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Agenda Item #15.B.1 TAT Qfl"CAl.lfl"ORNIACl e aDEPARTMENT OF CONSUMER AFFAIRSBUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GOVERNOR EDMUND G. BROWN JR.BOARD OF VOCATIONAL NURSING & PSYCHIATRIC TECHNICIANS2535 Capitol Oaks Drive, Suite 205, Sacramento, CA 95833-2945Phone (916) 263-7800 Fax (916) 263-7855 Web www.bvnpt.ca.govDATE:November 16, 2018TO:Board MembersFROM:Faye Silverman, RN, MSN/Ed, PHN, WOCNNursing Education ConsultantSUBJECT:Pasadena City College Vocational Nursing Program – Consideration ofProvisional Approval (Director: Carla Christensen – Pasadena, Los Angeles County,Community College).STAFF SUMMARY:The Board initially placed the program on provisional approval on November 4, 2016,through November 30, 2018, due to noncompliance with regulatory requirements relativeto program pass rates on the licensure examination.RECOMMENDATIONS:1. Extend Pasadena City College, Vocational Nursing Program’s provisional approval fora one year period beginning November 16, 2018, and direct staff to issue a certificateaccordingly.2. Continue the program’s requirement to provide no less than one instructor for everyten students in clinical experiences.3. Require program to submit all documentation to clear the seven violations byDecember 1, 2018.4. Require the program to admit no additional classes without prior approval by the Board.5. Require the program, when requesting approval to admit students, to:a. Submit all documentation in final form, using the forms provided by theBoard, no later than two months prior to the requested start date for theclass.b. Provide documentation that adequate resources, i.e. faculty and facilities,are available to support each admitted class of students.
Agenda Item #15.B.1c. Ensure that the program maintains an average annual pass rate that iscompliant with Section 2530(l) of the Vocational Nursing Rules andRegulations.6. Continue to require the program to comply with all approval standards in Article 4 ofthe Vocational Nursing Practice Act, commencing at Business and Professions CodeSection 2880, and Article 5 of the California Code of Regulations, Title 16.History of Prior Board Actions(See Attachment A, History of Board Actions)EnrollmentPasadena City College, Vocational Nursing Program offers a 47 – week course ofinstruction. The program is required to obtain Board approval prior to the admission ofeach class.The following table represents current and projected student enrollment based on currentand projected class starts and completions. The table indicates a maximum enrollment of20 students for the period August 2017 through August 2019.ENROLLMENT DATACLASS t orCompletedTotalEnrolled201616-1616 – 16 0190 19 198/28/17(*8/16/18)8/16/18(Class 8/17)8/27/18Unapproved Class19(*8/15/19)*Indicates projected graduation dateLicensing Examination StatisticsThe following statistics, furnished by Pearson Vue and published by the National Councilof State Boards of Nursing as “Jurisdictional Summary of All First-Time CandidatesEducated in Member Board Jurisdiction” for the period October 2016 through September2018, specify the pass percentage rates for graduates of the Pasadena City CollegeVocational Nursing Program on the National Council Licensure Examination forPractical/Vocational Nurses (NCLEX-PN ).2
Agenda Item #15.B.1NCLEX-PN Licensure Examination DataQuarterOct – Dec 2016Jan – Mar 2017Apr – Jun 2017Jul – Sep 2017Oct – Dec 2017Jan – Mar 2018Apr – Jun 2018Jul – Sep 2018Quarterly StatisticsAnnual Statistics*##%StateProgramStateVarianceCandidates Passed Passed Average AverageAveragefrom StateQuarterly AnnualAnnualAveragePass Rate Pass RatePass RateAnnual Pass[CCR §2530(l)]Rate121192%70%92%74% 183267%72%87%73% 14No Candidates Tested68%87%74% 13No Candidates Tested74%87%71% 16121083%69%80%71% 93267%81%80%73% 7No Candidates Tested79%80%76% 4No Candidates Tested77%80%76% 4*The Annual Pass Rate changes every quarter. It is calculated by dividing the number of candidates who passedduring the current and previous three-quarters by the number of candidates who tested during the same period. Ifno data is available for the relevant period, the statistic is carried over from the last quarter for which data is available.California Code of Regulations § 2530(l) states:“The program shall maintain a yearly average minimum pass rate on thelicensure examination that does not fall below 10 percentage points of thestate average pass rate for first time candidates of approved vocationalnursing schools for the same period.”Based on the most recent data available (July through September 2018), the program’saverage annual pass rate is 80%. The California average annual pass rate for graduatesfrom approved vocational nursing programs who took the NCLEX-PN for the first time is76%. The pass rate for the National Career College Vocational Nursing Program is fourpercentage points above the state average annual pass rate.Faculty and FacilitiesSection 2534(d) of the Vocational Nursing Rules and Regulations states:"For supervision of clinical experience, there shall be a maximum of 15students for each instructor."However, based on the Board’s November 2016 decision, the program is required toprovide no less than one instructor for every ten students in clinical classes.The current number of Board-approved faculty is four, including the program director. Thedirector and all instructors are approved to teach in the clinical area.Based on a maximum enrollment of 19 students, two instructors are required for clinicalsupervision. The utilization of faculty at clinical facilities is such that clinical instruction iscovered adequately.3
