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The Hospice may not allow an aide to provide services to patients independently until the aide has successfully completed competency testing, either at the hospice or at another training facility, and the Hospice has verified successful completion through documentation provided by the applicant or the training facility. Competency testing should include:

• Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other Hospice staff;
• Reading and recording temperature, pulse, and respirations;

Appropriate and safe techniques in performing personal hygiene and grooming tasks that include, but are not limited to:

• Bed bath;
• Sponge, tub, and shower bath;
• Hair shampooing in sink, tub, and bed;
• Nail and skin care;
• Oral hygiene; toileting and elimination;
• Safe transfer techniques and ambulation; and
• Normal range of motion and positioning.

These skills must be evaluated by observing the aide’s performance while carrying out the task with a patient or pseudo patient in a practicum laboratory or other setting as per §418.76(b)(1) of the Conditions of Participation (CoPs). A pseudo-patient is a person who is trained to participate in a role-playing situation or is a computer-based mannequin device. A pseudo-patient must be capable of responding to and interacting with the Hospice aide trainee and must be similar in characteristics to the primary patient population served by the Hospice in key areas such as age, frailty, functional status, and cognitive status.

When pseudo-patients are used to test hospice aide competency, the simulated environment must mimic the reality of the homecare environment, including environmental distractions and constraints that evoke or replicate substantial aspects of the real world in a fully interactive fashion, in order to assess proficiency in performing skills. 

In accordance with the CoPs a registered nurse (RN), in consultation with other skilled professionals (as appropriate), must observe the hospice aide candidate perform each of the tasks above to confirm the competence of the candidate.

The hospice must ensure that the skills learned or tested elsewhere can be transferred successfully to care of the hospice patient in all settings. The Hospice should give careful attention to evaluating both employed aides and those aides who provide services under arrangement or contract. This review of skills could be done when the nurse assigns an aide into a new patient care situation or during a supervisory visit. A mannequin may not be used for this evaluation. 

If the Hospice’s admission policies and the case-mix of patients demand that the aide care for individuals whose needs require additional competency beyond the minimum required in the regulation, the Hospice must document how these additional skills are taught and tested.

A hospice aide is not considered competent in any task for which he or she is evaluated unsatisfactory. An aide must not perform that task without direct supervision by a RN until after he or she has received training in the task for which he or she was evaluated as “unsatisfactory,” and successfully completes a subsequent evaluation. A hospice aide is not considered to have successfully completed a competency evaluation if the aide has an “unsatisfactory” rating in more than one of the required areas. This aide would be precluded from functioning as a hospice aide in any subject area. The regulations place no restrictions on the number of times or the time frame in which an aide can be tested in the deficient area.

The Hospice must maintain documentation that demonstrates the requirements are being met.