CNA Student Application

Affidavit

The Affiant, (Name), states the following under oath and based upon personal knowledge:

Elder Justice Act and sign off (EJA)

PURPOSE/REQUIRED STANDARDS:

To comply with the (EJA) regarding reporting a reasonable suspicion of a crime under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act (ACA), 6703 (b)(3).

Reporting Requirements:

1. When someone suspects a crime has occurred against a resident in a facility, they must report the incident to State Survey Agency and local law enforcement.
2. Report a suspicion of a crime to the State Survey Agency and at least one local law enforcement entity within a 2 hour time frame by e-mail, fax or telephone.  The individual does not need to determine which local law enforcement entity to report a suspicion of a crime; but must report to at least one local law enforcement entity.  This will meet the individual’s obligation to report.
3. Report the same incident as a single complaint or multiple individuals may file a single report that includes information about the suspected crime from each staff person.
4. If, after a report is made regarding a particular incident, the original report may be supplemented by additional people that become aware of the same incident.  The supplemental information may be added to the form and should include the name of the additional people along with the date and time of their awareness of such incident or suspicion of a crime.  However, in no way will a single or multiple person report preclude an individual from reporting separately.  Either an individual or joint report will meet the individual’s obligation to report.
5. If the reportable event results in a serious bodily injury, report the suspicion immediately, but not later than 2 hours after forming the suspicion.
6. If the reportable event does not result in serious bodily injury, report the suspicion immediately to the Administrator and Legacy CNA Training Program Director, who shall file a report within 24 hours.
7. Failure to report in the required time frames may result in disciplinary action, including up to termination.
8. Report the suspicion of an incident to the Administrator and Legacy CNA Training Program Director immediately per Abuse Reporting policy.

ELDER JUSTICE ACT

IF YOU HAVE REASONABLE SUSPICION THAT A CRIME HAS OCCURRED AGAINST A RESIDENT OR PERSON RECEIVING CARE AT THIS FACILITY, FEDERAL LAW REQUIRES THAT YOU REPORT YOUR SUSPICION DIRECTLY TO BOTH LAW ENFORCEMENT AND THE STATE SURVEY AGENCY.

If you believe the crime involves serious bodily injury including criminal sexual abuse to the resident, you must report it immediately, but no later than 2 hours after forming the suspicion.

OR

If the crime does not appear to cause serious bodily injury to the resident you must report it within 24 hours after forming the suspicion.

WHO MUST REPORT

• Individuals who must comply with this law are: owner(s), operators, employees, managers, agents or contractors of this LTC facility. This law applies to the above individuals associated with nursing facilities, skilled nursing facilities, hospices that provide services in LTC facilities, and Intermediate Care Facilities for the Mentally Retarded (ICFs/MR).

PENALTIES FOR NOT REPORTING

• Individuals – who fail to report, are subject to a civil monetary penalty of up to $300,000 and possible exclusion from participation in any Federal health care program as an “excluded individual.”

Reporting a reasonable suspicion of a crime against a resident

Contact Information for Reporting

Each employee, agent, contractor, manager, owner, or operator of this facility is individually responsible to report the reasonable suspicion of a crime against a resident.

Reports of the reasonable suspicion of a crime against a resident of this facility must be made to the Indiana State Department of Health and to a local law enforcement agency within 2 hours if there is serious bodily injury.  Otherwise, it must be reported within 24 hours.

The following is contact information for the reporting of a reasonable suspicion of a crime against a resident:

Legacy Medical Academy – Student Code of Conduct

I understand that I must comply with the following standards in order to successfully complete the course:

