APPENDIX A · Web viewThe Temporary Nurse Aide does not have a pending or substantiated finding of...

North Carolina Department of Health and Human ServicesDivision of Health Service Regulation

Health Care Personnel Education and Credentialing SectionPhone: 919-855-3969

Temporary Nurse AideNurse Aide I Training Equivalency Application Due to COVID-19

Table of Contents

Instructions ..........................................................................................................................2

Part 1: Determine Eligibility .................................................................................................3

Part 2: Temporary Nurse Aide Personal Information...........................................................4

Part 3: North Carolina Licensed Nursing Home Facility Information....................................5

Part 4: Pending or Substantiated Findings .........................................................................7

Part 5: Federal Law 42 CFR §483.152 Requirements ........................................................8

Part 6: Nurse Aide I Skills Competency Evaluation ..........................................................11

Part 7: Competency Examination Testing Dates ..............................................................35

Part 8: North Carolina Licensed Nursing Home Facility Attestation ..................................35

Part 9: Temporary Nurse Aide Attestation.........................................................................35

DHSR/HCPEC-4523 (Effective 4/2021) of 35

INSTRUCTIONS:

This application is only available to Temporary Nurse Aides working in North Carolina licensed nursing home facilities.

The Division of Health Service Regulation will accept the Temporary Nurse Aide I Training Equivalency Application Due to COVID-19 during the period of its Waiver for Temporary Nurse Aide Services dated April 27, 2020 or thirty (30) days thereafter.

If you are listed on the North Carolina Nurse Aide I Registry in expired status, please ensure your First and Last Name is correct. Click here to verify your name.

Review Part 1 of the application to determine if the Temporary Nurse Aide meets the eligibility requirements. If the eligibility requirements are met, then complete and submit all pages of the application. Incomplete applications will not be processed or approved.

Return the completed application by mail or fax. o Mailing Address: 2709 Mail Service Center, Raleigh, NC 27699-2709o Fax Number: 919-733-9764

PART 1: DETERMINE ELIGIBILITY


https://www.ncnar.org/verify_listings1.jsp

https://www.ncnar.org/pdf/Waiver_Temporary_NA.pdf

https://www.ncnar.org/pdf/Waiver_Temporary_NA.pdf

All six (6) criteria must be met.

1. The Temporary Nurse Aide received training that meets federal requirements outlined in 42 CFR §483.152.

2. A Registered Nurse with an unencumbered license to practice in North Carolina deemed the Temporary Nurse Aide competent to perform all skills and steps outlined in 42 CFR §483.152, the Nurse Aide I Candidate Handbook and in Part 6 of this application.

3. The Temporary Nurse Aide does not have a pending or substantiated finding of abuse, neglect, exploitation, or misappropriation of resident or patient property recorded on the North Carolina Health Care Personnel Registry for unlicensed health care personnel.

4. The Temporary Nurse Aide does not have a pending or substantiated finding of abuse, neglect, exploitation, or misappropriation of resident or patient property recorded on any State registry of nurse aides.

5. The North Carolina licensed nursing home is not prohibited from operating a Nurse Aide Training and Competency Evaluation Program (NATCEP/CEP) per Sections 1819(f)(2)(B)(iii)(I) and 1919(f)(2)(B)(iii)(I) of the Social Security Act:

a. operating under a waiver for coverage by licensed nurses; b. subject to an extended survey or partial extended survey; c. assessed a Civil Money Penalty (CMP) of at least $10,483 as adjusted by 45 CFR 102; or, d. subject to imposition of a denial of payment, temporary manager, or termination.

6. The individual worked, for monetary compensation, as a Temporary Nurse Aide performing nursing or nursing-related tasks delegated and supervised by a Registered Nurse on or after April 2, 2020 and not to exceed 30 days after the termination of DHSR’s current waiver.

PART 2: TEMPORARY NURSE AIDE PERSONAL INFORMATION


https://home.pearsonvue.com/getattachment/856d1d81-6619-4772-8cbe-cf48f491c10a/North%20Carolina%20Nurse%20Aide%20I%20Candidate%20Handbook.aspx

https://www.govinfo.gov/content/pkg/CFR-2009-title42-vol5/pdf/CFR-2009-title42-vol5-sec483-152.pdf



Answer all 13 questions. Include hyphens and suffixes in the legal name (No Nicknames). Your legal name must match your social security card and photo identification on the

day you take the North Carolina state-approved Nurse Aide I competency examination.

