The Center for Medicare Advocacy shined a spotlight on a 2017 rule that makes it possible for some facilities to maintain nurse aide training and competency evaluation programs through waivers from CMS even after those NATCEPs would have been suspended due to regulatory penalties or extended surveys. 

The Trump-era rule gave CMS the discretion to use case-by-case judgment to allow facilities to maintain their training and evaluation programs — a power which has proved contentious. 

“[CMS] has largely ignored the directive to strengthen the enforcement of standards of care for nursing facilities,” wrote Toby Edelman, Senior Policy Attorney at CMA, in a Dec. 14 article for the organization. “Instead, it has allowed Trump administration policies which explicitly overturned Obama administration policies and otherwise reduced enforcement, to remain in place. The Center for Medicare Advocacy calls on CMS to strengthen enforcement and protect residents.”

But staffing shortages across the country have left many in the long-term care sector frustrated by regulations that suspend the programs working to bring more care staff into the workforce. 

“In the midst of a historic labor crisis, allowing facilities the ability to offer CNA training programs to train crucially needed caregivers is exactly the type of workforce solutions we need,” wrote the American American Health Care Association in a statement to McKnight’s Long-Term Care News. “Now is not the time to take away critically important workforce development resources and programs, such as in-house CNA training.”

Some policymakers sympathize with that sentiment. A bipartisan House bill currently in committee would remove NATCEP suspensions for facilities that didn’t endanger residents, and also offer facilities more and simpler ways to reinstate their programs after correcting deficiencies.

AHCA and LeadingAge have endorsed the bill as a way to improve workforce numbers and quality of care nationwide.

Some experts have gone so far as to suggest CMS should stop suspending NATCEPs entirely until the staffing crisis has been adequately addressed.

“NATCEP programs are sometimes a key lifeblood for facility operations, providing needed advertising of the profession to potential CNAs,” wrote attorney Neville Bilimoria in a blog post for McKnight’s Long-Term Care News. “Taking that crucial program away from nursing homes is especially onerous for facilities trying to improve their staffing numbers in the midst of the very real shortage of CNAs.”
Staffing shortages and proposed regulation are set to continue as vital issues for the skilled nursing sector next year. Whether CMS continues to offer some leniency on NATCEPs or follows advocates’ suggestions and takes a firmer hand could have consequences for already struggling facilities.

Researchers found that scheduling CNAs regularly with the same group of teammates reduced turnover by nearly 25%. 

If nursing homes capitalize on the results of the study, it could go a long way toward cheaply and effectively addressing the nursing home staffing crisis, according to lead author Kevin Mayo, PhD, assistant professor of finance and management science at Washington State University. 

“These findings suggest that managers may be able to leverage part-time CNA scheduling to reduce turnover,” the study asserts, “improving both the quality and cost of care.”

The study also found that giving part-time CNAs one additional hour of work per week could reduce turnover by about 2%. Turnover was increased both by too few hours worked and too many, however, so facilities need to be more cautious in this regard. 

Building cohesive, consistent teams is the most important factor to consider, Mayo said, but nursing homes should consider all aspects of the study to achieve the best results. 

“By both balancing working hours and maintaining consistent teams, healthcare facilities can greatly reduce staff turnover,” Mayo told Newswise. 

Between greater scheduling consistency and tweaking hours worked, the authors estimate that facilities can save 7% of their operating costs with greater employee retention. 

Nursing homes have already felt the pressure to employ more flexible, worker-focused scheduling in response to the staffing crisis. The results of this study suggest that there are large benefits to be gained from this approach, and at very low cost.

Greater retention should also lead to higher quality of care for residents. After analysis of their data, the researchers concluded that CNA turnover had measurable negative effects on care quality that could be eliminated by increased retention. 

The study, published in the journal Manufacturing & Services Operations Management, analyzed data for more than 6,000 part-time CNAs from 157 facilities. 

Other authors included University of Cincinnati Assistant Professor Eric Webb, PhD, as well as Indiana University’s George Ball, PhD, and Kurt Bretthauer, PhD.

That was the message this week from Karl Steinberg, MD, CEO of Stone Mountain Medical Associates, and certified nurse aide Telisa Green, who addressed barriers to quality, end-of-life care during a webinar hosted by the National Association of Health Care Assistants.

