A nurse helping a senior citizen
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Phasing out several COVID-related waivers, including one allowing temporary nurse aide training, over the next several weeks will further complicate workforce struggles, skilled nursing providers said Thursday. 

The new concerns follow the Centers for Medicare & Medicaid Services announcement that the agency will eliminate 16 waivers, some in 30 days and some in 60. They affect regulations on doctors, discharge requirements and the special use of rooms and buildings, all of which CMS had eased due to the public health emergency. 

“Now is not the time to let crucial supports and flexibilities necessary to combat the virus end,” said Holly Harmon, RN, senior vice president of quality, regulatory and clinical services, for the American Health Care Association. “This is especially true for the temporary nurse aides, who stepped up to serve our vulnerable seniors during this global crisis and are hoping to build a career in long-term care.” 

The waiver for nurse aide training and certifications let SNFs and other nursing facilities employ aides for longer than four months even if they hadn’t completed the necessary training and certification requirements. The agency first waived the requirements in April 2020. 

The waiver will now be phased out 60 days from the memo’s release. 

CMS also is rescinding liberties allowing doctors to relinquish some obligations to nurse practitioners or other non-physicians. And it is returning some requirements for in-person physician visits that have given way to telehealth capabilities. The full list of affected waivers can be found in the CMS memo, which outlined numerous reasons and clarifications about conditions for the waivers’ removal.

Bad timing

The end of this nurse-training waiver comes at a time when providers need staff most, said Amy Stewart, MSN, RN, vice president of education and certification strategy for the American Association of Post-Acute Care Nursing. 


“While we are making gains in the fight against COVID-19, we continue to suffer the ill-effects from it, including staff turnover,” Stewart told McKnight’s Long-Term Care News on Thursday. “The temporary waiver helped fill nurse aide vacancies. These individuals will now need to juggle education and work, limiting their availability to fill shifts.” 

Harmon also argued that state capacities are not sufficient to accommodate the training and testing needs for thousands of temporary nurse aides in this short timeframe.

“We cannot lose these heroes in the midst of a historic labor shortage,” Harmon told McKnight’s Thursday. “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.”

Thursday’s memo from CMS to reinstate pre-pandemic requirements for temporary nurse aide employment is “concerning,” added Janine Finck-Boyle, vice president for regulatory affairs at LeadingAge. She noted that there are more than 10 million job openings in the service economy now, while federal data shows more than 240,000 workers have left nursing home jobs. 

“Although the waiver ends, workforce challenges have not. There is no current plan to help nursing homes with staffing,” Finck-Boyle told McKnight’s Thursday. “The reality is that we are looking for workers that, at the present time, don’t exist. At the end of the day, this is about equity – in access, in quality and in professionalizing our direct care workforce.” 

Future of other waivers

The agency expressed concern that a lack of in-person physician visits may have led to a lack of recognition of certain patient conditions, and that some buildings might not have had enough fire- and life-safety inspections because of waivers.

Cynthia Morton

The agency will end a waiver that allowed for a state-approved, non-SNF building to be temporarily certified and available for use by a SNF in the event there were needs for isolation processes for COVID-19 positive residents to ensure residents could still be treated. 

CMS said onsite surveys have revealed “significant concerns with resident care that are unrelated to infection control (e.g., abuse, weight-loss, depression, pressure ulcers, etc.). We are concerned that the waiver of certain regulatory requirements has contributed to these outcomes and raises the risk of other issues.”

Cynthia Morton, executive vice president of the National Association for the Support of Long Term Care, interpreted the move as CMS reexamining the waivers’ necessity in light of decreased COVID infection numbers. But what the agency might not understand is that the impact of the pandemic is still with us, she said. 

Morton added that this could foreshadow what’s ahead for other waivers, like those surrounding telehealth.

“I would be concerned that CMS could pull back therapists’ ability to utilize telehealth. Congress did put in place the five month extension for telehealth beyond the end of the [public health crisis],” Morton told McKnight’s Thursday. “So, it is very important to patients that Congress did that. We have such a dire shortage of rehab therapists around the country right now that telehealth is an incredibly necessary tool in order to get services to patients in nursing facilities.”