1. Name of Temporary Nurse Aide First Name: Middle Name: Last Name:

2. Prior Name(s) (if applicable):First Name: Middle Name: Last Name: First Name: Middle Name: Last Name:

3. Mailing Address: Street: City: State: Zip Code: County:

4. Social Security Number (include all 9 numbers):

5. Date of Birth (mm/dd/yyyy):

6. Email Address:

7. Home Telephone Number (include area code):

8. Work Telephone Number (include area code):

9. Mother’s Maiden Name:

10. Place an X beside the correct response. Gender: Male: Female:

11. Place an X beside the correct response. Did You Serve in the Military? Yes: No:

12. Place an X beside the correct response. Did You Work in a Military Occupational Specialty (MOS) Where You Performed Nursing or

Nursing-Related Tasks? Yes: No: I Did Not Serve in the Military:

13. Place an X beside the correct response. Are You Currently Married to an Active Member of the Military or a Military Veteran? Yes: No:

PART 3: NORTH CAROLINA LICENSED NURSING HOME FACILITY INFORMATION

Answer all 14 questions.


1. Name of North Carolina Licensed Nursing Home Facility: 2. Name of Facility Administrator: 3. Name of Director of Nursing: 4. Facility ID Number: 5. License Number (example: NH1234):

Note: The Facility ID Number and License Number can be found on the facility licensure certificate.

6. Site Address: Street: City: State: Zip Code: County:

7. Mailing Address: Street: City: State: Zip Code: County:

8. Contact Information at Facility Regarding Application: Name: Title: Telephone: Email:

9. Place an X beside the correct response.Are you currently prohibited from operating a Nurse Aide Training and Competency Evaluation Program (NATCEP/CEP) per Sections 1819(f)(2)(B)(iii)(I) and 1919(f)(2)(B)(iii)(I) of the Social Security Act?Yes: No:

10. Place an X beside the correct response.

Did the training that the Temporary Nurse Aide receive include the skills and steps outlined in 42 CFR §483.152, the Nurse Aide I Candidate Handbook and in Part 6 of this application? Yes: No:

11. Place an X beside the correct response. Did a Registered Nurse with an unencumbered license to practice in North Carolina deem

the Temporary Nurse Aide competent to perform all skills and steps outlined in 42 CFR §483.152, the Nurse Aide I Candidate Handbook and in Part 6 of this application?Yes: No:

12. Place an X beside the correct response.Was the Temporary Nurse Aide employed as a nurse aide for monetary compensation performing nursing or nursing-related tasks delegated and supervised by a Registered Nurse? Yes: No:







13. The Original Hire Date of the Temporary Nurse Aide (mm/dd/yyyy):

14. When Did the Individual Begin Working as a Temporary Nurse Aide in North Carolina at the Licensed Nursing Home Facility (mm/dd/yyyy):

PART 4: PENDING OR SUBSTANTIATED FINDINGS

Answer both questions.



Does the Temporary Nurse Aide have any pending or substantiated findings of abuse, neglect, exploitation, or misappropriation of resident or patient property recorded on any State registry of nurse aides?Yes: No:

2. Place an X beside the correct response.Does the Temporary Nurse Aide have any pending or substantiated findings of abuse, neglect, exploitation, or misappropriation of resident or patient property recorded on the North Carolina Health Care Personnel Registry for unlicensed health care personnel? Yes: No:

PART 5: FEDERAL LAW 42 CFR §483.152 REQUIREMENTS

Answer all 14 questions.



Did the training that the Temporary Nurse Aide receive, at a minimum, meet federal regulation 42 CFR §483.152? Yes: No:

2. Place an X beside the correct response.Did the training that the Temporary Nurse Aide receive consist of at least a minimum of 75 clock hours? Yes: No:

3. Place an X beside the correct response.Did the training that the Temporary Nurse Aide receive include at least 16 hours of supervised practical training? Supervised practical training means training in a laboratory or other setting in which the trainee demonstrates knowledge while performing tasks on an individual under the direct supervision of a registered nurse. Yes: No:

4. Place an X beside the correct response.Was the training of the Temporary Nurse Aide performed by or under the general supervision of a registered nurse with an unencumbered license to practice in North Carolina who possessed a minimum of 2 years of nursing experience, at least 1 year of which was in the provision of long-term care facility services?Yes: No:

5. Place an X beside the correct response.Did the instructors complete a course in teaching adults or have experience in teaching adults or supervising nurse aides?Yes: No:

6. Place an X beside the correct response.In a facility-based program, was the training of the Temporary Nurse Aide performed under the general supervision of the director of nursing for the facility who is prohibited from performing the actual training?Yes: No:

7. Place an X beside the correct response.Other personnel from the health professions may supplement the instructor, including, but not limited to, registered nurses, licensed practical/vocational nurses, pharmacists, dietitians, social workers, sanitarians, fire safety experts, nursing home administrators, gerontologists, psychologists, physical and occupational therapists, activities specialists, speech/language/hearing therapists, and resident rights experts. Supplemental personnel must have at least 1 year of experience in their fields. Did the North Carolina licensed nursing home facility meet this requirement? Yes: No: Does Not Apply:

8. Place an X beside the correct response.Did the training that the Temporary Nurse Aide receive include at least a total of 16 hours of training in the following areas prior to any direct contact with a resident?

