Personal Care Aide Training Requirements

  Requirements across all, uniformRequirements across all, not uniformSome requirementsNo requirements
Number of states 19 10 11 11
STATEUniform requirements across all programs Requirements across all programsRequirements in some programsNo training requirements
Alabama       X
Alaska X      
Arizona X      
Arkansas X      
California       X
Colorado     X  
Connecticut       X
Delaware X      
D.C. X      
Florida   X    
Georgia   X    
Hawaii       X
Idaho X      
Illinois    X    
Indiana     X  
Iowa        X
Kansas       X
Kentucky   X    
Louisiana X      
Maine   X    
Maryland     X  
Massachusetts     X  
Michigan       X
Minnesota X      
Mississippi X      
Missouri   X    
Montana   X    
Nebraska       X
Nevada     X  
New Hampshire   X    
New Jersey     X  
New Mexico X      
New York     X  
North Carolina X      
North Dakota X      
Ohio     X  
Oklahoma X      
Oregon X      
Pennsylvania     X  
Rhode Island    X    
South Carolina X      
South Dakota       X
Tennessee     X  
Texas     X  
Utah       X
Vermont       X
Virginia X      
Washington X      
West Virginia   X    
Wisconsin X      
Wyoming   X    

For Personal Care Aides –who constitute the second fastest-growing occupation in the nation—training standards vary considerably from state to state. Unlike other direct-care occupations, their training is not governed by any federal standards. The result is that only a minority of states have any uniformity in training standards across personal assistance services programs. But even among the states with uniform requirements, these requirements are often minimal and do not prepare PCAs adequately to provide high quality services to people with diverse and complex disabilities.

The Personal Assistance Workforce

  • Nearly 2 million workers (includes Independent Providers in public programs)
  • Provide nonmedical care and assistance to: elders, people with physical and intellectual disabilities
  • Titles include: personal care aide, personal assistant, home attendant, direct support professional
  • About 40 percent are employed directly by participants in publicly funded programs
  • Second fastest-growing workforce in the US—expected to increase 50 percent between 2012 and 2022.
  • Average wage: $9.67/hour
  • Half have incomes below 200 percent of poverty and qualify for public benefits such as Medicaid and food stamps

PHI State-By-State Survey of PCA Training Standards

The PHI 50-State PCA Training Project has collected information about PCA training standards in Medicaid State Plans and HCBS waivers for persons who are elderly or individuals with physical, intellectual and/or developmental disabilities.

Project goals

The goals of this project are to catalogue and assess PCA training requirements for each state and the District of Columbia, and then to highlight promising initiatives.

Methodology

To identify PCA training standards, we conducted systematic searches of state administrative code, Medicaid provider manuals, and Medicaid waiver documents.

Key Findings

  • Without federal standards, states have implemented an assortment of training requirements. Even within a given state, there is typically little uniformity across programs.
  • 23 states (45 percent)  have at least one personal assistance services program with no training requirements. (Note: this count excludes participant-directed PCA services)
  • Less than a 20 percent of states have a state-sponsored curriculum. Furthermore, only 35 percent of states have a training hours requirement for PCAs in one or more programs, and, of these, only 5 require 40 hours of training or more.
  • While 19 states have uniform training requirements for PCAs across programs, only 7 specify detailed skills or offer a state-sponsored curriculum.
  • 7 states require PCAs to complete home health aide or certified nurse aide training.

Detailed state-by-state findings will be posted at the PHI State Data Center.

The PHCAST Demonstrations

As our research shows, there is tremendous need to improve PCA training standards. The federal government took an initial step in this direction in 2010, when six states--California, Iowa, Maine, Massachusetts, Michigan, and North Carolina—were awarded three-year grants to develop competency-based training and credentialing systems for PCAs in their states. workersAccording to the federal agency in charge of administering the grant program—the Health Resources and Services Administration (HRSA) — “It is expected that the training standards established under these State grants would be utilized as a ‘Gold Standard’ for future training of personal and home care.” The PHI Workforce and Curriculum Development team has worked with several of these states to identify core competencies, adapt the PHI model personal services curriculumto meet the specific needs of the state, and develop appropriate competency testing and credentialing systems.

PHI Recommendations

To address the training needs of personal care aides, federal and state governments should invest in:

  • Comprehensive federal training standards for PCAs that address core competencies, including communication and problem solving skills necessary for delivering quality care.
  • A training infrastructure that offers accessible, learner-centered teaching which is effective for adults with multiple learning barriers.
  • Reimbursement for PCA training expenses for workers providing Medicaid-funded long-term services and supports.

Download PHI’s comprehensive policy position on training direct-care workers (pdf).

Download: Personal Care Aide Training Requirements, Summary of State Findings


Alabama

Personal assistance services are offered through four Medicaid HCBS Waivers in Alabama: the Mental Retardation (MR) Waiver, the State of Alabama Independent Living Waiver (SAIL), the Living at Home (LAH) Waiver, and the Elderly and Disabled (ED) Waiver. The MR Waiver, SAIL Waiver and the LAH Waiver do not specify training for PCAs but leave specialized training to the discretion of the participant. The ED Waiver requires PCAs to be trained in specific topics, such as basic infection control, prior to providing services, but the method for training is left to the agency. Participant-directed services are available under the Personal Choices program, which serves clients in both the SAIL and E+D waivers. The training of these aides is left to the discretion of the participant.

Alaska

Personal assistance services are offered through the Medicaid State Plan in Alaska. Agency-employed PCAs must complete an Alaska Medicaid-app roved competency-based curriculum of 40 hours (16 clinical) and evaluation within 4 months of beginning employment. Aside from training in CPR and First Aid, training for PCAs employed in the participant-directed program is conducted at the discretion of the participant.

