Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Nurse Aide Training 
JANET REHNQUIST 
Inspector General 
NOVEMBER 2002 
OEI-05-01-00030  O I G
FFICE OF  NSPECTOR  ENERAL

http://www.oig.hhs.gov/ 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended 
by Public Law 100-504, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and inspections 
conducted by the following operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of HHS programs and operations in 
order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the 
Department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and the 
public.  The findings and recommendations contained in the inspections reports generate rapid, accurate, 
and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil 
monetary penalties.  The OI also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support in OIGs internal 
operations.  The OCIG imposes program exclusions and civil monetary penalties on health care providers 
and litigates those actions within the Department.  The OCIG also represents OIG in the global settlement 
of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops model compliance plans, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  E X E C U T I V E   S U M M A R Y  
PURPOSE 
To determine whether nurse aide training prepares nurse aides for their jobs in nursing homes. 
BACKGROUND 
Nurse aides are the front-line workers in nursing homes.  The well-being of a nursing home 
resident depends not only on the skills of the nurse aide, but also on the relationship that 
develops between the nurse aide and the resident. Federal regulations require that all nurse 
aides, who work in nursing homes that participate in Medicare and Medicaid, complete a 
State-approved training program, pass a competency exam, and receive certification from the 
State in which they are employed.  State-approved training programs must be a minimum of 75 
hours and include 16 hours of supervised clinical training. To maintain certification, all nurse 
aides must complete 12 hours of continuing education annually. 
We reviewed the Federal nurse aide training requirements as mandated in the Omnibus Budget 
Reconciliation Act of 1987 (OBRA 87).  We examined factors affecting nurse aide training by 
obtaining data about current State nurse aide training requirements from 48 States and the 
District of Columbia. We compiled responses from nearly 1,000 nurse aides. We interviewed 
29 nursing home administrators and nurse supervisors (hereinafter referred to as nursing home 
supervisors), 14 nurse aide trainers, 5 long-term care ombudsmen, 3 academicians, and 5 
experts in the field.  Overall, we held discussions with 39 licensed or registered nurses from the 
different respondent groups. 
FINDINGS 
Nurse aide training has not kept pace with nursing home industry needs 
Approximately 90 percent of our respondents (nursing home supervisors, nurse aide trainers, 
State ombudsmen, State directors of nurse aide training programs, and experts) reported that 
the medical and personal care needs of todays nursing home residents have 
i 
Nurse Aide Training  OEI-05-01-00030  changed since implementation of OBRA 87. We held discussions with nursing home staff and 
experts who indicated that compared to nursing home residents 15 years ago, todays nursing 
home residents are older, sicker, require more assistance with activities of daily living, and take 
more medications.  Approximately half of the nursing home supervisors we interviewed, and 61 
percent of State directors of nurse aide training programs believe that nurse aide training has not 
kept pace with demands of the changing care needs of nursing home residents. 
Nurse aides need more skill training on behavior and cognitive disorders, catheter care, 
colostomy care, lifting, feeding, hydration, and infusion therapies.  They also need more training 
in interpersonal skills, including communication, teamwork, coping with death and dying, time 
management, and new technologies. 
Teaching methods are often ineffective, clinical exposure is too short and 
unrealistic 
Although Federal law requires that State-approved nurse aide training programs consist of at 
least 75 hours of total instruction, 26 States have already extended their training programs 
beyond 75 hours. Eighteen of twenty-nine nursing home supervisors reported that nurse aides 
were not ready to begin work on the nursing home floor upon completion of nurse aide training. 
Fifty percent of nurse aides we surveyed reported a lack of  hands on experience and 
unrealistic training scenarios. 
In-service training may not be meeting Federal requirements 
We had difficulty determining whether nursing homes are meeting the Federal requirement that 
in-service training address areas of weakness for individual nurse aides.  Besides recording the 
number of hours of completed in-service training, there are no other documentation 
requirements in the Federal regulations for in-service training. 
RECOMMENDATION 
Responses from 29 nursing home supervisors, 14 nurse aide trainers, 5 long-term care 
ombudsmen, 3 academicians, and 5 experts (39 of all these respondents were licensed or 
registered nurses) show that the nurse aide training curriculum needs to be updated, and clinical 
experience needs to occur earlier and needs to be more realistic.  Responses from nearly 1,000 
nurse aides and 48 State directors of nurse aide training programs also indicate that nurse aide 
training programs need improvement. Although the nursing home 
ii 
Nurse Aide Training  OEI-05-01-00030  environment has changed considerably since OBRA 87 nurse aide training regulations 
were implemented, nurse aide training has not kept pace with nursing home resident needs. 
We are recommending that CMS: 
Improve nurse aide training and competency evaluation program 
requirements 
	 Ensure that the content of the nurse aide training curriculum and testing (as described in 
42 CFR Part 483) remains relevant to todays complex resident care needs. 
Strengthen nurse aide training by recognizing current nurse aide needs and by 
embracing modern technologies and equipment. Consider enhancing the 
communication and interpersonal skills of nurse aides (i.e., by including training in time 
management and teamwork). 
	 Continue to work with States to assure that nurse aide training is effective and efficient. 
This collaborative effort could include (but not be limited to) increasing the ratio of 
clinical hours and ensuring that clinical experience occurs earlier in the training period, is 
more realistic, and includes a full range of skills needed on the job. 
	 Ensure that nursing homes are in compliance with in-service training requirements. 
Revise 42 CFR 483.75 to include a requirement that nursing homes document that in-
service training is conducted to address weaknesses identified in nurse aides 
performance reviews. 
AGENCY COMMENTS 
The draft of this report was reviewed by CMS, and the agency concurred with our recommendations. 
In concurring with our recommendations, CMS stated that the agencys own independent study 
reached essentially the same conclusions as found in our study. The CMS reports that the agency has a 
contract in place to examine nurse aide training curriculum, content, and skills. The CMS also intends 
to develop specific policy and programmatic options for improving the administration of nurse aide 
training programs and for ensuring that nursing home in-service training complies with regulatory 
requirements. The full text of CMS comments can be found in Appendix A. 
iii 
Nurse Aide Training  OEI-05-01-00030  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY ...................................................... i

INTRODUCTION ............................................................. 1

FINDINGS

Training has not kept pace  .................................................9

Clinical exposure and teaching methods are often inadequate  ......................  12

