The purpose of this course is to prepare healthcare professionals to identify elder abuse and to respond appropriately.
Target audience includes: ARNP, CNA, CNS, HHA, LPN, LVN, RN, PT and PTA
All professionals listed in the target audience will benefit from this course as they interact with the elderly population in numerous healthcare settings. This course will help the learner to recognize the signs and symptoms of elder abuse and how to utilize resources available to help their elderly patients.
After completing this course, the learner will be able to:
In the United States, the elderly population, or those age 65 and older, continues to grow at a rapid rate. Due to the Baby Boomer generation, or those born between 1946 and 1964, the United States currently has over 40 million individuals age 65 and older. By 2050, this number is expected to double. Due to advancements in healthcare, better exercise and dietary practices, and new technologies, individuals continue to live longer, healthier lives. As our population ages, it is our responsibility to ensure we protect geriatric individuals; this includes understanding how to recognize and report suspected elder abuse.
Approximately one in ten elderly individuals are abused or neglected annually.1 Still, for every case that is reported, there are at least five others that are not reported.2 The National Council on Aging defines Elder Abuse as “intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or person who stands in a trust relationship to the elder.3”
Elder abuse or maltreatment is a significant public health problem. Each year, hundreds of thousands of adults over the age of 60 are abused, neglected, or financially exploited. In the United States alone, over 500,000 older adults are believed to be abused or neglected each year. These statistics are likely an underestimate because many victims are unable or afraid to tell the police, family, or friends about the violence.4 Furthermore, those who become aware of the issue may fail to accurately report the abuse or neglect.
It has become such a concern worldwide, in fact, that World Elder Abuse Awareness Day occurs each year on June 15th. This is a day to educate the public on the signs of elder abuse, how to report suspected abuse, and what circumstances surround this abuse.5
There are six forms of abuse that occur in people over the age of 60 include:
Physical abuse is “the use of physical force that may result in bodily injury, physical pain, or impairment.6” This includes striking, hitting, beating, shoving, pushing, shaking, slapping, kicking, pinching, and burning. In addition to these, utilizing drugs or physical objects to restrain a patient or forcing them to eat or drink against their will are also classified as physical abuse. It often begins with what is excused as trivial contact escalating into more frequent and serious attacks.
As healthcare providers, we must diligently assess our patients for signs of physical abuse, document these signs, and report them to the appropriate individuals. Be aware of possible signs of physical abuse, including6:
Sexual abuse is classified as any sexual act performed with an elderly individual who does not consent to the act or who is incapable of giving consent to sexual acts. Sexual acts can include unwanted touching, rape, sodomy, coerced nudity, or sexually explicit photography.6
Although the elderly population still is very involved in sexual activities, as sex is a natural part of human life, we must ensure these acts are consensual for all parties involved. Signs of sexual abuse that warrant further investigation include6:
Emotional or psychological abuse is “the infliction of anguish, pain, or distress through verbal or nonverbal acts,” including constant harassment, verbal assaults, threats of harm or restraint, intimidation, and humiliation. Furthermore, isolating an elderly individual from others also classifies as emotional abuse, as social interaction is one of the most basic human needs.6
We may mistake “simple arguments” or disagreements as innocent in nature, but they could be signs of a much larger problem. Regardless of the amount of abuse, any act listed above can cause severe emotional harm and distress. Signs that one may suffer from psychological abuse include:
Neglect is a major problem with the frail and elderly, due to older individuals often needing more care and assistance. As people age, they become less able to do activities of daily living independently, and their actions become much slower. The decline in the ability to function independently can lead their caretakers to neglect the elderly. Neglect is “the refusal or failure to fulfill any part of a person’s obligations or duties to an elder,” including refusing to provide basic necessities.6 These necessities are things Maslow’s Hierarchy of Needs defines as physiological and most important, including food, water, and shelter. Neglect also involves not providing necessary medications to an elderly individual under one’s care, which can be detrimental to their health.
Signs and symptoms of neglect include:6
Abandonment is when someone who has responsibility for an elderly individual leaves them. Abandonment can happen when the elderly individual is deserted at a facility, and it could put the elderly individual at risk. Abandoned elders may be confused, unable to call for assistance, or without left without money or a phone.