Arizona

Personal assistance services are offered through Arizona's Long Term Care System (ALTCS) - under the state’s Medicaid 1115 Waiver. Direct-care workers providing attendant care and personal care are required to complete an Arizona Medicaid approved training and testing program. For this training, the state provides a model curriculum, "Principles of Caregiving," or requires that direct-care workers be trained in a curriculum based on the same core competencies. Direct-care workers providing Self-directed Attendant Care (SDAC) and independently registered caregivers are exempt from these training and testing requirements. Instead, training in CPR/First Aid, universal precautions, and HIPAA is required and additional training is conducted at the discretion of the participant.

Arkansas

Personal assistance services are offered through Arkansas’s Medicaid State Plan as well as two Medicaid HCBS Waivers: the Alternatives for Adults with Physical Disabilities HCBS Waiver and the Community First Choice Waiver. As outlined in agency licensing standards, agency-employed personal care providers in these programs must complete 40 hours of training with a state-approved curriculum and a competency evaluation in order to become “certified.” No training requirements are specified for participant-directed providers.

California

Personal assistance services are available under the Medicaid State Plan and two Medicaid HCBS Waivers in California: the In-home Operations Waiver, and the Multipurpose Senior Services Program. Agency-employed aides under the State Plan and the Waivers have no formal training requirements. Participant-directed services are available under the In-Home Services and Supports (IHSS) Program in which case training is at the discretion of the participant and can be facilitated by the county-based public authorities. Additionally, California is one of 6 states awarded a 3-year grant by the federal government to develop a training and credentialing program for PCAs, as part of the Personal and Home Care Aide State Training (PHCAST) Program, a provision of the Affordable Care Act of 2010.

Colorado

Personal assistance services are available under two Medicaid HCBS waivers in Colorado: the HCBS Waiver for Persons who are Elderly, Blind, and Disabled, and the Supported Living Services Waiver. Agency-employed personal care aides in the HCBS Waiver for Persons who are Elderly, Blind, and Disabled are required to have minimum of 20 hours of training or pass an agency-administered skills validation test. Broad skills for the training are outlined by the state, but the agency is responsible for ensuring that aides meet the requirement. Under the Supported Living Services Waiver, training for agency-employed aides is not specified, however, aides must be competent in providing the necessary tasks. The participant is responsible for training the attendant under the participant-directed options in both waiver programs.

Connecticut

Personal assistance services are offered through four Medicaid HCBS Waiver programs in Connecticut: the CT Home Care Program for Elders, the Personal Care Assistance Waiver, the Individual and Family Supports Waiver, and the Comprehensive Supports Waiver. Participant-directed options are available under each of these waiver programs. Neither agency-employed, nor participant-directed independent providers have specific training requirements, but both types of workers must demonstrate competency in general areas outlined by the state. Generally, agencies or participants must ensure that direct-care workers are competent. Fiscal intermediaries will assist participants in providing training for their workers.

Delaware

Personal assistance services are provided through one Medicaid HCBS Waiver in Delaware: the Elderly and Disabled Waiver program. The State outlines which skills must be addressed by agency-sponsored training programs and competency evaluations, but agencies are responsible for ensuring that aides are competent. Delaware does not offer participant-directed personal assistance through Medicaid.

District of Columbia

Personal assistance services are provided under the Medicaid State Plan and two Medicaid HCBS Waivers in the District of Columbia: the HCBS Waiver for Mental Retardation and Developmental Disabilities (MRDD) and the HCBS Waiver for the Elderly and Disabled. Personal Care Aides in these programs are required to be certified as home health aides and therefore must complete 125 hours of training and pass a competency evaluation. Participant-directed services are not offered under Medicaid.

Florida

Personal assistance services are provided through the Medicaid state plan as well as under three Medicaid waivers programs in Florida: the Aged and Disabled Adult Waiver, the Channeling for the Frail Elderly Waiver, and the Developmental Disabilities Waiver. In all but the DD Waiver, Personal Care Aide Services must be delivered by a certified home health agency by direct-care providers that meet the training standards of a Home Health Aide.  Independent Providers are permitted to provide these services as well if they have one year of experience providing services in a medical or setting for developmental disabilities or alternatively have completed college, vocational or technical training in medical, psychiatric, nursing, child care, or developmental disabilities equal to 30 semester hours, 45 quarter hours, or 720 classroom hours.  The Developmental Disabilities waiver requires online training modules facilitated by the Agency for Persons with Disabilities for both agency-employed aides and independent providers.

Georgia

Personal assistance services are offered through four Medicaid HCBS Waivers in Georgia: the Independent Care Waiver Program, the Community Care Services Waiver Program (CCSP), the New Options Waiver Program (NOW), and the Comprehensive Supports Waiver Program (COMP). Agency-employed aides are required to complete at least 40 hours of agency-provided training in broad areas outlined by the state. Aides providing participant-directed services in the COMP Waiver must be certified direct-support professionals or have equivalent training.

Hawaii

Personal assistance services are offered under a Medicaid 1115 Waiver program, Managed Long-Term Care Plan called Quest Expanded Access (QExA) (expanded from the Medicaid Managed Care Program- MedQuest), as well as through a Medicaid HCBS Waiver for persons with developmental disabilities and intellectual disabilities (DD/ID). The state specifies that providers of personal assistance services must be trained in several broad areas, but leaves the training to the employer agencies. Under the managed care waiver, personal assistance is provided by two Managed Care Organizations (MCOs), Evercare and ‘Ohana, which are responsible for determining contracting standards for provider agencies. For example, Evercare provides orientation for personal care aides in disease management and other topics, which is also mandatory for participant-directed aides. Participant-directed services are available under the managed care waiver as well as the DD/ID waiver. Under the latter, training is at the discretion of the participant.

Idaho

Personal assistance services are provided through the Medicaid State Plan and two Medicaid HCBS Waivers in Idaho: the Aged and Disabled Waiver, and the Developmental Disabilities Waiver. All aides providing personal assistance must be successfully trained in specific competencies set forth in the “Idaho Skills Matrix.” The Matrix lists required competencies and the person or entity responsible for verifying. Aides must pass a written examination and demonstrate competency in each listed task. Each employer will determine the methods used to train and assess direct care staff competencies. In the case of participant-directed services, which are offered under the waivers, the fiscal intermediary must oversee training in communication, confidentiality, and patient rights. All other training is overseen by the participant.