a. Communication and interpersonal skills



b. Infection controlc. Safety/emergency procedures, including the Heimlich maneuver d. Promoting residents' independence e. Respecting residents' rights

Yes: No:

9. Place an X beside the correct response.Did the training that the Temporary Nurse Aide receive include the following basic nursing skills?

a. Taking and recording vital signsb. Measuring and recording heigh and weightc. Caring for the residents’ environmentd. Recognizing abnormal changes in body functioning and the importance of reporting

such changes to a supervisore. Caring for residents when death is imminent

Yes: No:

10. Place an X beside the correct response.Did the training that the Temporary Nurse Aide receive include the following personal care skills?

a. Bathingb. Grooming, including mouth carec. Dressingd. Toiletinge. Assisting with eating and hydrationf. Proper feeding techniquesg. Skin careh. Transfers, positioning, and turning

Yes: No:

11. Place an X beside the correct response.Did the training that the Temporary Nurse Aide receive include the following mental health and social service needs?

a. Modifying aide's behavior in response to residents' behaviorb. Awareness of developmental tasks associated with the aging processc. How to respond to resident behaviord. Allowing the resident to make personal choices, providing and reinforcing other

behavior consistent with the resident's dignitye. Using the resident's family as a source of emotional support

Yes: No:

12. Place an X beside the correct response.Did the training that the Temporary Nurse Aide receive include the following items pertaining to the care of cognitively impaired residents?


a. Techniques for addressing the unique needs and behaviors of individual with dementia (Alzheimer's and others)

b. Communicating with cognitively impaired residentsc. Understanding the behavior of cognitively impaired residentsd. Appropriate responses to the behavior of cognitively impaired residentse. Methods of reducing the effects of cognitive impairments

Yes: No:

13. Place an X beside the correct response.Did the training that the Temporary Nurse Aide receive include the following basic restorative services?

a. Training the resident in self-care according to the resident's abilitiesb. Use of assistive devices in transferring, ambulation, eating, and dressingc. Maintenance of range of motiond. Proper turning and positioning in bed and chaire. Bowel and bladder trainingf. Care and use of prosthetic and orthotic devices

Yes: No:

14. Place an X beside the correct response.Did the training that the Temporary Nurse Aide receive include the following residents’ rights?

a. Providing privacy and maintenance of confidentiality b. Promoting the residents' right to make personal choices to accommodate their needs c. Giving assistance in resolving grievances and disputesd. Providing needed assistance in getting to and participating in resident and family groups

and other activitiese. Maintaining care and security of residents' personal possessionsf. Promoting the resident's right to be free from abuse, mistreatment, and neglect and the

need to report any instances of such treatment to appropriate facility staffg. Avoiding the need for restraints in accordance with current professional standards

Yes: No:

PART 6: NURSE AIDE I SKILLS COMPETENCY EVALUATION

Answer all questions for each skill.


Each answer must be clearly and separately marked with an X. Electronic signatures will not be accepted.

SKILL 1 — HAND HYGIENE (HAND WASHING)The numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.

STANDARD METPlace an X beside the

correct response.1. Address client by name and introduces self to client by

nameYes: No:

2. Turns on water at sink Yes: No: 3. Wets hands and wrists thoroughly Yes: No: 4. Applies soap to hands Yes: No: 5. Lathers all surfaces of wrists, hands, and fingers

producing friction, for at least 20 (twenty) seconds, keeping hands lower than the elbows and the fingertips down

Yes: No:

6. Cleans fingernails by rubbing fingertips against palms of the opposite hand

Yes: No:

7. Rinse all surfaces of wrists, hands, and fingers, keeping hands lower than the elbows and the fingertips down

Yes: No:

8. Uses clean, dry paper towel/towels to dry all surfaces of fingers, hands, and wrists starting at fingertips then disposes of paper towel/towels into waste container

Yes: No:

9. Uses clean, dry paper towel/towels to turn off faucet then disposes of paper towel/towels into waste container or uses knee/foot control to turn off faucet

Yes: No:

10. Does not touch inside of sink at any time Yes: No:

Temporary Nurse Aide:Name of Temporary Nurse Aide: Signature of Temporary Nurse Aide: _________________________________________________Date (mm/dd/yyyy):

Registered Nurse with an Unencumbered License to Practice in North Carolina Evaluating Competency of Temporary Nurse Aide:Name of Registered Nurse: Signature of Registered Nurse: _____________________________________________________Date (mm/dd/yyyy): Registered Nurse License Number:

Answer all questions for each skill. Each answer must be clearly and separately marked with an X. Electronic signatures will not be accepted.


