Inside the Race to Certify Temporary Nurse Aides as End to Waiver Nears

The Centers for Medicare & Medicaid Services temporary nurse aide waiver will come to an end early next month, leaving nursing homes just four months from the June 7 date to get thousands of temporary workers trained and certified — or risk losing them.

TNAs hired after June 7 will have four months from their hiring date to meet testing requirements, CMS has said.

Some operators, like PruittHealth, will look to move their TNAs to non-clinical roles as they move forward with training and certification.

“I am concerned about getting everyone certified in time but we’re doing everything we can,” PruittHealth CEO and Chairman Neil Pruitt told Skilled Nursing News. “We’re hopeful that we can find ways to place these workers and it’s our intention to move them to other non-clinical roles until we can enroll them in classes. We aren’t turning anyone away.”

Others, like SavaSeniorCare, plan to push as many TNAs through certification and testing as they can before the deadline hits.

“In North Carolina, we have a training program where we have an instructor, that’s one of our employees that’s trying to get as many folks through that program and certified [as possible],” said Annaliese Impink, SavaSeniorCare’s executive vice president of compliance, ethics, and customer experience.

Nurses must complete a state approved nurse aide competency evaluation program to become a certified nurse aide with a curriculum that typically includes training on respecting residents’ rights, basic nursing skills, personal care skills and caring for cognitively impaired residents.

Nurses must also pass a written or oral exam to demonstrate the skills they’ve learned.

Disappointed to see the program end, Pruitt wished CMS would have aimed to end the waiver once the staffing crisis eased.

“Our critics want us to staff the buildings and this is a good way to do it and unfortunately they’re taking away one of our tools so I’m very disappointed with that,” he said.

Testing delays could be a factor

CMS cited long-term care survey findings that linked resident weight loss, depression and pressure ulcers to the “lack of certain minimum standards” as one reason why the waiver was coming to an end, according to a memo issued by the agency.

Still the program proved essential in bringing new employees to the sector. In Michigan alone, the waiver brought more than 2,000 workers to the long-term care industry as temporary aides.

Ray Thivierge, SavaSeniorCare’s chief strategy officer, believes the waiver program brought on more frontline staff that otherwise may not have joined the sector because it allowed them to “jump right in” to providing care.

“Overall, I think we expected it [to end] and to a certain extent we planned for it and have been preparing for it but the timing of it is just adding more fuel and more challenges for us to deal with when we’re already dealing with staffing problems,” Thivierge told SNN.

Impink thinks the biggest time crunch will be getting everyone tested in time as many states, including Texas, are currently backlogged and don’t have enough instructors to meet the number of applicants ready to test.

Holly Harmon, senior vice president of quality, regulatory and clinical services for the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), feared the short timeframe to get everyone certified and tested could be a challenge for operators.

“Our concern is that state capacities are not sufficient to accommodate the training and testing needs for thousands of temporary nurse aides in this short timeframe,” she said. 

Harmon doesn’t think now is the time to let such a crucial flexibility for nursing homes amidst a historic labor shortage.

“We are seeking for Congress to take action in providing a reasonable grace period to allow TNAs to transition to long-term roles,” she said.

PruittHealth, for example, currently employs 277 TNAs with 192 that are actively enrolled in a nurse aide training program. While the additional 85 are seeking a training program, the Georgia-based nursing home operator is currently unable to enroll them due to capacity issues, according to Pruitt.

“We are aware that there may be instances where the volume of aides that must complete a state approved [program] exceed the available capacity for enrollees in a training program or taking the exam,” CMS wrote in the memo announcing the waiver ending. “This may cause delays in nurse aides becoming certified.”

CMS said that if a facility or nurse aide has documentation that shows their attempts to complete the training or testing, they may continue to work in the facility while working to become certified as soon as possible.

Lori Porter, co-founder and CEO for the National Association of Health Care Assistants (NAHCA) – an organization that supported the waiver ending when it was announced last month – told SNN that there was already a shortage of places to get CNAs certified prior to the latest CMS decision.

Trying to get everyone trained in time will likely worsen the problem, she said.

“There’s nowhere to send [CNAs] to get them certified, especially if you’re in a rural area,” Porter said. “There is a nationwide nurse instructor shortage even at nursing schools as well.”

About 420,000 nursing home workers have left the industry since the start of the pandemic, according to the U.S. Bureau of Labor Statistics data, as nursing homes have lost 15.2% of the industry’s total workforce.

Worker shortages could worsen

CNA turnover has been an issue of particular concern for nursing homes, and the waiver — like other initiatives enacted over the past two years — has provided a much needed infusion of new workers into the sector.

“The waiver has been instrumental for us. We’ve had about 989 temporary nursing assistants, and about a third of those are still employed with us,” Pruitt said.

Impink said that during the height of the pandemic the waiver was very beneficial at a time when it was “desperately” needed.

A recent survey of 69 owners and executives of senior housing and skilled nursing operations across the nation found that one-quarter of respondents had more than 20% of their full-time positions currently unfilled, according to data from the National Investment Center for Seniors Housing & Care (NIC).

The Evangelical Lutheran Good Samaritan Society has more than 200 TNAs that it’s working to get certified.

“We are really grateful for the waivers that were put into place by the government and the regulatory agencies to help us operate through really the height and the peak of COVID-19 but now as we see some of those waivers be rescinded and start to untie there are new challenges,” Rochelle Rindels, VP of nursing and clinical services at Good Samaritan, said .

Rindels said Good Sam’s partnership with Sanford Health has proven to be beneficial on this front as it allowed the not-for-profit provider to create an internal CNA training program to allow the TNAs to train on-site.

Out of more than 600 students that have come through the Good Samaritan TNA program, the organization has seen a 91% certification pass rate.

“We’ve always wanted to provide training to the CNA position, recognizing how important it is in our facilities,” Rindels said. “They’re the ones that are side-by-side with the residents everyday. We’ve got several instances where we’ve had a CNA go on and obtain their nursing license and then work as director of nursing in the same facility.”