Illinois

Personal assistance services are provided through three Medicaid HCBS Waivers in Illinois: the Waiver for Adults with Developmental Disabilities (DD), the Waiver for Persons who are Elderly (part of the Community Care Program), and the Waiver for Persons with Disabilities. Under the Waiver for Adults with Developmental Disabilities, personal support workers employed by agencies must complete state-approved direct support personnel training and a competency-based assessment and be certified as Illinois direct support professionals. The training curriculum mandates 40 hours of classroom training, and 80 hours of on-the-job training. Under the Waiver for Persons who are Elderly, PCAs must complete 24 hours of pre-service training, with specific topics outlined by the state. Participant-directed services are offered under the Waiver for Adultes with DD as well as the Waiver for Persons with Disabilities. Training for individual providers providing participant-directed services in these programs is left to the discretion of the participant.

Indiana

Personal assistance services are available under two Medicaid HCBS Waivers in Indiana: the Developmental Disabilities (DD) Waiver and the Aging and Disabled Waiver. Training for agency-employed direct-care staff in the DD Waiver Program is provided by employer agencies, which must document that attendants are trained in several broad areas. Under the Aging and Disabled Waiver Program, no training requirements are specified by the state. Participant-directed services are offered under the Aging and Disabled Waiver; no training is specified for aides performing these services.

Iowa

Personal assistance services are offered through three Medicaid HCBS Waivers in Iowa: the HCBS Waiver for Persons with a Physical Disability, the HCBS Elderly Waiver, and the HCBS Intellectual Disabilities Waiver. Each waiver offers a participant-directed option. Currently, there are no formal training requirements outlined for personal care attendants in Iowa. However, personal care attendants must demonstrate proficiency through documentation of prior training or experience. For participant-directed services, training is at the discretion of the participant. Iowa is one of 6 states awarded a 3-year grant by the federal government to develop a training and credentialing program for PCAs, as part of the Personal and Home Care Aide State Training (PHCAST) Program, a provision of the Patient Protection and Affordable Care Act of 2010. The Iowa Department of Public Health has implemented this pilot training and credentialing system for direct care professionals that will standardize core training across programs and create career ladders for these workers through advanced specialized training modules. The pilot program ends in September 2013, with statewide implementation to follow.

Kansas

Personal assistance services are provided through three Medicaid HCBS Waivers in Kansas: HCBS for the Frail and Elderly, the Physical Disability Waiver, and HCBS MR/DD Waiver. Each waiver offers a participant-directed option for recipients. There are no formal training requirements outlined by the state for agency-employed or participant-directed providers in Kansas. At most, personal care assistants are required to have "general knowledge of the necessary tasks."  For participant-directed services, training is left to the discretion of the participant.

Kentucky

Personal assistance services are offered under three HCBS Medicaid Waivers in Kentucky: the Home and Community Based Services (HCBS) Waiver, the Michelle P Waiver (for individuals with intellectual and developmental disabilities), and the Supports for Community Living Waiver. For the HCBS Waiver, personal care providers must be employed by certified home health agencies, which means aides must complete the same training requirements as home health aides – a formal training and competency evaluation program. For the Michelle P. Waiver, and Supports for Community Living, services are participant-directed. Aside from mandatory training in abuse, neglect, and exploitation, training for these aides and the participant-directed aides under the HCBS Waiver is specified.

Louisiana

Personal assistance services are provided through the Medicaid State Plan as well as two Medicaid HCBS Waivers: the Elderly and Disabled Adult (EDA) Waiver and New Opportunity Waiver (NOW) for Developmentally Disabled. The Medicaid State Plan and NOW program offer participant-directed services. Training requirements for agency-based and participant-directed are outlined within facility licensing standards, which require 16 hours of training in certain broad areas. The one exception is for participant-directed aides in the NOW program for whom training is conducted at the discretion of the participant.

Maine

Personal assistance services are provided through the Medicaid State Plan and three Medicaid HCBS Waivers in Maine: the HCBS for Adults with Intellectual Disabilities and Autistic Disorders, the HCBS Waiver for the Elderly and Adults with Disabilities, and the HCBS Waiver for the Physically Disabled. The Medicaid State Plan and the Waiver for Elderly and Adults with Disabilities both require a minimum of 50 hours of training for providers, utilizing a State-approved curriculum, and successful completion of a competency exam. The Waiver for Adults with Intellectual Disabilities or Autistic Disorders requires direct support professionals to complete a 45 hour training program from the College of Direct Support. For participant-directed services under the State Plan and the Physically Disabled Waiver, training is at the discretion of the participant. Additionally, Maine was one of 6 states awarded a 3-year grant by the federal government to develop a training and credentialing program for PCAs, as part of the Personal and Home Care Aide State Training (PHCAST) Program, a provision of the Affordable Care Act of 2010.

Maryland

Personal assistance services are offered through the Medicaid state plan and four Medicaid HCBS waivers in Maryland: the Living at Home Waiver Program, the Older Adults Waiver, the Community Pathways Waiver, and the New Directions Independence Plus Waiver. All waivers except the New Directions Waiver offer participant-direction. Personal care aides providing services under the State Plan, Living at Home Waiver, and Older Adults Waiver are required to receive training by an RN in the provision of all services included in the Plan of Care. The Community Plus Waiver and New Directions Independence Plus Waiver specify additional minimal training for agency employed aides – CPR, First Aid, and other broad skill areas – tied to licensing standards for agencies providing services to individuals with intellectual and developmental disabilities. Training requirements for individual providers in participant-directed programs are at the discretion of the participant, who can potentially waive all provider requirements.

