Personal Care Aide Training Curriculum for Virginia 

Understanding Caregiver Training Requirements for Virginia

Department of Medical Assistance Services
Personal Care Aide Training Curriculum  

Content:​
​
I . Introduction
 A. DMAS Expectations 
 B. DMAS Requirements for Personal Care Aides

II. The Elderly
 A. Physical and Biological Aspects of Aging
 B. Psychological Aspects of Aging
 C. Physical and Emotional Needs of the Elderly
 D. Critical Situations that the Personal/Respite Care Aide may be Involved
 E. Orientation to Types of Physical Disabilities of Handicaps

III. Personal Care and Rehabilitative Services
 A. Body Mechanics
 B. Limitations on the Personal/Respite Care Aide Activities 
 C. Techniques used by Personal/Respite Care Aide 
 D. Goals of Personal Care 
 E. Prevention of Skin Breakdown 
 F. Vital Signs 

IV. Home Management
  A. Care of the Home and Personal Belongings 

V. Safety and Accident Prevention in the Home
 A. Common Types of Accidents 
 B. Accident Prevention 
 C. Typical Hazards in the Ho me 
 D. Ways to safety-Proof the Home 
 E. Policies and Procedures Regarding Accidents or Injuries 

VI. Food, Nutrition, and Meal Preparation
 A. Importance of Nutrition to the Individual 
 B. General Concept of Planning Meals 
 C. Special Considerations of Normal Diet 
 D. Special Considerations in Preparation of Special Diets 
 E. Food Purchasing and Preparation 
 F. Food Storage and Sanitation 

VII. Documentation Requirements for Medicaid Recipients
A. Aide Records
B. Provider Agency Plan of Care

​

I. Introduction

A. This program has been developed by the Department of Medical Assistance Services (DMAS) to establish a uniform training curriculum. Its purpose is to train and teach qualified persons to provide personal care services under Medicaid Waivers. DMAS hopes that this program will assist in recruiting and retaining qualified personal care aides.

B. DMAS Requirements for Personal Care Aides (PCA) include:
1. Must be 18 years of age or older;
2. Must be able to read and write in English to the degree necessary to perform the tasks expected; and
3. Must be able to perform the tasks required.

II. The Elderly

A. Physical and Biological Aspects of Aging

 1. Cardiovascular changes:
   a. The heart rate slows, causing a slower pulse and less efficient circulation.
   b. Blood vessels lose elasticity and develop calcium deposits, resulting in narrowing.
   c. Blood pressure increases because of changes to the walls of the blood vessels. 
   d. It takes longer for the heart rate to return to normal after exercise. 
   e. Veins become enlarged, causing the blood vessels near the surface of the skin to become more prominent.

2. Respiratory Changes: 
  a. Lung capacity is decreased because of muscular rigidity in the lungs
  b. Cough becomes less effective, allowing pooling of secretions and fluid in the lungs, increasing the risk of infection.
  c. Shortness of breath may occur on exertion.
  d. Less effective gas exchange takes place in the lungs.

3. Urinary System Changes:
  a. Bladder capacity decreases, increasing the frequency of urination.
  b. Kidney function increases at rest, causing the elderly to get up during the night to urinate.
  c. Bladder muscles weaken, causing leaking of urine or inadequate emptying of the bladder.
  d. The prostate gland (found in men) frequently enlarges, increasing the frequency of urination and causing dribbling, urinary obstruction, and urinary retention.

4. Digestive System Changes:
  a. Saliva production in the mouth decreases, interfering with digestion of starch
  b. Taste buds on the tongue decrease, beginning with sweet and salt
  c. The gag reflex in the throat is less effective, increasing the risk of choking
  d. Movement of food into the stomach through the esophagus is slower
  e. The stomach takes longer to empty into the small intestine, so food remains there longer
  f. Fewer digestive enzymes are present in the stomach, causing indigestion and slower absorption of fat

5. Nervous System Changes:
  a. More time is needed for tasks involving speed, balance, coordination, and fine motor activities, such as those involving fingers
  b. Problems develop with balance and coordination as a result of deterioration of the nerve terminals that provide information to the brain on the movement and position of the body.
  c. The lens in the eye becomes less flexible, causing visual changes.
  d. Decreased secretion of fluid in the eye causes dryness and itching
  e. Nerves and blood supply to the ears decrease, causing a difficulty hearing
  f. There is a decrease in the ability to feel pressure and Temperature, resulting in a higher potential for injury
  g. Blood flow to the brain decreases, which may result in mental confusion and memory loss.

6. Musculoskeletal Changes:
  a. A decrease in strength, endurance, muscle tone, and reaction time is caused by loss of elasticity of muscles, and decrease in muscle mass. 
  b. Bones lose minerals, become brittle, and break more easily. 
  c. The spine is less stable, less flexible, and more easily injured.
  d. Posture may become poor because of weakness in back muscles.
  e. Degenerative changes, or deterioration, occur in the joints, resulting in limited movement, stiffness, and pain.

7. Integumentary (Skin) Changes:
  a. The skin thins and becomes less elastic; wrinkles appear, and the skin becomes irritated and breaks more easily.
  b. Blood vessels that nourish the skin become more fragile and break more easily, resulting in bruising, senile purpura, and skin tears.
  c. Blood flow in vessels that nourish the skin is reduced resulting in slower healing.
  d. Oil glands that supply the skin secrete less, causing drying of the skin and itching.
  e. Perspiration decreases, and the body’s ability to regulate temperature is impaired.
  f. Subcutaneous fat diminishes.
  g. Blood supply to the feet and legs is diminished.
  h. Fingernail and toenail growth slows and nails become brittle.
  i. Hair thins and turns gray.

