Health and Human Services

Health Care Facility Licensing

Rule R432-45: Nurse Aide Training and Competency Evaluation Program

Effective Date: 05/08/2025

Admin. Code Reference: R432-45

Rule Type: Current Rule

R432. Health and Human Services, Health Care Facility Licensing.

R432-45. Nurse Aide Training and Competency Evaluation Program.

R432-45-1. Authority and Purpose.

(1)(a) The Omnibus Budget Reconciliation Act of 1987 (OBRA), Pub. L. No. 100 203, 101 Stat. 1330, Section 4211 and Subsections (b)(5)(A) through (G), (e)(1) and (2), and f(2)(A) and (B) authorize the Nurse Aide Training and Competency Evaluation Program (NATCEP).

(b) 42 CFR 431.10(b)(2)(ii) (2024) authorizes the Department of Health and Human Services (department) to make and follow rules in the administration of the Utah State Medicaid Plan that are also binding upon the local contractors that administer the Utah State Medicaid Plan.

(2) The department uses NATCEP to carry out the requirements of 42 U.S.C. Sec. 1396r(5), which specifies requirements for nursing facilities to ensure nurse aides are trained according to federal requirements. The Utah State Medicaid Plan requires that the department administer the NATCEP and Utah Nursing Assistant Registry (UNAR) to certify and regulate certified nurse aides (CNA) and approve the required training instructions.

R432-45-2. Definitions.

Terms used in this rule are defined in Rules R380-600 and R432-1. Additionally:

(1) "Applicant" means an entity applying to the UNAR to request approval to operate a NATCEP.

(2) "Candidate" means a student who is actively enrolled in a NATCEP or an individual who applies for certification as a nurse aide.

(3) "CMS" means the Centers for Medicare and Medicaid Services and is a federal agency that provides healthcare coverage and delegates healthcare oversight to state entities.

(4) "CNA" means certified nurse aide and is a person who:

(a) completes the NATCEP and passes the competency evaluation;

(b) is approved for certification through reciprocity; or

(5) "Competency evaluation" means a written or audio-narrated examination and a demonstration of the skills administered to verify the knowledge and abilities essential to carry out the duties of a nurse aide.

(6) "DACS" means the Direct Access Clearance System that is the Division of Licensing and Background Checks' (division) online background check system.

(7) "Instructor" means a UNAR-approved licensed nurse who is employed by a NATCEP that provides supervised and documented nurse aide training in accordance with state and federal requirements and UNAR policies to candidates in a classroom or supervised practical training setting.

(8) "Instructor-assistant" means a CNA in good standing with UNAR, and in each state where the individual is certified, who assists candidates with skills taught by the NATCEP and who works under the direct supervision of an instructor.

(9) "NAPP" means nurse aide proficiency performance and is a record maintained by the NATCEP for each candidate nurse aide to document each candidate's successful demonstration of competence of tasks generally performed by a nurse aide.

(10) "NAR" means the nurse aide registry that lists each individual who has completed the Utah certification requirements and holds active certification in Utah.

(11) "NATCEP" means the UNAR-approved nurse aide training and competency evaluation program that provides classroom, laboratory, and in-facility training and experience for a candidate for certification as a nurse aide.

(12) "NATCEP loss list" means a list maintained by CMS including the reason for NATCEP loss, the effective date of the loss, the effective date of any waiver issued, and the restore date, as applicable.

(13) "NATCEP loss waiver" means a waiver requested by a nursing care facility and submitted to OL for permission to allow separately approved training and competency evaluation programs to use the facility as a site location for supervised practical training.

(14)(a) "Nurse aide" means any individual who provides nursing or nursing-related services to residents in a nursing care facility.

(b) "Nurse aide" does not mean an individual who:

(i) is a licensed professional; or

(ii) who volunteers to provide services without monetary consideration.

