Common wisdom says that we’ve learned much about nursing facilities during the COVID years. I read my fair share of articles and reports dealing with nursing facility policy. What do they say? Something along the lines of “COVID-19 exposed preexisting weaknesses in nursing facility operations and policy.”
True enough. Now, as COVID recedes (knock on wood), what should we do about it?
The danger, as always, is that nothing really changes. Strong proclamations of “never again!” dissipate as major stakeholders get back to the business of hiring, supervising, reporting, paying, collecting, and inspecting.
Consider the linchpin of nursing facility operations, the certified nurse aides who provide the majority of hands-on care. Nurse aide work always has been challenging, but COVID raised the difficulty level exponentially. For well over a year, nurse aides worked under the specter of a virus that killed hundreds of thousands of residents and staff members. Even worse, during this time nurse aides were under quarantine and working largely in isolation.
What preexisting nurse-aide–related weaknesses were exposed by COVID? One obvious issue is compensation. Nurse aide pay generally has been in the neighborhood of minimum wage, with meager benefits. With limited exceptions, nurse aide wages during the pandemic continued to hover around the minimum wage, despite the increased danger. And the limited benefits were particularly egregious in pandemic circumstances. More than ever, nurse aides needed comprehensive healthcare coverage and sick leave, but too frequently had access to neither.
Pre-pandemic, multiple studies recommended that nurse aide training requirements be increased.
Another weakness has been the undervaluing of nurse aides and their work. Compensation is only one marker; another is the limited respect given nurse aides in many facilities. Nurse aides know residents and their needs better than anyone else does, but facility management often takes little interest in what nurse aides know or say. Federal regulations require that nurse aides participate in a resident’s care-planning team, but in practice nurse aides often are subservient to nurses in care-planning conversations.
Lack of Training a Key Issue
Yet another weakness (and the main topic of this blog post) is the limited training required for nurse aide certification. The federal Nursing Home Reform Law (including nurse aide training provisions) was enacted in 1987 and has been effective since October 1990. Accompanying regulations were issued in the early 1990s. Under these laws, a nurse aide within the first four months of work must complete at least 75 hours of training in specified topics, and then pass tests of knowledge and hands-on competence.
The training must be performed by or under the general supervision of a registered nurse with at least two years of nursing experience, at least one of which must be in a nursing facility.
Pre-pandemic, multiple studies recommended that that nurse aide training requirements be increased. Over the past 30-plus years, the care needs of nursing facility residents have increased significantly, as has the complexity of nursing facility care. In addition, increased training would support the larger goal of creating a viable career ladder. Nurse aide jobs often are perceived as dead-end positions. Expanding training would be an important step in giving nurse aides real opportunities to transition into other types of healthcare jobs.
There is broad consensus among stakeholders to increase the sense of professionalism around nurse aides. Regardless, as the pandemic began to wind down, the federal government and some state governments took steps to reduce nurse aide certification training for those persons who had been working on an emergency basis, with little or no training, during the pandemic.
Here’s a quick recap of the COVID-related waiver of nurse aide training requirements. In Spring 2020, the federal Centers for Medicare & Medicaid Services (CMS) waived nurse aide training and testing requirements, leaving only the requirement that a facility find an aide to be “competent.” As a result, the only “formal” training for many temporary nurse aides has been an 8-hour online course offered by a national nursing facility trade association.
To be clear, waiving certification requirements during the pandemic was not irrational. Federal and state governments had reason to fear that nursing facilities wouldn’t be able to hire enough trained nurse aides, particularly given the pervasive uncertainty at the time. The issue now is the need to train those nurse aides who have been working with little or no training during the pandemic.
What Can, and Should, Be Done
Federal laws suggest a clear answer. As discussed above, a person can work as a nurse aide for four months before completing certification requirements. CMS could announce the end of the waiver and start a four-month clock for completing the required training and testing.
Some nursing facility lobbyists, however, have urged that temporary nurse aides be allowed to “grandfather” into permanent status, arguing that the temporary aides have been learning on the job. Unfortunately, some states accepted this argument and adopted some level of grandfathering. In general, these states eliminate many (or all) of the required hours of training, but retain testing requirements.
‘CMS could announce the end of the waiver and start a four-month clock for completing the required training and testing.’
Virginia, for example, requires no more than a competency verification from the employer nursing facility. New Jersey asks for only slightly more: the “temporary” training required during the COVID emergency and at least 80 hours of work in a nursing facility, with a letter from the facility’s director of nursing documenting the aide’s “adequate competency.”
In Louisiana, a temporary nurse aide must complete an 8-hour class (such as the national online course mentioned above) along with 16 hours of “lab/skills checkoffs” and at least 60 hours of work as a temporary nurse aide. New York similarly gives automatic credit for 35 training hours if the aide has worked for at least 30 days or 150 hours. Finally, in a “bridge” program that terminated in December 2021, Tennessee required completion of the original “temporary” training, at least 200 hours of employment in a nursing facility, and facility attestation of the aide’s competence.
Unfortunately, as best as can be determined, CMS has not taken any steps to push back against these state policy retreats. Instead, CMS twice issued unnecessarily equivocal guidance (April 2021 and April 2022). On the plus side of the ledger, CMS in each instance states that “temporary” nurse aides must complete certification requirements within four months of the waiver’s end. On the other hand, each guidance document includes gratuitous and confusing references to work hours being counted as training hours, presumably as some sort of accommodation to provider arguments.
Nurse aide training policy is just one example of the constant push and pull in government and facility decision-making. Too often, the pushing and pulling results in public policy that conflicts with supposedly consensus principles.
Did COVID-19 expose preexisting weaknesses in nursing facility operations and policy? Does the quality of nursing facility care depend upon having first-rate nurse aides? Should nurse aides and the nurse aide job classification be treated with more respect? If we truly believe these things, now would be the time to stand up and prove it.
Eric Carlson is a directing attorney for Justice in Aging in its Los Angeles office.