If you see an elderly individual left alone, it is your responsibility to ensure they are unharmed and have the care they need. You should suspect abandonment if6:
Financial exploitation includes “illegal taking, misuse, or concealment of funds, property, or assets of a vulnerable elder.6” Examples of financial abuse are when someone cashes an elderly person’s check without their permission, forges their signature on financial forms or checks, steals money or valuable possessions, or coerces them into signing contracts or wills.6
As many elderly individuals do not work and may be living off of retirement funds, Social Security, or personal savings, being fiscally responsible is exceedingly important. At times, this responsibility is given to those who care for the elderly, which puts the elderly at risk for exploitation and mismanagement of funds. Signs and symptoms of financial or material exploitation include6:
As our elder population increases, more family members become caregivers and more healthcare workers are required to care for aging individuals. As with all cases of abuse, the reasons for elder abuse are complex. However, there are some special considerations in elder abuse.
Caring for frail elders can be a difficult and stressful job. If an elderly individual is mentally or physically impaired, they will likely be more dependent on their caregiver. Dependence on others is sometimes a contributing factor to elder abuse, and those who are dependent on others may be unable to report that they are being abused. Examples include those who are physically or mentally impaired. Furthermore, if the caregiver is unable to perform certain tasks for the elderly due to physical or financial constraints, they may become frustrated and more likely to abuse. Lastly, if the resources necessary to provide care are unavailable, this may lead caregivers to be unable to provide basic needs, which can also lead to increased stress.
Those who are in poor health are more likely to be abused than those in good health, possibly due to the increased dependence on others. Abuse tends to occur when the stress level of the caregiver is increased as a result of a worsening of the elder’s impairment.
The abuser is a family member in almost all of the abuse cases in which the perpetrator is known.2 In fact, the abuser is typically a child or spouse. Also, substance abuse is the most frequently cited risk factor associated with elder abuse.
The Washington State Department of Social and Health Services (DSHS) has determined that vulnerable adults such as senior citizens, who neglect themselves, are unwilling or unable to do needed self-care suffer from self- neglect.7 This can include such things as7:
Common characteristics of people who neglect themselves are the following7:
Signs to look for in the home and on the person include the following7:
Self-neglect does not include a mentally competent older individual who voluntarily participates in unsafe acts. Mentally competent individuals understand the potential ramifications of their actions, but they choose to continue participating in them regardless.8
Social support by family, friends, members of the community, and healthcare providers is extremely important in helping vulnerable adults to remain safe.
Family and friends can assist by7:
Neighbors can help by7:
Public Service Providers can7:
As the “baby boomer” generation reaches retirement age and improved healthcare allows Americans to live longer, the difficult questions of who will care for our elderly citizens and how they will afford the cost of such care have challenged our society.
Consequently, many elderly Americans who can no longer care for themselves are relying on nursing homes, community living centers, and other long-term care facilities on providing such care. Depending on the level of care required, these institutions can range from an assisted living environment to full nursing home care.
Institutional abuse is abuse found at a facility or organization that provides elder care. These include assisted living facilities, intermediate care facilities, community living centers, rehabilitation facilities and nursing homes. Mistreatment can include any of the previously mentioned types of abuse.
Frequent abuse seen in an institutional setting is the misuse of chemical or physical restraints. Misuse means that restraints are used beyond what the physician ordered or is not within accepted medical practice. Examples are staff failing to loosen the restraints within adequate time frames or attempting to cope with a resident’s behavior by inappropriate use of drugs.9 This can lead to wounds in areas that restraints have been placed and eventually, if not treated, to infections and even death.
Factors external to the facility that may lead to abuse are the supply and demand of facility beds and the unemployment rate. A surplus of beds may cause patients to be accepted without adequate assessment, resulting in misplacement. A shortage of beds may force patients into facilities with reputations for poor care. Unemployment rates and pay rates affect the staffing levels.9
Nursing homes oriented toward custodial care often experience more abusive situations. Other environmental factors that may affect abuse include the physical design of the building, the level of care, size, cost of care, staff-to-patient ratio, and the turnover rate of both patients and staff.10
As in the domestic setting, patients who are mentally or physically incapacitated are more likely to be the victims of abuse. Additionally, patients who lack regular visitors who can watch for abusive situations are more likely to be victimized.10
Long-term care for the elderly is typically extremely expensive (well over $5,000 per month in many places), the vast majority of residents go through most, if not all, of their assets in a matter of months and then become eligible for federal Medicaid benefits. This process is known as “spending down.” The cost of over 90% of nursing home residents is paid by Medicaid. Consequently, almost all nursing home facilities receive Medicaid funds.
Facilities accepting Medicare or Medicaid funds must abide by government regulations setting minimum standards for the care of residents in such facilities. Many of these regulations are promulgated by the Centers for Medicare and Medicaid Services (CMS). CMS regulations set guidelines for the evaluation, care and treatment of residents, aimed at maximizing the quality of each resident’s daily life and minimizing abuse and neglect.
Many of the institutions that provide long-term care for the elderly are owned by for-profit corporations. In an effort to maximize profits, a lot of institutions have cut back on staff or hired less qualified workers for lower salaries in an attempt to decrease costs. Often, elderly and or disabled residents of long-term care facilities are not getting the attention they require and have to compete with dozens of other residents for the attention of too few staff. As a result, residents who require assistance with activities of daily living (ADL) such as feeding, bathing, toileting, and walking, are not receiving adequate care.
Most often in the institutional setting, the typical abusers are nursing aides. These are often the lowest paid and most uneducated positions in healthcare facilities. This neglect can lead to disastrous consequences. Residents can suffer from debilitating falls, the development of painful and immobilizing decubitus ulcers, malnutrition and sometimes death. Typically, the staff member is a male, young, and often lacks experience. He may be poorly educated and suffers from job burnout, leading to a loss of concern for the patients.9
As our elderly population continues to grow, states are better attempting to address institutional abuse by healthcare workers. Various authority figures, such as Adult Protective Services (APS), are allowed to investigate reports of abuse or neglect in nursing homes or other elderly care facilities. Based on the findings, the institution in question may have their permits or licenses revoked, suspended, or denied. This is of one of the many ways that states are attempting to strengthen laws and regulations surrounding how the elderly population is treated within facilities.
Aside from patient or family members, workers are also one of the ways that complaints may be received about poor care within a facility. To help motivate employees to report concerns within their work environments, states are enacting provisions that protect the employees from retaliation.
In addition to investigations by authorities, Ombudsman programs have been established in each state. The purpose of these programs is to advocate for elderly patients in long-term care facilities, as well as to attempt to change laws so that elderly patients are better cared for.11
In an effort to help decrease the amount of convicted elder abuse offenders hired into healthcare roles, certain states have registries to alert potential employers of these prior offenses. When used correctly prior to employment, similarly to a background check, these registries help ensure facilities do not risk the safety of their patients by hiring someone who is known to abuse elderly individuals. For example, Missouri has an Employee Disqualification List (EDL), which includes individuals who have abused or neglected patients, exploited patients through mismanagement of their funds or property, or falsified documentation.12 According to Washington State Legislature, Washington also approved a similar bill in 2011 in which all long-term care facility employees must undergo a criminal background check, including one with the Federal Bureau of Investigations, to ensure no unfit employees are hired to work with the aging population. They also determined the need to begin a registry in which all workers found guilty of abuse, neglect, or exploitation of elderly individuals would be listed.13
Unfortunately, depending on the setting, not all healthcare organizations require background checks on their employees. Because of the increase in chronic disease and the need for home health management, many elderly individuals who live independently, or within assisted living areas, see home health agents on a frequent basis. This creates an area for potential elder abuse, as these patients are often alone with their providers, and abuse may be less likely to be noticed by others or reported. According to the Office of Inspector General in 2014, ten states did not require background checks for their Home Health Agency employees.14 Of the remaining states which do require background checks, only seventeen required both in-state and FBI background checks.14 An additional concern is that certain employers in all areas of healthcare allow employees to start working while their background check is pending placing the elderly patients at increased risk for harm until the background check is completed and reviewed.
A lot of states have passed residents' bills of rights which prohibit mental and physical abuse of patients and encourage the filing of grievances or complaints by or on behalf of the resident. Some states also authorize the commencement of a civil action for the violation of a resident's rights.
A successful plaintiff may be awarded punitive damages when the respondent's conduct was a malicious, willful disregard of the older patient's rights.
In an effort to deter crimes against elderly victims and to express society's abhorrence toward such offenses, many state legislatures have created special offenses involving crimes against the elderly. All 50 states have passed some form of elder abuse prevention laws. Laws and definitions vary from state to state, but all states have reporting systems. Adult Protective Services (APS) receive and investigate reports of suspected elder abuse. The rights and services available to all crime victims by statute, legislators at both the federal and state levels have enacted laws that provide special protections and privileges to elderly victims of crime. Much of this legislation simply modifies or extends existing general victims' rights legislation to address the special needs of older victims.
Numerous accounts of maltreatment led policymakers to pass a series of laws intended to protect the elderly victim. The passage of the Federal Older Americans Act of 1965 (OAA), and the creation of the Vulnerable Elder Rights Protection Program 42 U.S.C. '' 3058, et seq. in 1992 were instrumental in promoting state laws to address the needs and concerns of the elderly.
The Vulnerable Elder Rights Protection Program legislation promoted the following15:
State elder abuse laws are patterned after legislation designed to address the problem of child abuse and neglect, and, like the response to child maltreatment, often involve the combined efforts of both criminal justice officials and social services staff.15
Laws criminalizing abuse of the elderly define the conduct which constitutes a specific form of abuse and may make a distinction between abuses committed in a domestic, as opposed to an institutional, setting.
States such as Massachusetts and North Carolina developed laws which subject anyone over the age of 18 who has sufficient means, but neglects or refuses to support a parent who is unable to support him/herself due to age or disability, to a fine or imprisonment.16, 17
In some states, elder abuse laws are incorporated into assault, battery, domestic violence or sexual assault statutes, and a sentencing enhancement imposed if the victim is over a specified age. Illinois uses a combination approach, enacting separate crimes for aggravated battery of a senior citizen and criminal neglect or financial exploitation of an elderly person, but including the age of the victim as a special classification under its aggravated criminal sexual assault and abuse laws.15
Every state has a long-term care ombudsman program to investigate and resolve nursing home complaints. State Attorney General’s Office is required by Federal law to have a Medicare Fraud Control Unit to investigate and prosecute Medicaid provider fraud and patient abuse or neglect in health care programs which participate in Medicaid, including home health care services.6
In 1987, President Ronald Reagan signed into law the first major revision of the Federal standards for nursing home care since the 1965 creation of both Medicare and Medicaid 42 U.S.C1396r,42 U.S.C. 1395i-3,42 CFR 483. This legislation changed society’s legal expectations of nursing homes and their care. Long term care facilities wanting Medicare or Medicaid funding are to provide services so that each resident can “attain and maintain her highest practicable physical, mental, and psycho-social well-being.
Most physical, sexual, and financial/material abuses are considered crimes in all states. However, elder abuse may or may not be a crime, depending on the statutes of a given state. Self- neglect is not a crime in all states.6
Adult Protective Services (APS) can be a part of a community’s involvement in aiding a self-neglecting vulnerable adult. Once self-neglect is reported, the individual needing help has to give their consent for help. If an individual refuses assistance, then there is a balance between a person's right to independence versus his safety and well-being. Family, friends and service providers can work together to help this individual. It is vital that everyone stay involved and support the vulnerable adult as much as possible.
A majority of states now require certain classes of professionals to report suspected abuse and neglect. The most common categories of mandatory reporters are medical professionals, healthcare providers, mental health counselors, service providers, and virtually all government agents who come in contact with the elderly. Most require such individuals to report evidence that leads them to "reasonably believe" that the elderly person in question is the victim of abuse or neglect.
Some states have established 24-hour hotlines in an attempt to make reporting of abuse easier to secure the safety of the victim as quickly as possible. While most statutes establish penalties for those who fail to report, many also provide immunity from civil suits or prosecution to those who make reports in "good faith" -- even if those reports cannot be substantiated, to encourage further reporting of suspected abuse.
Laws have helped to increase the reporting of elder abuse -- up 150 percent from 1986 to 1996 -- it is still widely believed to be underreported.6
The Adult Protective Services (APS) is the principal public agency responsible for both investigating reported cases of elder abuse and for providing victims and their families with treatment and protective services... An APS is usually located within the Human Service Agency as part of the county departments of social services. Many other public and private organizations are actively involved in efforts to protect vulnerable older persons from abuse, neglect, and exploitation.