(15) "Nursing care facility" means a skilled nursing facility, or an intermediate care facility, that provides long-term, 24-hour inpatient care and services through utilizing licensed healthcare professionals and ancillary staff to meet the complex physical, mental, and psychosocial needs of residents.

(16) "Program director" means a UNAR-approved registered nurse (RN), employed by a UNAR-approved NATCEP, who:

(a) has the primary responsibility for assuring the program is conducted in accordance with each regulation, rule, and UNAR policy;

(b) serves as the primary administrative contact with the UNAR; and

(17) "Qualified personnel" means:

(a) a dietitian;

(b) a fire safety expert;

(d) a licensed practical or vocational nurse;

(e) a nursing home, or health care facility administrator;

(f) a pharmacist;

(g) a physical or occupational therapist;

(h) a psychologist;

(i) a registered health specialist or registered sanitarian;

(j) a social worker; or

(k) a speech and language therapist;

(l) an activities specialist; or

(m) an RN.

(18) "Renewal" means the process UNAR conducts every 24 months to verify that each CNA has provided at least 200 hours of compensated nursing or nursing-related services under the direction of a licensed nurse.

(19) "Resident" means an individual who resides and receives services in a nursing care facility.

(20) "SSA" means the state survey agency and is the Office of Licensing (OL) in the division within the department that is responsible for the certification activities of Medicaid and Medicare health care providers, including nursing care facilities.

(21) "Supervised practical training" means training on individuals or mannequins in a laboratory setting or on residents in a nursing care facility where the candidate demonstrates knowledge, skills, and competence while performing tasks under the direct supervision of a licensed nurse, who is a UNAR-approved instructor.

(22) "Train-the-trainer program" means a UNAR-approved program designed to educate instructors on how to use demonstrations and lectures to educate nurse aide candidates.

(23) "UNAR" means the Utah Nursing Assistant Registry and is the state agency that:

(a) approves and monitors test sites;

(b) approves, monitors, and withdraws approval of NATCEPs;

(d) develops, updates, and validates the competency evaluation;

(e) grants reciprocity to qualified individuals certified in other states;

(f) maintains the NAR;

(g) maintains an abuse registry for any substantiated allegations of resident neglect, abuse, or misappropriation of resident property by a CNA in a nursing care, Medicaid, or Medicare facility; and

(h) renews certifications of each qualified CNA.

(24) "Waiver of NATCEP" means a provision allowing a qualified nursing student, nurse, or in-state expired CNA to challenge the competency evaluation requirement.

R432-45-3. Pathways to Become a CNA.

(1) A nurse aide performing nursing or nursing-related services in a Medicare or Medicaid certified nursing facility shall meet necessary requirements and become certified within 120 days of the first date of employment.

(2) An individual who was certified as a nurse aide on or before July 1, 1989, meets the OBRA requirement upon completion of the approved in-service training on intellectual disabilities and mental illness.

(3) To become certified through a NATCEP, a candidate:

(a) shall be at least 16 years old;

(b) shall enroll in a UNAR-approved NATCEP;

(d) may not be an inmate, in accordance with Subsection 64-13-48(8).

(4)(a) UNAR may grant a waiver of NATCEP and require only the competency evaluation when accompanied by an application for certification testing to:

(i) a nursing student who has successfully completed the first semester of nursing school within the past two years and can provide an official transcript demonstrating proof of a passing grade in a nurse fundamentals class;

(ii) a nurse with an expired license from any state or U.S. territory who can provide proof of previous licensure in good standing with the professional board; or

(iii) a CNA who has no findings on UNAR's abuse registry and who:

(A) has a Utah certificate that has been expired for fewer than 24 months; or

(B) has not worked at least 200 hours under the direction of a licensed nurse in the previous 24 months.

(b) UNAR shall grant the candidate three attempts to pass both the skills and written portion of the examination within:

(i) 12 months of submitting the waiver of NATCEP application for:

(A) a nursing student; or

(B) a nurse with an expired license from any state or U.S. territory; or

(ii) two years for any CNA with a Utah certificate that has been expired for fewer than 24 months.