1. Professional Conduct
   • Treat all instructors, classmates, patients, and staff with respect.
   • Unprofessional behavior, including cursing, disrespect, or inappropriate outbursts, is not permitted.
   • Follow all classroom and clinical guidelines as directed by the instructor.
2. Classroom and Clinical Etiquette
   • No cell phone use during class or clinical time.
   • Sleeping during class or clinical is not permitted.
   • Pay attention and avoid disruptions while the instructor is teaching.
3. Dress Code
   • Scrubs must be worn, along with a white t-shirt and white or black tennis shoes.
   • A name tag must be visible at all times.
   • Hair must be pulled back and away from the face.
   • No jewelry is permitted.
   • Nails must be neatly trimmed, no longer than fingertip length. Clear or light-colored polish is acceptable.
4. Preparedness
   • Students must bring required materials to each class and clinical session, including the RCP book.
5. Attendance and Participation
   • Students must attend all scheduled classes and clinical sessions.
   • Absences will only be excused under approved circumstances, such as illness or emergency, and must be communicated promptly to the instructor.
   • Excessive absences or tardiness may result in disciplinary action or removal from the program.
   • Active participation in both classroom and clinical activities is required.
6. Confidentiality and HIPAA
   • Students must protect the privacy and confidentiality of all patients, staff, and facilities encountered during clinical training.
   • Sharing or discussing patient information outside of the clinical setting is strictly prohibited.
   • Any violation of confidentiality or HIPAA regulations may result in disciplinary action, up to and including removal from the program.
7. Social Media Policy
   • Students may not post or share photos, videos, or information from the classroom, clinical sites, or patients on any social media platform.
   • Posts that reference Legacy Medical Academy, its staff, or students must be professional and respectful.
   • Any social media activity that violates confidentiality, HIPAA standards, or reflects unprofessional conduct may result in disciplinary action, up to and including removal from the program.

By signing below, I acknowledge that I have read, understand, and agree to abide by the Code of Conduct. I understand that failure to comply may result in disciplinary action, up to and including removal from the program.

Student Agreement

Certified Nurse Aide (CNA) Training Program – Student Agreement

This Agreement is made between Legacy Medical Academy, LLC (hereinafter referred to as “Legacy”) and myself (hereinafter referred to as “Student”).

This Agreement is in force for 120 days from the class start date.

1. Program Commitment & Regulatory Framework

   Legacy agrees to provide the Student with the 105 hour Nurse Aide Training Program, which includes:

   • ≥ 30 hours of classroom instruction aligned to the Indiana Department of Health (IDOH) Core Curriculum; and
   • ≥ 75 hours of clinical/lab experience at an approved facility under 410 IAC 16.23.114 (Indiana rules for Nurse Aide Training Programs).

   Clinical Site Requirements. Clinical sites may impose additional conditions. For example, some clinical sites may require a COVID19 vaccination or an approved medical/religious exemption. Students must comply with all site rules to participate. As visitors, we must abide by all clinical site policies at all times.

   Equal Opportunity. Legacy is an equal opportunity training entity and does not discriminate on the basis of race, color, age, sex, sexual orientation or gender identity, national origin, creed, or disability.

2. Tuition Coverage, Costs & Student Responsibilities

   What Tuition Includes (All Students): Required texts, supplies, uniforms, and liability insurance covering errors and omissions during approved clinical activities.

   Background Checks:

   • Adults (18+): A state criminal background check is required and coordinated by Legacy.
   • High School Students (Minors): A limited criminal background check is required and will be coordinated by Legacy.

   Health Requirements (All Students):

   • TB screening: 2step TB test or QuantiFERONTB Gold blood draw (chest X-ray if positive).
   • Physical examination: Must indicate ability to safely perform CNA duties.
   • Timing: All health requirements must be completed by the due date to remain eligible.

   Cost Responsibility:

   • High School Students: Program costs are generally covered through tuition arrangements made by the school/district. High school students are not personally responsible for program related costs (e.g., background checks, physical/TB testing, uniforms, state exam fees).
   • Adult Students: Program tuition covers all core costs including scrubs, background check, physical/TB voucher, and state exam fees. Students are responsible only for personal items not included in tuition (e.g., personal insurance).

   Uniforms:

   • Scrubs are provided by Legacy for all students as part of tuition. Students are responsible for providing appropriate closed toe shoes, socks, and a plain undershirt. Hair must be tied back; minimal jewelry only (small studs acceptable); no perfume; nails neat, clean, and of reasonable length.

3. Criteria for Completion & Academic Standards

   To successfully complete the program and remain eligible for state testing, Students must:

   1. Meet Attendance Requirements: Complete ≥ 30 classroom hours and ≥ 75 clinical/lab hours.
      • FirstDay/Clinical Absences: Absence on the first day of class or the first two days of clinical may result in removal from the current cohort. Reentry is at Legacy’s discretion and space availability.
   2. Tardiness & Reporting: Attendance and timeliness are critical. Report tardiness greater than 10 minutes using the phone number provided by Legacy. NoCall/NoShow results in dismissal and forfeiture of tuition/fees.
   3. Coursework: Read assigned materials and submit worksheets on time.
   4. Assessments: Achieve ≥ 70% on topic quizzes.
      • High School Students: Failing six (6) quizzes jeopardizes continuation. Progressive discipline (verbal warning → written warning → removal) may also be applied, with removal from the program possible.
      • Adult Students: Failing the same quiz three (3) times results in removal from the class; reinstatement, if offered, requires a $200 reinstatement fee.
   5. Skills Competency: Demonstrate 100% accuracy on all Resident Care Procedures (RCPs) as required by IDOH Administrative Standards.
   6. Scope of Duties: Do not perform any CNA tasks for which you have not been trained and validated as competent.
   7. Injury/Medical Status: If any injury or condition (real or suspected) arises during training, the Student must provide a physician’s full duty release confirming ability to bend, stoop, push, pull, lift, and walk without restriction. Students must not be under the influence of substances that could impair performance.

4. Professional Conduct & Learning Environment

   Prohibited Behaviors (All Students):

   • Use of alcohol, illegal drugs, or nonprescribed controlled substances during class/clinical, or being under their influence.
   • Fighting, swearing, cursing, theft, harassment/abuse (verbal, emotional, physical, or sexual), possession of weapons.
   • Disruptive conduct (including sleeping in class/clinical or interrupting instruction).
   • Use of cell phones or other recording devices in classroom/clinical areas, except with express instructor authorization for instructional or accessibility needs.
   • Children are not permitted in classroom or clinical settings.

   Dress & PPE: Students must be properly dressed for all sessions and follow all facility PPE policies, Standard Precautions, and Resident Rights.

5. Discipline & Conflict Resolution

   • Legacy may use progressive discipline, which can include verbal counseling, written counseling, written warning, or termination from the Program, depending on severity.
   • Disciplinary actions are documented in the Student file; copies are available upon request.
   • High School Students (Minors): Parents/guardians may be notified and signatures may be required on disciplinary documents.
   • The Program Director has final authority to terminate a Student or to refuse submission of a testing application at their sole discretion if standards are not upheld.
   • Dismissal for violation of this Agreement results in loss of all tuition and fees paid.

6. Testing & Certification

   • Legacy offers optional, no cost tutoring and test prep sessions (written and/or skills) prior to the state exam.
   • Cancellations: Students must notify Legacy at 574-239-8973 at least 72 hours in advance to cancel or reschedule a test. Failure to do so results in forfeiture of testing fees, unless an excused absence is documented and approved by the state testing entity.
   • Applications: Once submitted, testing applications become the property of the State Testing Entity. Applications may be withheld only for substantiated complaints of abuse, misappropriation, or neglect pending IDOH investigation.
   • 120 Day Window: If a Student declines to test within 120 days of the start of training or forfeits fees due to late cancellation/noshow, they may request their original testing application and assume responsibility for remitting fees and scheduling with the State Testing Entity.
   • Certificate of Course Completion is issued only after Legacy receives documentation of successful completion of the state exams, as required by IDOH.

7. Financial Liability & Reinstatement

   • High School Students: All program costs (tuition, uniforms, background checks, physical/TB testing, and state exam fees) are covered through tuition arrangements made by the school/district. High school students, who are enrolled in a program at their high school, are not personally responsible for program related financial obligations.
   • Adult Students: Once registered and assigned a class date:
     • A $200 reinstatement fee is required if requesting a class date change, if dismissed for attendance/tardiness, or if reinstated after failing assessments, when reinstatement is permitted.
     • Students are responsible only for personal items not included in tuition (e.g., personal insurance).

8. Liability & Safety

   Liability insurance for errors and omissions at the clinical site is included in tuition. Legacy and the clinical facility bear no liability for accident, theft, or injury to the Student or the Student’s property. Students are encouraged to maintain personal health/accident insurance for nonclinical liability needs.

9. Acknowledgment & Signatures

   I have read this Agreement, had an opportunity to ask questions, and agree to abide by its terms.