The speakers recognized that education in this care area can be hard to come by for CNAs, who are broadly trained in vitals and other care-taking tasks.

“Almost all of the palliative care skills that CNAs learn are on-the-job training,” Steinberg acknowledged. “I absolutely will advocate for increasing the availability of palliative care training for nursing assistants.”

He said palliative and end-of-life care might be distinct facets of long-term care, but certified nursing assistants can apply their principles generally to their work in nursing homes.

“A lot of the care that’s given in nursing homes, whether we call it that or not, is palliative care,” Steinberg said, “because its team-based care, it’s care that relates to not just the physical person but the quality of life. We’re all about symptom control, symptom management, and making each day the best day it can be. And I hope we do that for just about all of our nursing home residents.”

During the COVID-19 pandemic, many nursing homes that usually relied on consultations with outside palliative care experts were forced to adapt their own regular care methods, despite a lack of further training and resources.

Nursing home workers face other obstacles to providing palliative care, including staffing and workload issues. Even care workers trained in palliative care may struggle to meet the complex psychosocial needs of patients nearing the end of their life. 

“Staffing is a big issue,” Steinberg told McKnight’s Long-Term Care News. “Part of palliative care is listening, and part of it is ‘slow medicine’ where just holding space and being present with a patient can have immense value.  A busy CNA on a busy unit is going to have a hard time being able to really incorporate all that at the level that would be ideal.”

Takeaways for CNAs 

Steinberg emphasized that if there was one thing any nursing home CNA — whether regularly engaged in palliative or hospice care or not — needs to be able to do, it’s to develop comfort around the topic of death. 

“A lot of times if you’re dealing with family members — or even a resident that knows what’s going on — in my experience, they really appreciate when somebody is willing to be honest with them and talk openly with them,” Steinberg said.

“I believe in being honest and I also try to make a good one-on-one relationship with the patient and the family,” Green elaborated, “assuring them I’m gonna be there until the end.”

Both presenters emphasized the importance of prioritizing a patient and their family’s comfort over too much devotion to a formalized care plan, as well as being an advocate for the patient’s well-being — especially in end-of-life and hospice settings. 

“If the patient is comfortable — if the family knows the patient is comfortable and in no distress — I would advocate for letting them be in as little pain as possible,” Green said.

Steinberg advised CNAs to approach nurses with suggestions for adjusting care plans when necessary to avoid unnecessary pain. In end-of-life care, for example, it’s possible that routinely repositioning a patient might result in more pain than benefit to the patient’s wellbeing.

He reminded CNAs that doctors and nurses rely on them because they have so much more time spent with individual residents and can observe key changes in demeanor and condition.

The speakers also touched on meeting patients’ psychological and spiritual needs with an attitude of openness and care, even if their beliefs and practices are different.

“I never push my view on them, but if they’re open and want to have prayer, I will do that and I let them lead in whatever way that they want,” said Green. “I’m always open and willing to close my eyes or hold their hand —anything to help them feel comforted.”

“One thing I didn’t get into as much as I would have liked to is just that in our homes, death is pretty commonplace. And that we work in a sacred place,” Steinberg told McKnight’s following the event. “Some facilities have small rituals of various types, but we could also do a lot better on that. Monthly or quarterly memorial services where families are invited, that kind of thing—in addition to stuff like ringing a bell over the intercom, or even just a candle-lighting at the time of shift change/report? These things can help.”

Highlighted were plans for a new pilot for a nurse aide apprenticeship program, tools to strengthen resident councils, and meetings to raise awareness of facility renovation needs.

The Moving Forward Nursing Home Quality Coalition was formed in the wake of a 2022 report from the National Academies of Sciences, Engineering, and Medicine that industry leaders described as a wake-up call. 

The coalition of providers, residents, advocates and policymakers set out to develop actionable methods to fix the major issues, resulting in a nine-part plan they announced in July 2023. 

During Tuesday’s webinar, coalition leaders spent the most time focused on staffing issues. Coalition Chair Alice Bonner put a spotlight specifically on certified nursing assistants.

She referenced the struggles that nursing homes nationwide have had with retaining their workforce, including CNAs. 

“Across the country, CNAs are not well paid, they don’t get good benefits,” she pointed out. “We need to do something about that.”

Beyond simply offering higher wages and benefits, though, Bonner stressed the need to create a standardized career path for CNAs. 

