Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANET REHNQUIST 

Inspector General 

NOVEMBER 2002 

OEI-05-01-00030 

Nurse Aide Training 
OFFICE OF INSPECTOR GENERAL

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 OIG’s 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. 
EXECUTIVE SUMMARY 

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 today’s nursing home residents have 

Nurse Aide Training i 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, today’s 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 

Nurse Aide Training ii 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 today’s 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 inservice 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 agency’s 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. 

Nurse Aide Training iii OEI-05-01-00030 
TABLE OF CONTENTS 

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
INTRODUCTION 

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 aide’s primary duty is 

direct care, they are often the first to identify changes in a resident’s 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 resident’s 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) 

Nurse Aide Training 1 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 resident’s 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 resident’s behavior; 

raising awareness of developmental tasks associated with the aging process; allowing 

the resident to make personal choices; and using the resident’s 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 resident’s right to 

be free from abuse, mistreatment, and neglect, 

2 OEI-05-01-00031 

Nurse Aide Training 2 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 skillsdemonstration 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 

Nurse Aide Training 3 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 State’s 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 

Nurse Aide Training 4 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. 

Nurse Aide Training 5 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 

Nurse Aide Training 6 OEI-05-01-00030 
State and the State’s 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 onsite 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 ttest 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 

Nurse Aide Training 7 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 President’s Council on Integrity and Efficiency. 

Nurse Aide Training 8 OEI-05-01-00030 
FINDINGS 

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 today’s nursing home residents have changed since implementation of OBRA 87. 

Recent research on the characteristics of nursing home 

Nurse Aide Training 9 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 Alzheimer’s 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. 

Nurse Aide Training 10 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 today’s 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. 

Nurse Aide Training 11 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 

Nurse Aide Training 12 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 

day’s 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 

Nurse Aide Training 13 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. 

Nurse Aide Training 14 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 

Nurse Aide Training 15 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 resident’s 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. 

Nurse Aide Training 16 OEI-05-01-00030 
CONCLUSION 

RECOMMENDATION 

AND 

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 today’s 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. 

Nurse Aide Training 17 OEI-05-01-00030 
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 agency’s 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 

CMS’s comments. The full text of CMS’s comments can be found in Appendix A. 

Nurse Aide Training 18 OEI-05-01-00030 
APPENDIX A 

Centers for Medicare & Medicaid Services 

Comments on the Draft Report 

Nurse Aide Training 19 OEI-05-01-00030 
Nurse Aide Training 20 OEI-05-01-00030 
Nurse Aide Training 21 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 home’s 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 

Aides19 

12 28 71 79 30 134 

Nurse Aide Survey Response 

Rate 

83% 

(n=10) 

54% 

(n=15) 

87% 

(n=62) 

84% 

(n=66) 

0% 

(n=0) 

7% 

(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 NFPCorp FPCorp NFPCorp FPCorp NFPCorp NFPCorp 

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. 

Nurse Aide Training 22 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 

Aides21 

53 125 20 61 36 14 

Nurse Aide Survey Response Rate 23% 

(n=12) 

38% 

(n=48) 

35% 

(n=7) 

20% 

(n=12) 

67% 

(n=24) 

100% 

(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 NFPChurch 

Related 

NFPChurch 

Related 

NFPCorp FPCorp NFPOther FPCorp 

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. 

Nurse Aide Training 23 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 

Aides23 

85 197 50 24 93 54 

Nurse Aide Survey Response 

Rate 

85% 

(n=72) 

62% 

(n=123) 

24% 

(n=12) 

25% 

(n=6) 

43% 

(n=40) 

61% 

(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 NFPChurch 

Related 

NFPCorp FPCorp FPCorp FPCorp FPIndividual 

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. 

Nurse Aide Training 24 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% 

(n=46) 

1% 

(n=2) 

21% 

(n=16) 

55% 

(n=61) 

31% 

(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 FPIndividual GovtCity/ 

County 

NFPCorp NFPCorp NFPCorp 

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. 

Nurse Aide Training 25 OEI-05-01-00030 
Table 5--Washington Nursing Homes In Our Survey 

Nursing Home 

Characteristics 

WA1 WA2 WA3 WA4 WA5 WA6 

Approximate Number of 

Nurse Aides27 

85 24 37 73 102 160 

Nurse Aide Survey 

Response Rate 

22% 

(n=19) 

36% 

(n=15) 

51% 

(n=19) 

5% 

(n=4) 

0% 

(n=0) 

22% 

(n=35) 

In-House Training Program No Yes No No No Yes 

Total Number of Certified 

Beds 

22 117 129 135 190 215 

Total Number of 

Residents28 

144 70 94 124 168 200 

Type of Ownership NFPOther FPCorp FPPartnership FPCorp FPCorp NFPChurch 

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 

Survey 

10/16/00 5/24/01 5/21/01 8/31/01 4/24/01 11/21/00 

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. 

Nurse Aide Training 26 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 

greater 

92% 820 

Hourly wage (mean) $10.33 751 

Minorities 65% 775 

Household income of $15,000 

or less 

32% 631 

Working as a nurse aide for 3 

years or more 

70% 868 

Nurse Aide Training 27 OEI-05-01-00030 
APPENDIX D 

Hours of Training by State

State Minimum Training Hours 

(Total) 

Minimum Clinical Hours 

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 

Nurse Aide Training 28 OEI-05-01-00030 
APPENDIX D 

Hours of Training by State

State Minimum Training Hours 

(Total) 

Minimum Clinical Hours 

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 

Nurse Aide Training 29 OEI-05-01-00030 
APPENDIX D 

Hours of Training by State

State Minimum Training Hours 

(Total) 

Minimum Clinical Hours 

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 

Nurse Aide Training 30 OEI-05-01-00030 
ACKNOWLEDGMENTS 

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 

Dennis Tharp, Lead Analyst 

Tricia Fields, Program Analyst 

Erin Guay, Program Analyst 

Stuart Wright, Director, Medicare and 

Medicaid Branch 

Sandy Khoury, Program Specialist 

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 

Nurse Aide Training 31 OEI-05-01-00030