SKILL 2 — APPLIES ONE KNEE-HIGH ELASTIC STOCKINGThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.1. Explains procedure, speaking clearly, slowly, and directly,

maintaining face-to-face contact whenever possibleYes: No:

2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Client is in supine position (lying down in bed) while stocking

is appliedYes: No:

4. Turns stocking inside-out, at least to the heel Yes: No: 5. Places foot of stocking over toes, foot, and heel Yes: No: 6. Pulls top of stocking over foot, heel, and leg Yes: No: 7. Moves foot and leg gently and naturally, avoiding force and

over-extension of limb and jointsYes: No:

8. Finishes procedure with no twists or wrinkles and heel of stocking, if present, is over heel and opening in toe area (if present) is either over or under toe area; if using a mannequin, candidate may state stocking needs to be wrinkle-free

Yes: No:

9. Signaling device is within reach and bed is in low position Yes: No: 10. After completing skill, wash hands Yes: No:





SKILL 3 — ASSISTS TO AMBULATE USING TRANSFER BELTThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.

1. Explains procedure, speaking clearly, slowly, and directly, maintaining face-to-face contact whenever possible

Yes: No:

2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Before assisting to stand, client is wearing non-skid

shoes/footwearYes: No:

4. Before assisting to stand, bed is at a safe level Yes: No: 5. Before assisting to stand, checks and/or locks bed wheels Yes: No: 6. Before assisting to stand, client is assisted to sitting

position with feet flat on the floorYes: No:

7. Before assisting to stand, applies transfer belt securely at the waist over clothing/gown

Yes: No:

8. Before assisting to stand, provides instructions to enable client to assist in standing including prearranged signal to alert client to begin standing

Yes: No:

9. Stands facing client positioning self to ensure safety of candidate and client during transfer. Counts to three (or says other prearranged signal) to alert client to begin standing

Yes: No:

10. On signal, gradually assists client to stand by grasping transfer belt on both sides with an upward grasp (candidate’s hands are in upward position), and maintaining stability of client’s legs by standing knee to knee, or toe to toe with client

Yes: No:

11. Walks slightly behind and to one side of client for a distance of ten (10) feet, while holding onto the belt

Yes: No:

12. Assists client to bed and removes transfer belt Yes: No: 13. Signaling device is within reach and bed is in low position Yes: No: 14. After completing skill, wash hands Yes: No:





SKILL 4 — ASSISTS WITH USE OF BEDPANThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.1. Explains procedure speaking clearly, slowly, and directly,


2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Before placing bedpan, lowers head of bed Yes: No: 4. Puts on clean gloves before placing bedpan under client Yes: No: 5. Places bedpan correctly under client’s buttocks Yes: No: 6. Removes and disposes of gloves (without contaminating

self) into waste container and washes handsYes: No:

7. After positioning client on bedpan and removing gloves, raises head of bed

Yes: No:

8. Toilet tissue is within reach Yes: No: 9. Hand wipe is within reach and client is instructed to clean

hands with hand wipe when finishedYes: No:

10. Signaling device within reach and client is asked to signal when finished

Yes: No:

11. Puts on clean gloves before removing bedpan Yes: No: 12. Head of bed is lowered before bedpan is removed Yes: No: 13. Ensures client is covered except when placing and

removing bedpanYes: No:

14. Empties and rinses bedpan and pours rinse into toilet Yes: No: 15. Places bedpan in designated dirty supply area Yes: No: 16. Removes and disposes of gloves (without contaminating


17. Signaling device is within reach and bed is in low position Yes: No:





SKILL 5 — CLEANS UPPER OR LOWER DENTUREThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.1. Puts on clean gloves before handling denture Yes: No: 2. Bottom of sink is lined and/or sink is partially filled with

water before denture is held over sinkYes: No:

3. Rinses denture in moderate temperature running water before brushing them

Yes: No:

4. Applies denture toothpaste to toothbrush Yes: No: 5. Brushes all surfaces of denture Yes: No: 6. Rinses all surfaces of denture under moderate temperature

running waterYes: No:

7. Rinses denture cup and lid Yes: No: 8. Places denture in denture cup with moderate temperature

water/solution and places lid on cupYes: No:

9. Rinses toothbrush and places in designated toothbrush basin/container

Yes: No:

10. Maintains clean technique with placement of toothbrush and denture

Yes: No:

11. Sink liner is removed and disposed of appropriately and/or sink is drained

Yes: No:

12. Removes and disposes of gloves (without contaminating self) into waste container and washes hands

Yes: No:





SKILL 6 — COUNTS AND RECORDS RADIAL PULSEThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.




2. Places fingertips on thumb side of client’s wrist to locate radial pulse

Yes: No:

3. Count beats for one full minute Yes: No: 4. Signaling device is within reach Yes: No: 5. Before recording, washes hands Yes: No: 6. Records pulse rate within plus or minus 4 beats of

evaluator’s readingYes: No:



Answer all questions for each skill. Each answer must be clearly and separately marked with an X.


Electronic signatures will not be accepted.

