Fill - Free fillable Doug Ducey Joey Ridenour (Arizona State Board of Nursing) PDF form

Doug Ducey Joey Ridenour

Governor Executive Director

State: Zip:

Skills Lab

(Minimum 15)

__________

Arizona State Board of Nursing

MEDICATION ASSISTANT (MA) TRAINING PROGRAM

APPLICATION FOR APPROVAL

PROGRAM INFORMATION

Address:

City:

§32-1650.01.A.

The board shall approve medication assistant training programs pursuant to this section and rules adopted by the board. An entity that applies for approval of a medication assistant training

program must be either: 1. A postsecondary education institution in this state that is accredited by an accrediting agency recognized by the United States department of education. 2. A

postsecondary school that is licensed by the state board for private postsecondary education. 3. A long-term care facility that is licensed by the department of health services.

CNA Program:

Yes No

Program Code:

Name of MA Training School:

Number of Students (Total for previous 2 years)

(Re-Approvals)

Website:

Telephone #:

Fax #:

Mailing Address:

City:

Type of Entity:

R4-19-803(C)(1)

1. A medication assistant training program shall ensure each graduate received a minimum of 100 hours of total instruction

consisting of: a. Instructor-led didactic instruction for a minimum of 45 hours; b. Instructor supervised skill practice and testing for a minimum of 15 hours; c. Instructor supervised

medication administration for a minimum of 40 hours in a long-term care facility licensed by the Department of Health Services.

Minimum 100-Hour Program Divided Between Didactic, Skill Lab & Clinical

Instructor Supervised Clinical

(Minimum of 40)

________

Didactic

(Minimum 45)

___________

Total Hours

(Minimum 100)

____________

STUDENT DATA

Graduated

Enrolled

ENITY

HOURS

Telephone:

Email:

Possess at least two years or 3,000 hours of direct care nursing experience

YES NO

Have administered medications to residents of a long-term care facility for a minimum of 40 hours.

YES NO

Possess at least two years or 3,000 hours of direct care nursing experience

YES NO

Have administered medications to residents of a long-term care facility for a minimum of 40 hours.

YES NO

Possess at least two years or 3,000 hours of direct care nursing experience

YES NO

Have administered medications to residents of a long-term care facility for a minimum of 40 hours.

YES NO

Possess at least two years or 3,000 hours of direct care nursing experience

YES NO

Have administered medications to residents of a long-term care facility for a minimum of 40 hours.

YES NO

Possess at least two years or 3,000 hours of direct care nursing experience

YES NO

Have administered medications to residents of a long-term care facility for a minimum of 40 hours.

YES NO

Possess at least two years or 3,000 hours of direct care nursing experience

YES NO

Have administered medications to residents of a long-term care facility for a minimum of 40 hours.

YES NO

Possess at least two years or 3,000 hours of direct care nursing experience

YES NO

Have administered medications to residents of a long-term care facility for a minimum of 40 hours.

YES NO

R4-19-803(B)(1)

B. Instructor qualifications and duties

1. A medication assistant program instructor shall: a. Hold a current, registered nurse license that is active and in good standing or multistate privilege to practice as an RN under A.R.S. Title

32, Chapter 15; b. Possess at least two years or 3,000 hours of direct care nursing experience; and c. Have administered medications to residents of a long-term care facility for a minimum

of 40 hours.

Please provide the following information for each instructor.

PROGRAM PERSONNEL

ADMINISTRATOR - OWNER

Telephone:

Email:

Telephone:

Email:

RN License #:

Name (as it appears on license):

RN License #:

Telephone:

Name (as it appears on license):

Telephone:

USE ADDITIONAL PAGES AS NEEDED

Email:

Name (as it appears on license):

RN License #:

Telephone:

Email:

RN License #:

INSTRUCTORS

Name:

Name (as it appears on license):

RN License #:

Telephone:

Email:

NEW PROGRAMS MUST FILL OUT AN INSTRUCTOR CHANGE FORM (with resume attached) FOR EACH PERSON LISTED BELOW.