8. Endocrine System Changes:
  a. Blood sugar level increases because of delayed release of insulin, a hormone that regulates sugar use in the body.
  b. The amount of calories needed for the body to function normally decreases because of a lower metabolism rate, or slower body function.

9. Reproductive System Changes:
  a. Hormone production decreases, causing decreased size of testes, and a lower sperm count9
  b. More time is needed for an erection to occur
  c. Fewer female hormones are produced.
  d. The vagina becomes shorter and narrower.
  e. Vaginal secretions decrease.
  f. Breast tissue decreases and the muscles supporting the breasts weaken.


B. Psychological Aspects of Aging
  1. There are many factors that contribute to the psychological aspects of aging. These include, loss of income, loss of home, loss of independence, 
loss of spouse, illness or disease, loss of sense of security, and the loss of trust.
  2. There are numerous behaviors due to psychological factors. These include, poor appetite, depression, anger, and insomnia.

C. Physical and Emotional Needs of the Elderly 

  1. Basic Human Needs:

  a. Physiological needs-food, water, sleep, rest, physical activity, elimination, and oxygen.
  b. Safety and security-safe and protected from harm in the environment .
  c. Personal security in his or her family, relationships, and job. Financial security.
  d. Love and belonging-give love and receive love from others. Show recipient you care and accept him or her, regardless of  disability, condition, appearance, or behavior. Provide privacy during care, treatments, and procedures, and respect the recipient’s dignity.
  e. Self-esteem and respect-feel important and worthwhile; self-image may be threatened which may result in the recipient complaining frequently. The threat to self-esteem may result in recipient reacting with anger.
  f. Self-actualization-feeling a sense of accomplishment and success.

D. Critical Situations that the Personal/Respite Care Aide may be Involved

 1. Verbally abusive – The PCA is in the home to give care, support, and understanding. He/she would not be in the home if the recipient did not need professional medical assistance. The PCA must always maintain
professionalism, and never verbally attack the recipient.
 2. Combative – The PCA is never, under any circumstances, to hit a recipient. Usually, if you leave the recipient alone for a few minutes and then return and greet him/her, as if it were the first time you had seen him/her that day, he/she may have calmed down.
 3. Emergency – The PCA must be aware at all times of the recipient and what is happening with him/her. The recipient may stop breathing, have a heart attack, stroke, a diabetic complication, or other physical or psychological emergency. The PCA must be prepared with a plan of action in case of an emergency. Depending on the problem, the PCA should know when it is appropriate to call 911, the recipient’s physician, a family member, and/or the personal care agency.

E. Orientation to Types of Physical Disabilities or Handicaps
 The aide may encounter the following:
  1. Rheumatoid Arthritis – This is a severely crippling and painful disease.
Patience and gentleness must be used when moving, turning, bathing, or dressing the recipient;
  2. Stroke – This may result in slurred speech, difficulty swallowing, paralysis in one extremity, paralysis on one side of the body, or total paralysis. The PCA needs to ensure skill of transfers and, if necessary, the use of a Lift;
  3. Heart trouble – The recipient may show signs of chest pain on exertion, sweating, nausea, pain in the left arm, jaw, shoulder blade, and may become short of breath easily; and 
  4. Alzheimer’s – This can manifest in a variety of ways. Many people with Alzheimer’s may wander off, and therefore will need to be monitored at all times. They may present a danger to themselves and others by
attempting to perform tasks and then forgetting what they were doing. One example is in the attempt to cook, and the stove is left on. Recipients with Alzheimer’s may also be combative at times and not be aware of their
actions.

III. Personal Care and Rehabilitative Services

A. Body Mechanics

  1. Use of proper body mechanics by the personal care aide will prevent injury to the PCA and the recipient, and utilize the safest and often the easiest way to move/transfer the recipient.
  2.  Limitations on the personal care aide to activities –  The aide should always be aware of any skilled needs of the recipient, which may have an impact on positioning. The PCA should also be aware of any restrictions on the recipient’s activity and functioning ability.
  3. Techniques of body mechanics (Demonstration of these techniques is necessary for proper training.

     a: Helping the recipient sit up in bed – Make sure the bed is in its lowest position. If it is a manual bed, squat down to reach the handle, do not bend over. If the recipient is in his/her own bed, rather than a hospital bed, the recipient should be close enough to comfortably reach the bed. It may be necessary to position yourself on the bed with the recipient to maintain proper body alignment.
     b: Moving the recipient in bed – This may be achieved by having the recipient logroll from side to side.
     c:. Helping the recipient move from:
        i. Bed to chair and return – If this is a pivot transfer, the PCA must ensure the chair is positioned close to the bed. The recipient should have secure fitting shoes or slippers on for transfers. The PCA will position himself/herself in front of the recipient, place his/her feet against the toes of the recipient, put his/her arms under the recipients arms, place one knee in front of the recipient’s knee and stand straight up, holding on to the recipient
at all times.
      ii. Bed to wheelchair and return – The PCA must ensure the wheelchair is in the correct position with the wheels locked in place. Make sure the wheelchair is positioned so the recipient’s feet will not become entangled in the footrests. If footrests are movable, fold them up and out of the way. 
     iii. Bed to toilet/commode and return – The PCA should ensure the bedside commode is properly positioned beside the bed to allow the recipient to transfer with minimal exertion.
     iv. Bed to tub/shower and return – The PCA should ensure the recipient is wearing secure fitting shoes or slippers. Assist the recipient to a sitting position on the side of the bed. Assist the recipient as needed to a standing position; offer stand-by assistance to the bathroom.
     v. Chair to commode and return – Ensure the recipient is wearing secure fitting shoes or slippers. Assist the recipient to a standing position; provide stand-by assistance to the bathroom.
     vi. Chair to tub and return – Ensure the recipient is wearing secure fitting shoes or slippers. Assist the recipient to a standing position. Provide stand-by assistance to the bathroom. Assist the recipient to disrobe and stepping into the tub. 
     vii. Wheelchair to tub and return – Ensure the recipient is wearing secure fitting shoes or slippers. Roll the wheelchair into the bathroom and lock the wheels. Assist the recipient to a standing position. Assist the recipient in disrobing, and stepping into the tub.
     viii. Wheelchair to commode and return – Ensure the recipient is wearing secure fitting shoes or slippers. Roll the wheelchair into the bathroom and lock the wheels. Assist the recipient to a standing position. Assist the recipient in pulling down his/her underpants, and help him/her to sit safely on the commode.