In-service training may not meet Federal requirements  ...........................15

CONCLUSION AND RECOMMENDATION  .................................... 17

AGENCY COMMENTS  ...................................................... 18

APPENDICES

A: Centers for Mediare & Medicaid Services Response to Report ...................19

B:  Characteristics of Participating Nursing Homes  ..............................22

C: Demographics of Nurse Aide Respondents  .................................27

D:  Hours of Training by State  .............................................28

ACKNOWLEDGMENTS ..................................................... 31
 I N T R O D U C T I O N  
PURPOSE 
To determine whether nurse aide training prepares nurse aides for their jobs in nursing homes. 
BACKGROUND 
Nurse aides are healthcare workers in various settings, such as hospitals, home care, and 
nursing homes. In long-term care nursing homes, nurse aides assist residents in their activities of 
daily living, such as bathing, dressing, eating and toileting.  Nurse aides also tend to the 
psychological, social, and spiritual needs of residents. Because a nurse aides primary duty is 
direct care, they are often the first to identify changes in a residents condition. Some nursing 
home administrators liken nurse aides to the eyes and ears of the facility. 
Nurse aides must also demonstrate a professional attitude and behavior to enhance 
communication between herself/himself and the resident, the residents family members and 
nursing home staff.  The scope of duties for nurse aides varies among States and also among 
nursing homes within a State. 
Federal Training Requirements 
The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) mandated the Nurse Aide 
Training and Competency Evaluation Program (NATCEP) to establish minimum requirements 
for nurse aide competency. Nursing homes participating in Medicare and Medicaid may not 
employ anyone as a nurse aide for more than four months, unless the individual has completed a 
State-approved nurse aide training program and passed a competency exam.1 Federal 
regulations require that the training: 
  Consist of no less than 75 hours; 
1 
42 CFR 483.75(e)(2) 
1
Nurse Aide Training   OEI-05-01-00030  	 Be performed by, or under the general supervision of, a registered nurse who has a 
minimum of 2 years of nursing experience, at least 1 year of which must be long-term 
care; 
  Include hours in certain nursing skill areas; and 
	 Include at least 16 hours of supervised practical training [hereinafter referred to as 
clinical training]. 
Some States have chosen to require additional hours of classroom and clinical training. For 
more information, see our Office of Inspector General companion report on State Nurse Aide 
Training: Program Information and Data.2 
For classroom training, Federal regulations require instruction in the following areas: 
<	 Basic nursing skills--includes taking and recording vital signs; measuring and recording 
height and weight; caring for the residents environment; recognizing and reporting 
abnormal changes in body functioning; and caring for the dying resident. 
<	 Personal care skills--includes bathing, grooming, dressing, toileting and skin care; 
assisting with eating (proper feeding techniques) and hydration; and transferring, 
positioning and turning. 
<	 Mental health and social service skills--includes responding to a residents behavior; 
raising awareness of developmental tasks associated with the aging process; allowing 
the resident to make personal choices; and using the residents family as a source of 
emotional support. 
<	 Caring for cognitively impaired residents--includes addressing the behaviors of 
residents with dementia; and communicating and responding to residents with cognitive 
impairments. 
<	 Basic restorative skills--includes training the resident in self care; using assistive 
devices in transferring, ambulation, eating and dressing; maintaining range of motion; 
proper turning and positioning in bed and chair; bowel and bladder training; and caring 
for and using prosthetic and orthotic devices. 
<	 Residents rights--includes providing privacy and maintenance of confidentiality; 
promoting residents rights to make personal choices to accommodate their needs; 
giving assistance in resolving grievances and disputes; providing needed assistance in 
getting to and participating in resident and family groups and other activities; maintaining 
care and security of residents personal possessions; promoting the residents right to 
be free from abuse, mistreatment, and neglect, 
2
 OEI-05-01-00031 
2
Nurse Aide Training   OEI-05-01-00030  and the need to report any instances of such treatment to appropriate nursing home 
staff; and avoiding the need for restraints.3 
During clinical training, under the direct supervision of a registered or licensed practical nurse, 
the nurse aide trainee must demonstrate knowledge while performing tasks on an individual, 
such as taking vital signs of one of their fellow students. Upon completion of training, a nurse 
aide trainee must pass a State exam to become certified to work in a nursing home. As 
required by the regulations, the exam must include a written or oral component and a skills-
demonstration component.  Candidates for certification must pass both components. 
Continuing Education Requirement 
The OBRA 87 also mandates that nursing homes provide regular in-service education for nurse 
aides. Specifically, the regulations require a nursing home to complete a performance review of 
every nurse aide at least once every 12 months. Using the performance reviews, nursing homes 
must provide regular in-service education to address identified needs.  The in-service training 
must: 
<	 Be sufficient to ensure the continuing competence of nurse aides, but must be no less 
than 12 hours per year; 
<	 Address areas of weakness, as determined in nurse aides performance reviews, and 
may address the special needs of residents as determined by the facility staff; and 
<  Address aides providing services to individuals with cognitive impairments.4 
States may develop their own, more stringent, requirements for in-service education.  As a 
result, States vary as to the number of in-service hours and topics they require. 
The Centers for Medicare & Medicaid Services 
The Centers for Medicare & Medicaid Services (CMS) is responsible for establishing and 
enforcing regulatory requirements designed to ensure that nursing homes that participate in 
Medicare and Medicaid meet specific criteria (called Conditions of Participation) that are 
3 
42 CFR 483.152 
4 
42 CFR 483.75 
3
Nurse Aide Training   OEI-05-01-00030  designed to ensure resident health, safety, and quality of care.5 The CMS also is responsible 
for establishing the regulatory standards for State nurse aide training programs and providing 
funding for nurse aide training programs sponsored by nursing homes.6 According to 
information from CMS, a total of $45.5 million was spent for nurse aide training in Fiscal Year 
2000.7 Approximately $20.2 million of this total was paid by the Federal government.  The 
remaining funds were paid by State governments. Oversight and enforcement of the nurse aide 
training regulatory requirements are left to the States.8 
The CMS contracts with State agencies to certify long-term care nursing homes to participate 
in the Medicare and Medicaid programs.  These State agencies also are responsible for 
surveying nursing homes to ensure that they continue to meet both Federal and State 
requirements. As part of their nursing home survey, State surveyors review facility records to 
ensure that nurse aides employed in the nursing home have completed their nurse aide training 
and are certified by the State. Generally, these records are reviewed only when surveyors have 
severe quality of care concerns or observe incorrect performance by a nurse aide. 
The States Oversight of Nurse Aide Training 
The States have responsibility for approving nurse aide training programs. State NATCEP 
directors oversee nurse aide training programs and the administration of the competency exams. 
State NATCEP directors are charged with periodically recertifying all training programs and 
conducting on-site visits to ensure that they continue to adhere to Federal and State 
requirements. The director also may be in charge of the States nurse aide registry, which is a 
repository of information about nurse aides certified to work in the State. 
States have considerable freedom in developing nurse aide training programs. They determine 
the total hours of training required (as long as the 75-hour minimum is met). They may develop 
training manuals and curricula or approve those developed by the private or public sector. 
States also have considerable latitude in the administration of exams. States may administer 
exams directly or contract for this service. Thirty-two States hire private subcontractors to 
administer their State nurse aide exams.  The remaining 17 States use their own staff or work 
5
 P.L.100-203 4201(f)(1)

