With skilled nursing facilities facing significant staffing shortages amid the ongoing fallout of the COVID-19 pandemic, a group of lawmakers and operators called for making it easier to retain temporary nurse aides hired during the public health emergency — with one major operator reporting 1,500 unfilled jobs in the state of Pennsylvania.

Luke Pile, vice president and general manager at ProMedica Senior Care, said in a Thursday roundtable discussion on long-term care workforce problems and solutions that he is currently trying to fill 1,500 jobs posted across Pennsylvania alone; he oversees 42 SNFs and rehabilitation centers in the state for ProMedica, the non-profit health system that bought the operations of nursing home chain HCR ManorCare in 2018.

“While I think we are turning the corner on COVID-19, I don’t think we can declare victory in post-acute by any means,” Pile said. “Quite frankly, I think the wreckage left from the pandemic puts us in a worse position than in 2020 … My patient volume is down 15% to 20%. And in my locations in Pennsylvania, you would think you need less health care workers to provide for these individuals. The reality is much worse. I have less employees than ever before.”

In the first quarter of 2021, Pile said he has “raised wages across the board” at 29 of his facilities for recruiting and keeping internal staff that have remained — to the tune of $3.2 million before hiring the first new employee.

In the meantime, ProMedica is using outside agencies to fill open nursing positions. In 2020, the operator spent more than $32 million on those staffing agencies; in 2021, Pile’s annualized spend for agency costs is $66 million, he said.

ProMedica is also paying employees for their time off when they test positive for COVID-19, which cost about $5 million last year and $1 million in the first quarter of this year. An incentive program to encourage individuals to get vaccinated against COVID-19 has led to more than $3 million in spending just in Pennsylvania.

Testing costs have not gone away either, particularly as community spread continues to grow in Pennsylvania, with some counties necessitating twice-a-week testing under federal requirements. For ProMedica, testing in Pennsylvania cost almost $15 million, and projections for spend for the first quarter is $36 million to continue to test employees and patients in the Keystone State.

“We’re not giving up, we’re going to continue to fight, but the reality is: How do you pay for all this?” he said. “Really, we’re not self-sustaining right now. For my Pennsylvania portion of my operation, which is almost half of the eight states that I cover, my operating income for quarter one is a negative — not to budget — a negative cash flow of $24 million.”

Retaining temporary nurse aides

Much of the roundtable centered on a bipartisan bill introduced late last year by U.S. Reps. Susan Wild, a Democrat, and Fred Keller, a Republican, both from Pennsylvania, that would try to address some of the staffing shortages in long-term care facilities. The bill would address the problem by allowing temporary nurse aides (TNAs) hired under Section 1135 waivers issued by the Centers for Medicare & Medicaid Services (CMS) to keep their certification.

Specifically, the Nurses CARE Act would allow states “the necessary flexibility to ensure that competent TNAs who provided critical services during the pandemic can retain their certification after the national emergency declaration has expired,” according to the press release from Wild. It would also allow states and long-term care facilities to offer on-the-job experience as a partial stand-in for certification courses, testing, and other evaluations, as a way to allow TNAs a path to full-time employment.

The TNA program was praised by Deborah Rowe, vice president of workforce development at Genesis HealthCare, one of the largest nursing home operators in the U.S. and until recently, a publicly traded company.

Genesis hired more than 600 TNAs, with 319 still working; almost 60 of those are in the state of Pennsylvania, she said, emphasizing her support for a pathway for them to become more permanently certified.

Brett Boyer, vice president of human resources and workforce management at the operator Bedrock Care, said the TNA program was “a literal lifesaver” during the pandemic, allowing for fast hiring; certified nursing assistants (CNAs) did not have to pay out-of-pocket for their training and could start on-the-job training while being paid from the first day. Bedrock, which has eight long-term care facilities across Pennsylvania with about 2,000 beds and 1,800 employees, ended up hiring more than 100 TNAs.

He argued for keeping the program, “with a few tweaks,” as it would help fill the long-term care staffing needs in many communities.

Not everyone agrees with this assessment. The CNA Virtual March on Washington, hosted by the National Association of Health Care Assistants (NAHCA), featured speakers calling for an end to the TNA program, arguing that it creates more problems for the frontline than it solves.

Victoria Randle, the founder of the CNA training and consulting company The Secret Cocktail, argued during the virtual march that the TNA program is actually creating more problems and strain for current CNAs, because they have to provide so much direct supervision for the new hires.

“TNAs are not equipped, after eight hours of online education, to care for a person who’s in their most vulnerable state a person can ever be in their lifetime, aside from childhood,” Randle said. “Being sick or debilitated requires a certain level of holistic care that, I’m sorry, eight hours of online education could never give a person the ability to do.”

Indeed, as early as July 2020, the TNA program was coming under scrutiny from the Center for Medicare Advocacy, which works to advance access to Medicare coverage.

“With staff infected by COVID-19 and unable to work, new staff members are undoubtedly needed,” the center wrote last year. “But there are many questions about these workers that need answers. How prevalent is the use of these temporary aides? Is CMS tracking who they are, how many there are, which facilities they are working in, what tasks they are performing and how well? What happens to temporary aides after the pandemic ends?”

The Nurses CARE Act at least tries to answer some of the last question; the press releases from Wild and Keller indicate that the bill would allow certification retention for “competent TNAs.”

Like Boyer, Pile expressed support for the bill, citing the current operating landscape.

“I do think the Nurses CARE Act is a is a great step in the right direction,” he said. “But in my 18 years in this industry, I have never faced anything like this, and any solution is a good one right now.”