As part of its comprehensive nursing home reform agenda, the Biden-Harris Administration has promised to establish nurse staffing ratios that all facilities must meet and that are enforceable.[1] Only licensed nurses (registered nurses, licensed practical nurses) and certified nurse aides (CNAs) should be included in nurse staffing ratios. While other workers in nursing facilities, such as therapy aides, social services staff, and activities staff, provide critical and essential services for residents, they do not perform direct nursing care services and should not be counted in nurse staffing ratios. Decades of research on nurse staffing levels have focused on direct care staff; none of the research has considered the role of non-nursing staff in meeting residents’ nursing needs. The Center for Medicare Advocacy urges the Biden-Harris Administration not to count any non-nursing staff in the nurse staffing ratios that it establishes.
Of particular concern is a new category of worker, temporary nurse aides (TNAs), that was created during the COVID-19 pandemic. These workers should also be excluded from nurse staffing ratios.
Before the Nursing Home Reform Law was enacted in 1987, there was no federal requirement for nurse aides to receive training before they provided care to residents. Only half the states imposed any training requirement. In half the states, people could literally walk in the door of a nursing home and immediately be set to work as an aide. The 1987 law, for the first time, required that all aides take a state-mandated training course (minimum of 75 hours) and pass a state’s competency test in order to work more than four months at a nursing facility as a CNA.[2] The requirement for nurse aide training was one of the most important changes made by the federal law.
When the public health emergency was announced, the Centers for Medicare & Medicaid Services (CMS) issued a number of blanket (automatic) waivers for all nursing facilities nationwide.[3] One of the blanket waivers issued in March 2020 was the nurse aide training requirement. The American Health Care Association (AHCA) immediately created a free on-line eight-hour training program for a new position, which it called temporary nurse aide. Many states accepted that limited training as sufficient during the COVID-19 pandemic.[4] With support from CMS, many states also began to count time worked as a TNA as if it were time spent in actual training, permitting TNAs to take the state’s competency test without receiving comprehensive training.[5]
CMS ended the blanket waiver for nurse aide training in April 2022, expressing concern that removing minimum standards for quality, including nurse aide training requirements, had led to resident care problems unrelated to COVID-19.[6] After ending the blanket waiver, however, CMS created a new waiver authority and allowed states to request nurse aide training waivers on a state, county, or local level.[7] CMS granted statewide waivers to 17 states and to an unknown number of individual facilities. All of the waivers will end when the public health emergency ends on May 11, 2023.
AHCA claims that nursing facilities have lost more than 200,000 staff positions during the pandemic, “the worst job loss of any health sector,” and that facilities will not return to pre-pandemic staffing levels until 2027.[8] They also claim that more than 300,000 TNAs have been trained and that many TNAs are working in nursing homes.[9]
The paraprofessional nursing home workforce has shifted from a cohort of trained CNAs to a direct care workforce that includes a large percentage of TNAs, who do not have sufficient training to provide high quality care to residents or to prevent injury to residents or themselves.
The Center for Medicare Advocacy believes that counting TNAs in nurse staffing ratios would undermine meaningful nurse staffing standards. The Center urges the Biden-Harris Administration not to count TNAs, or any other non-nursing staff, in the nurse staffing ratios that it establishes.
March 2, 2023 – T. Edelman
[1] White House, “FACT SHEET: Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes” (Feb. 28 2022), https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/
[2] 42 U.S.C. §§1395i-3(b)(5), 1396r(b)(5), Medicare and Medicaid, respectively; 42 C.F.R. §483.35(d)
[3] CMS, “COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers” (updated Oct. 13, 2022), https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf
[4] “Who’s Providing Care for Nursing Home Residents? Nurse Aide Training Requirements during the Coronavirus Pandemic” (CMA Report, Jul. 23, 2020), https://medicareadvocacy.org/wp-content/uploads/2020/07/Report-Nurse-Aide-Training.pdf
[5] “Who Provides Care for Nursing Home Residents? An Update on Temporary Nurse Aides” (CMA Alert, Sep. 15, 2021), https://medicareadvocacy.org/special-report-update-on-tnas/, and (CMA Report, Sep. 15, 2021), https://medicareadvocacy.org/w
[6] CMS, “Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers,” QSO-22-15-NH & NLTC & LSC (Apr. 7, 2022), https://www.cms.gov/files/document/qso-22-15-nh-nltc-lsc.pdf
[7] CMS, “Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers,” QSO-22-15-NH & NLTC & LSC (Apr. 7, 2022, revised 8/29/2022), https://www.cms.gov/files/document/qso-22-15-nh-nltc-lsc-revised.pdf
[8] AHCA, “Data Show Nursing Homes Continue to Experience Worst Job Loss Of Any Health Care Sector” (Press Release, Jan. 19, 2023), https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Data-Show-Nursing-Homes-Continue-to-Experience-Worst-Job-Loss-Of-Any-Health-Care-Sector.aspx#:~:text=Nursing%20homes%20have%20lost%20210%2C000,over%20the%20last%20nine%20months.
[9] Ginger Christ, “Nursing homes rush to certify TNAs as CMS deadline looms,” Modern Healthcare (Jun. 8, 2022), https://www.modernhealthcare.com/post-acute-care/nursing-homes-rush-certify-tnas-cms-deadline-looms