In an October 30, 2020 letter, Congressman Lloyd Doggett (D, TX) and colleagues asked Seema Verma, Administrator of the Centers for Medicare & Medicaid Services (CMS), to promptly reinstate nurse aide training requirements that have been suspended since March 2020, to gather, and make publicly available, information about temporary nurse aides with minimal training who have been working in nursing facilities during the pandemic, and to ensure that temporary aides fully meet training requirements (i.e., prohibit “grandfathering” of temporary nurse aides).[1] They also seek reinstatement of training requirements for paid feeding assistants. The letter underscores the critical importance of having trained and competent workers provide care to residents and the dangers – to residents and workers alike – of allowing minimally trained workers to be caregivers.
Nurse aides provide most of the direct care that nursing home residents receive. The requirements that facilities not use aides for more than four months unless they are trained and determined by the state to be competent[2] is one of the major accomplishments of the 1987 Nursing Home Reform Law.[3] Federal regulations set out a minimum of 75 hours of training,[4] although many states require more hours of training.
In March 2020, in response to the public health emergency, CMS waived the aide training requirements, among other longstanding rules.[5] Immediately, the American Health Care Association (AHCA) announced that it had created a free on-line eight-hour training and competency evaluation program for temporary nurse aides.[6] Many states explicitly or implicitly gave approval to the eight-hour program, authorizing individuals who passed the eight-hour program to work as temporary aides in nursing facilities.[7]
In June, CMS reinstated the requirement, also waived in March, that nursing facilities report their staffing levels electronically to CMS, through the Payroll-Based Journal (PBJ) system, effective with the second quarter of 2020 (April-June 2020).[8] In a conversation with residents’ advocates, CMS confirmed that it could not revise the PBJ system to account for temporary aides with less than 75 hours of training and that facilities could report these temporary workers as if they were fully certified nurse aides (CNAs). CMS also confirmed that it had no plans to identify how many individuals with minimal training were providing quasi-aide care to residents or what types of care they were providing.[9]
Advocates’ concerns about minimally trained workers were intensified by a training program about staffing that CMS’s Quality Improvement Organizations conducted for nursing homes on October 20, 2020.[10] One of the two nursing home representatives who spoke at the session described successfully employing workers with eight hours of training. He said the facility paid these workers less than certified nurse assistants, reported them to CMS as if they were fully trained CNAs, and expected them to be permanently grandfathered as aides, if legislation passed in the state. Aside from on-line training, he said the temporary nurse aides followed a CNA to learn how to do the job. In a separate communication, the Center for Medicare Advocacy (Center) also heard that 86,000 individuals had taken AHCA’s eight-hour training course.
The Center views the federal nurse aide training and competency evaluation requirements as among the most significant achievements of the 1987 Nursing Home Reform Law. Jeopardizing the requirement that nursing home staff know how to provide the care that residents need threatens the health and safety of residents and workers and undermines the integrity of the Reform Law. Congressman Doggett and his colleagues are correct to call on CMS to restore – and enforce – aide training requirements. The Center for Medicare Advocacy strongly supports the immediate reinstatement of aide training rules.
November 5, 2020 – T. Edelman
[1] https://doggett.house.gov/sites/doggett.house.gov/files/CMS_
Nurse%20Aide%20Training%20Letter_
10%2030%2020_Signed.pdf.
[2] 42 U.S.C. §§1395i-3(b)(5)(A)(i), 1396r(b)(5)(A)(i), Medicare and Medicaid, respectively.
[3] 42 U.S.C. §§1395i-3(a)-(h), 1396r(a)-(h).
[4] 42 C.F.R. §§483.35(d)(1)-(7).
[5] CMS, “Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19” (Mar. 28, 2020, most recent update, Jul. 9, 2020), https://www.cms.gov/files/document/covid-long-term-care-facilities.pdf.
[6] AHCA, “Temporary Nurse Aide,” https://educate.ahcancal.org/products/temporary-nurse-aide.
[7] “Who’s Providing Care to Nursing Home Residents?” (CMA Alert, Jul. 29, 2020), https://medicareadvocacy.org/whos-providing-care-to-nursing-home-residents/. The full report, Who’s Providing Care for Nursing Home Residents? Nurse Aide Training Requirements during the Coronavirus Pandemic, is available at to: https://medicareadvocacy.org/wp-content/uploads/2020/07/Report-Nurse-Aide-Training.pdf.
[8] CMS, “Changes to Staffing Information and Quality Measures Posted on the Nursing Home Compare Website and Five Star Quality Rating System due to the COVID-19 Public Health Emergency,” QSO-20-34-NH (June 25, 2020), https://www.cms.gov/files/document/qso-20-34-nh.pdf.
[9] “CMS Will Not Track Minimally Trained Aides at Nursing Facilities” (CMA Alert, Aug. 6, 2020), https://medicareadvocacy.org/cms-will-not-track-minimally-trained-aides-at-nursing-facilities/.
[10] CMS, “National LAN Event: Staffing Challenges & Solutions: Insights from the Frontline” (Oct. 20, 2020), https://qioprogram.org/sites/default/files/National%20LAN%20Presentation_10-20-2020%20v3_FNL_508_1.pdf.