More depth to training

She referenced a National Association of Health Care Assistants survey that asked CNAs who were thinking about leaving the industry what could keep them at their jobs. Better wages and benefits topped the list, but better training was a major factor as well.

“People really do want those additional skills,” Bonner said, “they want that additional training, and they want to get compensated after that.”

She noted that state and federal apprenticeship programs already exist for CNAs, but also that those resources lack the standardization that Moving Forward advocates for. 

“A lot of what we’ve learned is that there’s such variability and fragmentation. It’s not that these programs don’t exist — they absolutely exist — but some states have way more structure than other states.”

To address this, the coalition proposes that a national CNA apprenticeship program should be created with the specific goals of providing training that can be reliably replicated at the state level and providing skills and certifications that can be taken and applied in jobs around the country.

Moving Forward plans to pilot an apprenticeship program with at least two nursing homes by July of 2024 and leverage that momentum to advocate with policymakers at the state and federal level. 

“[CNAs] are the heart and the soul of the nursing home workforce and they spend the greatest number of hours everyday with residents. They know things about residents that nobody else does,” Bonner said. “They are a critical member of the interprofessional team and they really need to be recognized in a different way than they are.”

Resident councils and renovations

Other presenters took turns describing the progress Moving Forward is making on two other areas of their nine-part plan. 

Sumire Maki, program manager for Moving Forward, laid out the group’s progress on strengthening resident councils, including drafting a guide with tools that nursing homes can use to amplify the voices of their residents. Moving Forward also plans to test some of these methods in a four-facility pilot program starting in January 2024 in New Jersey. 

​​“Resident councils center resident voices and are truly a vital part of community life,” Maki said.

Isaac Longobardi, director of the coalition, also updated attendees on how the coalition is working to make renovations viable for nursing homes that want to create a more home-like atmosphere. They are in the process of partnering with state and federal policymakers on the issue. 

Next week, Moving Forward is meeting with the Department of Housing and Urban Development to discuss actionable steps that could be taken to incentivize renovations in the short term. 

At the state level, Longobardi said the coalition is meeting with policymakers from several states to make them aware that these renovations are a key part of improving resident experiences. Currently, awareness is low, he said.

“We need to make these changes part of state priorities overall in order to drive those changes,” he said.

The event was hosted by Gray Panthers NYC as part of the Transformation Tuesday series. A full recording of the webinar can be found here.

Launched in October 2022, the statewide Gateway-In Project so far has graduated more than 1,200 CNAs and has a goal of developing a total of 2,700 CNAs by 2026. The California Department of Health Care Access and Information awarded the state’s LeadingAge affiliate more than $25 million for the project.

“I am thrilled with the remarkable outcomes made by The Gateway-In Project just one year after its launch,” said Jeannee Parker Martin, CEO of LeadingAge California, in a press release touting the program’s success. “This visionary recruitment, training and retention initiative is designed to help tackle California’s pressing healthcare workforce shortage head-on while also creating new opportunities for residents across the state.”

The association noted that there has been high demand throughout the state for CNA training, and there are training programs in 29 of the state’s 58 counties, with students ranging in ages from 19 to more than 56 years old. The goal is to send as many students as possible into the long-term care pipeline, which is struggling with a national, historic staffing crisis. 

In addition to ensuring students are proficient in nursing responsibilities, The Gateway-In Project provides wraparound support services such as childcare, transportation, scrubs and classroom materials. The press release noted that 62% of students earn less than $25,000 a year and 73% say their highest level of education is either high school or a GED. 

The state has the largest number of older adults in the country and an additional 275,000 direct care workers will be needed by 2026 to meet care needs, according to LeadingAge California. 

“The Gateway-In Project serves as a crucial intervention measure to create a new workforce pipeline to prepare for this growing population and avoid a crisis in the provision of care,” the group’s release said.

The Moving Forward Nursing Home Quality Coalition Workforce Committee is responsible for  putting two of those recommendations into action: 

1. Ensuring competitive wages and benefits for certified nursing assistants (CNAs) and
2. Advancing the role of and empowering the CNA

Action plans to address these recommendations — which were published in July — were developed by academic researchers, nursing home leadership, staff, residents, long-term care advocates, and policy experts who comprise the workforce committee. 