6
 P.L. 100-203 4201(f)(2)(A)(i)

7
 Based on Medicaid Financial Management Reports (HCFA-64) for FY 2000. 

8 
42 CFR 483.152 - 483.158 
4
Nurse Aide Training   OEI-05-01-00030  with other State or private entities to administer the State exams.9 
Training programs may be either facility-based (i.e., in a nursing home) or non-facility based, 
such as in a community college, vocational-technical school, high school, or private school. 
States report fees for non-facility based training ranging from a low of $190 to a high of 
$9,372. 
Changes in Long-Term Care Environment 
There have been many changes in the long-term care environment since passage of OBRA 87. 
Today, long-term care not only includes nursing homes, but also home care, personal care 
homes and assisted living facilities.  Healthcare policy changes that encourage shorter hospital 
stays have created a niche whereby nursing homes are providing sub-acute care that was 
previously provided in a hospital setting.10 
Longitudinal data suggests that acuity levels and complexity of care for elderly long-term care 
users have increased over time. The National Long-Term Care Survey11 indicates that in 1984, 
35.4 percent of elderly long-term care users required assistance with 3 to 6 activities of daily 
living (ADLs)12 and 33.7 percent were cognitively impaired.  In 1999,  75 percent of nursing 
home residents required assistance with three or more ADLs.13 Data from 2001 indicate that 
almost 60 percent of nursing home residents had moderately or severely impaired cognitive 
skills.14 
Other Studies 
Several other studies have examined the subject of nurse aides in nursing homes.  These studies 
have mainly focused on staffing issues. The Institute of Medicine published two reports in this 
9
 Two State NATCEP directors did not respond to our survey. 
10
 The Characteristics of Long-Term Care Users, AHRQ Research Report, January 2001. 
11
 The National Long-Term Care Survey, Center for Demographic Studies, Duke University. 
12
 ADLs are activities related to personal care and include bathing or showering, dressing, getting in and 
out of bed or a chair, getting around inside, using a toilet, and eating. 
13
 Jones A. The National Nursing Home Survey: 1999 summary. National Center for Health Statistics. Vital 
Health Stat 13(152).2002. 
14
 The Centers for Medicare & Medicaid Services, Minimum Data Set, 2001. 
5
Nurse Aide Training   OEI-05-01-00030  area.  The first, Nursing Staff in Hospitals and Nursing Homes:  Is It Adequate? (1996) 
looked at the evolving role of nurses in the health care system. The second, Improving the 
Quality of Long-Term Care (2001), identified problem areas, and offered recommendations 
for strengthening the caregiving workforce. The General Accounting Office provided testimony 
related to the current and projected supply of nurse aides in their report entitled Nursing 
Workforce: Recruitment and Retention of Nurses and Nurse Aides Is a Growing Concern.15 
This report included full demographic descriptions of nurse aides and a portrayal of current 
salary issues.  The CMS issued a report to Congress entitled, Appropriateness of Minimum 
Nurse Staffing Ratios in Nursing Homes (2001) which examined nurse aide training. That 
report, in its examination of nursing home staff turnover and retention, described the relationship 
between nurse staffing levels and the quality of care in nursing homes. 
SCOPE AND METHODOLOGY 
Pre-Inspection 
We conducted extensive pre-inspection work in three States16 to gain background knowledge 
and learn about pertinent issues in nurse aide training.  We met with the State NATCEP 
directors, nursing home administrators, licensed and registered nurses, nurse aides, nurse aide 
trainers, and long-term care ombudsmen during our pre-inspection visits to these three States. 
We also met with CMS regional and headquarters staff and attended conferences sponsored 
by a national nurse aide association and the Agency for Healthcare Research and Quality. We 
also interviewed representatives from industry and association groups.  One team member 
attended a full day of nurse aide training. 
Inspection Process 
Throughout the inspection process, we systematically gathered both quantitative and qualitative 
data from the different stakeholder groups to identify issues and learn their perspectives of nurse 
aide training. We used three methods for collecting data in this inspection. First, we gathered 
information from NATCEP directors in 48 State agencies and the District of Columbia. 
Twenty of the NATCEP directors identified themselves as registered nurses. Two State 
NATCEP directors did not respond to our request for information. We collected detailed 
information about nurse aide training requirements and numbers of hours of training in their 
States.  We gathered information about the various curriculum and clinical requirements in their 
15
 GAO-01-750T 
16
 Missouri, Ohio, and Wisconsin 
6
Nurse Aide Training   OEI-05-01-00030  State and the States role in oversight of these training programs. We received information on 
updates to training course content since the implementation of OBRA 87.  We also received 
suggestions from these State directors based on their years of experience in the field on whether 
any improvements needed to be made to the nurse aide training curriculum. 
Second, we conducted site visits in five States:  Florida, Louisiana, Minnesota,  New York, and 
Washington. States were selected following discussions with CMS staff and experts. States 
were also selected based on geographic location, nursing home population, and State budgets 
for nursing home care. These site visits were conducted during June and July 2001.  We 
systematically held discussions with State NATCEP directors, State long-term care 
ombudsmen, nursing home supervisors and nurse aide trainers in each of the five States. 
In each State, we selected five or six nursing homes, based on criteria, such as bed size, type of 
ownership (for-profit/not-for-profit), location (urban/suburban/rural), and the presence of 
facility-based training.  In each nursing home, we administered structured discussion guides with 
the nursing home administrator and nurse supervisor (hereinafter referred to as nursing home 
supervisor) as well as two to four nurse aides. We found out whether nurse aide training needs 
are met at the individual nursing homes, whether nurse aide training curricula can be improved, 
and whether nurse aides are prepared for their first day on the job after they complete their 
training. 
Appendix B contains descriptive information of the nursing homes we visited. During our on-
site visits, we gathered information systematically to assess quality of current nurse aide training 
and to determine whether improvements need to be made to nurse aide training programs. 
Whenever possible, we met with experts and members of academia to get their perceptions of 
nurse aide training programs. Overall, we met with 29 nursing home supervisors, 14 nurse aide 
trainers, 3 academicians (two of whom are actively involved in the education of nurse aides and 
registered nurses), and 5 experts. Of these respondents, 39 identified themselves as licensed or 
registered nurses. 
Third, we surveyed nurse aides. To elicit the opinions of a large number of nurse aides, we 
mailed ahead surveys and return envelopes for each nurse aide in each nursing home that we 
visited. We sent 2,639 surveys to nurse aides working in the 29 nursing homes that we visited 
and obtained 889 completed surveys. Response rates ranged from  0 to 100 percent 
for each nursing home. 
We analyzed the response rates to see if they differed based on the size of the nursing home 
(small and large) or type of ownership (for-profit and not-for-profit/government), and found no 
significant differences in response rates. Using the SAS statistical software, we conducted a t-
test to test the statistical significance of the difference between response rates from the nursing 
homes based on size and type of ownership.  Appendix C contains demographic information 
7
Nurse Aide Training   OEI-05-01-00030  about the nurse aides who responded to our survey.  Since we did not conduct a random 
sample of nurse aides, any statements regarding the responses we received cannot be 
generalized to the entire population of nurse aides working in nursing homes. 
Overall, we obtained information from nearly 1,000 nurse aides. In addition to the 889 nurse 
aides who completed our written survey, we interviewed 92 nurse aides. We also conducted a 
focus group with17 nurse aides. The focus group occurred in June 2001. Topics of discussion 
included how well the training prepared them for the job, and what content areas needed to be 
better addressed.  We collected information on specific skills that were lacking from their nurse 
aide training, since many years had passed and they had acquired many years of experience at 
nursing homes since their original training. In addition to those areas of nurse aide training that 
they rated as deficient or poor, participants also identified other areas in which they still need 
training, 
We conducted our review in accordance with the Quality Standards for Inspections issued 
by the Presidents Council on Integrity and Efficiency. 
8
Nurse Aide Training   OEI-05-01-00030  F I N D I N G S  
According to an Institute of Medicine report, nurse aide training is an essential element in the 
provision of quality care to nursing home residents.  Nurse aides make up the largest proportion 
of caregiving personnel in nursing homes and provide most of the direct care to residents. 