Agenda Item #15.B.1Section 2534(b) of the Vocational Nursing Rules and Regulations states:“Schools shall have clinical facilities adequate as to number, type, andvariety of patients treated, to provide clinical experience for all students inthe areas specified by Section 2533. There must be available for studentassignment, an adequate daily census of patients to afford a variety ofclinical experiences consistent with competency-based objectives andtheory being taught.”The program has sufficient clinical facilities to afford the number, type and variety ofpatients that will provide clinical experience consistent with competency-based objectivesand theory being taught for current and proposed students.Report of Unannounced visitOn October 15, 2018, a representative of the Board of Vocational Nursing andPsychiatric Technicians (Board) made an unannounced site visit to Pasadena CityCollege Vocational Nursing Program. During the one-day visit, the representativeassessed the physical resources for the program, inspected records for recentlygraduated and currently-enrolled students, and facilitated discussions with a cohortof students and the program director.The campus has adequate parking for all students, faculty and staff. The campus is clean.The building(s) are separate from the main campus. All the Health Science programs weremoved to a satellite location about three miles from main campus to repair the originalbuilding for earthquake preparedness. There is a main building and several trailers. Theclassrooms and labs are in the main building and the offices and storage is located in thetrailers. The campus also has an outside area for students to take a break from class.ResourcesLibraryThe Pasadena City College library is located on the main campus and was not observed.The vocational nursing students have access to an online library 24 hours per day andseven days per week. That online library contains a collection of nursing periodicalsubscriptions and other Cumulative Index of Nursing and Allied Health Literature (CINAHL)materials. On the main campus, students have access to a library and study space. Thesatellite campus has computers and study space.4
Agenda Item #15.B.1Computer LabsThe program has two portable computer labs that students and faculty may access forlecture, testing, remediation and tutoring. Each cart two hold 20 computers. Eachcomputer has access to all the college’s electronic data bases and resources, includingthe online library.ClassroomsThere is one dedicated classroom for the vocational nursing program on the second floorand the program has access to additional classrooms and computer rooms on the otherfloors. The class room contains a white board and a smart board, LCD projector, podiumwith computer and a DVD player. The student seating with desks is adequate for up to 32students. There is lecture hall on the first floor which can accommodate up to 60 students.This lecture hall can also be used for a large room for CPR where more space is needed.Skills labsThe program’s skills lab is set up to simulate a realistic hospital ward with a medicationcart, seven beds, each with a low or medium fidelity mannequin. Each patient area isequipped with a hospital bedside table, privacy curtain and simulated headboardcontaining oxygen, air, and suction. The skills labs have two sinks in each lab. Thereis storage room with supplies for the students. Extra baby mannequins were noted inthe storage room.5
Agenda Item #15.B.1Faculty SuppliesThe campus has a designated faculty room with a desk, computer, phone, and officesupplies provided for each instructor. There is a copy machine available to all facultymembers.Faculty InterviewsThe interviewed faculty member stated that she enjoys working for Pasadena CityCollege. She stated that the school has been very supportive of the vocational nursingprogram. She went on to say that the simulation lab for the RN program was beingexpanded to accommodate the VN program. They will be submitting paper work soonto get approval for this.Student InterviewsDuring the student interviews, student stated that they would recommend the programto friends and family members. The only complaint voiced by student’s is that the schoolhad asked the students to purchase an online charting system which has not been fullyimplemented. There were also a few extra books which were required to purchase that6