RENEWING PROGRAMS

ONLY NEED TO FILL OUT THE SECTION BELOW

(please add additional pages as needed)

Name (as it appears on license):

RN License #:

Telephone:

Email:

Name (as it appears on license):

State:

Medicare Certification Status:

State:

Medicare Certification Status:

State:

Medicare Certification Status:

State:

Program Administrator Name (Print) Program Administrator Signature

CLINICAL AGENCIES

Copies of cooperating agency agreements must be included in your application and remain on file with the Arizona State Board of

Nursing. (Non-Facility Programs Only)

City:

Name of long-term care facility that is licensed by the department of health services:

I hereby certify that I have read this application and further certify that the information provided is true and

correct. I also certify that I have read current rules (R4-19-801 and R4-19-803) and understand the requirements

and responsibilities of the medication assistant training program, and the qualifications and responsibilities of the

medication assistant training program instructor.

Facility Address:

Medicare Certification Status:

Zipcode:

USE ADDITIONAL PAGES AS NEEDED

Zipcode:

Telephone:

Name of Contact Person:

Name of long-term care facility that is licensed by the department of health services:

Facility Address:

City:

Zipcode:

Name of long-term care facility that is licensed by the department of health services:

Facility Address:

City:

Zipcode:

Name of Contact Person:

Telephone:

Name of Contact Person:

Name of long-term care facility that is licensed by the department of health services:

Facility Address:

City:

Name of Contact Person:

Doug Ducey Joey Ridenour

Governor Executive Director

Location in Packet

(Page# ONLY)

R4-19-801(B)(1) A training program shall promulgate and enforce written policies and procedures that comply with state and federal

requirements, and are consistent with the policies and procedures of the parent institution, if any. The program shall provide effective and review

dates for each policy or procedure.

R4-19-801(B)(2) A training program shall provide a copy of its policies and procedures to each student on or before the first day the student

begins the program.

Fees and Financial Aid Policy

Effective and Review Dates on Policy

Rule Citation

R4-19-801(A)(5)

a. Make all program costs readily accessible on the school’s website with effective dates,

b. Publically post any increases in costs on the school’s website 30 days in advance of

the increase; c. Include in the cost calculation and public posting, all fees directly paid to

the program including but not limited to tuition, lab fee, clinical fee, enrollment fee,

insurance, books, uniform, health screening, credit card fee and state competency exam

fee; and d. Provide a description of all program costs to the student that are not directly

paid to the program.

R4-19-801(A)(6)

Before collecting any tuition or fees from a student, a training program shall notify each

prospective student of Board requirements for certification including legal presence in

the United States, criminal background check requirements, and ineligibility for

certification under A.R.S. § 32-1606 (B) (17).

Notification of Board Requirements

Effective and Review Dates on Policy

R4-19-801(B)(3)

Admission requirements including: i. Criminal background, health and drug screening

either required by the program or necessary to place a student in a clinical agency; and ii.

English language, reading and math skills necessary to comprehend course materials and

perform duties safely.

Admission Requirements Policy

Effective and Review Dates on Policy

Arizona State Board of Nursing

MEDICATION ASSISTANT (MA) TRAINING PROGRAM

APPLICATION CHECKLIST

R4-19-804(A) Initial Approvals of Training Programs

An applicant for initial training program approval shall submit an application packet to the Board at least

90 days before the expected starting

date of the program. An applicant shall submit application documents that are unbound, typed or word processed, single-sided, and on white,

letter-size paper plus one electronic copy of the entire packet. The Board does not accept notebooks, spiral bound documents, manuals or books.

