Fillable Homemaker-Home Health Aide (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Homemaker-Home Health Aide (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Revised 6/13/19
Homemaker-Home Health Aide
New Jersey Offi ce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
Training Program
and
Instructor Personnel
Record Form
Information
2
Table of Contents
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3
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 47030
Newark, New Jersey 07101
(973) 504-6430
Homemaker-Home Health Aide Training Program Information
Overview
To protect the health and safety of the public, homemaker-home health aides are certied
by the New Jersey Board of Nursing (hereinafter referred to as “the Board”) after successfully
completing the required 76-hour training program, competency evaluation, and criminal history
background check. The program curriculum, the training faculty and the training facility must
be reviewed and approved by the Board. An applicant is eligible for certication when both the
classroom and clinical aspects of the Homemaker-Home Health Aide Training Program have
been satised.
The Homemaker-Home Health Aide Training Program is designed to meet the minimum state
requirement. The certied homemaker-home health aide’s training will continue in the home
care setting through regularly scheduled agency in-services, and supervision by a registered
professional nurse.
In accordance with N.J.A.C.13:37-14.2, a “homemaker-home health aide” means a person
who is employed by a home care services agency and who, under supervision of a registered
professional nurse, follows a delegated nursing regimen or performs tasks which are delegated
consistent with the provisions of N.J.A.C.13:37-6.2. A New Jersey registered professional
nurse must supervise the certied homemaker-home health aide and the program of care delivered.
The Board has the following material available, for printing or downloading, via the following link:
www.njconsumeraffairs.gov/hhh/Pages/default.aspx
4
Training Program Requirements
N.J.A.C. 13:37-14.4 Homemaker-Home Health Aide Training Program
1. A homemaker-home health aide training program may be conducted by a home care
servicing agency, an educational institution approved by the New Jersey State Department
of Education or the Commissioner on Higher Education.
2. A homemaker-home health aide training program shall consist of at least 76 hours, to
include 60 hours of classroom instruction and 16 hours of clinical instruction in a skills
laboratory or patient care setting. The student-to-instructor ratio for classroom instruction
shall not exceed 30 students to one classroom instructor.
3. The 16 hours of clinical instruction in a skills laboratory or patient care setting shall be
supervised by a registered professional nurse. The supervision ratio shall not exceed 10
homemaker-home health aides to one registered professional nurse.
4. The curriculum for a homemaker-home health aide training program shall be consistent
with the laws governing the practice of nursing and the delegation of selected tasks by
the registered professional nurse.
5. Written approval of the Board of Nursing is required prior to advertisement or commencement
of the training program, which approval shall be granted for a 12-month period.
6. At the discretion of the Board, program approval may be contingent upon a visit to the
program site by a representative of the Board.
Pursuant to N.J.S.A. 45:11-24.3 et seq., all initial applicants for homemaker-home health aide
certication must submit to a criminal history background check. The Board of Nursing shall
not issue a homemaker-home health aide certication to any applicant until the Board determines
that no criminal history record information exists on le in the Federal Bureau of Investigation,
Identication Division, or in the State Bureau of Identication in the Division of State Police, which
would disqualify that person from being certied.
New Jersey Board of Nursing
Homemaker-Home Health Aide Department
P.O. Box 47030
Newark, New Jersey 07101
Telephone number: (973) 504-6430
Fax number: (973) 648-6914
www.njconsumeraffairs.gov/hhh/Pages/default.aspx
5
An applicant for HHA certication must complete an online application. Instructions for
completing the application are available online.
The agency or school may assist the application on the procedures for completing the
Application for Certication and the criminal history background check information.
If the applicant has disclosed on the application that he or she has been arrested and/or
convicted of a crime or offense, the applicant must submit copies of police reports, complaints,
judgements of conviction, a narrative statement for each arrest/conviction, and provide proof of
satisfaction of all sentencing terms.
Applicants must answer all questions on the Application for Certication truthfully and
completely.
Upon completion of the program, the agency or school will immediately upload a letter of
completion for each applicant who successfully completed the training program.
Applicants are responsible for the accuracy of the information submitted with their application.
Training Program “Approval” Requirements
1. The materials for training program approval must be submitted to the Board at least (2)
two months prior to the date the program starts. The following materials are required:
a. The annual program approval fee – this fee [$250.00] is for each location where an
agency or school is offering the training program. Please submit a company check, or
a money order, made payable to the New Jersey Board of Nursing.
b. The completed Homemaker-Home Health Aide Training Program Application.