As members of the workforce committee, we provide a summary of what those action plans entail and where help is needed from states, nursing home leaders, policymakers and providers. This is particularly critical in light of the recent unveiling of the federal minimum staffing standards and the need to attract and retain more individuals to nursing home roles.

Action Plan 1: Increasing wages and benefits

Currently, the median pay for CNAs is $35,240 annually and $16.94 hourly. While this pay may work for someone just coming out of high school, it is not a liveable wage for the majority of CNAs, who have a median age of 36 years old and have multiple obligations, such as paying for housing, transportation, food, childcare and utilities among many other things. As a result, 38% of CNAs are living in or near poverty, 34% rely on public assistance, and 29% live in unaffordable housing.

Increased wages would lead to a better supported CNA workforce and an improved ability to recruit and retain workers, who otherwise could obtain increased wages in similar entry-level positions (e.g., $3-4 more per hour and greater) with less stress and burden.

To this end, the Moving Forward Coalition Workforce Committee seeks to improve CNA wages through Medicaid Incentive Payment Programs. These programs (e.g., quality incentive payment and value-based payment programs) are payment models that involve certain process, structure and outcome goals tied to an accompanying payment enhancement if those goals are met. 

States are able to develop such programs within their Medicaid payment structures to encourage improved CNAs’ wages, benefits and other workforce issues by incorporating relevant workforce metrics, yet few states have considered such metrics within their incentive programs to date. A 2022 scan found that only 12 of the 24 states with a nursing home Medicaid value-based payment program in place included a workforce metric, and only two of those states included a wage metric. 

Through exploring the value of incorporating these metrics into Medicaid Incentive Payment Programs, the Committee will develop a “how-to guide” for states with various program options on how they can incentivize workforce improvements (such as increased wages and benefits) through these nursing home programs. The Committee will also recommend the Centers for Medicare & Medicaid Services (CMS) consider including this guidance for states through a CMS memo, bulletin, or other communication and/or as part of the incentive payment program applications submitted to the CMS. 

Where help is needed: The coalition is asking for one or two states with existing nursing home payment incentive programs to include a metric designed to incentivize nursing home workforce improvements, potentially including increased CNA wages, benefits or other adjustments. Experts in wage related policy are needed as well as nursing homes that have participated in payment incentive payment programs that include workforce goals. 

Additionally, CMS support is needed in providing guidance to states to include CNA compensation metrics or other workforce metrics (e.g., staffing turnover) in their proposed nursing home Medicaid Incentive Payment Programs. Lastly, it would be beneficial for the committee to receive guidance from state and local workforce commissions on living and competitive wage indices.

Action Plan 2: Advancing the Role of the CNA

While making a living and competitive wage is important to CNAs, equally and arguably more important is that CNAs feel valued, respected and empowered by receiving sufficient education, training and advancement opportunities. CNAs care for an increasingly complex resident population, which has not kept pace with the education and training that they receive. They want to be able to do more but not necessarily leave the CNA role. 

Thus, CNA career lattices have been popular among CNAs, as they allow the CNA to advance in the CNA role while earning additional pay at each lattice and “earning and learning.” Such lattices have included the Health Support Specialist Program in Minnesota, the WIN A STEP UP Program in North Carolina, and the CNA Upskilling Pilot in California. These programs have resulted in improved retention among CNAs and better care for residents. However, CNA career lattice programs are currently not transferrable from nursing home to nursing home and there is no nationally recognized program.

To this end, the workforce committee plans on creating a standardized CNA career pathway model under the Registered Apprenticeship Framework and developing a robust evaluation plan to generate evidence for replicability and sustainability of this career pathway model on a national level. The pathway model will incorporate state-specific guidance for incremental wage increases with each pathway stage. 

Where help is needed: The coalition will be piloting a CNA pathway model in one or two states. Potential employers along with educational and apprenticeship partners are needed to create and implement this pathway and engage nursing homes and their CNAs. Additional needs include information on lessons learned from existing and past CNA career pathway programs, including barriers and opportunities.

The Committee will work over the next 12 months to put these plans into action. The success of the action plans is predicated on engaging with nursing home stakeholders in the areas where help is needed. With broad support, the CNA role can be transformed into an adequately paid career of experts in caregiving. 

More information about the action plans and co-chairs of this committee can be found here. 