R4-19-804(D)(1) Re-Approvals of Training Programs

A training program applying for re-approval shall submit a paper

and electronic application with accompanying materials to the Board before

expiration* of the current approval. The applicant program shall ensure that all documents submitted are unbound, typed or word processed,

single-sided, and on white, letter-size paper. The Board does not accept notebooks, spiral bound documents, manuals or books. A program or

site of a consolidated program that did not hold any classes in the previous approval period is not eligible for renewal of approval.

*R4-19-804(B)

The Board may impose disciplinary action including denial on any training program that has advertised, conducted classes, recruited or

collected money from potential students before receiving Board approval or after expiration of approval except for completing instruction to

students who enrolled before the expiration date.

Document

1. POLICIES

Code:

Program Name:

Location in Packet

(Page# ONLY)

R4-19-801(B)(3)(c)

A final examination policy that includes the following provisions; i. Require that its

students score a minimum 75% correct answers on a comprehensive secure final

examination with no more than one re-take. The program may allow an additional re-take

following documented, focused remediation based on past test performance. Any re-take

examination must contain different items than the failed exam, address all course

competencies, and be documented with score, date administered and proctor in the

student record.

Final Exam Policy

Effective and Review Dates on Policy

R4-19-801(B)(3)(c)(ii)

ii. Require that each student demonstrate, to program faculty, satisfactory performance

of each practical skill as prescribed in the curriculum before performance of that skill on

patients or residents without the instructor’s presence, direct observation, and

supervision.

R4-19-801(C)(8)(e)

Require satisfactory performance of all critical elements of each skill under R4-19-802

(H) for nursing assistant and R4-19-803(D)(4) for medication assistant before allowing a

student to perform the skill on a patient or resident without the instructor’s presence at

the bedside.

R4-19-802(H)

Skills: A nursing assistant instructor shall verify and document that the following skills

are satisfactorily performed by each student before allowing the student to perform the

skill on a patient or resident without the instructor present: 1. Hand hygiene, gloving and

gowning; and 2. Skills in subsection (F)(7), (8) and (11)(a), (c), (d), (f), and (g).

Skill Exam Policy

Effective and Review Dates on Policy

1. POLICIES cont.

Skill Exam Checklist

R4-19-801(B)(3)(d)

Student record maintenance policies consistent with subsection (D) including the

retention period, the location of records and the procedure for students to access to their

records.

R4-19-801(D)

A training program shall maintain the following program records either electronically or

in paper form for a minimum of three years for CNA programs and five years for CMA

programs: a. Curriculum and course schedule for each admission cohort; b. Results of

state-approved written and manual skills testing; c. Documentation of program

evaluation under subsection (A)(10); d. A copy of any Board reports, applications, or

correspondence, related to the program; and e. A copy of all clinical contracts, if using

outside clinical agencies.

2. A training program shall maintain the following student records either electronically

or in paper form for a minimum of three years for CNA programs and five years for

CMA programs: a. A record of each student's legal name, date of birth, address,

telephone number, e-mail address and Social Security number, if available; b. A

completed skill checklist containing documentation of student level of competency

performing the skills in R4-19-802(F) for nursing assistant, and in R4-19-803 (D)(4) for

medication assistants; c. An accurate attendance record, which describes any make-up

class sessions and reflects whether the student completed the required number of hours

in the course; and d. Scores for each test, quiz, or exam and whether such test, quiz, or

exam was retaken.

Student Record Maintenance Policy

Effective and Review Dates on Policy

R4-19-801(B)(3)(f)

Student conduct policies for expected and unacceptable conduct in both classroom and

clinical settings.

Student Conduct Policy

Effective and Review Dates on Policy

Rule Citation

Document

R4-19-801(B)(3)(b)

Student attendance policy, ensuring that a student receives the hours and types of

instruction as reported to the Board in the program’s most recent application to the

Board and as required in this Article. If absences are permitted, the program shall ensure

that each absence is remediated by providing and requiring the student to complete

learning activities that are equivalent to the missed curriculum topics, clinical experience

or skill both in substance and in classroom or clinical time.