SKILL 7 — COUNTS AND RECORDS RESPIRATIONSThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.1. Explains procedure (for testing purposes), speaking clearly,

slowly, and directly, maintaining face-to-face contact whenever possible

Yes: No:

2. Counts respirations for one full minute Yes: No: 3. Signaling device is within reach Yes: No: 4. Before recording, washes hands Yes: No: 5. Records respiration rate within plus or minus 2 breaths

of evaluator’s readingYes: No:



Answer all questions for each skill. Each answer must be clearly and separately marked with an X.


Electronic signatures will not be accepted.

SKILL 8 — DONNING AND REMOVING PPE (GOWN AND GLOVES)The numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.

1. Picks up gown and unfolds Yes: No: 2. Facing the back opening of the gown places arms through

each sleeveYes: No:

3. Fastens the neck opening Yes: No: 4. Secures gown at waist making sure that back of clothing is

covered by gown (as much as possible)Yes: No:

5. Puts on gloves Yes: No: 6. Cuffs of gloves overlap cuffs of gown Yes: No: 7. Before removing gown, with one gloved hand, grasps

the other glove at the palm, remove gloveYes: No:

8. Slips fingers from ungloved hand underneath cuff of remaining glove at wrist, and removes glove turning it inside out as it is removed

Yes: No:

9. Disposes of gloves into designated waste container without contaminating self

Yes: No:

10. After removing gloves, unfastens gown at waist and neck Yes: No: 11. After removing gloves, removes gown without touching

outside of gownYes: No:

12. While removing gown, holds gown away from body without touching the floor, turns gown inward and keeps it inside out

Yes: No:

13. Disposes of gown in designated container without contaminating self

Yes: No:

14. After completing skill, washes hands Yes: No:





SKILL 9 — DRESSES CLIENT WITH AFFECTED (WEAK) RIGHT ARMThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.


Yes: No:

2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Asks which shirt he/she would like to wear and dresses

him/her in shirt of choiceYes: No:

4. Avoids overexposure of client by ensuring client’s chest is covered

Yes: No:

5. Removes gown from the left (unaffected) side first, then removes gown from the right (affected/weak) side

Yes: No:

6. Before dressing client, disposes of gown into soiled linen container

Yes: No:

7. Assists to put the right (affected/weak) arm through the right sleeve of the shirt before placing garment on left (unaffected) arm

Yes: No:

8. While putting on shirt, moves body gently and naturally, avoiding force and over-extension of limbs and joints

Yes: No:

9. Finishes with clothing in place Yes: No: 10. Signaling device is within reach and bed is in low position Yes: No: 11. After completing skill, washes hands Yes: No:





SKILL 10 — FEEDS CLIENT WHO CANNOT FEED SELFThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.1. Explains procedure to client, speaking clearly, slowly, and

directly, maintaining face-to-face contact whenever possible

Yes: No:

2. Before feeding, looks at name card on tray and asks client to state name

Yes: No:

3. Before feeding client, client is in an upright sitting position (75-90 degrees)

Yes: No:

4. Places tray where the food can be easily seen by client Yes: No: 5. Candidate cleans client’s hands before beginning feeding Yes: No: 6. Candidate sits in a chair facing client during feeding Yes: No: 7. Tells client what foods and beverage are on tray Yes: No: 8. Asks client what he/she would like to eat first Yes: No: 9. Using spoon, offers client one bite of each type of food on

tray, telling client the content of each spoonfulYes: No:

10. Offers beverage at least once during meal Yes: No: 11. Candidate asks client if they are ready for next bite of food

or sip of beverageYes: No:

12. At end of meal, candidate cleans client’s mouth and hands Yes: No: 13. Removes food tray Yes: No: 14. Leaves client in upright sitting position (75-90 degrees) with

signaling device within client’s reachYes: No:

15. After completing skill, washes hands Yes: No:





SKILL 11 — GIVES MODIFIED BED BATH (FACE AND ONE ARM, HAND AND UNDERARM)The numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.


Yes: No:

2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Removes gown and places directly in soiled linen container

while ensuring client’s chest and lower body is coveredYes: No:

4. Before washing, checks water temperature for safety and comfort and asks client to verify comfort of water

Yes: No:

5. Puts on clean gloves before washing client Yes: No: 6. Beginning with eyes, washes eyes with wet washcloth

(no soap), using a different area of the washcloth for each stroke, washing inner aspect to outer aspect then proceeds to wash face

Yes: No:

7. Dries face with dry cloth towel/washcloth Yes: No: 8. Exposes one arm and places cloth towel underneath arm Yes: No: 9. Applies soap to wet washcloth Yes: No: 10. Washes fingers (including fingernails), hand, arm, and

underarm keeping rest of body coveredYes: No:

11. Rinses and dries fingers, hand, arm, and underarm Yes: No: 12. Moves body gently and naturally, avoiding force and over-

extension of limbs and jointsYes: No:

13. Puts clean gown on client Yes: No: 14. Empties, rinses, and dries basin Yes: No: 15. Places basin in designated dirty supply area16. Disposes of linen into soiled linen container Yes: No: 17. Avoids contact between candidate clothing and used linens Yes: No: 18. Removes and disposes of gloves (without contaminating







SKILL 12 — MEASURES AND RECORDS URINARY OUTPUTThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.