Massachusetts

Personal assistance services in Massachusetts are administered through the Medicaid State Plan by personal care attendants or through the Frail Elder Medicaid HCBS Waiver by agency-employed personal care homemakers and supportive home care aides. In Massachusetts, home care aides are classified into four categories: Homemakers (Home Care Aide I), Personal Care Homemakers (Home Care Aide II), Home Health Aides (Home Care Aide III), and Supportive Home Care Aides (Home Care Aide IV). Personal Care Attendants, not included in the hierarchy, are either consumer-delegated (meaning some employment functions are administered by the Fiscal Intermediary) or participant-directed and receive training at the discretion of the participant. Personal care homemakers must complete at least 60 hours of training. While employer-agencies can use their own curricula for this training, most use the state-endorsed curriculum and exam offered by the MA Council for Home Care Aide Services. Individuals with dementia receiving personal care services under the Frail Elder waiver are served by Supportive Home Care Aides who have 75 hours of HHA training plus an additional 15 hour dementia-related training. Additionally, Maine was one of 6 states awarded a 3-year grant by the federal government to develop a training and credentialing program for PCAs, as part of the Personal and Home Care Aide State Training (PHCAST) Program, a provision of the Affordable Care Act of 2010.

Michigan

Personal assistance services are provided under the Medicaid State Plan (Home Help Program) and two Medicaid HCBS Waivers in Michigan: the MI Choice Waiver, and the MI Habilitation Supports Waiver. In the Home Help program, aides, whether agency-employed or individual providers, must agree to participate in training if necessary. In either case, these providers are employed directly by the client and not by the state, and therefore training is at the discretion of the client. Aides providing services under the MI Choice Waiver are recommended to complete a certified nurse aide course, however, at a minimum, each aide must be trained through their employer-agency to properly perform each task required for each participant. Independent providers under these waivers must have training in universal precautions and blood-borne pathogens, with no other standards specified. Under the Habilitation Supports Waiver program, competency of aides, either employed by agencies or as individual providers, is overseen by the PIHP (prepaid inpatient health plans); these aides must be competent enough to provide the services in a particular client's plan of care but are not required by the state to complete any formal training. Consequently, each PIHP has established its own training requirements and mechanisms for delivering the training. Additionally, Michigan is one of 6 states awarded a 3-year grant by the federal government to develop a training and credentialing program for PCAs, as part of the Personal and Home Care Aide State Training (PHCAST) Program, a provision of the Affordable Care Act of 2010.

Minnesota

Personal assistance services are provided through the Medicaid State Plan and four Medicaid HCBS Waivers in Minnesota: the Community Alternative Care, the Elderly Waiver, the Developmental Disabilities Waiver, and the Community Alternative Disabled Individuals Waiver. In May 2009, the governor of Minnesota signed into law comprehensive reform of Personal Care Services which included the establishment of mandatory Department of Health Services-administered training for Personal Care Assistants (PCAs). This training and a competency test are available free online in 6 languages for all agency-employed PCAs and those participating in an agency-with-choice program option. The online training covers certain specific areas including: emergencies, infection control and standard precautions, body mechanics, understanding behaviors, boundaries and protection, timesheet documentation, fraud, and self-care. Participant-directed aides under each waiver program receive additional training at the discretion of the participant.

Mississippi

Personal assistance services are offered under two Medicaid HCBS Waivers in Mississippi: the Independent Living Waiver and the Intellectual Disabilities/ Developmental Disabilities (IDD) Waiver. Direct-care workers proving services under the IDD waiver are required to complete a minimum of 20 hours of training of which the general topics are determined by the agency with approval by the Department of Mental Health (DMH). Training for participant-directed attendants under the Independent Living Waiver must be provided by an agency that is permitted by the state to train nurse aides. The general content of the training is outlined, and Personal Care Attendants must demonstrate competency in the necessary skills.

Missouri

Personal assistance services are provided under the Medicaid State Plan as well as four HCBS Medicaid Waivers in Missouri: the Physically Disabled Waiver, the Community Support Waiver, the Comprehensive Waiver, and the Independent Living Waiver. Under the State Plan and PD Waiver, personal care aides are required to complete 20 hours of training, administered and documented by the employer agency. Broad skill areas for the training are outlined by the state. For the Community Support Waiver and Comprehensive Waiver, personal assistants must be trained according to areas outlined by the Division of Developmental Disabilities. These requirements do not specify training hours. For participant-directed services under the State Plan, the Comprehensive Waiver, the Community Supports Waiver, training of personal assistants is at the discretion of the participant.

Montana

Personal assistance services are offered under the Medicaid State Plan and four HCBS Medicaid Waivers in Montana: the Big Sky Waiver, the Big Sky Bonanza Waiver, the HCBS for Individuals with Developmental Disabilities (IDD) Waiver, and the Community Supports Waiver. Under the State Plan and the Big Sky Waiver personal assistant workers are required to complete 16 hours of agency-provided training, the general topics of which are outlined by the state. The agency is responsible for evaluating each worker's competency, documenting the training and evaluation, and issuing a certificate of completion. Training for aides providing participant-directed services under the Big Sky programs is at the discretion of the participant. Under the HCBS for Individuals with DD Waiver and the Community Supports Waiver, all direct support professionals must complete 20 hours of training through the College of Direct Support (CDS), explicitly paid for in the provider reimbursement rate. Which training modules an aide must complete is determined by the employer agency.

Nebraska

Personal assistance services are offered under the Medicaid State Plan and through the Aged and Disabled Medicaid HCBS Waiver. There are two kinds of personal care assistants in Nebraska--Basic Personal Assistant Service Providers (BPAs) and Specialized Personal Assistant Service Providers (SPAs). Training for BPAs is provided by agencies, but only to the extent that providers are qualified to provide the necessary level of care. SPAs have more formal requirements: either 4160 hours of previous personal care experience, certification equivalent to a CNA, or a basic training course approved by the Nebraska DOH. Accordingly, SPA reimbursement rates are higher than those for BPAs. The same requirements are in place for aides who are participant-directed.

