[UPDATED] CMS to Phase Out Nursing Home TNA Program, Other PHE Waivers

In light of steadily increasing vaccination rates for nursing home staff and residents, and overall improvement to outbreaks in the space, the Centers for Medicare & Medicaid Services (CMS) on Thursday said it is phasing out some of the temporary waivers linked to COVID-19 and the public health emergency (PHE).

Among those is the temporary nursing aide (TNA) program set to sunset in 60 days, CMS said, citing long-term care survey findings that link resident weight loss, depression and pressure ulcers to the “lack of certain minimum standards,” according to a memo issued by the agency.

CMS expects facilities to redirect efforts back to meeting regulatory requirements and continue integrated practices to handle COVID-19 outbreaks moving forward.


Temporary waivers for nurse aide certification will still be available in certain situations – for example, facilities with documented capacity issues in training or testing programs.

Individual state-based, county-based or facility-based waivers will be granted by CMS as needed until the expiration or termination of the PHE, the agency said in its memo.

“If there is a severe outbreak in a facility or geographically distinct group of facilities, CMS can quickly grant waivers to support the facilities’ response to COVID-19,” the agency stated. “If there is a nationwide surge of nursing home COVID-19 cases in the future, CMS can quickly re-issue national blanket waivers during the PHE.”


Nathan Schema, president and CEO of the Evangelical Lutheran Good Samaritan Society, was surprised to see hospitals able to keep their waivers in place while nursing homes are left to figure out worker shortages in a time crunch.

“That differentiation strikes me because, as we all know, in this industry, we’ve been on the front lines and we are serving some of the most vulnerable people throughout the pandemic,” Schema told Skilled Nursing News. “Disproportionately calling out [nursing homes] and rolling back these waivers at a time when we’re still reeling and coming back from such an extraordinary experience … that just seems off to me.”

Now is not the time to let such crucial support for nursing homes end, Holly Harmon, senior vice president of quality, regulatory and clinical services for the American Health Care Association (AHCA), said in an email.

“State capacities are not sufficient to accommodate the training and testing needs for thousands of temporary nurse aides in this short timeframe,” Harmon added. “We cannot lose these heroes in the midst of a historic labor shortage. These actions may further limit access to care for residents, as facilities may be forced to limit the number of residents they can serve due to staffing shortages.”

The nursing home industry has lost 241,000 direct care workers since the start of the pandemic, according to data collected by the U.S. Bureau of Labor Statistics, with 2,500 gone just this past month.

The National Association of Health Care Assistants (NAHCA), by contrast, expressed its support of the CMS decision to sunset the TNA program.

“NAHCA has always supported efforts to bring more qualified staff, including nursing assistants, into post-acute and long-term care settings. However, we have long been concerned about bringing in nursing assistants without appropriate training,” Lori Porter, co-founder and CEO of NAHCA, said in a statement.

NAHCA members reported instances of ill-equipped TNAs unable to handle tasks and care processes, Porter said, placing added burdens on CNAs and in some cases having a negative impact on care. Requiring less training puts residents at “great risk,” added Porter.

“NAHCA supports the elimination of the TNA training. We further support the resumption of the Nurse Aide Training & Competency Evaluation Program (NATCEP) requirements,” said Porter. “TNAs should be mandated to take the remaining hours of a typical course (about 75 hours) if they want to become CNAs.”

LeadingAge, which represents more than 5,000 nonprofit aging services providers, said the program provided a “welcome resource” to make sure residents got the care they needed.

“Although the waiver ends, workforce challenges have not,” Janine Finck-Boyle, vice president of health policy for LeadingAge, said in a statement. “There is no current plan to help nursing homes with staffing. Consider that over 10 million jobs are now open in the service economy – but the U.S. workforce is not looking for service jobs.”

Time’s running out

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.

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.

Good Samaritan has relied on the flexibility of the TNA program, Schema said, as a way to get people in the door more quickly.

“To have those waivers changed maybe within 30 or 60 days, it still feels too short,” Schema said. “We were hoping we’d have a little bit more time to get on the backside of this before things ultimately changed.”

The South Dakota-based nonprofit organization currently has more than 2,100 open positions.

Good Sam’s alternative care site in Arthur, N.D., which falls under the waiver allowing non-certified buildings to house SNF residents, has been serving residents under the PHE for about six months now, Schema said. The organization has 60 days to figure out where to place the 15 residents in their care.

“We’ve served a number of people throughout the last six months as our hospital partners have been full,” he added.

The operator’s top two priorities in light of the sunsetting waivers is to find alternative placements for those residents, and strengthen its workforce pipeline.

CMS Administrator Chiquita Brooks-LaSure said the agency’s actions are focused on ensuring safe, high-quality care for every nursing home resident.

“We’ve learned a lot from the pandemic over the last two years and are committed to using that knowledge to re-envision the next chapter of health care quality and patient safety and build a stronger health care system,” added Brooks-LaSure.

Nursing home-related waivers that will sunset in 30 days includes: 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.

At the beginning of the pandemic, waivers were attached to the PHE as a way to address “acute and extraordinary circumstances,” CMS said in its memo.

Inpatient hospices, intermediate care facilities for those with intellectual disabilities (ICF/IIDs) and end-stage renal disease facilities (ESRDs) were included in the waiver terminations announced on Thursday.

State programs step in

Florida and Minnesota, among other states, have been taking steps to create their own pipeline of nursing home staff in anticipation of CMS ending waivers attached to the PHE.

Minnesota surpassed its goal of recruiting 1,000 CNAs to the state via its Next Generation Assistant Training Program. The program was infused with $6.7 million to continue into the next several years, with an additional $13.3 million proposed for the 2024-2025 state budget.

The nurse aide waiver ending will add additional delays to state efforts to get CNA trainees on the floor.

“[CNAs] were able to work, you know, for four months until we got them up and running. We’re not going to be able to do that when this waiver ends,” said Patti Cullen, president and CEO of Care Providers of Minnesota, the state’s chapter of AHCA. “Our concern of course is any time delay at a time when they have a lot of employment choices, means we could potentially lose some new employees.”

As of April,1,278 Minnesotans have participated in the program; 940 are enrolled in free training courses and 338 high school students have accessed training through their school district, with the state footing the certification exam fee.

Florida’s Personal Care Attendant (PCA) Training program, outlined in House Bill (HB) 485, passed the 2021 legislative session. The state Agency for Health Care Administration will move forward with the program.

The bill codified the temporary program, which was first implemented in March 2020. It’s designed to help individuals develop the skills they’ll need to become a certified nursing assistant (CNA), while also receiving on-the-job experience.

Since its initial implementation, nursing homes reported a 130% increase in use of the program – nearly 3,000 enrollees have taken the CNA exam, 73% of whom passed and went on to receive their license.

As the program expands, the number of hours required for PCA training may increase based on suggestions from stakeholders like the American Association of Retired Persons (AARP).

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