1. Puts on clean gloves before handling bedpan Yes: No: 2. Pours the contents of the bedpan into measuring container

without spilling or splashing urine outside of containerYes: No:

3. Rinses bedpan and pours rinse into toilet Yes: No: 4. Measures the amount of urine at eye level with container

on flat surface (if between measurement lines, round up to nearest 25 ml/cc)

Yes: No:

5. After measuring urine, empties contents of measuring container into toilet

Yes: No:

6. Rinses measuring container and pours rinse into toilet Yes: No: 7. Before recording output, removes and disposes of gloves

(without contaminating self) into waste container and washes hands

Yes: No:

8. Records contents of container within plus or minus 25 ml/cc of evaluator’s reading

Yes: No:





SKILL 13 — MEASURES AND RECORDS WEIGHT OF AMBULATORY CLIENTThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.


Yes: No:

2. Client has non-skid shoes/footwear on before walking to scale

Yes: No:

3. Before client steps on scale, candidate sets scale to zero Yes: No: 4. Asks client to step on center of scale and obtains client’s

weightYes: No:

5. Asks client to step off scale Yes: No: 6. Before recording, washes hands Yes: No: 7. Records weight based on indicator on scale. Weight is

within plus or minus 2lbs of evaluator’s reading (If weight recorded in kg weight is within plus or minus 0.9 kg of evaluator’s reading)

Yes: No:





SKILL 14 — PERFORMS MODIFIED PASSIVE RANGE OF MOTION (PROM) FOR ONE KNEE AND ONE ANKLEThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.


Yes: No:

2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Ensures that client is supine in bed and instructs client to

inform candidate if pain is experienced during exerciseYes: No:

4. While supporting the leg at knee and ankle, bends the knee and then returns leg to client’s normal position (flexion/extension) (AT LEAST 3 TIMES unless pain is verbalized). Moves joints gently, slowly and smoothly through the range of motion, discontinuing exercise if client verbalizes pain.

Yes: No:

5. While supporting the foot and ankle close to the bed, pushes/pulls foot toward head (dorsiflexion), and pushes/pulls foot down, toes point down (plantar flexion) (AT LEAST 3 TIMES unless pain is verbalized). Moves joints gently, slowly and smoothly through the range of motion, discontinuing exercise if client verbalizes pain.

Yes: No:

6. Signaling device is within reach and bed is in low position Yes: No: 7. After completing skill, washes hands Yes: No:





SKILL 15 — PERFORMS MODIFIED PASSIVE RANGE OF MOTION (PROM) FOR ONE SHOULDERThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.


Yes: No:

2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Instructs client to inform candidate if pain experienced

during exerciseYes: No:

4. While supporting arm at the elbow and at the wrist, raises client’s straightened arm from side position upward toward head to ear level and returns arm down to side of body (flexion/extension) (AT LEAST 3 TIMES unless pain is verbalized). Moves joint gently, slowly and smoothly through the range of motion, discontinuing exercise if client verbalizes pain.

Yes: No:

5. While supporting arm at the elbow and at the wrist, moves client’s straightened arm away from the side of body to shoulder level and returns to side of body (abduction/adduction) (AT LEAST 3 TIMES unless pain is verbalized). Moves joint gently, slowly and smoothly through the range of motion, discontinuing exercise if client verbalizes pain.

Yes: No:






SKILL 16 — POSITIONS ON SIDEThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.




2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Before turning, lowers head of bed Yes: No: 4. Raises side rail on side to which body will be turned Yes: No: 5. Candidate assists client to slowly roll onto side toward

raised side railYes: No:

6. Places or adjusts pillow under head for support Yes: No: 7. Candidate repositions arm and shoulder so that client is not

lying on armYes: No:

8. Supports top arm with supportive device Yes: No: 9. Places supportive device behind client’s back Yes: No: 10. Places supportive device between legs with top knee

flexed; knee and ankle supportedYes: No:






SKILL 17 — PROVIDES CATHETER CARE FOR FEMALEThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.