     d: Helping the recipient walk with a walker, crutches, or a cane walker – Ensure the recipient is wearing secure fitting shoes or slippers. Place the walker in front of the recipient, and then place the recipient’s hands on the walker. Scoot the recipient to the edge of their seat and assist him/her to a standing position.
    e: Crutches – Ensure the recipient is wearing secure fitting shoes or slippers. Place the crutches in front of the recipient. Have the recipient place his/her hand on the handle of the crutches and assist the recipient to a standing position.
    f: Cane – Ensure the recipient is wearing secure fitting shoes or slippers. Assist the recipient in scooting to the edge of his/her seat. Place the cane in his/her strong hand.

B. Limitations on the Personal/Respite Care Aide’s Activities
There are some tasks that are never to be  performed by the PCA. These tasks include, but are not limited to, the following;

   1. A PCA may not perform a skilled nursing task, such as changing a catheter, giving an injection, changing a sterile dressing, performing any type of tube feeding, suctioning, or cutting finger and toe nails.
   2. A PCA may not provide care for other persons residing in the same home. The PCA is only to provide services to the Medicaid recipient(s).
   3. The PCA must understand there are limitations to the activities that are allowed within the area of his/her expertise. If the PCA does not follow these guidelines, he/she risks causing injury to the recipient.

C. Techniques used by Personal/Respite Care Aides
The instructor is to provide a demonstration for each procedure and then have each student demonstrate the procedure.

The PCA must observe Universal Precautions at all times. Washing hands before and after each procedure is necessary, and if possible, wash hands during the procedure. Whenever there is a possibility of coming into contact with blood or bodily fluids, you must wear gloves. The PCA should remove the gloves in the correct manner (A demonstration should be given by the instructor) to prevent contamination, and wash his/her hands immediately with soap and water. The most effective way to prevent the spread of infection is by washing your hands.

  1. Assisting the recipient with eating
Before feeding the recipient, ensure toileting needs are met, and all equipment used for personal care activities is removed from view. Make sure the recipient is in a safe and comfortable position to eat. Explain the procedure to the recipient. 
    a. Sit at or below the recipient’s eye level, if possible.
    b. Check the food temperature before feeding.
    c. Tell the recipient what the meal consists of.
    d. Recipient may be able to eat with his/her fingers.
    e. Offer liquids at intervals.
    f. Make pleasant conversation while feeding.
   g. Avoid rushing the recipient.
   h. Be emotionally sensitive to the recipient’s needs.

2. Assisting the recipient with dressing
 Before dressing the recipient, ask what he/she would like to wear. Prepare all needed articles and have them within reach. Ensure the recipient is in a safe and comfortable position.
Explain the procedure to the recipient before dressing him/her so that the recipient knows what you are going to do.

  a. Provide privacy and avoid exposing the recipient.
  b. Wear gloves and apply principles of universal precautions if you anticipate contact with blood, body fluids (except sweat), secretions, excretions, mucous membranes, or non-intact skin.
  c. Check the plan of care for special instructions and use of adaptive equipment.
  d. Encourage the recipient to do as much self care as possible.
  e. Clothing should be appropriate for age, and season, and color coordinated. Do not put torn clothes on recipient.
  f. If the recipient has one paralyzed or weak side, remove the clothing from the strong side first. Put clothing on the weak side first. Always support the weak or paralyzed extremity.
  g. It is easier to dress recipients who can assist if they are standing or sitting.
  h. It is easier to dress a dependent recipient in bed.
  i. Recipients who are dressed in street clothes should wear proper undergarments.
  j. When dressing a recipient with catheters or tubes, treat them as part of the recipient’s body. Avoid pulling on them or obstructing them. Do not disconnect them. Avoid elevating the urinary catheter above the level of the bladder during the dressing procedure.
  k. Gather the pant legs and sleeves before putting them on the recipient.

3. Mouth care
Ensure the recipient is in a safe and comfortable position.

Explain the procedure to the recipient.
  a. Gather all needed equipment.
  b. Encourage the recipient to do as much self care as possible.
  c. Allow the recipient to brush his/her own teeth. Take the recipient to the bathroom sink if possible.
  d. Always wear gloves when performing oral hygiene. Avoid contaminating environmental surfaces and clean supplies with your gloves.
  e. Observe and report any signs of irritation, sores, loose teeth, pain, swelling, or other abnormalities to the RN supervisor.
  f. Handle dentures carefully.
  g. Let the recipient remove the dentures from the mouth if able.
  h. Check the dentures for cracks, chips, or loose teeth.
  i. Store dentures in a marked denture cup. Some dentures are stored dry and others are stored wet.