Nevada

Personal assistance services are provided under the Medicaid State Plan and two Medicaid HCBS Waivers in Nevada: the Waiver for Persons with Disabilities, and the Waiver for Persons with Mental Retardation. PCAs providing services under the State Plan must complete 16 hours of training and agencies are required to evaluate provider competency. Training topics are outlined by the state, but there is no required curriculum or specified means for competency evaluation. The same is true for participant-directed providers under the State Plan. The Waiver for Persons with Mental Retardation offers both agency-directed and participant-directed options for personal care; neither category of providers has training specified beyond CPR and First Aid.

New Hampshire

Personal assistance services are available through the Medicaid State Plan and two Medicaid HCBS Waivers in New Hampshire: the Choices for Independence Waiver and the Developmental Disabilities HCB Waiver. PCAs providing services under the State Plan or Choices Waiver are required to have 8 hours of agency-sponsored training in basic skills which have been outlined by the state. PCAs employed at Home Health Care or Home Care Services Provider Agencies must have an additional four hours of medication administration training. Training for participant-directed aides under the State Plan is at the discretion of the participant. Under the Developmental Disabilities Waiver, PCAs (both agency and participant-directed) are required to complete an orientation in areas related to developmental disabilities, utilizing New Hampshire’s Introductory Training Instructional Guide & Resource Manual. PCAs who will be administering medication must complete 8 hours of medication administration training and pass an exam and competency evaluation.

New Jersey

Personal assistance services are offered through the Medicaid State Plan and two Medicaid HCBS Waivers in New Jersey: the Global Options Waiver and the Renewal Waiver. Under the State Plan, personal care attendants must either meet one of the following requirements: Homemaker/Home Health Aide training, a certified personal care assistant training program in a hospital or long-term care facility, a training course offered by the State Agency, or one year of experience working as a Personal Care Assistant. Under the Global Options waiver, agency-employed aides must be certified Homemaker/Home Health Aides, which requires 76 hours of training (16 clinical) and completion of a competency evaluation. Under the Renewal Waiver, which serves individuals with intellectual and developmental disabilities, agency-employed aides are required to complete pre-service training in a few broad areas, administered through the College of Direct Support. Participant-directed aides serving individuals in the Global options waiver have no specified training requirements. Participant-directed aides in the Renewal Waiver are trained at the discretion of the participant.

New Mexico

Personal assistance services are offered through the Medicaid State Plan and the Mi Via HCBS Medicaid Waiver. Participant-directed services are available under both programs. Agency-directed PCAs must pass a competency test administered by the employer agency and approved by the state. Participant-directed aides in the State Plan and Mi Via programs receive training at the discretion of the participant.

New York

Personal assistance services are provided under the Medicaid State Plan and three HCBS Medicaid Waivers in New York: the Long Term Home Health Care Program (LTHHCP), the Nursing Home Transition and Diversion Waiver, and the Office of People with Developmental Disabilities (OPWDD) HCBS Waiver. Under the State Plan, the LTHHCP Waiver, and the Nursing Home Transition and Diversion Waiver, PCAs (known as personal attendants) are required to complete a 40-hour state-approved training program and pass a competency evaluation, utilizing the state-sponsored curriculum as a minimum. Certified attendants are entered into the state's home care registry. Participant-directed attendants providing State Plan services are trained at the discretion of the participant. Under the OPWDD Waiver, direct-support professionals are trained by provider agencies in broad areas.

North Carolina

Personal assistance services are provided under the Medicaid State Plan and the Community Alternatives Program in North Carolina. The Community Alternatives Program (CAP) consists of four HCBS Medicaid Waivers: CAP for Disabled Adults (CAP-DA), the CAP- CHOICE, and the CAP for Mentally Retarded/Developmentally Disabled Individuals (MR/DD) Comprehensive Waiver, and the CAP-MR/DD Supports Waiver. In-home care services in these programs are organized in four levels and the required competencies for aides are specified for each level of service. In-home aides I and II providing personal care services must be deemed competent in specific areas by a supervising RN, but have no formal training requirements. In-home aides III and IV provide skilled care and require Certified Nurse Assistant licenses. Participant-directed aides under the CHOICE Waiver program receive training at the discretion of the participant. Additionally, North Carolina is one of 6 states awarded a 3-year grant by the federal government to develop a training and credentialing program for PCAs, as part of the Personal and Home Care Aide State Training (PHCAST) Program, a provision of the Affordable Care Act of 2010.

North Dakota

Personal assistance services are provided under the Medicaid State Plan and three HCBS Medicaid Waivers: the Medicaid Waiver for HCBS, the DD Self-Directed Supports Waiver, and the Traditional MRDD HCBS Waiver. Under the State Plan and Medicaid Waiver for HCBS agency-based and independent providers have the same requirements – they must demonstrate competency in certain specified skills. The training in these competencies must be conducted by a nurse educator and the documentation of competency submitted to the state. The same standards apply for in-home supports providers under the Traditional MRDD Waiver who may either be employed by department licensed agencies, or may be independent providers. Training for participant-directed aides under the Self-Directed Supports Waiver is at the discretion of the participant.

Ohio

Personal assistant services are available under six HCBS Medicaid Waivers: the PASSPORT Waiver, the Ohio Home Care Waiver, the Transitions Waiver, the Transitions Carve Out Waiver, the Individual Options Waiver, and the Choices Waiver. Workers in the PASSPORT program for older adults are required to complete 60 hours of training and a competency evaluation prior to service. The curriculum and exam must be submitted for approval by the Ohio Department of Aging. Under the Home Care and Transitions Waivers, personal care aides must complete the training and competency evaluation required of the state’s certified home health aides. The Level One and Individual Options Waivers for individuals with intellectual or developmental disabilities do not require set hours of training, but do require that personal care aides be trained in health and safety and in individual rights. Training for participant-directed home care attendants in the CHOICES Waiver is at the discretion of the participant.