2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Before washing, checks water temperature for safety and

comfort and asks client to verify comfort of waterYes: No:

4. Puts on clean gloves before washing Yes: No: 5. Places linen protector under perineal area including buttocks

before washingYes: No:

6. Exposes area surrounding catheter (only exposing client between hip and knee)

Yes: No:

7. Applies soap to wet washcloth Yes: No: 8. While holding catheter at meatus without tugging, cleans

at least four inches of catheter from meatus, moving in only one direction, away from meatus, using a clean area of the washcloth for each stroke

Yes: No:

9. While holding catheter at meatus without tugging, using a clean washcloth, rinses at least four inches of catheter from meatus, moving only in one direction, away from meatus, using a clean area of the washcloth for each stroke

Yes: No:

10. While holding catheter at meatus without tugging, dries at least four inches of catheter moving away from meatus using a dry cloth towel/washcloth

Yes: No:

11. Empties, rinses, and dries basin Yes: No: 12. Places basin in designated dirty supply area Yes: No: 13. Disposes of used linen into soiled linen container and

disposes of linen protector appropriatelyYes: No:

14. Avoids contact between candidate clothing and used linen Yes: No: 15. Removes and disposes of gloves (without contaminating self)

into waste container and washes handsYes: No:






SKILL 18 — PROVIDES FOOT CARE ON ONE FOOTThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.




2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Before washing, checks water temperature for safety and

comfort and asks client to verify comfort of waterYes: No:

4. Basin is in a comfortable position for client and on protective barrier

Yes: No:

5. Puts on clean gloves before washing foot Yes: No: 6. Client’s bare foot is placed into the water Yes: No: 7. Applies soap to wet washcloth Yes: No: 8. Lifts foot from water and washes foot (including between

the toes)Yes: No:

9. Foot is rinsed (including between the toes) Yes: No: 10. Dries foot (including between the toes) with dry cloth

towel/washclothYes: No:

11. Applies lotion to top and bottom of foot (excluding between the toes) removing excess with a towel/ washcloth

Yes: No:

12. Supports foot and ankle during procedure Yes: No: 13. Empties, rinses, and dries basin Yes: No: 14. Places basin in designated dirty supply area Yes: No: 15. Disposes of used linen into soiled linen container Yes: No: 16. Removes and disposes of gloves (without contaminating


17. Signaling device is within reach Yes: No:





SKILL 19 — PROVIDES MOUTH CAREThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.




2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Before providing mouth care, client is in upright sitting

position (75-90 degrees)Yes: No:

4. Puts on clean gloves before cleaning mouth Yes: No: 5. Places cloth towel across chest before providing mouth

careYes: No:

6. Secures cup of water and moistens toothbrush Yes: No: 7. Before cleaning mouth, applies toothpaste to moistened

toothbrushYes: No:

8. Cleans mouth (including tongue and all surfaces of teeth), using gentle motions

Yes: No:

9. Maintains clean technique with placement of toothbrush Yes: No: 10. Candidate holds emesis basin to chin while client rinses

mouthYes: No:

11. Candidate wipes mouth and removes clothing protector Yes: No: 12. Disposes of used linen into soiled linen container Yes: No: 13. Rinses toothbrush and empties, rinses, and dries basin Yes: No: 14. Removes and disposes of gloves (without contaminating







SKILL 20 — PROVIDES PERINEAL CARE (PERI-CARE) FOR FEMALEThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.


Yes: No:

2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Before washing, checks water temperature for safety and comfort

and asks client to verify comfort of waterYes: No:

4. Puts on clean gloves before washing perineal area Yes: No: 5. Places pad/ linen protector under perineal area including buttocks

before washingYes: No:

6. Exposes perineal area (only exposing between hips and knees) Yes: No: 7. Applies soap to wet washcloth Yes: No: 8. Washes genital area, moving from front to back, while using a

clean area of the washcloth for each strokeYes: No:

9. Using clean washcloth, rinses soap from genital area, moving from front to back, while using a clean area of the washcloth for each stroke

Yes: No:

10. Dries genital area moving from front to back with dry cloth towel/washcloth

Yes: No:

11. After washing genital area, turns to side, then washes rectal area moving from front to back using a clean area of washcloth for each stroke

Yes: No:

12. Using clean washcloth, rinses soap from rectal area, moving from front to back, while using a clean area of the washcloth for each stroke

Yes: No:

13. Dries rectal area moving from front to back with dry cloth towel/washcloth

Yes: No:

14. Repositions client Yes: No: 15. Empties, rinses, and dries basin Yes: No: 16. Places basin in designated dirty supply area Yes: No: 17. Disposes of used linen into soiled linen container and disposes of

linen protector appropriatelyYes: No:

18. Avoids contact between candidate clothing and used linen Yes: No: 19. Removes and disposes of gloves (without contaminating self) into

waste container and washes handsYes: No:



Continued Next Page



SKILL 21 — TRANSFERS FROM BED TO WHEELCHAIR USING TRANSFER BELTThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.