Nursing homes that participate in Medicare and Medicaid cannot employ anyone as a nurse 
aide for more than four months, unless the individual has completed a State-approved training 
program, passed a competency exam, and received certification by the State in which they are 
employed. 
We examined factors affecting nurse aide training by obtaining data about current State nurse 
aide training requirements from 48 States and the District of Columbia.  We compiled 
responses from nearly 1,000 nurse aides. We interviewed 29 nursing home supervisors, 14 
nurse aide trainers, 5 long-term care ombudsmen, 3 academicians, and 5 experts in the field. 
Overall, we held discussions with 39 licensed or registered nurses from the different respondent 
groups.  Based on this evidence, we found that nurse aide training has not kept pace with 
nursing home industry needs; training hours, clinical exposure, and teaching methods are often 
inadequate; and in-service training may not always meet Federal requirements. 
Nurse aide training has not kept pace with nursing home 
industry needs 
Although approximately 70 percent of State NATCEP directors (33 of 48 who responded to 
our question) said that their States had updated nurse aide training curriculum requirements 
since implementation of OBRA 87, 61 percent (30 of 49 State directors) believe there are still 
training needs that are not being met in their States. All of our respondent groups identified 
areas in which the training did not meet the needs of the current nursing home industry. 
Training does not meet needs of current nursing home residents 
Approximately 90 percent of our respondents (nursing home supervisors, nurse aide trainers, 
State ombudsmen, NATCEP directors, and experts) said that the medical and personal care 
needs of todays nursing home residents have changed since implementation of OBRA 87. 
Recent research on the characteristics of nursing home 
9
Nurse Aide Training   OEI-05-01-00030  residents supports our respondents opinions.17 Shorter hospital stays have resulted in nursing 
homes seeing more residents who are sicker and who require more care. 
In addition, new healthcare settings for the elderly population, including home care and assisted 
living facilities, have delayed entry into nursing homes. Consequently, nursing home residents 
are much older, require more help with their ADLs, and take more medications than nursing 
home residents of 15 years ago. Although the overall nursing home population is older, our 
respondents also report an increase in the number of younger nursing home residents.  Many of 
these younger residents have chronic conditions, such as multiple sclerosis or a traumatic brain 
injury. 
More than half (63 percent) of the nursing home supervisors we interviewed said that training 
has not kept pace with the care demands imposed by current resident diagnoses. Many of 
these supervisors pointed out that they are seeing more combative and violent residents. 
Accordingly, we were told that nurse aides need more training on caring for residents with 
behavioral and cognitive disorders, such as Alzheimers disease.  Six State NATCEP directors 
specifically emphasized the need for more training in this area. 
The need for training related to caring for residents with greater needs was voiced also by nurse 
aides and trainers. Specific skills mentioned by nurse aides include: catheter and colostomy 
care, lifting (e.g. Hoyer lift), skin care, feeding, hydration, infusion therapies, and dealing with 
behavioral problems.  Nurse aide trainers and supervisors point to the need for more 
information on specific diseases, such as diabetes, pneumonia, and cancer. These respondents 
further commented that nurse aides also need knowledge of medical equipment used by 
residents, such as feeding tubes and ventilators. 
Training does not adequately address interpersonal skills 
Nearly half (48 percent) of the nursing home supervisors we interviewed explained that it is not 
only the medical needs, but the psycho-social needs, that are lacking in nurse aide training. This 
involves training on communicating with residents, awareness of the aging process and treating 
residents as people, not just bodies. 
One out of every four nurse aides who responded to our survey reported that there were skill 
areas they used frequently on the job that their initial training did not adequately address.  These 
nurse aides have worked in nursing homes for an average of 3.5 years.  After they began 
working, they realized that training did not prepare them for skills 
17
 Sayhoun NR, Pratt LA, Lentzner H, Dey A, Robinson KN. The Changing Profile of Nursing Home 
Residents: 1985-1997. Aging Trends; No.4. Hyattsville, Maryland: National Center for Health Statistics. 2001. 
10
Nurse Aide Training   OEI-05-01-00030  associated with caring for nursing home residents.  Examples of interpersonal skills that nurse 
aides mentioned as lacking in their initial training include time and stress management, 
teamwork, developing relationships with residents, and coping with death and dying. 
Nationally, nurse aides care for 10-15 residents on a shift. Nurse aides told us they have 
difficulty finding enough time to deliver quality care to all of the residents entrusted to them. 
This problem is exacerbated when one or more nurse aides do not report to work or positions 
remain unfilled. 
Almost seventy percent of nurse aides responding to our survey question on death and dying 
reported experiencing the death of a resident at some time during their work week, and half of 
these reported experiencing a resident death on every shift or almost every shift. The nurse 
aides we spoke with in-person said that they were not prepared for helping residents at the end 
of life, and often felt helpless in reducing their pain and making them comfortable. Nurse aides 
also talked about their own difficulty in dealing with the grief they experienced when a resident 
under their care had passed away.  Based on our conversations with nurse aides, it appears that 
some training programs cover the topic of death and dying in more detail than others.  To 
address this issue, one nursing home that we visited is conducting a demonstration program 
consisting of 45 hours of training in end-of life care. 
Training has not kept pace with nursing home practices and new technologies 
During our discussions with nursing home supervisors, nurse aides, and nurse aide trainers, we 
learned that nurse aide training curriculum and testing may not reflect the current practice in 
nursing homes.  The nursing home supervisors we spoke with mentioned that a lot more 
technology is being used in nursing homes today than a decade ago. These supervisors and the 
experts we spoke with agree that nurse aides need training on newer technologies during their 
initial training.  A 1996 Institute of Medicine report states that medical technologies, such as 
intravenous feedings, ventilators, and oxygen, are now being used extensively in nursing homes. 
Previously, these medical technologies were available only in a hospital setting.  The report 
further noted that these services require more nursing care, judgment, and supervision than in 
the past. 
Nurse aides told us that they were taught outdated practices and how to use outdated 
equipment. They believe that the time spent learning these obsolete skills could be better spent 
on skills needed to care for todays nursing home residents. They specifically mentioned that 
time would be better spent not only on resident care skills but also on communication, 
teamwork, and advances in disease treatment. 
11
Nurse Aide Training   OEI-05-01-00030  While not asked specifically about outdated practices, 2 out of 14 nurse aide trainers expressed 
frustration with outdated curricula and tests. These trainers complained about having to teach 
to the test, instructing nurse aides how to perform obsolete procedures so that trainees can 
pass exams.  An example was a change in a State regulation with respect to the use of side 
rails; however, the change was not reflected in the nurse aide curriculum for that State.  The 
trainers say they teach this procedure twice: once, so that the nurse aide can pass the test, and 
once, to allow nurse aides to adhere to State regulations. 
Teaching methods are often ineffective, clinical exposure is 
too short and unrealistic 
Over half the States require more than 75 hours 
Although Federal law requires that State-approved nurse aide training programs consist of at 
least 75 hours of total instruction, 40 of 49 State NATCEP directors believe that  75 
hours of nurse aide training is not sufficient to prepare nurse aides for their first day on the job. 
Twenty-six States have already extended their nurse aide training programs beyond the 75 
hours required by Federal law. These State nurse aide training programs that were extended 
run from 76 hours to 175 hours (see Appendix D). 
Of the States that have minimum 75-hour programs, two-thirds of our State respondents 
believe that the number of training hours in their State is too low.  These respondents report 
having difficulty justifying more hours to their State legislature when the Federal requirement is 
only 75 hours. Some of these respondents argue that nurse aides have to care for terribly 
debilitated people and require classroom instruction in many topics and resident care skills that 
may not be adequately addressed within 75 hours.  As one NATCEP director said, I believe it 
is unreasonable to expect students to assimilate all the material in 75 hours. 