(5) An individual may seek reciprocity from the UNAR if the individual provides the certification demonstrating that the individual is currently certified in another state with no findings in that state's abuse registry or on the UNAR abuse registry.

(6) An individual with an expired certification from another state shall complete a NATCEP in Utah.

(7) A CNA with a Utah certificate that has been expired for fewer than six months and who had met each requirement before the expiration date may pay a late fee and have the certification reinstated as active for the remainder of the original 24-month renewal time frame.

R432-45-4. Competency Evaluation.

(1) A candidate shall pass, according to policy established by UNAR, both the written and skills portions of the competency evaluation.

(2) For the written portion of the competency evaluation, UNAR shall ensure that:

(a) each written test is available with audio narration;

(b) the evaluation addresses each course requirement as required in Subsection R432-45-5(6):

(i) are maintained in a system that preserves the integrity of both the pool of questions and the individual evaluations;

(ii) are periodically updated and validated; and

(iii) only a portion of the pool of questions are used in any one evaluation.

(3) UNAR shall use testing software to randomly select five tasks from the pool of the skills competency evaluation items and ensure the skills competency evaluation includes:

(a) a pool of skills as required in Subsection R432-45-5(9)(e); and

(b) a demonstration of the tasks the nurse aide is expected to perform as a CNA.

(4) Only a UNAR-approved testing center may perform competency evaluations.

(5) UNAR shall approve a testing center if the testing center:

(a) ensures any remote location can provide security and integrity and promote a positive testing environment;

(b) has any items necessary to simulate a long-term resident care room;

(d) has a comfortable temperature, ventilation, and lighting;

(e) has headphones and computer capabilities;

(f) has reliable internet access;

(g) has seating;

(h) has systems to ensure the maintenance of the security of the examinations;

(i) is ADASAD-compliant;

(j) is available to provide testing for a qualified candidate from any approved NATCEP;

(k) is in a clean and safe condition;

(l) provides a quiet testing environment; and

(m) provides supervision for monitoring and discouraging cheating.

(6) UNAR shall approve an application for a testing center if the applicant meets the criteria specified in each regulation, rule, and UNAR policy.

(7) UNAR shall ensure that the competency evaluation is available through technical colleges, community colleges, and universities throughout Utah.

(8) For testing center approval, UNAR shall ensure:

(a) an RN who has a current, active license in good standing with the Division of Professional Licensing to practice as an RN, is the skills observer who:

(i) administers the examination;

(ii) attends the UNAR mandatory training sessions; and

(iii) has at least one year of experience in providing care for the elderly or chronically ill of any age;

(b) each proctor and skill observer:

(i) recuses themself from observing any candidate who they have educated or trained in a nurse aide training program; and

(ii) signs a confidentiality disclosure and any other mandatory UNAR document; and

(9) UNAR shall:

(a) advise the candidate that a record of the outcome of the competency evaluation will be included in the NAR indicated in this section;

(b) ensure the NAR includes a:

(i) name;

(ii) certification number;

(iii) city, state, and zip code;

(iv) certification status, including issue and expiration dates;

(v) history of misconduct that is publicly searchable indefinitely; and

(vi) certification history publicly searchable while certification is active, plus two years;

(c) establish a NAPP record of major skills and duties for each candidate for the skills component of the evaluation that includes:

(i) a list of the skills listed in Subsection R432-45-5(9)(e);

(ii) a record that documents when the candidate performed each skill;

(iii) a record of satisfactory or unsatisfactory performance;

(iv) the date of each performance; and

(v) the instructor supervising each performance;

(d) inform each candidate of any area where the candidate was deficient at each exam attempt and that after three failed attempts on the written, audio, or skills component of the competency evaluation, the candidate shall complete re-training with an approved NATCEP; and

(e) provide the candidate an opportunity to review and consent to the release of information UNAR requires for the NAR.