Yes: No:

2. Privacy is provided with a curtain, screen, or door Yes: No: 3. Before assisting to stand, wheelchair is positioned alongside

of bed, at head of bed facing foot or foot of bed facing headYes: No:

4. Before assisting to stand, footrests are folded up or removed Yes: No: 5. Before assisting to stand, locks wheels on wheelchair Yes: No: 6. Before assisting to stand, bed is at a safe level Yes: No: 7. Before assisting to stand, checks and/or locks bed wheels Yes: No: 8. Before assisting to stand, client is assisted to a sitting

position with feet flat on the floorYes: No:

9. Before assisting to stand, client is wearing shoes Yes: No: 10. Before assisting to stand, applies transfer belt securely at the

waist over clothing/gownYes: No:

11. Before assisting to stand, provides instructions to enable client to assist in transfer including prearranged signal to alert when to begin standing

Yes: No:

12. Stands facing client positioning self to ensure safety of candidate and client during transfer. Counts to three (or says other prearranged signal) to alert client to begin standing

Yes: No:

13. On signal, gradually assists client to stand by grasping transfer belt on both sides with an upward grasp (candidates hands are in upward position) and maintaining stability of client’s legs by standing knee to knee, or toe to toe with the client

Yes: No:

14. Assists client to turn to stand in front of wheelchair with back of client’s legs against wheelchair

Yes: No:

15. Lowers client into wheelchair Yes: No: 16. Positions client with hips touching back of wheelchair and

transfer belt is removedYes: No:

17. Positions feet on footrests Yes: No: 18. Signaling device is within reach Yes: No: 19. After completing skill, washes hands Yes: No:


Continued Next Page



SKILL 22 — MEASURES AND RECORDS MANUAL BLOOD PRESSUREThe numbered lines below each skill are the steps needed to perform that skill. Critical Element Steps are in bold type.


correct response.


Yes: No:

2. Before using stethoscope, wipes bell/diaphragm and earpieces of stethoscope with alcohol

Yes: No:

3. Client’s arm is positioned with palm up and upper arm is exposed

Yes: No:

4. Feels for brachial artery on inner aspect of arm, at bend of elbow

Yes: No:

5. Places blood pressure cuff snugly on client’s upper arm, with sensor/arrow over brachial artery site

Yes: No:

6. Earpieces of stethoscope are in ears and bell/diaphragm is over brachial artery site

Yes: No:

7. Candidate inflates cuff between 160mm Hg to 180 mm Hg. If beat heard immediately upon cuff deflation, completely deflate cuff. Re-inflate cuff to no more than 200 mm Hg

Yes: No:

8. Deflates cuff slowly and notes the first sound (systolic reading), and last sound (diastolic reading) (If rounding needed, measurements are rounded UP to the nearest 2 mm of mercury)

Yes: No:

9. Removes cuff Yes: No: 10. Signaling device is within reach Yes: No: 11. Before recording, washes hands Yes: No: 12. After obtaining reading using BP cuff and stethoscope,

records both systolic and diastolic pressures each within plus or minus 8 mm of evaluator’s reading

Yes: No:




PART 7: COMPETENCY EXAMINATION TESTING DATES

The National Nurse Aide Assessment Program (NNAAP) examination consists of two components: a written or oral portion and a skills demonstration portion. The oral portion is offered in English and Spanish. Each candidate must successfully complete both components of the examination before a state can add their name to the state nurse aide registry.

Please review the North Carolina Nurse Aide I Candidate Handbook to ensure you are prepared to take the competency examination.

Carefully consider when you plan to take the competency examination. You will receive an email from Pearson VUE once you have been approved and can register for the competency examination in North Carolina.

Provide a two-week range of the dates you plan to take the competency examination in North Carolina. Comments such as “ASAP” or “Anytime” will not be accepted.

(mm/dd/yyyy) through (mm/dd/yyyy)

PART 8: NORTH CAROLINA LICENSED NURSING HOME FACILTY ATTESTATION

I certify that all the information provided in this application is true and complete to the best of my knowledge.

Director of Nursing:

First Name: Middle Name: Last Name: RN License Number:

Signature: ________________________________________Date (mm/dd/yyyy):

PART 9: TEMPORARY NURSE AIDE ATTESTATION

I understand that if the information provided in this application is found to be fraudulent, then my listing will be removed from the North Carolina Nurse Aide I Registry and I will be required to pass a North Carolina state-approved nurse aide I training program and the North Carolina state-approved nurse aide I competency examination.

I certify that I have reviewed the North Carolina Nurse Aide I Candidate Handbook. I understand that if I do not pass the North Carolina state-approved nurse aide I

competency examination within three attempts, then I will be required to pass a North Carolina state-approved nurse aide I training program and the North Carolina state-approved nurse aide I competency examination.

I understand that I must pass both portions of the competency examination within two (2) years of approval date or within three (3) attempts, whichever comes first, in order to be placed on the North Carolina Nurse Aide I Registry.

First Name: Middle Name: Last Name:

Signature: _______________________________________ Date (mm/dd/yyyy):




APPENDIX A · Web viewThe Temporary Nurse Aide does not have a pending or substantiated finding of...

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