Respondents seek improved clinical experience 
When asked how nurse aide training programs could be improved, the overwhelming response 
provided by our respondent groups was that nurse aides needed more and better clinical 
exposure. Nursing home supervisors (18 of 29) reported that nurse aides were not ready to 
begin work on the nursing home floor upon completion of nurse aide training, and needed more 
clinical exposure. In addition, 10 of 17 supervisors who hire nurse aides from community 
colleges and other non-facility based training sites said that these nurse aides were not 
adequately prepared for their first day on the job.  We were 
12
Nurse Aide Training   OEI-05-01-00030  told that this may be due, in part, to difficulties that some private programs have in arranging 
clinical training at nursing homes. 
Nurse aides themselves reported dissatisfaction with their clinical experience during training. 
Fifty percent of nurse aide survey respondents, who reported not being satisfied with their 
clinical training, cited not enough time on the floor, a lack of hands on training and unrealistic 
training scenarios.  During our in-person interviews with nurse aides and in the focus group, 
nurse aides frequently told us that they needed to experience, or at least witness, real-life 
scenarios during clinical training so that they would not be surprised or alarmed when something 
(such as a combative resident striking out at them) occurred on the job. 
Nurse aide training programs often do not expose students to the full range of resident care 
demands that they will experience in a nursing home environment. One nurse aide student told 
us that he was alarmed and felt unprepared when he had to change a resident after they had 
soiled themselves. We were repeatedly told that training focuses on acquiring skills needed to 
pass the State exam.  Other skills needed for the job may receive only limited coverage during 
their initial training. 
Nurse aides also told us about ineffective teaching methods they encountered during their 
training.  Participants in our focus group of 17 nurse aides told us that watching videos during 
training did not give them a realistic picture of the job.  Once they started working, they realized 
there were far more demands than the videos portrayed.  They described the videos as 
sugarcoated and unrealistic, often depicting a nurse aide grooming a resident.  These 
nurse aides reported having a difficult time once they started a job, and realized what a full 
days work entails. 
Early clinical exposure prepares and screens students 
Nearly all (26 of 29) nursing home supervisors stressed the importance of clinical training, and 
three supervisors specifically mentioned that an earlier introduction to the nursing home floor (or 
clinical skills) would greatly improve the preparedness of nurse aides.  Nursing home 
supervisors believe that early exposure to resident care will help to screen out those nurse aide 
students who cannot handle the real-life stressful situations demanded by the job. 
Federal and State funds are wasted by the large numbers of students who are trained each year 
and drop out when exposed to the realities of the nurse aide job. Of the nursing homes we 
visited for this study, 12 conducted onsite training programs.  The completion rates from their 
most recent nurse aide training class ranged from 20 to 100 percent.  Four nursing homes 
reported that more than 70 percent of the students in their training 
13
Nurse Aide Training   OEI-05-01-00030  programs dropped out when exposed to the actual realities of caring for a nursing home 
resident.  Three nursing homes reported that in earlier nurse aide training classes, no student 
completed the training course. It appears that early, realistic exposure to the job requirements 
helps to weed out nurse aide students, who may not be the most appropriate job candidates. 
Respondents cite ineffective teaching methods and formats 
We heard complaints about large classrooms and limited or no exposure to the actual job 
requirements.  Respondents felt that the following teaching methods and formats impeded nurse 
aide training: 
<  poor instructional videotapes and presentations 
<  too much medical technology jargon 
<  classes taught over the heads of students 
<  failure to recognize diversity or backgrounds of students, including language barriers 
<  emphasis on tasks, rather than interpersonal communication skills 
<  teaching skills that will not be used often 
<  lack of feedback on the quality of the program 
<  training which lacks geriatric framework 
<  one-size-fits-all approaches to teaching 
<  limited time to practice clinical skills 
The teaching of nurse aides varies by site.  The actual instructor of the program may not be the 
person listed on the application to the State, and this person may not have any experience in 
adult education.  While all States report that they periodically visit training sites, few reported 
that they do so to assess the quality of instruction.  Only five States report that they make some 
effort to evaluate instructor or training effectiveness. 
In our discussions with nurse aides during our on-site visits, nurse aides said that they preferred 
instructors who included personal examples or anecdotes from their past nursing home jobs. 
Instructors who were willing to be candid, and those who did not mince unpleasant details were 
among those considered to be the most helpful. 
14
Nurse Aide Training   OEI-05-01-00030  In-service training may not be meeting Federal requirements 
We had difficulty determining whether nursing homes are meeting the Federal requirement that 
in-service training address areas of weakness for individual nurse aides.  Federal in-service 
training regulations18 do not define how in-service training should be documented. Our review 
of in-service training at 29 nursing homes disclosed that training log documentation was not 
consistent across nursing homes. Only 8 of the 29 nursing homes we visited had documentation 
about why in-service sessions were held.  We also learned that nursing homes sometimes 
conduct informal one-on-one or unit-specific training to immediately address any skill 
deficiencies, but this information was not regularly recorded in the in-service logs we reviewed. 
When we spoke with nurse aides in a focus group setting, we learned that in-service is not 
always looked upon favorably. During an in-depth discussion on the subject, almost half of the 
participants believed that in-service education sessions were not very helpful. They reported 
that in-service sessions were often repetitious and sometimes not relevant to everyday work 
situations.  Furthermore, aides stated that in-service training occasionally consisted of reading 
and signing a bulletin board on a training topic (whether or not the information was understood), 
rather than absorbing the material through class participation. 
Long-term care ombudsmen and experts we spoke with also expressed concerns about 
in-service education. They reported that nursing home supervisors tend to view in-service 
sessions as cutting into resident care, and that nurse aides or nursing home staff do not view the 
classes as a way to improve their skills.  Often, nurse aides are not covered on the floor when 
they attend in-service sessions, so they are thinking about the work waiting for them when they 
get back to the floor, rather than concentrating on the class material. Ombudsmen also stated 
that insufficient time is devoted to in-service training, which reduces its effectiveness. 
Respondents offered suggestions for improving in-service training 
Nursing homes we visited highlighted the various methods they employ to improve in-service 
training for nurse aides: 
<	 Using educational tools, such as realistic videos, workbooks, interactive computer 
programs, and games. 
18
 42 CFR 483.75 
15
Nurse Aide Training   OEI-05-01-00030  <	 Having a system for documenting individual nurse aide training needs that indicates a 
problem area, and outlines the intervention taken to remedy the problem.  This system 
is used when making decisions about in-service training needs. 
<  Providing crisis intervention training to help nurse aides deal with the emotional aspects 
of the job. 
<  Having nurse aides participate in pharmaceutical in-service training to understand 
behavior changes and side effects of drugs. 
<	 Involving other nursing home staff and healthcare professionals in in-service education. 
For example, using the social service director to talk about residents psycho-social 
needs, or having the long-term care ombudsman come in to talk about residents rights. 
<	 Having nurse aides involved in the planning and presentation of the in-service sessions 
(peer teaching). 
<	 Having family members come and talk to aides about their concerns regarding care of 
their relatives, and having nurse aides interact with families to help improve 
communication. 
<	 Holding short in-service training every week (usually 15-30 minutes in length) or 
holding impromptu in-service training for specific units and for specific staff. 
<  Offering in-service training on all shifts to accommodate nurse aide schedules. 
Nurse aides play an important role in the overall resident care team because they have the most 
interaction with the residents.  Nursing homes differ as to the amount of resources they have to 
invest in in-service training, and not every home has the capacity to implement these best 
practices. Nevertheless, the nursing home supervisors and trainers we spoke with highlighted 