(10) At the completion of the training, the NATCEP shall give the nurse aide candidate a copy of the NAPP record.

R432-45-5. Nurse Aide Training Program Requirements Under UNAR.

(1)(a) An applicant shall apply to UNAR on behalf of an entity, including a:

(i) Medicare or Medicaid certified nursing facility;

(ii) secondary or post-secondary educational institution; and

(iii) private business.

(b) An entity may not include an educational program offered to an incarcerated inmate in accordance with Subsection 64-13-48(8).

(2) Within 90 days of receipt of an application for a NATCEP, UNAR shall advise the applicant of UNAR's:

(a) approval;

(b) denial, including a summary of the reasons for denial; or

(3) An entity may not operate a NATCEP without UNAR approval.

(4) A NATCEP shall ensure the program director and any NATCEP instructor or employee who has direct patient access successfully completes a background check in accordance with Rule R432-35.

(5) UNAR shall ensure DACS reflects the current status of each individual required to have a clearance.

(6) A NATCEP shall provide at least 100 hours of supervised and documented training by a licensed nurse using curriculum containing:

(a) basic nursing skills;

(b) comprehensive orientation to the training program and the nursing assistant's role on the healthcare team;

(d) infection control;

(e) promoting resident independence;

(f) respecting resident rights; and

(g) safety and emergency procedures.

(7) A NATCEP shall ensure each candidate:

(a) completes at least 24 of the required 100 hours of supervised practical training in a nursing care facility; and

(b) completes the skill competencies and skill curriculum listed on the NAPP record before training in a facility.

(8)(a) UNAR may approve a written request from a NATCEP to use a Type II assisted living facility for no more than eight of the 24 required hours of supervised practical training if the NATCEP:

(i) identifies the Type II assisted living facility the NATCEP wishes to use; and

(ii) provides documentation of the lack of availability of nursing care facility locations to fulfill eight of the required 24 hours of supervised practical training for each NATCEP candidate.

(b) A NATCEP may not continue supervised practical training in a Type II assisted living or nursing care facility if that facility's supervised practical training approval has been withdrawn by UNAR.

(c) A nursing care facility listed on the NATCEP loss list may not allow separately approved NATCEPs to utilize the facility as a site location for supervised practical training unless the facility:

(i) obtains an approved NATCEP loss waiver from OL; or

(ii) is reinstated following the mandatory two-year ban following placement on the NATCEP loss list.

(9) NATCEP shall ensure the skills training requires demonstration of competencies in:

(a) basic nursing skills, including:

(i) caring for a resident when death is imminent;

(ii) caring for a resident's environment;

(iii) measuring and recording weight and height;

(iv) recognizing abnormal changes in body functioning and the importance of reporting the changes to a supervisor; and

(v) taking and recording vital signs;

(b) basic restorative services including:

(i) bowel and bladder training;

(ii) care and use of prosthetic and orthotic devices;

(iii) maintenance of range of motion;

(iv) proper turning and positioning in bed and chair;

(v) transfer techniques;

(vi) training a resident in self-care according to the resident's ability; and

(vii) use of assistive devices in ambulating, dressing, eating, and transferring;

(i) appropriate responses to the behavior of a cognitively impaired resident;

(ii) communicating with a cognitively impaired resident;

(iii) methods for reducing the effects of cognitive impairments;

(iv) techniques for addressing the unique needs and behaviors of a resident with dementia or Alzheimer's; and

(v) understanding the behavior of a cognitively impaired resident;

(d) mental health and social service skills, including:

(i) allowing a resident to make personal choices and providing and reinforcing other behavior consistent with the resident's dignity;

(ii) awareness of developmental tasks associated with the aging process;

(iii) how to respond to resident behavior;

(iv) modifying the nurse aide's behavior in response to a resident's behavior; and

