AFL 20-89.1 From the California Department of Public Health
June 7, 2021
TO: Skilled Nursing Facilities
Intermediate Care Facilities
SUBJECT: Requirements for Application Submission for Online or Distance Learning Nurse Assistant Training Programs (NATPs)
All Facilities Letter (AFL) Summary
- The eLearning Review Unit was created as a result of the chaptering of Assembly Bill (AB) 2850 (Chapter 769, Statutes of 2018), allowing NATPs to offer 60 hours of California Department of Public Health (CDPH) approved classroom training in an online or distance learning format. This AFL lists the online NATP requirements and necessary application components for prospective facility and educational institution applicants.
- This AFL has been updated to permit SNFs and ICFs to contract with an existing CDPH-approved online NATP for the provision of online NATP theory instruction. The SNF or ICF must either develop or use the contracted online school’s clinical training to conduct the clinical portion of the NATP training in their facility using their own staff.
In response to AB 2850, CDPH’s Aide and Technician Certification Section established a new unit that reviews the applications of SNFs, ICFs, and educational institutions that would like to conduct the classroom or theory portion of a NATP in an online or distance learning format. Additionally, HSC section 1337.16 provides CDPH the authority to implement, interpret, or make specific additional standards by means of an AFL or similar instruction for online or distance learning programs.
Online NATPs must meet the same basic standards as traditional classroom-based NATPs. Therefore, in addition to conducting 60 hours of theory training remotely, the online providers must conduct 100 supervised hours of clinical training in person at an approved SNF or ICF. The providers are subject to regulatory oversight and enforcement by the eLearning Unit in the form of unannounced site visits, class audits, complaint investigations, and desk audits.
Application Submission and Processing Requirements
It is the responsibility of the training-program applicant to submit a complete application package that includes a prototype or fully developed learning management system that is in a format such that the review of the prototype or system provides the Department with a clear description of the expected consumer-level experience. All applicants must submit their completed applications to the eLearning Unit’s email inbox, eLearning@cdph.ca.gov. All required forms and instructions are available on the eLearning Unit’s Online/Distance Learning NATP webpage or CDPH’s forms index webpage.
Once received, each application will be issued an application tracking number for referencing future communications between the eLearning Unit and the applicant. To ensure compliance with applicable portions of HSC, the California Code of Regulations (CCR), and the Code of Federal Regulations (CFR), the eLearning Unit will review the submitted forms and documents and may request additional information. The eLearning Unit will also request a live walk through of the applicant’s Learning Management System and may conduct an onsite survey prior to approval if necessary.
The applicant will receive up to two notices about incomplete application items that need to be addressed and will have 10 business days to respond to each notice. A lack of timely or adequate response may lead to application denial. As stated in Title 22 CCR section 71835(h)(2), CDPH’s decision on an application approval must be made within 90 calendar days.
After approval, the provider is required to renew the approval every two years starting from the date indicated on the written approval notice. Applicants must submit a request for CDPH’s review and approval 30 calendar days prior to a change in core curriculum content, training hours, or contracted services. The eLearning Unit must approve these changes prior to their implementation.
The program provider is responsible for maintaining compliance with all codes, regulations, and CDPH rules pertaining to the operation of their NATP. CDPH may verify a provider’s compliance at any time.
