Page 5 is completed and signed by the nursing home

Page 5 is completed and signed by the Nursing Home Administrator and submitted with Report of Change
Rationale for Change of Clinical Site is attached
192

III. CHANGE in THEORY/LAB/CLINICAL SITE
B. Basic Equipment for Skills Training in Laboratory (continued)
Verify by checkmark that the following equipment is available for the Nurse Aide Training and Competency Evaluation
Program :
Mock Resident Unit In Theory/Lab
(one per six students) or within 25 feet
Adjustable bed with side rails in working condition Paper towels
Basin, wash and emesis (sufficient for students not Restroom(s)
to reuse) Sink with running water
Bedpan or fracture pan for each bed Skin cleanser
Bedside cabinet for each bed Waste basket with liner
Bedside chair for each bed
Cups (disposable)
Linen (minimum of six sets per bed)
Lotion for each bedside cabinet Equipment Needed
Mattress that can be cleaned for In-Facility Testing
Over bed table for each bed
Pillows for beds and positioning Antimicrobial spray*
(minimum of five per bed) Beverage (water is acceptable) *
Privacy curtains Designated Fax machine*
Signaling device for each bed Spoon-fed foods
Skin cleanser/hand sanitizer (applesauce, pudding, diced fruit) *
Soiled linen container Yellow food coloring*
Toilet tissues for each bedside cabinet
Urinal for each bed
Training Supplies
Alcohol swabs Mannequin in good condition (male and female)
Bath blankets, one for each student and extras* Meal tray with utensils, napkin, variety of
Bath thermometer foods available, clothing protectors
Bedside commode or collection container Measuring container (at least 6)
Blood pressure cuffs (regular and large) Mechanical lifts
Calibrated scale (dial or bar with weights) Orange Sticks
Colostomy bag Patient gowns (at least 6)
Catheter for mannequin – internal, external (male) PPE equipment (isolation gowns, mask)
(with drainage bag) Restorative devices
Clothing (tops, bottoms, socks, non-skid Sample charting sheets
footwear, male and female) at least two sets Shampoo (according to facility policy)
Clothing protectors, one for each student Thermometer sheaths or similar
Denture cups (at least two sets) Thermometers – mercury free (oral and rectal)
Denture solution (sufficient for each student to have and to read)
Dentures Toothbrushes or toothettes (sufficient for each
Disposable briefs student to have own)
Dual earpiece stethoscopes Toothpaste (1 tube labeled mouth care, 1 dentures)
Emery boards Towels (sufficient for each student to have own)
Gloves (disposable) Transfer belt
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Incontinent pads Wall clock with second hand*
Knee-high elastic stockings (several sizes) Washcloths (sufficient for each student to have own)
Liquid soap Wheelchair with foot rests
* Required for In-Facility Testing
Signature of Program Coordinator or Primary Instructor Date
III. CHANGE in THEORY/LAB/CLINICAL SITE
C. Clinical Site (continued)
__________________________________________________________________
(Name of Clinical Site)
It is mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1987 42 CFR
§ 483.151 that the Pennsylvania Department of Education must document the status of the long-term care facility
where the clinical experience is offered for nurse aide training.