1. Please include the beginning and completion dates of all courses scheduled.
2. Please ll in the program coordinator’s name (a minimum of a bachelor’s degree in
nursing (B.S.N.) is required).
3. Please ll in the agency or school’s Health Care Service Firm Registration (H.P.)
number, facility number or district code number, as applicable.
4. Program Coordinator information.
c. The completed Instructor Personnel Record. All instructors must have an
Instructor Personnel Record on file with the Board. Please complete all of the
sections and submit the document with a current resume.
d. The completed Application for the Homemaker-Home Health Aide Training Faculty for
each training date requested. Please include the credentials of the multi-disciplinary
instructors, if applicable (i.e., P.T., S.T., O.T.).
6
Training Program General Requirements
The training program content outlines, which are to be followed for the training program, are
included in this packet (pages 8 and 9) as is the Homemaker-Home Health Aide Training Faculty
form. The Training Faculty form identies the appropriate instructor(s) for each section of the
program (page 11).
Please notify the Board, in writing, prior to the date the program starts, if there are any changes
in the information previously submitted including the program dates, program locations or program
instructors. The Board must also be notied of any program cancellations.
Training Program “Completion/Submission” Requirements
1. After completion of the 76-hour Homemaker-Home Health Aide Training Program and
competency evaluation, the agency or school must submit the following to the Board for
each applicant:
a. The completed “Graduate List” (included in this packet) with each applicant’s name and
address typed. Each applicant’s name must be on the submitted Graduate List.
b. Individual letters of completion for each graduate.
Note: The application fee is nonrefundable.
Letters of completion must be submitted electronically to: NJHHA@dca.lps.state.nj.us .
Program Coordinator Responsibilities
(a) The program coordinator shall provide an appropriately equipped classroom and skills
laboratory with sufcient equipment and resources to provide for efcient and effective
theoretical and clinical learning experiences.
(b) The program coordinator shall submit the following to the Board of Nursing at least two
months prior to the commencement of the training program:
1. A Board of Nursing application for program approval. The application form requests
the name and address of the agency or school, the date and location of course
offerings, the tentative number of trainees and the name and address of the program
coordinator. Two supplemental forms which must accompany the application are a
faculty approval application which requests the name of the instructor assigned to
each session and an instructor personnel record which requests brief biographical
and educational information for each instructor;
2. The annual program approval fee for each location at which the program will be
offered: $250.00; and
3. The resume(s) of the nursing instructor(s). The resume shall include the instructor’s
name, address, education (the institution, the type of degree or diploma, the month
and year of graduation), work experience (the employer’s name and address, the
dates of employment, including the month and year, the job title, and whether the
employment was full-time or part-time), and the New Jersey license or certication
number, as appropriate.
(c) The program coordinator shall not, without prior notice to and approval by the Board,
make additions to or deletions from a training program which has been approved by
the Board of Nursing.
7
(d) The program coordinator shall notify the Board of Nursing, at least two weeks prior
to each program session, of the location and the beginning and ending dates of the
program session.
(e) Except in an emergency situation, the program sponsor shall notify the Board of Nursing
in writing of any program session cancellation or change, such as a change in location,
nursing instructor or dates, at least one week prior to any such cancellation or change.
No cancellation or change shall be implemented without the written approval of the
Board.
(f) The program coordinator’s responsibilities shall include, but not be limited to, the
following:
1. Establishing and implementing policies and procedures for the coordination of
instruction, including designating a responsible program manager;
2. Maintaining on le a copy of the lesson plan for the curriculum;
3. Establishing methods or provisions to ensure that an absent student receives the
required classroom and/or clinical instruction missed;
4. Establishing and maintaining records for each student. The student record shall
include, at a minimum, the following:
i. The beginning and ending dates of the program session;
ii. An attendance record, including the dates of any makeup sessions; and
iii. Evaluation of the student’s performance by the classroom instructor and by the
registered professional nurse who supervised the student’s clinical instruction;
and
5. Developing, implementing and maintaining on file a plan for evaluating the
effectiveness of the program. The evaluation plan shall include, at a minimum, the
following:
i. The name of the person responsible for implementing the evaluation plan;
ii. An annual written training program evaluation report, including findings,
conclusions and recommendations;
iii. A written evaluation of instructor(s) performance; and
iv. Program, faculty and student data, which shall include, at a minimum, the
following:
(1) The beginning and ending dates of each program session;
(2) The number of students enrolled;
(3) The number and percentage of students who satisfactorily completed the
program; and
(4) The number and percentage of students who failed the program.