A complete online NATP application includes:
- CDPH E276 (PDF) – Online Nurse Assistant Training Program Application
- CDPH E276A (PDF) – Online Nurse Assistant Training Program Skills Checklist
- CDPH E276B (PDF) – Online Nurse Assistant Training Program Daily Clinical Schedule
- A daily theory instruction schedule
- CDPH E276C (PDF) – Online Nurse Assistant Training Program Individual Student Record
- CDPH E276D (PDF) – Online Nurse Assistant Training Program Disclosure of Ownership
- CDPH E276E (PDF) (For educational institutions only) – Online Nurse Assistant Training Program Clinical Site Agreement
- CDPH E276P (PDF) – Online Nurse Assistant Training Program Policies and Procedures
- A review and revision policy
- A job description policy
- An organizational chart
- An instructor monitoring policy
- An instructor monitoring tool
- An instructor availability policy
- A clinical student to instructor ratio policy
- An attendance and assignments policy
- An equipment failure policy
- A virtual student handbook policy
- A record keeping and gathering statistics policy
- A personal information protection policy
- CDPH E278C (PDF) (For SNFs and ICFs only) – Facility Declaration of Participation in an Approved Online Training Program
- CDPH E279 (PDF) – Online Nurse Assistant Training Program Instructor or Director of Staff Development Application
- Training Curriculum
- A copy of training curriculum that meets all the requirements listed in HSC 1337.1(b)(3), HSC 1337.1(b)(4), HSC 1337.3(c)(2)(A), HSC 1337.3(c)(3), Title 22 CCR section 71835(n), and Title 42 CFR 483.152(a)(2) and (b)
- The training curriculum training hour requirements exclude self-study and examination hours
- Lesson Plans – All lesson plans, exams, and answer keys
- Crosswalk – A document describing the proposed curriculum and matching it to the requirements listed in Title 22 CCR 71835(n), HSC 1337.1(b)(3), HSC 1337.1(b)(4), HSC 1337.3(c)(2)(A), HSC 1337.3(c)(3), Title 42 CFR section 483.152(a)(2) and (b)
- Learning Management System – A reviewable online learning management system that is developed enough so that it can be assessed in a consumer-level format upon application (This system may not be altered during the application review process without CDPH’s consent).
The eLearning website contains the most recent information on application and review procedures, online NATP requirements, and the latest version of the application forms.
Online Training Program and Learning Management System Requirements
An online NATP must meet the same standards as traditional, classroom-based programs, and comply with any other standard established by CDPH for online or distance learning NATPs. This includes, but is not limited to, providing a minimum of 60 hours of approved theory training online or in a distance learning format and a minimum of 100 hours of supervised clinical training in an approved SNF or ICF.
- An online NATP must provide distance learning (synchronous) or online (asynchronous) instruction during which the students and the approved instructor(s) are connected at the same or similar times using real-time or other collaborative software that combines audio, video, and file sharing.
- Synchronous instruction is similar to a video conference or live-streamed lecture where students and instructors interact in a specific virtual place at a set time and all parties can see and interact with each other. Instructors commonly take attendance as they would in a lecture hall.
- Asynchronous instruction is more independent and is similar to participating in a virtual library or self-guided lesson modules. The NATP provides a combination of materials for reading, lectures for viewing, assignments to verify understanding, and exams for evaluation. The students complete these assignments at their own schedule so long as they meet the expected course deadlines. Students are expected to interact with an instructor daily. To be approved for asynchronous instruction, online NATPs must institute a method of daily interaction between the students and instructors for the purposes of assessing student understanding of the material.
- Both synchronous and asynchronous programs must evaluate the student’s understanding of the NATP content. For asynchronous instruction, each course module must provide an exam to evaluate the student’s understanding of the content. To proceed to the next module, students must pass each module at the NATP’s predetermined proficiency level.
- Asynchronous programs must have a time/pause mechanism built into their Learning Management System to ensure students participate in the minimum number of required NATP theory hours.
- For asynchronous instruction, each course module must not allow students to skip forward but should allow them to go back to review the module’s content. The students must not be allowed to proceed directly to the module exam and print a certificate of completion without participating in the entire module content for the required time. The course modules must minimally total 60 hours of theory instruction.
- An online NATP must ensure that enough instruction is provided to meet each full-required hour. To receive credit for a full hour of instruction, students must participate a minimum of 50 minutes for each hour.
