RCW. Engaging in conduct that includes, but is not limited to:

(a) Failure to adhere to and perform in accordance with the provisions for delegation of certain tasks as stated in WAC 246-841A-405;

(b) Failure to provide care in accordance with the delegation accepted from a designated registered nurse;

(c) Performance of nursing care tasks without being delegated to do so by a designated registered nurse;

(d) Failure to report and document accurately and legibly the provision of delegated care tasks and other information pertinent to the care of a client or resident in accordance with the delegation accepted from a designated registered nurse. Examples include, but are not limited to, a client's or resident's status; a change in status; observation of patient responses to care; progress; or a client's or resident's expressed concern;

(e) Altering or destroying entries or making incorrect, illegible, or false entries in a client or resident record or an employer or employee record pertaining to delegated care tasks; or

(f) Failure to follow the employer's or workplace policy and procedure for the wastage of medications.

(3) Additional standards of practice for nursing assistants-certified who train and test to earn a medication assistant endorsement. These nursing assistants-certified may perform care tasks beyond those indicated in WAC 246-841A-400 when they work under the direct supervision of a designated registered nurse in a nursing home. A nursing assistant-certified with a medication assistant endorsement can administer certain medications and perform certain prescriber-ordered treatments as described in WAC 246-841A-589. The following conduct may subject a nursing assistant-certified with a medication assistant endorsement to disciplinary action under the Uniform Disciplinary Act, chapter 18.130 RCW. Engaging in conduct that includes, but is not limited to:

(a) Failure to adhere to and perform in accordance with the requirements for medication administration and prescriber-ordered treatments in WAC 246-841A-589;

(b) Failure to administer medications or provide prescriber-ordered treatments in the scope of a nursing assistant-certified with a medication assistant endorsement in accordance with:

(i) The direction of the supervising registered nurse;

(ii) Written orders; or

(iii) Common safety and infection control practices for the care tasks performed;

(c) Failure to report and document accurately and legibly:

(i) The administration of medication and performance of prescriber-ordered treatments into the resident's medical records using the facility-approved form or format (e.g., electronic record); and

(ii) Supporting information pertinent to the care of a resident. Examples include, but are not limited to, a resident's status; a change in status; observations of patient responses to care or treatment(s); progress; or a resident's expressed concern;

(d) Altering or destroying entries or making incorrect, illegible, or false entries in a client or resident record or an employer or employee record pertaining to medication administration or performance of prescriber-ordered treatments;

(e) Administering medications or performing prescriber-ordered treatments beyond the scope of a nursing assistant-certified with a medication assistant endorsement as identified in WAC 246-841A-589; or

(f) Failure to follow the employer's or workplace policy and procedure for the wastage of medications.

The commission adopts the rules for mandatory reporting in chapter 246-16 WAC.

If the certificate has been expired for three years or less, the practitioner must meet the requirements as provided in WAC 246-12-020 through 246-12-051. If the certificate has expired for over three years, the practitioner must:

(1) Demonstrate competence to the standards established by the commission;

(2) Meet the requirements of WAC 246-12-020 through 246-12-051.

(1) Credentials must be renewed every year on the practitioner's birthday as provided in WAC 246-12-020 through 246-12-051.

(2) The following nonrefundable fees will be charged for registration credentials:

(3) The following nonrefundable fees will be charged for certification credentials:

(4) The following nonrefundable fees will be charged for medication assistant endorsement credentials: