Next Steps for Facilities Using 1135 Waiver for Training and Certification of Nurse Aides

COVID-19; Workforce; Nursing

The release of CMS QSO​-22-15-NH & NLTC & LSC​ has caused concern and confusion as to what it means for the ability of nursing homes to employ Temporary Nurse Aides (TNAs). AHCA understands members concerns and challenges, as the TNA role has been invaluable to the care of residents throughout the pandemic and TNAs serve as key support to the other staff in nursing homes.​

AHCA is seeking some clarifications from CMS which we expect to receive next week. In the meantime, below are some key takeaways and next steps facilities can take to prepare for the upcoming end of the 1135 waiver. 

Please note: Yesterday’s announcement about waiver end dates does not impact the 3-Day Stay or the Spell of Illness waivers. Those waivers remain in force nationwide for all hospitals, communities, and SNFs.​

What training do TNAs need to complete to become CNAs? 
Per CMS QSOTemporary Nurse aides (TNAs) who were hired during the blanket waiver period must complete a state approved Nurse Aide Training and Competency Evaluation Program (NATCEP) to become a certified nurse aide (CNA). If your state has approved a transition or bridge program from TNA to CNA, follow your state approved program. 

What do I do if my state has backlogs in training and/or testing which is delaying the TNAs in my facility from becoming CNAs? 
CMS acknowledges that there may be instances where the volume of temporary nurse aides who must complete a state approved NATCEP may exceed the available state capacity. In states where backlogs and delays for training and/or testing may exist, the facility should: 

  • Evaluate status of all TNAs employed including progress towards becoming certified as a nurse aide. Maintain supporting documentation for each TNA’s progress. 
  • Have written documentation demonstrating all attempts made to have TNAs complete their training and testing. This can include documentation from both the facility and the TNAs to training programs and testing sites in multiple locations. ​
  • Have frequent communication to state officials (may include CNA registry, survey agency, Board of Nursing, Department of Education) regarding the delays and backlogs in training and/or testing and outline the facility’s attempts to enroll TNAs into training/testing programs. Document those communications. 
  • Enroll TNAs into training and/or testing centers as soon as possible, even if the only option is a waitlist. 
  • Keep all communications to and from state agency overseeing nurse aide programs. Maintain a log showing ongoing and multiple attempts. 
  • Keep all communications to and from training and/or testing centers. Maintain a log showing ongoing and multiple attempts. 
  • AHCA is developing a template for facilities to use to guide the process of notification asking to retain the waiver. Providers will be updated when the template is complete. 

What should I do if my state does not have backlogs in training or testing and we have TNAs working in our facility? 
In states that do not have a backlog or delay in training and/or testing sites, facilities should be actively seeking to transition all TNAs into CNAs as soon as possible. As noted above, maintain documentation for each TNA and their progress towards CNA to ensure it is timely according to allowed timeframes. 

How long can TNAs still work as nurse aides in training after the 1135 waiver ends? 
The waiver is set to end on June 6, 2022. The traditional four months’ time per CMS requirement to get nurse aides in training to become certified, will begin on June 6, 2022. To this end, facilities will need to have TNAs become certified before October 6, 2022, to continue working as a nurse aide. If a TNA is not certified by the end of the four months post-waiver termination, the TNA cannot continue working as a nurse aide in training, except for those who are experiencing testing and/or training capacity issues and have received approval from their state official. 

How can my facility engage individuals who had served as TNAs but do not want to become CNAs or are unable to within the allowed timeframes? 
Facilities who are not able to get TNAs transitioned into CNA positions within the allowed timeframes, could consider how to engage TNAs in non-nurse aide work. This could be in the role of valet, hall monitor, shift coach, answer call-lights, spend time with resident's one-on-one, provide stimulating activities, or any other number of tasks that do not require a CNA. 

AHCA will continue to advocate for innovative approaches to resident care and services and seek new ways for enhancing the workforce to support members in providing quality care to residents. Please email with any questions.