- The online NATP must collect, and have available for CDPH to access, statistics about the performance of trainees in the program including, but not limited to, student time spent on each course module, the grades of each student per module, the rate at which students repeat each course module, average certification examination passage rate (over a 2 year period), and test and overall course pass/fail rate. This information must be available to CDPH in the provider’s Learning Management System at any time. CDPH may request additional information regarding student participation and completion of the program.
- CDPH must have initial and ongoing access rights to the online program for the purpose of accessing statistical data, verifying provider compliance, and ongoing monitoring of the online or distance learning sessions.
- An online NATP must provide student records such as transcripts to its students upon request, and any NATP records to CDPH immediately upon request.
- An online NATP must safeguard student personal information in a manner equal to current technological industry standards. For example, file access should be restricted to appropriate personnel and online files should be password protected. Students and instructors must use a Personal Identification Number or personal identification information to confirm their identity. Students must attest to their identity under penalty of perjury.
- When the use of passwords and login information is required, an online NATP must accept a unique login and password with valid credentials for each user that are unique to that user. The NATP should provide each user with the ability to reset their password. Password strength requirements must be equal to current technology industry standards. For example, a minimum of eight characters, using a combination of upper and lowercase letters, numbers, and special characters.
- An online NATP must ensure that instructors are accessible to students outside of the normal instruction times.
- An online NATP must provide a clear explanation of the requirements necessary for students to successfully complete the training program. These requirements must also be displayed on its website (landing page) and include, but are not limited to:
- technology hardware and software requirements for students to access and complete the program, such as a computer, minimum operating system, and webcam;
- grade requirements for passing the training program;
- training program fees;
- brief descriptions of required coursework;
- course deadlines;
- training program lengths, such as length in days, weeks, or semesters and;
- cities in which the training program’s clinical sites are located.
- An online NATP must minimally develop and implement operational policies regarding staffing, instructor monitoring, instructor availability (during and outside of normal instruction times), student to instructor ratios, student attendance (including definitions of excused and unexcused absences), personal information protection, NATP and/or contracted service equipment failure mitigation, record keeping, statistical data gathering, and students’ ability to makeup coursework and complete assignments past deadlines.
Alternative Online NATP Program Requirements
This option is available to facilities that can secure an agreement with an existing CDPH-approved online NATP for theory instruction and that have the capability to teach the clinical portion using facility staff with the materials from the contracted online NATP. Facilities have the option of developing their own clinical instruction material. However, this material must be complementary to the contracted online NATP’s curriculum, meet state and federal requirements, and be approved by CDPH prior to its implementation. If the facility’s application is approved, CDPH will issue a distinct provider identification number, consider the facility to be a NATP provider, provide the facility with an approval letter, and hold the facility to NATP statutes, regulations, and department rules, including this AFL.
When using this option, facilities must require their nurse assistants to attend and complete the online NATP provider’s theory training courses based on that provider’s training schedule. Clinical instruction cannot begin unless the mandated preclinical theory hours are completed first.
Facilities using this option are responsible for all student training records. Each facility must obtain, maintain, and provide CDPH with all theory and clinical instruction program records and statistics as described in the previous sections of this AFL.
Facilities using this option are responsible for having a complete application package when applying. A complete application package includes all the elements described above, access to the contracted learning management system, and a copy of the contract between the CDPH-approved online NATP provider and the facility. The application package excludes the theory curriculum, theory lesson plans, theory crosswalk, and the form CDPH E276C. The application package may exclude the form CDPH E276B if the facility is using the contracted online NATP clinical curriculum schedule. Some elements from CDPH E276P may be satisfied by submitting the contracted online NATPs policies. These include the equipment failure policy, the virtual student handbook policy (updated to include the facility’s clinical instruction), and the personal information protection policy.
CDPH’s failure to expressly notify facilities of statutory or regulatory requirements does not relieve facilities of their responsibility to follow all laws and regulations. Facilities should refer to the full text of all applicable sections of the Health and Safety Code and Title 22 of the California Code of Regulations to ensure compliance.
Original Signed Cassie Dunham
Acting Deputy Director