4. Hair care
Allow the recipient to assist with hair care, as he/she is able.

Explain the procedure to the recipient.
  a. Assist the recipient with shampooing, drying, and styling the hair as needed.
  b. The PCA should not cut or perm the recipient’s hair.
  c. Use caution when using any type of heated device to style or dry hair.

5. Shaving male patients

Allow the recipient to assist, as he/she is able.
Gather all needed equipment, and explain the procedure to the recipient.
  a. It is preferable that an electric razor is used when shaving the recipient.
  b. The provider agency should ensure the PCA is competent to use a
disposable razor with minimal injury to the recipient.

6. Bathing (tub, shower, bed)
It is important to provide privacy for the recipient. Gather all necessary equipment and explain the procedure to the recipient. If the recipient has an indwelling catheter, washing around the urethra is considered part of the bath. If the recipient has a condom catheter, the PCA should remove the catheter, cleanse the penis and apply a new condom catheter following appropriate procedure. Instruction and return demonstration should be given in this procedure.

  a. Consult the plan of care for the type of bath to be given, special information, recipient’s self-care ability, routines, use of adaptive devices, recipient needs.
  b. Gloves are worn for part of the bathing procedure. You will have to wash your hands and change your gloves several times during the procedure to maintain universal precautions.
  c. If you have open cuts or sores on your hands, you will have to wear gloves for the entire bathing process.
  d. Moving the recipient to the side of the bed near you may be helpful.
  e. Be sure the room is warm and comfortable.
  f. Keep the recipient’s body covered with a towel or blanket for modesty and warmth. Expose only one part of the body at a time.
  g. Change the water if it cools off or becomes soapy or dirty.
  h. Soap can be irritating or drying to the skin. Be sure it is rinsed off.

7. Beds (making with and without the recipient in the bed)
Begin by gathering all needed supplies, and then explain the procedure to the recipient.
  a. Have the recipient turn to one side of the bed. Ensure the rails are up, if applicable, or that the recipient is not in danger of falling.
  b. Remove the linens from one side of the bed. Roll them under the recipient’s back.
  c. Apply the clean linens to the same side, and roll them under the dirty linens.
  d. Assist the recipient to turn to the other side. Again, ensure the recipient is safe.
  e. Pull the dirty linens out from under the recipient’s back, pull the clean
linens out, and straighten the linens out as needed.

8. Elimination
Depending on the physical abilities of the recipient this function may require the use of a bedpan, bedside commode, or going to the bathroom. Always ensure privacy for the recipient. Help the recipient wash his/her hands after he/she is finished.

 A. Bedpan
    i. I f the recipient uses the bedpan, have the recipient roll over to one side. Apply a minimal amount of powder to the bedpan, which will prevent the recipient’s skin from sticking to the bedpan. Place the bedpan against the recipient’s buttocks and hold it in place while assisting the recipient to turn over on to the bedpan.
   ii. When the recipient is finished using the bedpan, have the recipient turn over on their side again, while holding on to the bedpan to prevent spillage.
   iii. If the recipient is able to wipe himself/herself, give some toilet tissue to do so. If the recipient is unable to wipe himself/herself off, put your gloves on and wipe the recipient as needed. If necessary, use a warm washcloth and mild soap.
   iv. Ensure that the recipient is safe and comfortable, then remove the bedpan and clean it thoroughly.

B. Urinal
  i. If the male recipient needs to use the urinal, the PCA should wash his/her hands first, and then put gloves on.
  ii. Explain the procedure to the recipient. iii. Provide privacy for the recipient
  iv. If he is able to properly place it, hand the urinal to the recipient. If the recipient requires assistance with the urinal, place it between his legs, and place his penis inside of the urinal. 
  v. Provide him some privacy, and return in a minute or two to see if he has finished.
  vi. Assist the recipient with cleaning himself off as needed.
  vii. Record the amount in the urinal if the output is being tracked.
  viii. Report to the RN supervisor any complaints of burning, itching, urgency, or hesitancy by the recipient.

C. Bedside commode 
  i. Always ensure privacy for the recipient.
  ii. Assist the recipient to sit on the side of the bed to get his/her bearings and balance.
  iii. Place secure fitting slippers or shoes on his/her feet.
  iv. Assist to a standing position and transfer to the bedside commode.
  v. When the recipient has finished, help the recipient to wipe himself/herself off.
  vi. Remove the container from the bedside commode and clean it thoroughly.

D. Toilet
  i. Ensure privacy for the recipient.
  ii. Help the recipient put secure fitting shoes or slippers on.
  iii. Assist the recipient to sit on the edge of the bed to get their bearings and balance.
  iv. Assist the recipient to a standing position, and ambulate to the bathroom.
  v. When the recipient has finished, help him/her wipe off.
  vi. Assist the recipient with washing his/her hands.
 

e. Back rub – the recipient should be lying on his/her side in a safe and comfortable position. Wash your hands, and explain the procedure to the recipient.
   i. Apply lotion to your hands and rub your hands together to warm the lotion.
   ii. Apply the lotion to the recipient’s back, rubbing a long circular motion.
   iii. Observe the back and hip areas for any signs of redness or breakdown. Report any changes to the RN.

D. Goals of Personal Care

 1. Promote self-care and independence– Allow the recipient to perform as much of his/her care as possible.
 2. Assure safety and comfort – Always make sure the recipient is safe and not at risk of injury.
 3. Maintain dignity and self-respect – Provide privacy during all procedures.
 4. Maintain stability.