These agencies include:
The power each agency has is dependent upon the state law enacted to protect elders. There is an internet site to find local reporting agencies. Use the Eldercare Locator at www.eldercare.gov or call 1-800-677-1116. The National Council for Aging Care's guide on Elder Abuse is available at http://www.aginginplace.org/guide-to-recognizing-elder-abuse.
Nationwide training programs to increase public awareness and better prepare those required by law to report have been implemented in California, Florida, and Mississippi, in an attempt to further promote reporting of elder abuse.
Many states have prevention activities which include:
The Administration on Aging is a federal agency dedicated to policy development, planning, and the delivery of supportive home and community-based services to elders and caregivers. This agency provides critical information, assistance and programs that protect the rights of vulnerable, at-risk older individuals, through the national aging network. The administration does not have oversight responsibility for APS.5
All calls to APS are confidential. The APS screens calls for seriousness and decide if the situation is a possible violation of state elder abuse laws. If so, the APS assigns a caseworker to conduct an investigation, usually within 24 hours if it is an emergency. Crisis intervention services are utilized as warranted. If it is not an emergency, the APS agencies work with other community agencies to obtain social and health services that the older person needs.
Most states empower both social service and law enforcement agencies to investigate reports, intervene, and even remove elderly victims from abusive circumstances. In some jurisdictions, multidisciplinary teams are being used -- combining the knowledge of medical, mental health, social service, legal, and law enforcement professionals to better evaluate an elderly victim's needs. Appropriate protective services can then be offered to elder abuse victims. In some states, such as Colorado, a restraining order may be imposed to prohibit further emotional abuse of an elderly victim.
Tennessee has created an innovative Victimization Prevention Program, an extension of the Tennessee State University's Center for Aging's program on the prevention and treatment of elder abuse, neglect and criminal victimization.
The prevention program is designed to: collect data on the problems of elderly abuse, neglect and criminal victimization; engage in prevention activities through presentations at churches, community centers, schools, and senior citizen centers; conduct workshops for government employees and police, as well as for the elderly and their families; and implement an advocacy program to assist victims in responding to and recovering from abuse, neglect and criminal victimization. This program's research findings will provide the basis for the development of stronger assistance and prevention initiatives designed specifically to aid elderly victims.15
Special classifications for elderly victims are often included in a state's robbery, assault, battery, murder, and even carjacking statutes. A few states, such as Iowa and Oregon, have chosen to include age as a hate violence characteristic. States are also starting to address telemarketing schemes and consumer fraud crimes which often seem to target especially vulnerable victims, including the elderly.6
Other states impose sentencing enhancements -- increased penalties -- when the victim is elderly. In Nevada, an offender who commits a crime against a person over the age of 60 is subject to a prison term twice as long as that normally allowed for the same offense. A Louisiana law mandates that all violent crimes against the elderly be punished by a minimum of five years’ imprisonment with no opportunity for parole. Georgia imposes an enhanced penalty for unfair or deceptive business practices directed toward the elderly. A number of states consider the victim's advanced age to be an aggravating factor to be taken into account when determining a sentence.6
Healthcare professional often are the first to see signs and symptoms of elder abuse and neglect. Their observations are crucial in substantiating that abuse and or neglect has been occurring. They are in a key position to help because of the trust and respect the patients often have for their healthcare providers.
Healthcare professionals evaluating patients for elder abuse will note the following:
Healthcare professionals should document all subjective and objective findings including the patient’s and caregiver’s explanations of the injuries. Quotation marks should be placed around their remarks and note any discrepancies in their stories. They should photograph injuries and document injury sites on a body map.19
You are the Nurse Manager of a nursing home. You have recently begun interviewing candidates for charge nurse, and you have selected an applicant you believe best fits your needs and qualifications. What is your duty/responsibility before allowing the newly hired nurse to have contact with your elderly patients?
Answer: It depends on the state’s laws. Some healthcare settings do not require background checks on employees, and some allow them to start working while background checks are pending. However, as a nurse manager, these may be conditions you want to consider in your role. Many states do require either a statewide background check or FBI background check to be done prior to allowing patient contact. Furthermore, some states have “Employee Disqualification Lists (EDLs)” or registries that should be checked for any potential employees’ names. These lists contain names of those who have abused, neglected, or exploited patients. Above everything else, as the Nurse Manager, you are expected to uphold your facility’s policies and ensure your patients’ safety.