Attendance Policy

Effective and Review Dates on Policy

Location in Packet

(Page# ONLY)

Location in Packet

(Page# ONLY)

2. Misc. Program Requirements

1. POLICIES cont.

Rule Citation

Document

R4-19-801(B)(3)(e)

Clinical supervision policies consistent with clinical supervision provisions of this

Section, and: i. R4-19-802 (C) and (D) for CNA programs, or ii. R4-19-803 (B) and (C)

for CMA programs.

Also, R4-19-801(C)(10)

A qualified RN instructor shall supervise any student who provides care to patients or

residents by: a. Remaining in the clinical facility and focusing attention on student

learning needs during all student clinical experiences; b. Providing the instructor’s

current and valid contact information to students and facility staff during the instructor’s

scheduled teaching periods; c. Observing each student performing tasks taught in the

training program; d. Documenting each student’s performance each day, consistent with

course skills and clinical objectives; e. During the clinical session, engaging exclusively

in activities related to the supervision of students; and f. Reviewing all student

documentation.

Clinical Supervision Policy

Effective and Review Dates on Policy

R4-19-801(B)(3)(g)

Dismissal and withdrawal policies

Withdrawal and Dismissal Policies

Effective and Review Dates on Policy

R4-19-801(B)(3)(h)

Student grievance policy that includes a chain of command for grade disputes and

ensures that students have the right to contest program actions and provide evidence in

support of their best interests including the right to a third party review by a person or

committee that has no stake in the outcome of the grievance.

Student Grievance Policy

Effective and Review Dates on Policy

Rule Citation

Document

Clinical Contracts

(Non-Facility Programs)

R4-19-801(A)(4) - NON LTC FACILITY PROGRAMS

A training program that uses external clinical facilities shall execute a written agreement

with each external clinical facility that: a. Provides the program instructor the ability to

assign patient care experiences to students after consultation with facility staff, and b.

Contains a termination clause that provides sufficient time for enrolled students to

complete their clinical training upon termination of the agreement.

R4-19-801(B)(3)(i)

Program progression and completion criteria

Program Progression & Completion Policy

Effective and Review Dates on Policy

R4-19-801(C)(6)

A training program shall utilize an electronic or paper textbook corresponding to the

certification level of the course that has been published within the previous five years.

Unless granted specific permission by the publisher, a training program shall not utilize

copies of published materials in lieu of an actual textbook.

R4-19-801(C)(7)(a)

A training program shall provide, to all program instructors and enrolled students, access

to the following instructional and educational resources: a. Reference materials,

corresponding to the level of the curriculum.

R4-19-801(C)(1)

During clinical training sessions, a training program shall ensure that each student is

identified as a student by a name badge or another means readily observable to staff,

patients, and residents.

Textbook, Author, Publisher and Year

(copy of the front of book & copyright pg)

List of Current Reference Materials

Name Badge (copy)

R4-19-804(D)(2)(i)

Copies of the redacted records of one program graduate

Redacted Student Record

Location in Packet

(Page# ONLY)

Location in Packet

(Page# ONLY)

Location in Packet

(Page# ONLY)

R4-19-801(C)(4)

A training program shall provide, in either electronic or paper format, a written

curriculum to each student on or before the first day of class that includes a course

description, course hours including times of instruction and total course hours, instructor

information, passing requirements, course goals, and a topical schedule containing date,

time and topic for each class session.

R4-19-801(C)(5)

For each unit or class session the program shall provide, to its students, written: a.

Measurable learner-centered objectives, b. An outline of the material to be taught, and c.

The learning activities or reading assignment.

R4-19-801(C)(8)

a. Plan each learning experience; b. Ensure that the curriculum meets the requirements of

this Section; c. Prepare written course goals, lesson objectives, class content and learning

activities; d. Schedule and achieve course goals and objectives by the end of the course;

and e. Require satisfactory performance of all critical elements of each skill under R4-19-

802 (H) for nursing assistant and R4-19- 803(D)(4) for medication assistant before

allowing a student to perform the skill on a patient or resident without the instructor’s

presence at the bedside.