E. Prevention of Skin Breakdown

The recipient is dependent on the PCA to either assist with activities of daily living or perform the tasks for the recipient.

 1. The tasks are important for several reasons:
  a. It provides the aide an opportunity to inspect the recipient’s skin. The PCA should ensure the recipient has no red marks, bruising, bedsores, or skin tears that need to be reported. If there are skin problems, the PCA needs to communicate the problem immediately to the RN supervisor.
  b. It promotes interaction and conversation with the recipient
  c. It stimulates circulation, and helps prevent skin breakdown
  d. It may stimulate nutrition and hydration
  e. It promotes range of motion and may help to prevent contractions.

 2. The PCA should monitor all bony prominences, because they may easily break down and result in a decubitus or bedsore. Other areas are also susceptible to skin breakdown as well and must be monitored during care.

 3. The most effective way to prevent skin breakdown is to change the recipient’s position a minimum of every two hours. Any part of the body that touches the mattress is at risk of breakdown. These parts may include
the following:
  a. Hips
  b. Heels
  c. Elbows
  d. Buttocks
  e. Ears
  f. Ankles
  g. Knees
  h. Head

4. Symptoms of skin breakdown, decubitus/bedsores:
  a. Redness
  b. Blisters
  c. Itching
  d. Warm to touch
  e. Dark discoloration

F. Vital Signs

The measurement of temperature, pulse, respiration, and blood pressure, which indicates  functioning of body systems and numerous types of problems. The PCA should wash his/her hands before and after this procedure. The PCA should wear gloves when assessing the recipient’s temperature orally and rectally. The normal temperature is 98.6. (The instructor should demonstrate these techniques and receive a proper return demonstration from each PCA).

1. Temperature
This is measuring the amount of heat generated by the body. The normal temperature is 98.6. There are four ways to measure the temperature.

 a. Oral (O) – A thermometer is placed under the tongue. 
    i. The PCA must ensure the recipient will not bite down on the glass thermometer while it is in the recipient’s mouth.
    ii. Make sure that the recipient has not eaten or drank any food or liquid in the past five minutes, hot or cold. The liquids may give an incorrect reading of the body temperature. 
    iii. The thermometer, which is normally glass, should be held at the end and briskly shaken with a snap of the wrist to ensure the mercury is below the normal temperature of 98.6. It is preferable that the temperature be 96 degrees or below before placing the thermometer in the recipient’s mouth.
   iv. The bulb end of the thermometer is to be placed under the tongue of the recipient and left for at least three minutes. 
   v. Remove the thermometer and hold it horizontally to read the temperature. 
   vi. Temperatures over 100 degrees should be documented and reported to the RN supervisor.
   vii. Remove and discard the plastic sheath if used and clean the
thermometer with a disinfectant such as alcohol.
​
 b. Rectal (R) – A thermometer is placed in the anus;
  i. The temperature is taken rectally only when the adult is not safely able to hold a thermometer in his/her mouth.
  ii. Hold the thermometer by the end and briskly shake with a snap of the wrist, to 96 degrees or below.
  iii. Apply a plastic sheath, if available, and a small amount of lubricant to the bulb end, such as K-Y Jelly or Vaseline, before inserting in the rectum.
  iv. The thermometer should stay in place at least three minutes. 
  v. Remove the thermometer and hold it horizontally to read.
  vi. Report temperature over 100 degrees to the RN supervisor.
  vii. Remove and discard the plastic sheath if used and clean the thermometer with a disinfectant such as alcohol.

 c. Axillary (AX) – A thermometer is placed in the armpit. This is the least reliable place to check the body temperature. This is taken when the recipient is unable to safely hold a thermometer in the mouth and using
a rectal thermometer is not possible.
  i. Hold the thermometer by the end and briskly shake it with a snap of the wrist to ensure the temperature is down to 96 degrees before placing it under the recipient’s arm.
  ii. Place the thermometer under the recipient’s arm and hold it in place for a minimum of three minutes.
  iii. Remove the thermometer and hold it horizontally to read.
  iv. Report a temperature over 100 degrees to the RN supervisor.
  v. Clean the thermometer with a disinfectant such as alcohol.

  d. Tympanic – the thermometer is placed in the ear. These are generally used in doctor offices or hospitals, however it can be found in the home. These are electronic devices and work rapidly and effectively.
  i. Make sure the thermometer is turned on, if applicable.
  ii. Place a plastic sheath over the con shaped end.
  iii. Place the thermometer into the ear canal.
  iv. Within a second or two the device will beep and the temperature will be ready to read.

2. Pulse (P)
This is counting the number of times the heart beats in one minute. This procedure requires a watch with a second hand. There are two ways to check the recipient’s heart rate or pulse. 

a. Radial pulse (RP) – The PCA should wash his/her hands before starting. The PCA places his/her first two fingers (not the thumb), on the recipient’s wrist, straight down from the thumb. The normal pulse range is 60-80 beats per minute.
   i. The PCA should hold her fingers here and count how many times the heart beat or pulse is felt for a full 60 seconds.
   ii. The PCA should note if the pulse is regular or irregular.
   iii. The pulse should be reported to the RN supervisor if it is below 60 times in one minute.

​b. Apical pulse (AP) – A stethoscope is placed on the recipient’s chest,  over the heart area. The normal pulse range is 60-80 beats per minute.
  i. The PCA should count the heartbeat for a full 60 seconds. ii. The PCA should note if the pulse is regular or irregular.
  iii. The pulse should be reported to the RN supervisor if it is below 60.