Agenda Item #15.B.1they have not used. This class is in Term 1 and some of these items are used throughoutthe program.Other Considerations:During the October 15, 2018, unannounced site visit to Pasadena City College sevenviolations were identified during the program inspection.Section 2526(a) (11) of the Vocational Nursing Rules and Regulations states:“The institution shall apply to the Board for approval. Writtendocumentation shall be prepared by the director and shall include:. . . (11) Evaluation methodology of clinical facilities.”Violation # 1The Program does have a set policy for Evaluation methodology of clinicalfacilities. The program does not have written documentation. Clinical sitevisits have been made but the documentation does not reflect accuratelythe number of visits which were completed.Section 2526(a) (12) of the Vocational Nursing Rules and Regulations states:“The institution shall apply to the Board for approval. Written documentationshall be prepared by the director and shall include: (12) Admission criteria.Section 2526(a) (13) of the Vocational Nursing Rules and Regulations states:“The institution shall apply to the Board for approval. Written documentationshall be prepared by the director and shall include: (13) Screening and selection criteria.Violation # 2Board records confirm the program has approved policies for admission,screening and selection of applicants to the program. Examination ofstudent files during the program inspection indicate that some studentswho scored below the stated minimum of the entrance exam as listed inthe college admissions catalog were admitted to the program. It wasidentified that three students had taken the entrance test and not met theminimum of 58 but were admitted into the program in spite of not passingthe admission examination.Section 2530(b) of the Vocational Nursing Rules and Regulations states:“Regular faculty meetings shall be held. Minutes shall be available to the Board'srepresentative.”7
Agenda Item #15.B.1Violation # 3Per the interview with the Program Director “Our faculty meetings are tobe held every month.” The Program Director went on to say that theprogram has more informal meetings, than formal meetings. Theprogram director was informed that while the Vocational Nursing Rulesand Regulations do not mandate how often regular faculty meetings areheld, the regulations do require that the program follows their own Boardapproved policies. When asked if the program had documentation ofboth formal and informal faculty meetings, the program director stated“some but not all.” The program director went on to say, “They had manyinformal meetings but they were not always documented.”Section 2530(f) of the Vocational Nursing Rules and Regulations states:“The program’s instructional plan shall be available to all faculty.”Violation # 4The program did not provide documentation that all faculty have accessto the program’s instructional plan. Currently, per the program director,all staff members (Theory and Clinical) do not have copies of theinstructional plan.Section 2530(h) of the Vocational Nursing Rules and Regulations states:“Each school shall have an attendance policy approved by the Board. Thepolicy shall include but not be limited to, criteria for attendance and thespecific course objectives for which make-up time is required. Acceptablemethods for make-up include:(1)(2)Violation # 5Theory: case studies, independent study, written examination,attendance at seminars or workshops, auto-tutorial laboratory, andresearch reports.Clinical: performance evaluation in skills laboratory or additionaltime in the clinical area with clients/patients.”Board records substantiate that the program has an approvedattendance policy.However, based on the lack of a clearattendance/remediation tracking system it was determined that theprogram has failed to follow the approved policy.During the program inspection on October 15, 2018, the programdirector stated, “that the students who had missed clinical and or skillslabs were making up the day(s)”. The program director went on to statethat students were completing case studies for clinical/skills lab make up.The program director stated she “tracked if each student had made upthe hours, but did not have documentation to reflect make up hours had8
