CMS: Sunsetting TNA Program, PHE Waivers the Right Next Step for Nursing Homes

Following this month’s announcement to sunset certain waivers associated with the public health emergency (PHE) during the pandemic, the Centers for Medicare & Medicaid Services (CMS) said it’s time to restore “minimum protections” to the nursing home setting, and “get back to normal operations.”

Evan Shulman, director for the division of nursing homes under CMS discussed the waivers to be discontinued, including changes to the Nurse Aide Training Competency and Evaluation Program, which is set to end on June 7.

The waiver allowed certified nursing assistant trainees, or temporary nurse aides (TNAs) to work on the front lines longer than the federally mandated four months before taking a state exam.


As of June 7, that four-month cutoff will be restored. Anyone hired prior to June 7 will have until Oct. 7 to meet testing requirements, Shulman said.

“These aides provided a valuable service through the pandemic, they helped facilities to maintain staffing and obtain staff. Now we need to make sure that those staff are appropriately trained to meet each resident’s needs,” Shulman told listeners during an industry stakeholder call.

CMS will end some waivers 30 days after the memo was issued, while others will terminate in 60 days. Such timeframes give providers and state agencies time to adjust day-to-day operations and adhere to reinstituted requirements, CMS said.


This is coupled with Health and Human Services Secretary (HHS) Xavier Becerra extending the public health emergency order (PHE) through July 17.

Jean Moody-Williams, deputy director of the center for clinical standards and quality under CMS, urged facilities to utilize the flexibility of the PHE waivers only if absolutely necessary.

“Restoring the minimum standards for compliance with CMS is really the right direction we should be going in, it’s the right thing for our residents, for our staff and for the system overall,” Moody-Williams said. “We are beginning to think about what actions we should be taking now, even before the end of the PHE.”

Waivers ending in 60 days include: allowing non-certified nurse aides to work for longer than four months as they prepare for their exams; using non-SNF-certified buildings or rooms for isolation purposes; and waiving maintenance of dialysis machines and ancillary dialysis equipment, among other waivers.

Nursing home-related waivers that will sunset in 30 days include: restricting in-person resident groups; physician delegation of tasks to other clinical positions; physician visits made by other clinical positions; physician telehealth visits; suspending quality assurance and performance improvement (QAPI) efforts; waiving utilization of certain resources to help residents choose a post-acute care provider; and suspending the requirement to provide residents with a copy of their records within two working days.

Shulman touched on the telemedicine waiver related to practitioners during the call as well – physicians must go back to conducting required 30-60-day visits in person, instead of via telemedicine.

“We encourage practitioners to continue to use telemedicine and supplement those required visits, but the required visits must be conducted in person,” Shulman said.

Listeners asked about the three-day-stay waiver during the call – prior to the pandemic, a patient needed to have a three-day inpatient hospital stay before Medicare would cover the SNF stay that followed.

“If something was not listed in the memoranda that indicate what waivers are being terminated, then that other waiver is still in place,” Shulman said.

The initial rule change was made by the CMS at the beginning of the pandemic in order to allow hospitals to reserve beds for severely ill patients, discharging those who could recover at a SNF. Currently, the only waivers set to sunet are those already published on April 7, Shulman said.

Bipartisan legislation was introduced in June to make the three-day-stay waiver permanent, but Congress has yet to act on the bill.

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