3. Respirations (R)
This is the measurement of how many breaths the recipient is taking per minute. A breath is considered one inhalation and one expiration. The normal respiratory rate is 18-20 per minute.  
   a. The PCA should try not to stare at the recipient’s chest while counting
respirations; this may make the recipient inadvertently change their breathing pattern.
   b. Generally, respirations can be counted after taking the pulse. Just continue to hold the recipient’s wrist as if you were still counting the pulse, but watch the breathing pattern. This should be counted for a full minute.
   c. The PCA should document the rate and note if there were periods when no breath was taken (apnea).
   4. Blood Pressure (BP)-Measuring the pressure of the heart contracting and at rest. The normal blood pressure range is 120-140/70-80. This requires a blood pressure cuff and a stethoscope. A demonstration and a return
demonstration by each student are required.
  a. The PCA must ensure the blood pressure cuff is fully deflated before applying it to the recipient’s arm, just above the recipient’s elbow.
  b. Place the stethoscope in the bend of the elbow. Make sure the valve is closed, and pump the cuff up to 160. If the recipient complains of pain during this procedure, you have pumped the cuff up too tight.
  c. Slowly release the valve and listen for the very first beat while watching the gauge. This is the top number, or systolic. This measures the heart contracting.
  d. Continue listening for the last beat, while watching the gauge. This is the bottom number, or diastolic. This measures the heart at rest. 
  e. Record the BP and report it to the RN supervisor if it is under 110- (systolic)/60-(diastolic), or over 140/90.
  f. Note if the recipient is experiencing any adverse symptoms, such as a headache or nosebleed, which may indicate high blood pressure. Also note if the recipient is feeling dizzy or lightheaded, which may indicate
a low blood pressure. 

IV. Home Management

The PCA has many responsibilities that go beyond the health care of the recipient.
These responsibilities include the home, environment, and safety. DMAS recommends each agency request the local police department to give a class or an in-service in personal safety for the class. It is also recommended that each agency request the local fire department give a demonstration of fire safety in the home. The fire demonstration should include how and when to remove a bedbound recipient from a burning home, how to properly use a fire extinguisher, and when to call for help.

    A. Care of the Home and Personal Belongings

1. Importance of maintaining a clean environment – To promote health and prevent the spread of disease or possible injury.
2. Housekeeping duties are for the living areas of the recipient. The PCA is not a Housekeeper for other family members in the home.

   a. Scheduling of tasks – The RN supervisor will discuss with the recipient and caregiver how often the housekeeping tasks need to be performed. This information will be included in the plan of care. If the recipient
requests the task more often than authorized, permission should be obtained from the RN supervisor.
  b. Types of cleaning and laundry supplies – Each recipient has his/her own preference for what types of cleaning supplies are to be used. All supplies are to be furnished by the recipient. The PCA should ensure
proper ventilation when using cleaning supplies near the recipient.
  c. Organization of supplies and equipment – The PCA should gather all
supplies and equipment prior to beginning the cleaning of any one room or area. This will promote efficiency.
  d. Use of proper body mechanics – The PCA should ensure the use of proper body mechanics when performing any housekeeping task to prevent injury.

 3. Routine care and use of:
     a. Cleaning equipment
All equipment should be cleaned after the completion of the task.
    b. Laundry equipment
The PCA should make sure he/she knows how to use the washer and dryer. The PCA should also know what detergent /fabric softener the recipient uses. Any spillage of detergent or fabric
softener should be immediately wiped up.
   c. Kitchen equipment
The PCA should make sure he/she knows how to use the stove, oven, microwave, and dishwasher. Any spillage of food should be immediately cleaned up.

4. Emergencies related to heating equipment
The PCA should notify the caregiver immediately if there is no heat. If there is a financial problem that hinders the recipient from purchasing fuel for heat, the RN supervisor
may contact a community resource for assistance. 
   a. Water supply – The PCA should notify the caregiver and the RN supervisor if the water has been turned off. Water is essential for bathing, cooking, and proper functioning of the toilet.
   b. Electricity – The PCA should notify the caregiver and the RN supervisor if the electricity is turned off. There may be community resources able to assist the recipient.


5. Care of furniture
The PCA should dust the furniture or clean the glass on the furniture in the recipient’s immediate area, as needed.
6. Repair of clothing and linen
The primary caregiver should be notified when clothing or linen requires repairs. The PCA is not to repair these items.
7. Pest Control
If pests are observed, it should be reported to the RN supervisor who will contact the primary caregiver or will take whatever action is appropriate.
8. Care of the recipient’s environment – The Plan of Care will list what housekeeping duties are required. The PCA is required to clean up whatever was used to prepare the recipient a meal. The kitchen floor should be swept as needed, and damp mopped at least once a week. The recipient’s linen should be changed as indicated on the plan of care, and the bed should be made daily. The recipient’s bedroom should be dusted
and vacuumed at least once a week.

V. Safety and Accident Prevention in the Home

A. Common Types of Accidents
  1. Falls
  2. Burns
  3. Medication errors

B. Accident Prevention
  1. Wiping up all spills immediately can prevent falls. Any area rugs should be removed to prevent the recipient’s foot from catching on the rug. The recipient should never be left alone to get in or out of the tub by himself/herself.
  2. Burns are best prevented by the PCA assisting with all cooking unless the recipient is independent in this activity. The PCA should make sure the bath water is not too hot to the touch. 
  3. Using a pre-filled medication box can prevent medication errors. This allows a qualified person to set up the recipient’s medications for a week. 
The PCA can assist the recipient to open the box, or remind the recipient it is time to take the medication, and furnish a liquid to the recipient. If a pre-filled medication box is not used, the PCA should remind the recipient
when it is time to take a medication, and document in the Aide Record that the recipient took medications as directed.