the above practices as creating positive changes for nurse aides working in their homes, and 
they thought other nursing homes might benefit from exploring similar practices for their staff. 
16
Nurse Aide Training   OEI-05-01-00030  C O N C L U S I O N   A N D  
R E C O M M E N D A T I O N  
Responses from 29 nursing home supervisors, 14 nurse aide trainers, 5 long-term care 
ombudsmen, 3 academicians, and 5 experts (39 of all these respondents were licensed or 
registered nurses) show that the nurse aide training curriculum needs to be updated, and clinical 
experience needs to occur earlier and needs to be more realistic.  Responses from nearly 1,000 
nurse aides and 48 State directors of nurse aide training programs also indicate that nurse aide 
training programs need improvement. Although the nursing home environment has changed 
considerably since OBRA 87 nurse aide training regulations were implemented, nurse aide 
training has not kept pace with nursing home resident needs. 
We are recommending that CMS: 
Improve nurse aide training and competency evaluation 
program requirements 
	 Ensure that the content of the nurse aide training curriculum and testing (as described in 
42 CFR Part 483) remains relevant to todays complex resident care needs. 
Strengthen nurse aide training by recognizing current nurse aide needs, and by 
embracing modern technologies and equipment. Consider enhancing the 
communication and interpersonal skills of nurse aides (i.e., by including training in time 
management and teamwork). 
	 Continue to work with States to assure that nurse aide training is effective and efficient. 
This collaborative effort could include (but not be limited to) increasing the ratio of 
clinical hours and ensuring that clinical experience occurs earlier in the training period, is 
more realistic, and includes a full range of skills needed on the job. 
	 Ensure that nursing homes are in compliance with in-service training requirements. 
Revise 42 CFR 483.75 to include a requirement for nursing homes to document that 
in-service training is conducted to address weaknesses identified in nurse aides 
performance reviews. 
17
Nurse Aide Training   OEI-05-01-00030  A G E N C Y   C O M M E N T S  
The draft of this report was reviewed by CMS, and the agency concurred with our 
recommendations.  In concurring with our recommendations, CMS stated that the agencys own 
independent study reached essentially the same conclusions as found in our study. The CMS 
reports that the agency has a contract in place to examine nurse aide training curriculum, content, 
and skills. The CMS also intends to develop specific policy and programmatic options for 
improving the administration of nurse aide training programs and for ensuring that nursing home 
in-service training complies with regulatory requirements. 
Some grammatical and technical changes were also made to this report following receipt of 
CMSs comments.  The full text of CMSs comments can be found in Appendix A. 
18
Nurse Aide Training   OEI-05-01-00030  APPENDIX A 
Centers for Medicare & Medicaid Services 
Comments on the Draft Report 
19
Nurse Aide Training   OEI-05-01-00030  20
Nurse Aide Training   OEI-05-01-00030  21
Nurse Aide Training   OEI-05-01-00030  APPENDIX B 
Characteristics of Participating Nursing Homes 
The tables on the following pages provide descriptive information about the nursing homes in the five 
States that we visited during this inspection. The information was obtained using the Online Survey, 
Certification, and Reporting System (OSCAR), except where noted. The deficiency information was 
obtained from the results of each nursing homes most recent survey, as reported in the OSCAR 
database. 
Table 1--Florida Nursing Homes In Our Sample 
Nursing Home Characteristics  FL1  FL2  FL3  FL4  FL5  FL6 
Approximate Number of Nurse  12  28  71  79  30  134 
Aides19 
Nurse Aide Survey Response  83%  54%  87%  84%  0%  7% 
Rate  (n=10)  (n=15)  (n=62)  (n=66)  (n=0)  (n=10) 
In-House Training Program  No  Yes  No*  No*  No  No* 
Total Number of Certified Beds  29  80  179  153  76  212 
Total Number of Residents20  29  74  162  165  57  209 
Type of Ownership  NFP- FP- NFP- FP- NFP- NFP-
Corp  Corp  Corp  Corp  Corp  Corp 
Located Within a Hospital  Yes  No  No  No  No  No 
Overall Deficiencies  3  4  10  4  9  18 
Health Deficiencies  2  3  5  4  8  13 
Date of Most Recent Survey  9/26/01  7/19/01  12/15/00  6/22/01  7/3/01  6/14/01 
* These nursing homes have a local technical college provide training, but the classes and clinical trainings are 
conducted at the nursing home. 
19 
This information was provided to us by the nursing homes we visited. 
20 
This number reflects the resident census on the date of the nursing homes most recent survey. 
22
Nurse Aide Training   OEI-05-01-00030 Table 2--Louisiana Nursing Homes In Our Sample 
Nursing Home Characteristics  LA1  LA2  LA3  LA4  LA5  LA6 
Approximate Number of Nurse  53  125  20  61  36  14 
Aides21 
Nurse Aide Survey Response Rate  23%  38%  35%  20%  67%  100% 
(n=12)  (n=48)  (n=7)  (n=12)  (n=24)  (n=14) 
In-House Training Program  No  No  Yes  Yes  No  No 
Total Number of Certified Beds  117  200  171  120  64  66 
Total Number of Residents22  110  172  171  118  63  32 
Type of Ownership  NFP- NFP- NFP- FP- NFP- FP-
Church  Church  Corp  Corp  Other  Corp 
Related  Related 
Located Within a Hospital  No  No  No  No  No  Yes 
Overall Deficiencies  5  9  9  19  15  1 
Health Deficiencies  0  1  0  16  12  0 
Date of Most Recent Survey  1/18/01  2/1/01  9/14/01  2/9/01  4/25/01  9/13/01 
21 
This information was provided to us by the nursing homes we visited. When they did not provide this 
information, we used the number of nurse aide surveys sent to the nursing home. 
22 
This number reflects the resident census on the date of the nursing homes most recent survey. 
23
Nurse Aide Training   OEI-05-01-00030  Table 3--Minnesota Nursing Homes In Our Sample 
Nursing Home Characteristics  MN1  MN2  MN3  MN4  MN5  MN6 
Approximate Number of Nurse  85  197  50  24  93  54 
Aides23 
Nurse Aide Survey Response  85%  62%  24%  25%  43%  61% 
Rate  (n=72)  (n=123)  (n=12)  (n=6)  (n=40)  (n=33) 
In-House Training Program  No  Yes  No  No  No  Yes 
Total Number of Certified Beds  303  559  93  54  200  134 
Total Number of Residents24  301  555  75  52  193  126 
Type of Ownership  NFP- NFP- FP- FP- FP- FP-
Church  Corp  Corp  Corp  Corp  Individual 
Related 
Located Within a Hospital  No  No  No  No  No  No 
Overall Deficiencies  1  0  7  4  5  0 
Health Deficiencies  1  0  7  4  5  0 
Date of Most Recent Survey  6/8/01  2/1/01  2/2/01  4/2/01  3/1/01  2/15/01 
23
 This information was provided to us by the nursing homes we visited. When they did not provide this 
information, we used the number of nurse aide surveys sent to the nursing home. 
24 
This number reflects the resident census on the date of the nursing homes most recent survey. 
24
Nurse Aide Training   OEI-05-01-00030  Table 4--New York Nursing Homes In Our Sample 
Nursing Home Characteristics  NY1  NY2  NY3  NY4  NY5 
Approximate Number of Nurse Aides25  228  230  77  111  346 
Nurse Aide Survey Response Rate  20%  1%  21%  55%  31% 
(n=46)  (n=2)  (n=16)  (n=61)  (n=106) 
In-House Training Program  Yes  No  Yes  Yes  Yes 
Total Number of Certified Beds  561  1389  81  262  705 
Total Number of Residents26  523  1366  82  256  686 
Type of Ownership  FP- Govt- NFP- NFP- NFP-
Individual  City/  Corp  Corp  Corp 
County 
Located Within a Hospital  No  Yes  No  No  No 
Overall Deficiencies  2  10  5  6  2 
Health Deficiencies  1  2  3  3  1 
Date of Most Recent Survey  5/5/00  1/31/00  7/17/01  8/15/01  1/24/01 
25 
This information was provided to us by the nursing homes we visited. When they did not provide this 
information, we used the number of nurse aide surveys sent to the nursing home. 
26 
This number reflects the resident census on the date of the nursing homes most recent survey. 
25
Nurse Aide Training   OEI-05-01-00030  Table 5--Washington Nursing Homes In Our Survey 
Nursing Home  WA1  WA2  WA3  WA4  WA5  WA6 
Characteristics 
Approximate Number of  85  24  37  73  102  160 
Nurse Aides27 
Nurse Aide Survey  22%  36%  51%  5%  0%  22% 
Response Rate  (n=19)  (n=15)  (n=19)  (n=4)  (n=0)  (n=35) 
In-House Training Program  No  Yes  No  No  No  Yes 
Total Number of Certified  22  117  129  135  190  215 
Beds 
Total Number of  144  70  94  124  168  200 
Residents28 
Type of Ownership  NFP- FP- FP- FP- FP- NFP-
Other  Corp  Partnership  Corp  Corp  Church 
Related 
Located Within a Hospital  No  No  No  No  No  No 
Overall Deficiencies  17  15  10  29  14  14 
Health Deficiencies  14  12  10  24  14  6 
Date of Most Recent  10/16/00  5/24/01  5/21/01  8/31/01  4/24/01  11/21/00 
Survey 
27 
This information was provided to us by the nursing homes we visited. When they did not provide this 
information, we used the number of nurse aide surveys sent to the nursing home. 
28 
This number reflects the resident census on the date of the nursing homes most recent survey. 
26
Nurse Aide Training   OEI-05-01-00030  APPENDIX C 
Demographics of Nurse Aide Respondents 
The following demographic information characterizes the nurse aides who responded to our 
survey. 
Characteristic  Data Point  Number of 
Respondents 
Age (mean)  36  793 
Gender  84% female  859 
High school graduation or  92%  820 
greater 
Hourly wage (mean)  $10.33  751 
Minorities  65%  775 
Household income of $15,000  32%  631 
or less 
Working as a nurse aide for 3  70%  868 
years or more 
27
Nurse Aide Training   OEI-05-01-00030  APPENDIX D 
Hours of Training by State

