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I-1163: Evaluating the Relevance of Required Training for Long-Term Care Workers

March 1, 2022 Download this report as a PDF »

Long-term care workers support people who need extended care due to age or disability. This care can help people preserve their independence and avoid institutional care. It can allow them to sustain the best possible level of functioning for as long as possible.

Washington law requires certain groups of long-term care workers to meet minimum training requirements. The Department of Social and Health Services (DSHS) oversees this training program. Some long-term care workers, known as “individual providers,” must take 75 hours of training to provide paid care to Medicaid-eligible clients in the clients’ own homes. The training’s goal: equip caregivers with the knowledge and skills needed to meet the needs of their client population.

Washington’s training is highly regarded overall. Some sources cite the state as “an exemplar,” leading the way in personal care training standards. However, some stakeholders question the training’s relevance to certain groups of clients. This audit examined how Washington could make the required 75-hour training for individual providers more relevant to clients with complex or special care needs. To do this, it sought the views and opinions of both caregivers and clients alike.

Read a two-page summary of the report.

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 Report Credits Report Number 1029902

State Auditor’s Office contacts

State Auditor Pat McCarthy

Scott Frank – Director of Performance and IT Audit

Justin Stowe – Assistant Director of Performance Audit

Tania Fleming – Principal Performance Auditor

Patrick Anderson – Lead Performance Auditor

Performance Audit Team
Carly Schmidt, Lisa Weber, Hannah Yourd

Kathleen Cooper – Director of Communications

Key results

We conducted surveys of both individual providers and clients, reaching providers who had been recently trained and their clients. Both groups indicated they were happy with the training and how it helped providers meet the needs of their clients.

The audit concluded that the training program for providers was clearly strong. However, it also noted areas for improvement. Specifically, some providers have expressed a desire to receive training in first aid and CPR. (Other long-term care providers in other settings must take that training.) In addition, some clients felt their caregivers’ training lacked specialty knowledge in certain areas.

We recognized there are challenges in making a standardized training more relevant to the needs of a diverse client and provider population. The current training program could likely benefit from more flexibility in population-specific options. To further enhance the training’s relevance over time, we recommend DSHS develop an ongoing process to assess alignment between training content and the needs of clients, and adjust the training requirements accordingly.


A 2008 voter-approved Initiative required long-term care workers to be certified by the Washington State Department of Health as “home care aides” after completing specific training and passing an examination. Initiative 1163, passed in 2011, advanced the date by which the state had to put the requirements into effect. It also mandated annual performance audits on in-home long-term care.

There are five earlier audits in this series:

Providers and clients broadly satisfied

The audit found, through separate surveys, that providers and clients were generally satisfied with the state’s required training.

The provider survey asked:

  • Did the training help them feel confident about meeting the needs of their clients
  • Which aspects of required training that they found most and least useful or relevant
  • Key topics and skills they believe the training could have better taught to help prepare them to meet clients’ needs

Most providers were satisfied with the training. They also said the training helped them feel confident about meeting the needs of their clients.

We also sought the views of clients. Most interviewees (93 percent) said their provider met their needs. Clients said their providers did a good job helping them with a range of personal care needs, such as dressing, bathing and meal preparation. They often offered very positive feedback about their provider, with many describing them as conscientious, respectful, professional or good listeners.

Nearly 90 percent said that their provider helps them do things the way they wanted them done. This suggests that many providers incorporate client preferences into their caregiving activities. And 80 percent answered “yes” when asked if they felt their provider had the right training to meet their needs.

Some noted training needs

Despite general satisfaction with the training, some providers and clients thought it could be improved. A small percentage of providers and clients were dissatisfied with the training. A larger percentage felt there the training had room for improvement. Training that lacks relevance to certain client needs can mean that clients, their families and their providers must take on the responsibility of training.

Some providers and clients mentioned wanting better training in certain population-specific topics. Suggestions for such areas included:

  • Mental health
  • Managing challenging behaviors
  • Developmental disabilities
  • Caring for children

DSHS faces challenges in making standardized training more relevant to the needs of all members of a diverse client and provider population. Nonetheless, we considered opportunities to further enhance the training’s relevance. For example, offering trainees greater flexibility in selecting population-specific training could make it more relevant to diverse client needs.

Desire for first aid and CPR training

In Washington, other long-term care workers with the same scope of practice as individual providers receive training in first aid and CPR. Some long-term care training models in other states also require or include first aid and CPR. However, state regulations do not require training in first air or CPR for individual providers.

DSHS officials explained that home care aides are not medical professionals. As such, it does not consider first aid and CPR within the scope of an individual provider’s job. For this reason, it does not require either skill. Officials also mentioned numerous challenges and risks associated with training providers in first aid and CPR, including costs and increased liability.

Nonetheless, some providers felt such training would prepare them to help their clients until emergency services arrived. Our survey asked a sample of providers to list topics or skills they wish had been included or better covered in the training to give them more confidence in an emergency. About 40 percent (21 of 53) of them said “first aid and/or CPR.”

Aligning training and client needs

State law requires DSHS to implement a system of quality improvement for long-term care services. It also directs the agency to focus on customer satisfaction and outcomes. However, DSHS lacked a robust process for regularly assessing how well training content aligns with client needs. Furthermore, while DSHS does review the curricula when it approves the training, it does not explicitly review it for relevance to client needs.

Establishing such a process is consistent with the stated goal of DSHS’ quality improvement system. In addition, robust evaluation of content would ensure the training is more relevant to the full range of its providers and clients going forward.


We recommended DSHS better align the first aid and CPR training requirements for individual providers with those of other providers in Washington by offering training in first aid and/or CPR. We also recommended the agency improve the relevance of the training by establishing a more robust process for ensuring alignment between training content and client needs.