As a society, we all have to take responsibility in protecting our aging population by actively sharing our knowledge, experience, and resources which will help keep our elders safe and productive. We must all help our political representatives to understand the needs of our aging population and the funds required. At times we must assist them in developing laws to prevent elder abuse.
1. Sewell, D. Aging America: Elder abuse on the rise. NBC News. (Visit Source). Published January 27, 2013. Accessed May 30, 2016.
2. National Council on Aging. Elder Abuse Fact Sheet. (Visit Source). Published March 2009. Revised March 30, 2010. Accessed May 3, 2016.
3. National Council on Aging. Elder Abuse Facts. (Visit Source). Published February 25, 2015. Accessed March 30, 2016.
4. Centers for Disease Control and Prevention. Elder Abuse Prevention. (Visit Source). Revised June 14, 2016. Accessed July 10, 2016.
5. Administration for Community Living. World Elder Abuse Awareness Day is June 15. (Visit Source). Updated 7/25/2016. Retrieved August 12, 2016.
6. National Center on Elder Abuse. Risk Factors for Elder Abuse (Visit Source). Published 2015. Accessed September 5, 2016.
7. Washington State Department of Social and Health Services. Aging and Long-Term Support Administration (Visit Source). Accessed September 6, 2012.
8. McNamee, C., & Murphy, M. Elder Abuse in the United States. National Institute of Justice. 2006; 255.
9. Acierno, Ron; Melba Hernandez-Tejada; Wendy Muzzy, and Kenneth Steve. National elder mistreatment study. (Visit Source). Published March, 2009. Retrieved September 3, 2012.
10. National Legal Resource Center. Elder Justice Act. (Visit Source). Accessed November 15, 2016
11. Administration on Aging (AoA). What is Elder Abuse? (Visit Source). Revised July 22, 2016. Retrieved July 25, 2016.
12. Missouri Department of Health & Senior Services. Employee Disqualification List. (Visit Source) (n.d.). Accessed September 06, 2016.
13. Washington State Legislature. RCW 74.39A.056: Criminal history checks on long-term care workers. (Visit Source). Published 2012. Accessed September 10, 2016.
14. Office of Inspector General. State Requirements for Conducting Background Checks on Home Health Agency Employees. (Visit Source). Published May 29, 2014. Accessed August 5, 2016.
15. New York City Alliance Against Sexual Assault. Factsheet: Elder Abuse and the Law. (Visit Source). Published 1999. Accessed Novemeber 10, 2016.
16. Mass Code ‘273-20. statues.laws.com. Accessed September 5, 2012
17. North Carolina code ’14-3261. statues.laws.com. Accessed September 5, 2012.
18. Gray-Vickrey, P. (1999). Recognizing Elder Abuse, Springhouse Corporation.
Bonnie, Richard, and Robert Wallace, Elder mistreatment, abuse, neglect and exploitation in an aging America. Retrieved September 5, 2012 from (Visit Source), 2003.
California Nursing Homes: Federal and State Oversight Inadequate to Protect Residents in Homes with Serious Care Violations, Op. Gen. Accounting Off. /T-HEHS98-219 (July 28, 1998).
Environmental Protection Agency’s Aging Initiative, “Aging Initiative Home”, Retrieved September 6, 2012 from (Visit Source)
Florida Code ' 400.023. Retrieved September 6, 2012 from (Visit Source).
National Committee for the Prevention of Elder Abuse, “Financial Abuse,” (Visit Source).
The Elder Justice Coalition. “One Year Anniversary of the Elder Justice Act”. Retrieved September 6, 2012 from (Visit Source).
The Older Americans Act of 1965 (42 U.S.C. 3001 et seq.) Retrieved. September 6, 2012 from (Visit Source).
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Clinical Nurse Specialist (CNS), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Occupational Therapist (OT/OTA), Physical Therapist (PT/PTA), Registered Nurse (RN)
CPD: Practice Effectively, Domestic Violence, Geriatrics, Medical Surgical, ProCert Approved Courses, Texas Requirements/Recommendations