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Get CA CDPH 278B 2011

TOPIC TIME Total Hours Approved CDPH 278B 06/11 By This form is available on our website at Program Consultant www. Print Form State of California-Health and Human Services Agency California Department of Public Health CDPH Licensing and Certification Program L C Aide and Technician Certification Section ATCS MS 3301 P. O. Box 997416 Sacramento CA 95899-7416 916 327-2445 FAX 916 324-0901 IN-SERVICE TRAINING PROGRAM To be completed by ALL skilled nursing and intermediate care facilities See page two for instructions Facility name and address F Provider identification training number Phone County All Parties Must Sign Required Signatures Administrator Signature Director of Nursing Director of Staff Development Each nursing facility shall provide 24 hours of in-service training annually which shall be accessible to all certified nurse assistants employed by the facility. The content of the in-service training program shall be an enhancement to the basic training program consistent with the needs of the facility residents as determined by facility staff and shall also address areas wherein the facility received deficiencies following the last licensing survey. Include 5 hours of dementia specific training per year. Programs shall be reviewed for reapproval every two years. Please list the in-service topics below totaling at least 24 hours Include time allocated for each topic minimum 1 hour. cdph. ca*gov Date Page 1 of 2 Submit two lesson plans from two different topics listed which shall include the following a* Student behavioral objectives. b. Descriptive topic content technique method procedures. c* Method of teaching. d. Method of evaluation that indicates that learning has occurred* Submit your proposed three-month schedule calendar of in-service training programs. Indicate your method for including all three shifts for in-service training. I certify that When in-service videos and/or tapes are utilized the instructor is present for discussion and/or demonstration* All records of in-service training programs and attendance records are kept on file for a period of four years. Home/independent study is not done. Before sending to CDPH for review and approval check the following Did you get all required signatures Did you include two lesson plans Did you indicate how three shifts are in-serviced Did you fill in all information on this form Original signatures must be submitted* A faxed or scanned copy will not be accepted* Keep copies for your records. Print Form State of California-Health and Human Services Agency California Department of Public Health CDPH Licensing and Certification Program L C Aide and Technician Certification Section ATCS MS 3301 P. O. Box 997416 Sacramento CA 95899-7416 916 327-2445 FAX 916 324-0901 IN-SERVICE TRAINING PROGRAM To be completed by ALL skilled nursing and intermediate care facilities See page two for instructions Facility name and address F Provider identification training number Phone County All Parties Must Sign Required Signatures Administrator Signature Director of Nursing Director of Staff Development Each nursing facility shall provide 24 hours of in-service training annually which shall be accessible to all certified nurse assistants employed by the facility. .

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