Oklahoma

Personal assistance services are provided through the Medicaid State Plan and three Medicaid HCBS Waivers: the Advantage Waiver for Elderly and Disabled, the My Life My Choice Waiver, and the Sooner Seniors Waiver. Agency-employed personal care aides must be certified as home health aides, as stated in the licensing requirements for home care agencies. Participant-directed aides under the State Plan, My Life My Choice, and Sooner Seniors waivers must demonstrate competency to provide the services under the plan of care. Training for these aides is left to the discretion of the participant.

Oregon

Personal assistance services are offered through the Medicaid State Plan and two Medicaid HCBS Waivers in Oregon: the Aged and Disabled waiver and the Comprehensive Waiver. Agency-employed aides in the State Plan and Aged and Disabled Waiver must complete training by the employer-agency in broad topics outlined by the state. The agency must also conduct competency evaluations for each aide. Participant-directed aides must complete an orientation within 30 days of providing service, and otherwise are trained at the discretion of the participant. In the Comprehensive Waiver program, which offers only participant-directed personal care services, training of aides is at the discretion of the participant.

Pennsylvania

Personal assistance services are provided through five Medicaid HCBS Waivers in Pennsylvania: the Attendant Care Waiver, the Independence Waiver, the OBRA Waiver, the Home and Community Based Waiver for Individuals Aged 60 and Older, and the Person/Family-Directed Supports Waiver. Under the three waivers for persons with physical disabilities: the Attendant Care, Independence, and OBRA Waivers, aides must complete an agency/registry-based training and competency evaluation program meeting certain state-specified subject requirements. The same requirements are in place for agency-employed aides under the HCB Waiver for Individuals Aged 60 and Older. Under the Person/Family-Directed Supports Waiver, the agency is required to ensure that direct-service providers are trained and qualified to provide services under the support plan, but formal training requirements are not specified. Each of these waivers offers a participant-directed option – these aides must be competent to provide services in the individual’s plan of care, and submit to training if necessary.

Rhode Island

Personal assistance services are offered under the Medicaid State Plan and under a Global 1115 Waiver that combines the state's prior waivers into one program. Within the global waiver, the state offers 4 programs that allow persons with disabilities to remain in their homes or in the community: Personal Choice Program, Habilitation Program, Developmental Disabilities Program, and Rite@Home – an option for adults who cannot live alone but wish to live with their caregiver and receive personal care and homemaker services. Aides who work for licensed home care agencies must be certified as Certified Nurse Assistants and are required to complete the state’s 80 hour training course and competency evaluation. Aides employed in participant-directed options, offered under the Personal Choice program and the Rite@Home program, have no formal training requirements.

South Carolina

Personal assistance services are available in three Medicaid HCBS Waivers in South Carolina: the Community Choices Waiver, the Mental Retardation and Related Disabilities Waiver, and the Community Supports Waiver. Training requirements for PCAs are the same across all waivers. For Personal Care Aides (II) and Attendants, broad subject areas for training are outlined by the state and aides must complete a state-sponsored competency evaluation. Personal Care Aides (I), who perform only instrumental activities of daily living, must complete 6 hours of provider-documented training in certain broad areas before providing service. Participant-directed aides in the Community Choice and Mental Retardation and Related Disabilities Waivers have the same requirements as agency-directed aides.

South Dakota

Personal assistance services are provided under the Medicaid State Plan and two Medicaid HCBS Waivers in South Dakota: the HCBS for South Dakotans Waiver, and the Family Supports Waiver. Under the State Plan and the HCBS Waiver, providers must be certified home health agencies (CHHAs), as per Federal regulations. Personal care aides employed in CHHAs are required to be competent in certain skill areas, but there is no formal requirement for competency evaluation. For the Family Supports Waiver, personal care attendants are participant-directed, under the Agency with Choice model. In this case, training is at the discretion of the participant, and the plan of care outlines who will provide the training in each necessary skill.

Tennessee

In Tennessee the Medicaid program is now operated under a Medicaid 1115 Waiver called TennCare. TennCare’s CHOICES program for long-term care covers personal care services and attendant care through Managed Care Organizations (MCOs) that contract with the state. Under these arrangements, MCOs are responsible for contracting with long-term care providers who employ qualified aides to provide these services. TennCare's CHOICES program also offers participant-directed services, in which case the Fiscal Agent is responsible for ensuring a certain minimum level of training (including CPR/FA), and the consumer is responsible for conducting additional training on individual needs and preference. The state also operates three waivers for individuals with intellectual and developmental disabilities: the Arlington Waiver, the Self-Determination Waiver, and the Statewide Waiver. For the workers providing these services, competencies are outlined by the state and training is conducted using the College of Direct-Support.

Texas

Personal assistance services are offered under several programs in Texas. These services are provided under the Medicaid State Plan as well as through a 1929 (b) waiver program called Community Attendant Services, which serves individuals up to 300% of regular Medicaid eligibility. Additionally, the state provides personal assistance services under its Managed Long Term Care Waiver, "Star+PLUS," and two Medicaid HCBS Waivers: the Community-Based Alternatives Waiver, and the Home and Community Based Services Waiver. The requirements for agency-employed aides are essentially universal under these programs, and quite minimal. Providers must be deemed competent by their employer agency, with no further guidance from the state. The Home and Community-Based Services Waiver (IDD) is the one exception – the provider agency must outline a plan for initial and ongoing training of service providers and administer a written competency-based assessment of the applicant's ability. Each of these programs offers a participant-directed option, in which case the participant is responsible for conducting training of the aide.

Utah

Personal assistance services are administered under the Medicaid State Plan and four Medicaid HCBS Waivers in Utah: the Waiver for Individuals Age 65 and Older, HCBS Waiver for Individuals with Physical Disabilities, the New Choices Waiver, and the Community Supports Waiver for Individuals with Intellectual Disabilities or Related Conditions. Under the State Plan, PCAs must be employed by home health agencies, which must ensure that they are trained in all aspects of delivery of care and can demonstrate competency in all areas of training. The content of training and methods of evaluation are not specified by the state. The same broad agency-based requirements apply to agency-employed PCAs serving clients under the waiver programs. Participant-directed options are available under each of the waivers and under these programs training for aides is at the discretion of the participant.