(v) using a resident's family as a source of emotional support;

(e) personal care skills, including:

(i) assisting with eating and hydration;

(ii) bathing;

(iii) dressing;

(iv) grooming that includes mouth care;

(v) proper feeding techniques;

(vi) skin care;

(vii) toileting; and

(viii) transferring, positioning, and turning;

(f) resident's rights including:

(i) aiding in getting to and participating in resident and family groups and other activities;

(ii) aiding in resolving grievances and disputes;

(iii) maintaining care and security of a resident's personal belongings;

(iv) promoting a resident's right to be free from abuse, mistreatment, or neglect and the requirement to report any instances of abuse, mistreatment, or neglect to the appropriate staff, Adult Protective Services, and OL;

(v) promoting a resident's right to be free from physical and chemical restraints, unless the use is required to treat a medical symptom and is not used for discipline or staff convenience;

(vi) promoting a resident's right to make personal choices to accommodate the resident's needs; and

(vii) providing privacy and confidentiality.

(10) A candidate may not perform any services that the candidate has not been trained and found proficient to conduct by an instructor.

(11) A NATCEP shall have:

(a) a program director who:

(i) is an RN with an active license to practice nursing and is in good standing with the Division of Professional Licensing;

(ii) has two years of nursing experience with at least one year providing nursing care facility services, caring for the elderly, or caring for the chronically ill of any age;

(iii) establishes policies to ensure a minimum of three hours consulting time with a NATCEP for a new program and can provide at least three hours consulting time per month at renewal application for an existing NATCEP;

(iv) may be the director of nursing in a nursing care facility-based NATCEP if the facility remains in compliance with OBRA requirements; and

(v) may be the instructor;

(b) one or more instructors, each of whom:

(i) holds an active license to practice nursing and is in good standing with the Division of Professional Licensing; and

(ii) has two years of nursing experience with at least one year of experience providing nursing care facility services, caring for the elderly, or caring for the chronically ill of any age.

(12) Before approval of a NATCEP, the program director and any instructors shall successfully complete a UNAR-approved train-the-trainer program or demonstrate competence to teach candidates.

(13) Each high school instructor shall complete the train-the-trainer program or become certified to teach as defined by the Utah State Board of Education before providing instruction in the classroom.

(14)(a) A licensed UNAR-approved nurse instructor shall directly supervise each candidate who provides services to a resident.

(b) Each instructor's supervised practical training oversight time is solely for the direct oversight of a candidate and the instructor may not be used to perform other facility services simultaneously.

(15)(a) Qualified personnel from the health professions may assist the program director and any instructor.

(b) The program director or any instructor shall be present during any training provided by another qualified professional.

(16)(a) UNAR shall require qualified personnel to have at least one year of recent experience in the care of the elderly, in the care of the chronically ill of any age, or equivalent experience.

(b) Qualified personnel shall meet current licensure requirements regardless of whether they are licensed, registered, or certified in that person's field.

(17)(a) A NATCEP shall maintain a candidate-to-instructor ratio of 12:1 for supervised practical training and may not exceed a 30:1 ratio for theory instruction.

(b) A NATCEP shall ensure there is an instructor assistant when the program has more than 20 candidates.

(18) A NATCEP shall provide a classroom that:

(a) has a comfortable temperature, ventilation, and lighting;

(b) has adequate seating;

(d) has appropriate textbooks and reference materials;

(e) has skills lab equipment to simulate a resident's living unit; and

(f) is maintained in a clean and safe condition.

(19)(a) UNAR shall place a newly approved NATCEP on a one year probationary period.

(b) UNAR shall withdraw program approval if a NATCEP fails to comply with each regulation, rule and UNAR policy at any time.