8
Recommended Content/Hour Allocation Outlines
Section I Introduction to the role of the U.A.P. in nursing care settings 2.00
Section II Foundations for working with people 6.00
Section III Safety
A. Conditions 1.50
B. Fire 2.00
C. Standard Precautions for Infection Control 2.00
D. Body Mechanics 0.50
E. Emergencies 1.50
Section IV Systems and Related Care
A. Musculoskeletal 6.00
B. Integumentary System 9.75
C. Gastrointestinal System: Upper 4.00
D. Gastrointestinal System: Lower 2.00
E. Urinary System 3.00
F. Cardiovascular and Respiratory System 4.00
G. Neurological System 0.75
H. Endocrine System 1.00
I. Reproductive System 1.00
J. Immune System 1.00
K. Rest and Sleep 0.50
L. Death and Dying 1.50
Classroom Hours 50.00
Clinical/Laboratory Hours 16.00
Curriculum Total 66.00
Training of U.A.P. transferring from another setting, i.e. Nurse Assistant (N.A.) or
Homemaker-Home Health Aide (H.H.A.)
Step 1 Establish competency of knowledge and skills by facility.
Step 2 Optional: knowledge and skills competency remediation plan.
Step 3 Module (Institutional, L.T.C. or Home Care)
Step 4 Competency testing and application to state registry (as applicable: N.A. or
H.H.A.)
I. Unlicensed Assistive Personnel (U.A.P.) Curriculum Content Outline Hours
9
Recommended Content/Hour Allocation Outlines
III. Long -Term Care (L.T.C.) Recommended Hour Allocation Outline Hours
U.A.P. Curriculum classroom hours 50.00
U.A.P. Curriculum clinical/laboratory hours 16.00
U.A.P. Curriculum Total Course Hours 66.00
Long-Term Care module hours 6.00
Long-Term Care clinical hours 18.00
Long -Term Care Total Module Hours 24.00
Total Course Hours 90.00
Training of U.A.P. transferring from another setting as N.A. with L.T.C. Module
II. Home Care/Hospice Recommended Hour Allocation Outline Hours
U.A.P. Curriculum classroom hours 50.00
U.A.P. Curriculum clinical/laboratory hours 16.00
U.A.P. Curriculum Total Course Hours 66.00
Home Care module hours 10.00
Total Course Hours 76.00
Training of U.A.P. transferring from another setting with Home Care Module
Step 1 Establish competency of knowledge and skills by facility
Step 2 Optional: Knowledge and skills competency remediation plan
Step 3 Home Care module
Step 4 Agency competency testing, H.H.A. application and C.H.B.C.
Step 1 Establish competency of knowledge and skills by facility
Step 2 Optional: Knowledge and skills competency remediation plan
Step 3 Home Care module
Step 4 Agency competency testing, H.H.A. application and C.H.B.C.
10
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Homemaker-Home Health Aide Training Program Application
Name of Agency or School: __________________________________________________________
Business Address: _________________________________________________________________
Street address City State ZIP code
Telephone number: _________________________ Fax number: ____________________________
(include area code) (include area code)
Name of Program Coordinator: _______________________________________________________
Program Coordinator E-mail address: __________________________________________________
Training program address:
__________________________________________________________
Street address City
__________________________________________________________________________
State ZIP code Telephone number (include area code)
Minimum number
Tentative dates of courses of course hours = 76
(60 hours/classroom-16 hours/clinical)
H.P. number: _________________ Facility number: _____________ District code: ______________
___________________________________ __________________________________
Program Coordinator’s Signature Date
For State Use Only
________________________________
______________________________
Approved by Date
Number of students per classroom
(ratio = 1 instructor : 30 students)
Number of students per clinical setting
(ratio = 1 instructor : 10 students)
11
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Application for Homemaker-Home Health Aide Training Faculty
Name of Agency or School/City:
Date of Course
Beginning: ______________ Ending: __________________
Section
Name of instructor and credentials
Recommended
Hours
Submitted by:
V. Home Care Module Hours 10.00
VI. Clinical/Laboratory Hours
U.A.P. Curriculum Content Outline
Additional
Hours
16.00
60.00
76.00
Classroom Hours
Curriculum Total
I.