Vermont

Vermont has recently consolidated its Medicaid programs under two Medicaid 1115 Waivers. The Choices for Care 1115 Waiver now encompasses most Medicaid HCBS Waivers. The Global Commitment 1115 Waiver includes State Plan services as well as services for specific populations who do not qualify for traditional Medicaid. Personal assistance services are available under both waivers. Under Choices for Care, agency-based personal assistance must be delivered through a certified home health agency, which is responsible for training and ensuring the competency of its PCAs. Under the participant-directed option available in the Choices for Care program, training for the attendant is at the discretion of the participant. The Global Commitment Waiver offers only participant-directed personal assistance to adult participants (agency-based services are offered only for children), in which case the participant is responsible for determining the training needs of the attendant.

Virginia

Personal assistance services are offered under three Medicaid HCBS Waivers in Virginia: the Elderly and Disabled Waiver, the Individual and Family Developmental Disabilities Waiver, and the Intellectual Disability/Mental Retardation Waiver. All three waivers offer participant-directed options. All agency-employed aides under these waivers must complete, at a minimum, a 40-hour curriculum, exam, and skills-checklist, all provided by the Department of Medical Assistance Services (DMAS). Agencies may adapt these materials to add additional units, but must teach the curriculum as a minimum. Under the Individual and Family Developmental Disabilities Waiver and the Intellectual Disability/Mental Retardation Waiver, providers must also ensure that PCAs are trained to work with individuals with developmental disabilities. This additional training can be done utilizing the State-sponsored Mental Retardation Staff Orientation Workbook and accompanying exam, or using specified units/tests from the College of Direct-Support. Under the participant-direction options, training for aides is at the discretion of the participant.

Washington

Personal assistance services are offered under the Medicaid State Plan and six Medicaid HCBS Waivers in Washington: the Community Options Program Entry System (COPES), the Medically Needy In-Home Waiver (MNIH), the New Freedom Consumer-Directed Services Waiver, the BASIC Waiver, the BASIC Plus Waiver, and the CORE Waiver. In all of these programs, personal assistance can be provided by agency-employed personal care aides or participant-directed independent providers. As of January 2012, a 75-hour basic training curriculum is required for all long-term care aides, excluding parents providing personal care. Aides must also pass a Department approved competency evaluation and be certified. With Department approval, agencies provide training. The training partnership provides training for independent providers, who are then listed on the state’s Referral Registry where they are connected to employment opportunities.

West Virginia

Personal assistance services are provided under the Medicaid State Plan and two Medicaid HCBS Waiver Programs: the Aged and Disabled Waiver, and the MR/DD Waiver. Under the State Plan, PCAs must complete 32 hours of state-approved training provided by the agency. The broad areas of this training are outlined by the state. For workers under the Aged and Disabled Waiver, training by the agency in certain broad areas is required, but no curriculum or hours are specified. Participant-directed PCAs under this waiver must complete the same training requirements with the assistance of a Resource Consultant. For Agency or Agency with Choice options under the MR/DD Waiver, agencies are required to ensure basic levels of training in broad areas. Training in the same broad areas must also be documented for participant-directed workers under this waiver. West Virginia has passed legislation in 2012 (SB 171, HB 4062) that will require the Bureau of Senior Services to establish educational standards for certification for "in-home direct care workers" and will also create a direct-care worker registry.

Wisconsin

Personal assistance services are offered through the Medicaid State Plan and four Medicaid HCBS Waivers in Wisconsin: the Community Options Waiver, the Community Integration Program, the Community Opportunities and Recovery Waiver, and the IRIS Waiver program. In recent years, Wisconsin has consolidated these programs under the Family Care managed long-term care waiver. Participant-directed services are still available under IRIS. PCAs providing services under the state plan must complete agency-provided training in general topics and specific skills included in the plan of care. Agency-directed aides providing “supportive home care” in the waiver programs are governed by the same agency-related standards as those under the state plan. Additionally, all supportive home care providers (agency-employed and independent) must complete the broad areas of training outlined in the Medicaid Waivers Manual Appendix T. Compliance with this training is done by county waiver agencies. These requirements exist also for aides providing participant-directed services in the IRIS Waiver.

Wyoming

Personal assistance services are administered under two Medicaid HCBS Waivers in Wyoming: the Long-Term Care Waiver, and the Adult Developmental Disabilities Waiver. Under the Long Term Care Waiver, agency-administered services must be provided by a certified nurse aide employed by a certified home health agency. In Wyoming, CNAs are required to complete 75 hours of training and a competency evaluation that meets the federal standards for this occupation. Participant-directed aides are trained at the discretion of the participant. Under the Adult Developmental Disabilities waiver, agency and participant-directed aides have the same requirements: CPR and First Aid training, as well as general and participant-specific training. This training must be documented by the agency (for agency and agency with choice delivery) or by the recipient and support broker under the Fiscal Employer Agent Model.