C. Typical Hazards in the Home 
  1. Bathroom (i.e., slippery floor, hot water, towels or clothes in the floor)
  2. Kitchen (i.e., stove, hot water, sharp utensils)
  3. Stairway (i.e., no hand rail, carpet on stairs, slippery stairs)
  4. General (i.e., area rugs, extension cords, space heaters)

D. Ways to Safety-Proof the Home:
  1. Remove all area rugs
  2. Assist the recipient with all activities as needed in the kitchen
  3. Assist the recipient in the bathroom
  4. Remove all clothes and towels from the floor
  5. Ensure extension cords are not running across the path the recipient would walk
  6. Ensure there is a hand rail on the stairs and it is strongly attached to the wall
  7. Make sure the recipient is always wearing secure fitting shoes or slippers when ambulating
  8. Ensure there is adequate ventilation when a space heater is in use 
  9. Suggest that the caregiver turn the temperature down on the hot water heater, if needed and if recipient is at risk of a burn.

E. Policies and Procedures Regarding Accidents or Injuries 
1. Limitations of the PCA.
  a. The PCA should never move a recipient after a fall until the recipient has been evaluated. The recipient may break a hip or another bone from a fall, which could lead to more damage if the recipient is moved.
  b. The PCA should never clean a wound with anything other than soap and water.
  c. If the PCA needs to apply a bandage to an injury, it should not include any salve, cream, ointment, or medication.
  d. The PCA should call the RN supervisor immediately about any accidents or injuries, and 911 if needed.

2. Techniques of simple first aid

a. Treatment of abrasion
The abrasion should be cleaned with a clean  washcloth and mild soap and water. The RN supervisor should be notified; he/she will evaluate and call the doctor for orders if needed.

b. Treatment of cuts and bruises
There is no treatment for bruises. However, if the recipient bumps into something and a knot starts forming, a cold compress may be applied to relieve some of the pain.
The RN supervisor should be notified of the incident before the application of any type of compress. The incident should also be documented in the Aide Record. Cuts should be reported to the RN supervisor immediately. Some cuts may require an emergency room  visit for sutures. If the recipient should sustain a cut, apply direct pressure with a clean washcloth or towel. Do not remove the compress to see if the cut has stopped bleeding. A medical professional will remove it in the emergency room. 

​c. Treatment of first and second-degree burns – A first-degree burn will appear red. Apply cold water. Do not apply ice; ice may cause further damage. Do not apply any ointment, cream, or salve without RN supervisor instruction. A second-degree burn will blister. Apply cool water. Notify the RN supervisor of any  burns  immediately, and document in the Aide Record. Do not apply any salve, cream, ointment, and especially do not apply butter to the burn. 

d. Poisoning – Immediately notify the RN supervisor.  Do not give the recipient anything to eat or drink. There are some poisons that cause more damage if the recipient vomits. Do not induce vomiting unless specifically told to do so by the RN supervisor, a physician, 911, or the Poison Control Center.

VI. Food, Nutrition, and Meal Preparation

A. Importance of Nutrition to the Individual
1. Proper nutrition promotes health and wound healing. Research has shown that proper nutrition also alleviates some confusion in the elderly.

B. General Concept of Planning Meals
​  1. Nutritional value – Meals should consist of foods from the major food groups. There should be limited sweets at mealtime. Protein is an important part of nutrition in the elderly.
  2. Cultural and ethnic food patterns – Different cultures and religions have limitations on what types of food are permitted. Foods should be appropriate to the recipient’s culture, ethnic, and religious beliefs.
  3. Individual likes and dislikes – These must be observed. The recipient should have input into the meal planning process with likes and dislikes of the recipient respected. Appropriate substitutes may be found.
  4. Budgetary limitations – Most recipients are on a fixed income, and therefore are limited to what types of food they can buy. If it appears the recipient is not buying nutritious foods due to income, the RN supervisor
should be notified; there might be a community resource that can assist with groceries.

C. Special Considerations of Normal Diet
  1. Elderly – The recipient may be on a normal diet; most elderly persons benefit from six small meals rather than three large meals. The recipient’s ability to chew food must also be considered. Food may need to be
chopped or pureed to prevent choking while eating. 
  2. Illness – The recipient may be on a normal diet but may not be able to tolerate foods because of illness. It would be appropriate to provide the recipient with what he/she can tolerate.

D. Special Considerations in Preparation of Special Diets
  1. Importance of Special diets – If the recipient is on a special diet, it must be observed as closely as possible. A special diet may be used for someone who has diabetes, kidney failure, severe burns, respiratory problems, ulcers, or circulatory problems.
  2. Common types of special diets – Diabetics may be on a diet that limits foods that convert to sugars. Someone with ulcers may need a bland diet to prevent stomach discomfort. Someone with a history of blood clots may need foods that are low in vitamin K, which works against blood thinners.
Recipients who have kidney failure may have frequent changes to their dietary requirements, especially if they are receiving dialysis.
  3. Policy and procedure regarding the aide’s activities in relation to special diets – The PCA may not decide if a recipient needs a special diet and impose such a diet. The PCA’s responsibility is to be aware of the dietary
requirements of the recipient and prepare food as required. If the PCA does not understand the dietary requirements, he/she should notify the RN supervisor immediately for clarification.