Introduction to the role of the U.A.P. in nursing care settings
2.00
II. Foundations for working with people 6.00
III. Safety
A. Conditions 1.50
B. Fire 2.00
C. Standard Precautions for Infection Control 2.00
D. Body Mechanics 0.50
E. Emergencies 1.50
IV. Systems and Related Care
A. Musculoskeletal 6.00
B. Integumentary System 9.75
C. Gastrointestinal System: Upper 4.00
D. Gastrointestinal System: Lower 2.00
E. Urinary System 3.00
F. Cardiovascular and Respiratory System 4.00
G. Neurological System 0.75
H. Endocrine System 1.00
I. Reproductive System 1.00
J. Immune System 1.00
K. Rest and Sleep 0.50
L . Death and Dying 1.50
12
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Homemaker-HomeHealthAideTrainingProgram,
ProgramCoordinatorandInstructorPersonnelRecord
Agency/School Telephone Number (include area code)
E-mail address
Name: __________________________________________________________________________
Home address: ____________________________________________ ______________________
Home Telephone Number (Include area code)
Agency/School name and address:
 
Check each session for which you are applying for approval to teach:
I.
Introduction to the role of the U.A.P. in nursing care settings
f. Cardiovascular and respiratory system
II. Foundations for working with people g. Neurological system
III. Safety h. Endocrine system
a. Conditions i. Reproductive system
b. Fire j. Immune system
c. Standard precautions for infection control k. Rest and sleep
d. Preventing the spread of disease l. Death and dying
e. Body mechanics V. Homecare/Hospice module
f. Emergencies VI. Clinical/Laboratory Hours
IV. Systems and related care
(Must have supervision experience of CHHA.)
a. Musculoskeletal
b. Integumentary
c. Gastrointestinal system: upper
d. Gastrointestinal system: lower
e. Urinary system
Education:(Please upload your resume)
Name of college or professional school Type of degree and major Year graduated
13
WorkExperience:(Please attach resume)
Signature: ______________________________________________ Date: _________________
RegisteredNursesApplyingtoInstructCertiedHomemaker-HomeHealthAideProgram
The following qualications are required to be an instructor for the Homemaker-Home Health Aide
Training Program:
(1) You must be a registered nurse currently licensed in the State of New Jersey.
(2) You must have been a registered nurse for at least two years preceding application.
(3) You must have at least one year of community health, public health or home care experience.
(4) You must have at least six months’ experience supervising homemaker-home health aides.
Please sign to certify that you meet these requirements:
__________________________________ ____________________
Signature Date
Name of employer
Title of position
Number of hours
worked per week
Dates employed (month/year)
From: __________ To: ___________
Social Worker, Physical Therapist (etc.)
Professional Licenses and/or Certicates Related to the Session(s) for which you are
applying.
Type State of authority License or Certicate number Expiration date
14
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Homemaker-Home Health Aide Training Program Coordinator Certication
I hereby certify that I have been employed as the Training Program Coordinator for _______________________________
Name of training facility
since __________________________. I have read and understand the Qualications and Responsibilities of a homemaker-
Date of hire
home health aide training program coordinator, set forth in N.J.A.C. 13:37-14.7, and accept those responsibilities.
_____________________________________________ ______________________________________________
Name of applicant (please print) Signature of applicant
Sworn and subscribed to before me this _____________
day of __________________________, ____________
Month Year
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
Afx Seal
Here
_____________________________________________________________________________
My Commission Expires
15
Submitting agency/school: __________________________________________________________________
Site approval address: _____________________________________________________________________
Street City State ZIP code County
Telephone number: _____________________________ Fax number : ____________________________
(include area code)
(include area code)
Instructor’s name: ______________________________ Program date: from _________ to ___________
E-mail address: ________________________________
All names and addresses must be typed.
The New Jersey Board of Nursing will determine eligibility.
Name
(last name, rst name, middle initial)
Address
month/day/year
month/day/year
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
www.NJConsumerAffairs.gov/nur
Homemaker-Home Health Aide Training Program Graduate List
16
I hereby certify that the above-listed individuals have successfully completed the Homemaker-Home Health
Aide Training Program which consisted of 60 classroom hours and 16 hours of clinical practice.
I hereby certify that I will ensure that the foregoing list has not been altered, changed or tampered with in any
way after it has been stamped and approved by the Board of Nursing.