Terminology

Medication action

Syllabus with Course Description, Course

Objectives, Instructor Information,

Passing Requirements, Hours & Times of

Instruction, and Topical Schedule

Program Evaluation Plan with Outcomes

(RENEWING PROGRAMS ONLY)

Rule Citation

R4-19-801(A)(10)

A training program shall provide and implement a plan to evaluate the program that

includes the frequency of evaluation, the person responsible, the evaluative criteria, the

results of the evaluation and actions taken to improve the program. The program shall

evaluate the following elements at a minimum every two years: a Student evaluations

consistent with subsection (A)(9); b. First-time pass rates on the written and manual

skills certification exams for each admission cohort; c. Student attrition rates for each

admission cohort; d. Resolution of student complaints and grievances in the past two

years; and e. Review and revision of program policies.

Rule Citation

Document

Curriculum Including:

Unit objectives, Unit outline, Learning

activities and Hours of instruction for each

unit of instruction - May use Board

template with activities and hours

completed by the program.

R4-19-803(D) A medication assistant training program shall provide classroom and clinical

instruction in each of the following subjects:

4. SYLLABUS

5. STANDARDIZED CURRICULUM

R4-19-801(A)(9)

A training program shall provide each student with an opportunity to anonymously and

confidentially evaluate the course instructor, curriculum, classroom environment, clinical

instructor, clinical setting, textbook and resources of the program.

Drug references

Laws affecting drug administration

Blank Student Evaluation Form

3. EVALUATIONS

Document

Student Evaluation Policy

Effective and Review Dates on Policy

Medication administration across the human lifespan

Eye and ear medications

Skin medications

Cardiovascular medications

Documentation

Medication safety

Asepsis

Medication properties, uses, adverse effects, administration and care implications for the following types of

medications:

Medication administration theory of:

Dosage calculation

Respiratory medications

Gastrointestinal medications

Urinary system medications and medications to attain fluid balance

Endocrine/reproductive medications

Musculoskeletal medications

Nervous system/sensory system medications

Psychotropic medications

Vitamins, minerals, and herbs

Antimicrobials

Oral tablets, capsules, and solutions

Ear drops, eye drops and eye ointments

Topical lotions, ointments and solutions

Rectal suppositories

Nasal drops and sprays

Location in Packet

(Page# ONLY)

Program Administrator Name (Print) Signature

6. THIS SECTION IS FOR INITIAL PROGRAMS ONLY

Rule Citation

Document

Instructor Forms

R4-19-804(C)(9)(b)

List and description of classroom facilities, equipment, and instructional tools the

program will provide.

Classroom Facilities and Equipment

R4-19-804(C)(9)(i)

An implementation plan including start date and a description of how the program will

provide oversight to ensure all requirements of this Article are met.

Implementation Plan

R4-19-801(A)(10)

A training program shall provide and implement a plan to evaluate the program that

includes the frequency of evaluation, the person responsible, the evaluative criteria, the

results of the evaluation and actions taken to improve the program. The program shall

evaluate the following elements at a minimum every two years: a Student evaluations

consistent with subsection (A)(9); b. First-time pass rates on the written and manual

skills certification exams for each admission cohort; c. Student attrition rates for each

admission cohort; d. Resolution of student complaints and grievances in the past two

years; and e. Review and revision of program policies.

Blank Program Evaluation Plan

R4-19-804(C)(4)

4. Name, license number, telephone number, e-mail address and qualifications of each

program instructor including clinical instructors as required in either R4-19-802 for NA

programs or R4-19-803 for CMA programs

By signing, I verify this information is complete and true to the best of my knowledge. I have read the rules

associated with this document. I

have also verified that each document provided corresponds with the page

number in the right hand column of this checklist.

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