Agenda Item #15.B.1been completed.” No clear attendance tracking system was produced bythe director.The attendance policy listed in the school catalog does not include therequired aspects of acceptable methods of make-up and does notconform to regulatory attendance policy requirements.Section 2530(i) of the Vocational Nursing Rules and Regulations states:“The school shall evaluate student performance to determine the need forremediation or removal from the program.”Violation # 6The program has a remediation policy. There are no documents instudent files to indicate that remediation is initiated with assignments andgoals students must meet. No documentation of re-evaluation of studentprogress was documented.Section 2530 (k) of the Vocational Nursing Rules and Regulations states:“The program shall have prior Board approval to increase the number ofstudents per class and/or increase the frequency of admission ofclasses ”Violation # 7 On November 4, 2016, the Board initially placed the program on provisionalapproval for the period of November 4, 2016, through November 30, 2018due to noncompliance with regulatory requirements relative to programpass rates on the licensure examination. At that time, the program’sapproval for ongoing admissions was rescinded and the program wasrequired to obtain Board approval prior to the admission of each class.Board records substantiate the Executive Officer’s decision of January23, 2017, approving the program’s admission of 20 students on August28, 2017 only, to replace students who graduated on August 22, 201718, 2009.Paperwork submitted by the program director in preparation forconsideration of provisional approval for the November 2018 Boardmeeting indicated a class had been started without prior permission. Thatclass began on August 27, 2018, and is scheduled to graduate August 15,2019. Currently, the program has 19 students in this non-approved cohort.Recommendations:1. Extend Pasadena City College, Vocational Nursing Program’s provisional approval fora one year period beginning November 16, 2018, and direct staff to issue a certificateaccordingly.9
Agenda Item #15.B.12. Continue the program’s requirement to provide no less than one instructor for everyten students in clinical experiences.3. Require program to submit all documentation to clear the violations by December 1,2018.4. Require the program to admit no additional classes without prior approval by the Board.5. Require the program, when requesting approval to admit students, to:a. Submit all documentation in final form, using the forms provided by the Board,no later than two months prior to the requested start date for the class.b. Provide documentation that adequate resources, i.e. faculty and facilities, areavailable to support each admitted class of students.c. Ensure that the program maintains an average annual pass rate that iscompliant with Section 2530(l) of the Vocational Nursing Rules and Regulations.6. Continue to require the program to comply with all approval standards in Article 4 ofthe Vocational Nursing Practice Act, commencing at Business and Professions CodeSection 2880, and Article 5 of the California Code of Regulations, Title 16.Rationale:During the unannounced visit to Pasadena City College sevenviolations were noted, including the fact that the program elected toadmit a class without Board approval in August 2018. This class willgraduate in August 2019. Considering the foregoing information, it isrecommended to extend the provisional approval for a one-year period.The program has provided documentation of adequate resources,including clinical facilities, to support current and proposed students inaccomplishing program objectives in a manner consistent withregulations. This supports the recommendation to approve theirrequest to admit students.Board staff will continue to monitor the program’s effectiveness bytracking class admissions, the effectiveness of employed interventionsand the program’s licensure examination pass rates each quarter.Attachment A: History of Prior Board Actions10
Agenda Item #15.B.1Agenda Item #XX.X.X., Attachment A.Pasadena City CollegeVocational Nursing ProgramHistory of Prior Board Actions The Pasadena City College Vocational Nursing Program was initially accredited in1953. On May 16-17, 1984, the assigned Nursing Education Consultant conducted a surveyvisit. The Board considered the consultant’s report and recommendation at its June,1984 meeting that accreditation be continued after the program demonstratedcompliance with violations in performance objectives, admission criteria, attendancepolicy, credit granting policy and posting of required information. The programsubsequently substantiated full compliance to the Board’s satisfaction. On January 1985, the Board approved a major curriculum change with changes inhours contingent upon meeting specified time lines for submission of curriculummaterial. On June 16, 2000, the Board approved the program’s request for a major curriculumchange, including philosophy, conceptual framework, curriculum objectives andprogram hours. New program hours are total program hours are 1, 557, with totaltheory hours being 585 and clinical hours being 972. On April 14, 2004, the Board approved continued full accreditation for the PasadenaCity College Vocational Nursing Program for the four-year period from May 14, 2004,through May 13, 2008, and issued a certificate accordingly. On March 19, 2008 the Board approved continued full accreditation for the Pas
Nov 14, 2018 · Pasadena City College, Vocational Nursing Program offers a 47 – week course of instruction. The program is required to obtain Board approval prior to the admission of each class. The following table represents current and projected student enrollment bas