State  Minimum Training Hours  Minimum Clinical Hours 
(Total) 
Alaska  140  80 
Alabama  75  16 
Arkansas  75  16 
Arizona  120  16 
California  150  100 
Colorado  75  16 
Connecticut  100  50 
District of Columbia  120  not specified 
Delaware  75  37.5 
Florida  120  40 
Georgia  85  16 
Hawaii  did not respond to survey  did not respond to survey 
Iowa  75  30 
Idaho  120  40 
Illinois  120  40 
Indiana  105  75 
Kansas  90  45 
Kentucky  75  16 
Louisiana  80  40 
Massachusetts  did not respond to survey  did not respond to survey 
28
Nurse Aide Training   OEI-05-01-00030  APPENDIX D 
Hours of Training by State

State  Minimum Training Hours  Minimum Clinical Hours 
(Total) 
Maryland  100  40 
Maine  150  50 
Michigan  75  16 
Minnesota  75  37.5 
Missouri  175  100 
Mississippi  75  16 
Montana  75  25-30 
North Carolina  75  16 
North Dakota  75  16 
Nebraska  76  not specified 
New Hampshire  100  60 
New Jersey  90  40 
New Mexico  75  not specified 
Nevada  75  not specified 
New York  100  30 
Ohio  75  16 
Oklahoma  75  16 
Oregon  150  75 
Pennsylvania  75  37.5 
29
Nurse Aide Training   OEI-05-01-00030  APPENDIX D 
Hours of Training by State