I further certify that I will not release this list containing condential student information to any third party
pursuant to the Buckley Act.
______________________________________________________________________________________
Name of Program Coordinator (Bachelor of Science in Nursing) Signature Date
Name
(last name, rst name, middle initial)
Address
click to sign
signature
click to edit
17
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
CHHA Training Program
Additional Required Information
The following documentation is required by the Board of Nursing to maintain or obtain approval of a CHHA
Training Program. Failure to submit all requested information could result in a delay, denial or suspension
of program approval.
1. ___ Daily program instruction schedule, including subject content, time allocated, scheduled breaks/
meals and testing date/time (See atached Sample.)
Note: Time required for testing and competency evaluation is not included in the
76 hours of required instruction.
2. ___ Classroom location and oor plan indicating room size, entry/exit locations, location
of desks and/or tables for student instruction.
3. ___ Title and format (textbook, video, etc.) of all classroom instruction materials to be used.
Note: If a program is to be conducted in a language other than English, the instructor
must be bi-lingual and uent in English and the language in which instruction
will be given. Instruction may not be given through an interpreter. Classes may only
be conducted in one language at a time.
4. ___ Clinical instruction location and oor plan indicating room size, location of equipment.
5. ___ A minimum of ve (5) clear photographs of classroom and clinical instruction areas, including
entry/exit and all equipment
6. ___ List of clinical equipment used to adequately demonstrate clinical tasks (See attached Skills
Laboratory Equipment List.)
18
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
CHHA Training Program
Daily Program Schedule
To facilitate successful learning of training program objectives, a daily program schedule should be
completed for each day of training. Complete and submit the table below for your proposed Homemaker-
Home Health Aide Training Program. If you wish to submit the schedule in a different format, it must contain
all required iformation. Use additional sheets as needed.
Day 1 (Example Only)
Time
Beginning
End
Training Topic/Module
9:00 10:00
10:00 11:00
Foundation_for_Working
with_People
_
Introduction_to_role_of_CHHA
in_home_care_settings
_
11:00 12:30
Safety_-_Conditions
_
12:30 1:00 Lunch/Break
_
1:00 2:00
Safety_-_Fire
_
2:00 3:00
Safety_-_Infection_Control
_
3:00 4:00
Home_Care_Module
_
4:00 4:30 Review/Closing
Total Training
Hours for Day 1
Classroom
Instruction
Clinical
Instruction
6.5 0.0
Day ____
Time
Beginning
End
Training Topic/Module
Total Training
Hours for Day____
Classroom
Instruction
Clinical
Instruction
19
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
CHHA Training Program
Daily Program Schedule
Name of Agency/School and City: _______________________________________________________
Date of Course Beginning: ____________________________ Ending: _________________________
Day ____
Time
Beginning
End Training Topic/Module
Total Training
Hours for Day____
Classroom
Instruction
_
Clinical
Instruction
_
For Board
Use
Day ____
Time
Beginning
End Training Topic/Module
Total Training
Hours for Day____
Classroom
Instruction
_
Clinical
Instruction
_
For Board
Use
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20
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Skills Laboratory Equipment List
Equipment
Number of Items
Comments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Adult scale
Alternatiing mattress or the like, egg crate mattress
Assistive devices/equipment (e.g. extension stick,
sock donner, button loop
Bedpan (regular and fracture pan)
Catheter equipment (tubing, drainage bags,
leg bags)
Cane
Colostomy/ileostomy equipment
Commode
Crutches
Enteral feeding equipment
Feeding utensils (e.g. plate guard, rocking spoon)
Gowns/gloves/masks/face shields
Hi-rise toilet seat
Hospital bed
Hoyer lift
Infant/child equipment (e.g. bathtub, formula,
scale, hi-chair)
Mannequin (life-size, exible) and old clothes for
practice dressing and donning
Over-the-bed table
Oxygen equipment (nasal cannula, mask,
tank, concentrator)
Personal care items (e.g. emesis and bathing
basins, toothettes, denture cups combs)
Shower chair/bench/hand rail
Sink (for hand washing RDC)
Slide board
Slings/immobilizers (e.g. leg immobilizer,
ace wraps)
Thermometer (electronic)
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21
Equipment
Number of Items
Comments
26.
27.
28.
29.
30.
Transfer belt
TV, AV equipment
Urinal
Walker (e.g. rolling, platform)
Wheelchair
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Homemaker-Home Health Aide (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 29 June 2021

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