Credit: Getty Images

The formal extension of a waiver program that relaxes certification requirements for some nurse aides was widely embraced by providers a day after the Centers for Medicare & Medicaid Services announced it.

A waiver allowing temporary nurse aides to work pending completion of a full training program was set to end Oct. 7, though CMS had previously said some additional waivers would be available on an as-needed basis.

Monday’s updated guidance outlines how providers can demonstrate need and memorializes that CMS will allow extensions at the state, county or individual facility level when “localized barriers” to training or testing exist, through the end of the COVID-19 public health emergency.

That’s a relief for providers in Pennsylvania, for example, who have seen would-be certified nurse aides wait months for testing opportunities — despite attempts by providers to offer their facilities as testing sites and their registered nurses as proctors. There are clear concerns with the state’s testing capacity; however, providers have as yet been unable to convince state officials to apply for a waiver.

“Is the right answer not for the state to apply for a state waiver? This issue is a state issue,” Garry Pezzano, president & CEO of LeadingAge Pennsylvania, told McKnight’s Long-Term Care News Tuesday. “There are thousands of TNAs who are, let’s say, within the system. They’ve been hired. They’ve been working, and they’ve taken maybe one portion of the two-step testing. But they wait for availability of proctors for the competency testing. We’ve got thousands of TNAs who we’re going to lose in the workforce if we’re not able to get them fully tested.”

Pezzano also noted that leaving waiver applications and related documentation gathering in the hands of individual facilities would further burden operators who are struggling to staff their buildings.

“We have some information about documentation that would be required, but what kinds of support can we give these facilities?” he asked. “How much effort is it going to take them to apply individually?”

Iowa, Maryland, Massachusetts, Oklahoma, Texas and Virginia are among the other states that have expressed major concerns about being able to convert all temporary nurse aides to CNAs before the October deadline.

An estimated 300,000 aides had taken advantage of the waiver nationally and were being hustled through the process.

After CMS announced it would sunset its initial waiver, Pennsylvania reported during a statehouse hearing that TNAs were “giving up” after having their certification tests scheduled for 2023.

The state contracts with testing firms; the state has also been reluctant to pursue a waiver.

“They pointed out that they weren’t aware of other states that have had waivers accepted, possibly just one other state,” said Chuck Quinnan, senior vice president and chief government affairs officer for LeadingAge Pennsylvania. “Regardless of what’s going on in other states, we have a real crisis in Pennsylvania, so it really behooves the state to step forward….If they’re not able to retain those workers, it’s going to put further pressure on maintaining care and services.”

Waiver limits remain

In addition to some testing backlogs, Oklahoma CNA candidates also have faced challenges with the state process that adds credentials to a nurse registry.  State officials have already requested an 1135 waiver, according to Steven Buck, president and CEO of Care Providers Oklahoma.

“In this period of historic worker shortage, it is critical that barriers to continued employment be removed,” Buck told McKnight’s Tuesday. “Our members have appreciated the flexibility of the TNA program and know that the residents we serve have benefited from those employees recruited and trained through the program.”

The waiver program was activated during the pandemic to increase on-the-job training of aides as nursing homes dealt with crushing staff shortages. CMS, however, announced in April, that all aides would have to meet normal compliance standards by the first week of October. 

The Biden administration reinstated full training requirements, including a full 75 hours of training and passage of a state-level exam, effective June 7. Those hired after June 7 had four months from their date of hire to complete the training.

On Monday, CMS reiterated that any new training waivers would be granted “for a timeframe that is as short as possible.”

“Waivers are time-limited, and CMS expects state agencies to actively work towards resolution of barriers to certification,” the agency said in a memo. “CMS may require that state agencies provide progress reports on the submitted action plan to maintain the waiver.” 

If the PHE ends during or before the granted period of waiver for a facility, state or county, any granted waivers also will end, CMS said. Although the PHE is to officially expire in mid-October, most healthcare and government experts fully expect an additional extension that would push into mid-January. 

Withdrawal pains

But nursing home leaders are still worried about what will happen when the waiver ends, as many states have been unable to resolve their capacity issues as they, too, face staffing shortages.

“We appreciate CMS recognizing that temporary nurse aides should have a more realistic opportunity to get certified as a next step on their long-term care career path,” Holly Harmon, senior vice president of Quality, Regulatory & Clinical Services at AHCA/NCAL said Tuesday. “However, the concern remains that nationwide training and testing backlogs could extend well beyond the public health emergency — perhaps even for years —which ultimately, will restrict professional advancement opportunities for these heroic caregivers.”

She added that an eventual end of the temporary nurse aide program while the labor shortage continues “will cause care disruptions for the frail seniors we serve.”

Quinnan said he doubts states will have sufficiently ramped up testing if the end of the PHE is just a few months away.

“I don’t think January is necessarily the magic date because the testing capacity has been an issue for a while,” he said. “Continued flexibility is needed so that we can maintain the workers that we’ve gotten through the (TNA) pipeline.”

Quinnan also expressed concern about how quickly states could work to get their applications in and reviewed by CMS ahead of the expiration of the broader waiver on Oct. 7.

Repair, rebuild, reinvigorate

Janine Finck-Boyle, vice president of health policy for LeadingAge, said her organization had been “pushing for these details for months.”

“Many of our members tell us of barriers and extensive wait times for the CNAs using the waiver to take the training exam. So this is one step forward,” she said Tuesday. “At the same time, so much more is needed. Chronic underinvestment in and longstanding disregard for aging services — and primarily the valuable workers who are its core — created an opportunity for COVID to wreak havoc. That must not continue. Our country must repair, rebuild and reinvigorate this sector.”