Senior woman and caregiver outdoors on a walk in park, talking.
(Credit: Halfpoint Images / Getty Images)
Senior woman and caregiver outdoors on a walk in park, talking.
(Credit: Halfpoint Images / Getty Images)

Thousands of certified nurse aide candidates are struggling to find exam placements across the US, with many of them under a fast-approaching deadline to become certified before a four-month, temporary placement window closes.

During a legislative hearing last week in Pennsylvania, providers bemoaned a lack of testing dates, too-few sites for the in-person exam and major challenges with getting the state-contracted proctor organization to bring nursing home partners into the process.

“Right now, our providers are telling us that their TNAs are simply giving up. They’d rather leave our field and find a job in another industry than attempt to get certified and work against [these] barriers and burdens,” Zach Shambreg, president and CEO of the Pennsylvania Health Care Association, told the state Senate’s Health and Human Services Committee on June 21. “Prospective CNAs have to travel hundreds of miles and multiple hours just to test; tests cannot be scheduled for months, and some are even being pushed to next year … and those providers who have applied for their facility to serve as an RTS, or Regional Testing Site, report that their application — and ultimately, their willingness to help — often goes unanswered.”

The conditions there may be extreme, but providers in several states said they continue to grapple with getting temporary workers their certifications in a timely manner, while also trying to usher other CNA candidates not already placed under a temporary nurse aide waiver through the exam process.

During the pandemic, the Centers for Medicare & Medicaid Services established a Temporary Nurse Aide program that decreased training requirements and allowed aides to work up to four months before becoming certified. It was seen as a patch to keep buildings operational during extreme, COVID-driven staff shortages. But the waiver creating that program was lifted June 6. Nursing homes can no longer hire TNAs, and any remaining in frontline roles must now pass the CNA exam by Oct. 6.

Extension hopes

The reliance on TNAs remained significant in some states in recent months as recruiting and retaining workforce proved nearly impossible. But moving remaining TNAs through the testing process in the four months allowed has proven challenging both because of the demand and problems with testing processes in some states.

“We, too, have significant concerns about the ability to address the TNA backlog,” Kevin Warren, president and CEO of the Texas Health Care Association, told McKnight’s last week. “Texas anticipates there are between 7,000 and 8,000 nurse aides that will need to obtain certification. These numbers do not include the nurse aide students that are currently in classes across the state that will also be seeking testing and certification.”

This month, the state’s Health and Human Services Commission submitted a waiver request to CMS asking for a 24-month waiver extension. CMS has said it would consider such waivers for areas facing major testing complications.

As of April, Texas had 55 regional testing sites and more than 100 training programs and centers offering limited access as in-facility testing sites.

The sole exam vendor in Texas is Prometric, which operates nurse aide testing services in at least 13 states. Among those is Florida, where the legislature last year moved away from the federal waiver program and adopted its own permanent personal care attendant position.

Providers there aren’t beholden to convert TNAs to CNAs by the Oct. 6. federal deadline, but PCAs also must sit for an exam within 120 days to become permanent aides.

While that adds pressure on the system, a spokeswoman for the Florida Healthcare Association said ongoing meetings between Prometric and provider groups allow them to discuss test-taking issues and to share tips for providers to help their PCAs prepare and schedule their tests.

”They have also recently expanded an option to allow nursing facilities to set up testing sites in their buildings,” said FHCA’s Kristen Knapp.

In other places, such as Pennsylavnia, collaboration appears to be lacking as providers grow more concerned.

About half the respondents to a PHCA survey said they were experiencing significant challenges with the state’s contracted provider, Credentia, when trying to convert TNAs to CNAs. One provider reported 431 TNAs waiting to test. Another said their TNAs have had applications to schedule a test pending for more than a month, and others are being offered test dates in 2023.

Proctor shortage problems

During last week’s hearing, Jennifer Mankowski, executive vice president of Credentia’s program management and development, said the backlog started when COVID paused in-person testing.

She also said her company has been affected by nursing shortages, with just 16 RNs currently on staff to proctor. The company hired a recruiting firm to find more, but many applicants expect double the salary Credentia is offering, Mankowski said, according to coverage in the Morning Call.

It has increased its testing sites from 14 to 21 since January, but that still leaves many of Pennsylvania’s 67 counties unrepresented. Although the company also solicits potential test centers on its website, lawmakers said they’ve heard from facilities willing to volunteer that have gone six months with no response from the company.

Shamberg last week recommended the state ask RNs in the National Guard to step in as proctors to improve access to and timeliness of testing.

“We need this program to work,” he said. “Without our TNAs, our workforce crisis worsens. We can’t do this without them.”

As an alternative solution, Pennsylvania lawmakers are shopping a memo with colleagues that could lead to creating the state’s own PCA program. Meanwhile, legislation that would extend the federal TNA program by two years has been referred to committee. It picked up six new co-sponsors this month.