(20) Each UNAR on-site visit and NATCEP self-evaluation shall include a review of:

(a) any complaint received about the program;

(b) documentation of candidate skill proficiency;

(d) evidence that curriculum content meets the requirements of rule and UNAR policy; and

(e) files for the program director, each instructor, each instructor assistant, and qualified personnel used by the NATCEP since the last review date;

(f) whether any classroom facilities and equipment meet the requirements of rule and UNAR policy.

(21) UNAR shall require a plan of correction for a NATCEP that fails to comply with rule, UNAR policy, or any state or federal requirement.

(22) UNAR shall withdraw approval of a facility-based NATCEP that UNAR had approved within the last two years, if:

(a) the facility:

(i) has closed or has had residents transferred to other facilities in an emergency;

(ii) has been assessed a civil money penalty by CMS in an amount that compels approval withdrawal;

(iii) has been subject to a partial extended or extended survey;

(iv) has been subject to the enforcement remedy of a temporary manager;

(v) has been subject to the enforcement remedy of denial of payment for new admissions; or

(vi) has operated with an approved nurse staffing waiver; or

(b) otherwise directed by the SSA or CMS.

(23) Upon review of program performance standards, UNAR shall end a program that does not provide an acceptable plan to correct any deficiency.

R432-45-6. Nurse Aide Registry.

(1) NAR is the central registry for CNAs in Utah. This registry shall identify each individual who has:

(a) successfully completed a NATCEP;

(b) passed the written competency evaluation with a score of 75; and

(c) passed the skills competency evaluation with a score of 80% for each skill performed, including 100% of the required key steps.

(2) A NATCEP shall report to UNAR, within five days after the program ends, the name of each individual who satisfactorily completed the program.

(3) UNAR shall process renewals for each CNA who has performed a paid service for at least 200 hours of nursing or nursing-related services under the direction of a licensed nurse during the 24 months following the completion date of the NATCEP or certification renewal.

(4) The SSA shall enforce the standards of UNAR described in Pub. L. No. 100-203, 101 Stat. 1330, Secs. 4211 and 4212.

(5)(a) The SSA shall investigate complaints of resident abuse, neglect, or misappropriation of resident property by a CNA.

(b) A CNA may request a hearing through the Division of Medicaid and Health Financing before a substantiated claim is entered into the registry.

(6)(a) Upon notification by the SSA of a substantiated finding of resident abuse, neglect, or misappropriation of resident property, the UNAR shall include the following information on the abuse registry within ten working days of the finding, in accordance with 42 CFR 483.156(c)(1)(iv)(D) (2025):

(i) documentation of the SSA's investigation, including the nature of the allegation and the evidence that led the SSA to conclude that the allegation was valid;

(ii) the date of the hearing, if the individual chose to have one, and the hearing's outcome; and

(iii) a statement by the individual disputing the allegation, if applicable.

(b) Information shall remain in the registry permanently unless:

(i) the finding was made in error;

(ii) the individual was found not guilty in a court of law; or

(iii) the SSA is notified of the individual's death.

(7) In accordance with 42 CFR 483.156(c)(2), UNAR shall remove entries for each individual whose certification has been inactive for 24 consecutive months unless the individual's registry entry includes documented findings of resident abuse, neglect, or misappropriation of resident property.

R432-45-7. Limitations.

(1) UNAR may only approve a facility-based NATCEP if the facility's participation in the Medicare and Medicaid programs has not been terminated within the last two years.

(2) UNAR shall review and reapprove a NATCEP at least every two years.

(3) A skilled nursing facility that participates in a Medicare or Medicaid facility may not administer the written and skills components of the competency evaluation.

R432-45-8. Compliance.

Any provider found in noncompliance with any statute or rule under the division may be subject to the penalties in Rule R380-600 and Title 26B, Chapter 2, Part 7, Penalties and Investigations.

KEY: health care facilities

Date of Last Change: May 8, 2025

Notice of Continuation: April 4, 2024

Authorizing, and Implemented or Interpreted Law: 42 CFR 431.10