State  Minimum Training Hours  Minimum Clinical Hours 
(Total) 
Rhode Island  100  20 
South Carolina  80  40 
South Dakota  75  16 
Tennessee  75  35 
Texas  75  24 
Utah  80  16 
Virginia  120  40 
Vermont  75  16 
Washington  85  50 
Wisconsin  75  16 
West Virginia  120  55 
Wyoming  75  48 
30
Nurse Aide Training   OEI-05-01-00030  A C K N O W L E D G M E N T S  
This report was prepared under the direction of William C. Moran, Regional Inspector General for Evaluation and 
Inspections in Chicago, Brian T. Pattison, Regional Inspector General for Evaluation and Inspections in Kansas City, 
and Natalie Coen, Deputy Regional Inspector General in Chicago. Other principal Office of Evaluation and 
Inspections staff who contributed include: 
John Traczyk, Project Leader  Stuart Wright, Director, Medicare and 
Dennis Tharp, Lead Analyst  Medicaid Branch 
Tricia Fields, Program Analyst  Sandy Khoury, Program Specialist 
Erin Guay, Program Analyst  Bambi Straw, Program Specialist

Barbara Tedesco, Mathematical Statistician

To obtain copies of this report, please call the Chicago Regional Office at (312) 353-9867. 
Reports are also available on the World Wide Web at our home page address: 
http://oig.hhs.gov 
31
Nurse Aide Training   OEI-05-01-00030