E. Food Purchasing and Preparation

 1. Buying guides
  a. The PCA should buy brands of foods that the recipient prefers.
  b. The PCA should buy the size and quantity the recipient prefers. The PCA should not buy the largest size available just because it may be cheaper. There may be storage issues and the food may go bad before
the recipient can use it all. 

2. Techniques of food preparation
a. Must be prepared with the recipient’s dietary requirements in mind.
b. Should be prepared with limited seasonings, unless specifically
requested by the recipient.
c. If there are no dietary restrictions, food should be prepared in the
manner the recipient requests.
F. Food Storage and Sanitation
   1. Foods should be properly stored in the refrigerator, as needed, such as milk, butter, meats that will be used in the next three days.
   2. Meats and other normally refrigerated foods that will not be used in the next three days should be placed in the freezer.
   3. The PCA should wash his/her hands before touching any food. 
   4. To thaw meats or other items from the freezer, place the items in the refrigerator until they are usable. Do not set food items out on the counter to thaw.

VII. Documentation Requirements for Medicaid Recipients

A. Aide Record
All Medicaid Aide Records (DMAS-90) are to be completed at the time the service is provided to the recipient. Do not fill them out in advance. The Department of Medical Assistance Services (DMAS) requires the following documentation on all Aide Records:
​
  1. Recipient’s name
  2. The complete date for each day worked – include the month, day, and year, (example: 05/25/24).
  3. Place check marks (v) for each service that was provided to the recipient.

Only provide services that are checked on the recipient’s Plan of Care. If you are checking a task that is not marked on the plan of care, you must document the reason it was done. If you are not checking a task marked
on the plan of care, you must document why you did not do it.

  4. The PCA arrival time, including a.m. or p.m.
  5. The PCA departure time, including a.m. or p.m.
  6. The total number of hours provided to the recipient for the day
  7. Weekly comments that give a picture of the recipient’s response to services provided during the week include any complaints, and any important changes. Document the recipient’s appetite, complaints of pain,
if they stay in bed but they are usually up, if you notice any marks on the skin while bathing, and information that might be useful to the RN supervisor.
  8. The recipient or caregiver’s signature
  9. The signature of the PCA
  10. The PCA should never use white out to cover over errors. Mark one line through the error, initial and date the change, and re-write the correct information.

Definitions

Activities of daily living (ADL) – Personal care tasks such as bathing, dressing, toileting, dressing, eating, and ambulating.

Bathing – The process of washing the body or body parts, including getting to or obtaining the bathing water and/or equipment whether this is in the bed, shower or tub.

Body Mechanics – Process of using proper body alignment when moving a recipient to prevent injury to the recipient and the personal care aide.

Bowel movement – The physiological process of emptying feces from the bowel.

Complete bath – Bathing the recipient from head to toe, whether in the shower, tub, or bed. Condom catheter – A condom type covering over the penis to collect urine through a tube into a collection bag.

Decubitus – A sore that usually develops over a bony part of the body. It is also known as a bedsore or a pressure sore.

Department of Medical Assistance Services (DMAS) – Medicaid of Virginia

Dependent – Unable to care for one’s self. Someone must perform care for the recipient.

Dressing – The process of putting on, fastening, or taking off all items of clothing, braces, and artificial limbs that are worn daily by the recipient. This includes obtaining and replacing the items from a storage area in the immediate environment.

Eating/Feeding – The process of getting food by various means from the receptacle (plate, cup, bowl, glass, and bottle) into the body.

Extremity – Refers to arms or legs. Foley Catheter – a tube in the urethra to collect urine. Grooming – The process of brushing the recipient’s teeth, cleaning dentures, combing or brushing hair, and shaving.

Housekeeping – Cleaning of the living areas used by the recipient. Such as cleaning the kitchen after preparing a meal for the recipient, making the recipient’s bed, changing the linens, mopping the floor or cleaning the bathroom if the recipient uses it. This also includes washing the recipient’s laundry as needed.

Nothing per oral (NPO) – Nothing by mouth includes food, drinks, and medications.

Partial bath – Bathing only parts of the recipient rather than the entire body.

Personal Care – Services provided by a Medicaid provider agency to assist the recipient with activities of daily living.

Personal Care Aide (PCA) – Someone who has taken and passed a 40 hour training program with emphasis on how to provide personal care to recipients in the home environment

Plan of Care (POC) – Those activities and services that a recipient needs. A form used by the provider agency to develop a plan for the number of hours, days of the week, and the tasks the personal care aide is to assist with.

Respite Care – A service provided to the live- in primary caregiver, to give him/her relief in the 24-hour responsibility of care.

Recipient – A person who meets the Virginia Medicaid eligibility criteria requirements and is receiving or has received medicaid services.

Supervision – A block of time specified on the plan of care to allow the PCA to be with the recipient to ensure safety. This is for a recipient who would not be capable of calling for assistance and therefore should not be left unattended.

Toileting – The process of getting to and from the toilet room for elimination of feces and urine, transferring on and off the toilet, cleaning one’s self after elimination, and adjusting clothes.

Transferring – The process of moving horizontally and/or vertically between the bed, chair, wheelchair, and/or stretcher.

Universal (Standard) precautions – The technique of protecting oneself from the spread of infectious disease while providing care to the recipient and protecting the recipient from contracting a disease from the personal care provider.

Urination – The physiological process of emptying urine from the bladder.

Vital signs – blood pressure, pulse, temperature, and respirations. (BP, T, P, R)
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