Alabama: Alabama Administrative Code 560-X-35, 560-X-36, 560-X-54, 560-X-57, 560-X-58

Alabama: Alabama Administrative Code 560-X-35, 560-X-36, 560-X-54, 560-X-57, 560-X-58

Alaska: Alaska Administrative Code, Title 7, 43.750-795

Arizona: Arizona Administrative Code, article 5, R9-28-508; Medicaid provider manual

Arkansas: Arkansas Code 0.16.06.034, Medicaid provider manual; Medicaid waiver applications

California: California Code of Regulations, Title 22, Div. 3, Ch. 3, Art. 2, §51181, and Art. 3, §51204; IHSS Provider Handbook; Medicaid waiver applications

Colorado: Colorado Code of Regulations, Title 10, 2505-10, §8.489, §8.510.8, §8.500.90

Connecticut: Connecticut Regulations: 17a-218-8 through 17a-218-17; 17b-342-2; 17b-262-596

D.C.: D.C. Municipal Regulations, 29-1910, 1916, 4221, 5003

Delaware: Delaware Administrative Code, Title 16: 4406, 4469

Florida: Florida Administrative Rules 59G-13.030, 13.080, 13.083, Medicaid provider manuals; Medicaid waiver applications

Georgia: Georgia Administrative Rules 290-5-54-09, Medicaid provider manuals; Medicaid waiver applications

Hawaii: Hawaii Administrative Rules: 17-1421, 17-1439, 17-1441; Medicaid Provider Manuals

Idaho: Idaho Administrative Procedure Act 16.03.10.300, 16.03.10.320, 16.03.10.700 through 719; Idaho Code 39-5605; Medicaid waiver applications; Idaho Skills Matrix

Illinois: Illinois Administrative Code Title 89; 686.10; Medicaid waiver applications

Indiana: Indiana Administrative Code, 455 IAC 2-6-3; 460 IAC 614-6-14-3, 614-6-14-4; Medicaid waiver applications

Iowa: Iowa Administrative Code 441-83; Medicaid waiver applications

Kansas: Kansas Administrative Rules 30-20-17; 30-63-10; Medicaid provider manuals; Medicaid waiver applications

Kentucky: Kentucky Administrative Rules 906 KAR1:180; 907 KAR 1:090, 1:160, 1:835; 917 KAR 1:145; Medicaid provider manuals

Louisiana: Louisiana Administrative Code Title 50 §12901, Title 40 §9201; Medicaid provider manuals

Maine: Code of Maine Regulations 10-149 CMR Ch. 5, 63; MaineCare manual

Maryland: Code of Maryland Regulations 10.09.20.03, 10.09.55.06, 10.09.54.06, 10.09.22.11

Massachusetts: Code of Massachusetts Regulations, Title 130, 422.00, 422.411; Massachusetts Council for Home Care Aide Services

Michigan: Medicaid provider manuals; Medicaid waiver applications

Minnesota: Minnesota Statute 2009 Supplement 256B.0659

Mississippi: Mississippi Department of Mental Health Operational Standards; Medicaid waiver applications

Missouri: Code of State Regulations, 15-8.300; Medicaid provider manuals; Medicaid Waiver Applications

Montana: Administrative Rules of Montana 37.34.933; 37.34.934; Medicaid provider manuals; Medicaid waiver applications

Nebraska: Nebraska Administrative Code, Title 465, Ch. 15; Title 480, Ch. 5-005E

Nevada: Nevada Admin Code 435; Medicaid Services Manual, Ch. 2100, 2300, 2600, 3500; Medicaid waiver applications

New Hampshire: New Hampshire Administrative Rules He-W 552, He-P 820, He-M 517, He-M 525, He-M 1201, He-E 800; Medicaid waiver applications

New Jersey: New Jersey Administrative Code 10:44A; 10:44C: 10:140-5:1; Medicaid waiver applications

New Mexico: New Mexico Administrative Code 8.315.4, 8.315.6, 7.28.2

New York: New York Codes, Rules, Regulations 18.505.14, 18.505.28, 10.766.11, 10.700.2, 14.633.8

North Carolina: North Carolina Administrative Code 10A.06A.0100; Medicaid waiver applications

North Dakota: North Dakota Administrative Code, 75.03.23.07; 75.04.01

Ohio: Ohio Administrative Code 173-39-02.4, 5123:2-13-04 (J), 5101:3-47-04, 5101: 3-46-04, 5105:3-50-04, 5105:3-50-04, 5101: 3-31-06; Medicaid provider handbooks

Oklahoma: Oklahoma Administrative Code, 317:35-15-13.2, 317:35-17, 317:50-3, 317:50-5, 310-662; Medicaid waiver applications

Oregon: Oregon Administrative Code, 411-030-0020 through 0090; 411-030-0170; 411-031-0020 through 0050; 411-034-0333; 411-034-0536; Medicaid waiver applications

Pennsylvania: Pennsylvania Code Title 28, Part IV, H, Ch.611; Medicaid waiver applications

Rhode Island: Rhode Island Rules and Regulations, R23‐17.9‐NA.

South Carolina: Medicaid Provider Manuals, Medicaid Waiver Applications

South Dakota: South Dakota Administrative Rules 67:16:24, 67:44:03, 46:10:07

Tennessee: Tennessee rules 1200-13-01.05, Medicaid provider manuals

Texas: Texas Administrative Code Title 40, Part 1, Ch. 47; Title 40, Part 1, Ch. 97, SubCh C; Title 40, Part 1, Ch. 97, SubCh. D; Title 40, Part 1, Ch. 48, Sub. J; Title 40, Part 1, Ch. 9, Sub. D, 9.177; Title 40, Part 1, Ch. 44, Subch B.; Medicaid provider handbooks; Medicaid waiver applications

Utah: Utah Code Annotated 26-21, 62A-2, and/or 62A-3; Utah Administrative Code R432-700-23, R539-5; Medicaid provider manuals; Medicaid waiver applications

Vermont: Department of Vermont Health Access Rules 7406.3; Department of Disabilities, Aging, and Independent Living Rules; Code of Vermont Rules 13-110-010

Virginia: Virginia Administrative Code: 12-VAC 30-120-900, 950; 12-VAC 30-120-211, 225, 233; 12-VAC 30-120-700, 766, 770

Washington: Washington Administrative Code 388-106-0200, 388-106-0300, 388-106-0500,106-1400, 388-845

West Virginia: Medicaid provider manuals

Wisconsin: Wisconsin Administrative Code DHS 105.17; Medicaid Waivers Manual Appendix T

Wyoming: Medicaid Rules Ch. 34, Ch. 41, Ch. 45 Sections 14 and 26

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