Jasmine L. Travers, Ph.D., MHS, RN, is an assistant professor at NYU Rory Meyers College of Nursing and affiliated faculty of the Hartford Institute for Geriatric Nursing.

Marissa Bergh, BSN, RN, is a graduate student at NYU Rory Meyers College of Nursing and policy intern for the Moving Forward Coalition Workforce Committee.

Kim Hadson, BSN, RN is a graduate student at NYU Rory Meyers College of Nursing and policy intern for the Moving Forward Coalition Workforce Committee.

Natalie Baysinger is an undergraduate student at University of Delaware Biden School of Public Policy & Administration and policy intern for the Moving Forward Coalition Workforce Committee.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

PHI released a study Tuesday on the state of the frontline healthcare workforce that projected open positions for nursing assistants in nursing homes would grow to 769,300 by 2031. That comprises 442,400 job openings due to workers moving to other occupations and 311,100 openings due to people leaving the labor force entirely. 

Those figures were likely calculated in advance of a proposed federal staffing mandate that is likely to drive demand for certified nurse aide hours higher.

PHI, which advocates for frontline healthcare workers, actually expects the nursing assistant workforce to lose 17,200 jobs by 2031 due to a decreased demand for nursing home care because of both consumer preference and public policies.  But turnover will mean a constant cycle of hiring and rehiring.

“While demand for nursing home care has declined in recent years, nursing homes continue to play a critical role in supporting individuals with complex needs,” PHI said in the report. Nursing assistants provide 24-hour care to 1.2 million facility residents, it noted.

“Low wages, heavy workloads, and long work hours — driven by chronic understaffing and greatly exacerbated by the ongoing COVID-19 pandemic — contribute to high rates of stress, injury and burnout among nursing assistants in nursing homes,” the organization added.

The median turnover rate in this specialized workforce is “nearly” 100%, PHI noted, advocating for interventions to improve job quality such as higher wages and better support from employers. 

There are currently 447,940 nursing assistants in the US, and although their wages have risen slightly since 2012, the median hourly wage, when adjusted for inflation, increased to $17.06 in 2022 from $14.51. 

“This overall trend means that nursing assistants’ wages have only increased slightly faster than the costs of goods and services over the past decade,” the report noted. “Although overall demand for nursing homes is declining, there is still a pressing need to recruit and retain enough nursing assistants to support individuals with complex needs in this care setting.”

The report also found that nursing assistants are nearly eight times as likely than the typical US laborer to sustain workplace injuries, including illnesses that are contracted in professional settings. Due to COVID-19, the rate of workplace injuries for nursing assistants increased by more than 300% from 2019 to 2020, the latest year for which occupation-specific data is available, the report noted.  

Ensuring Seniors’ Access to Quality Care Act in the Senate by Sens. Mark Warner (D-VA) and Tim Scott (R-SC) would remove a blanket lockout that has stopped many facilities from providing training when they’ve been cited for too many deficiencies.

Since its passage in 1987, the lockout provision has confounded providers as being counterintuitive for those who have typically exhibited a demonstrable need for more staff training, not less.

Its existence has been increasingly problematic during the pandemic, as nursing homes have lost more than 210,000 workers, many of them certified nurse aides. A waiver allowing temporary nurse aides to work longer without completing all training and testing requirements has also expired, adding pressure on providers to find new ways to improve training access.

“Certified nurse aides are integral to the quality care that nursing homes provide; more are desperately needed,” Katie Smith Sloan, president and CEO of LeadingAge, said in a statement after the bill’s Thursday night introduction.

“In addition to providing a solid educational foundation, [on-site] training programs also serve as an introduction to aging services, exposing students to nursing homes’ daily work routines and community cultures. They’re critical,” Sloan added. “Particularly now, when nursing homes are in dire need of more staff, we must leverage every possible opportunity to bring qualified workers into the sector and build pipelines to help deliver quality care for our country’s aging population.”

The bill is a companion to a House version introduced on May 11, 2023. That bill had not picked up any co-sponsors as of Friday, a spokesman for one of the two initial sponsors told McKnight’s Long-Term Care News. Both the House and Senate versions have bipartisan lead sponsors.

Both the Senate and the House bills modify the training suspension mandated by the Omnibus Budget Reconciliation Act of 1987 (OBRA). A two-year suspension is required for fines that pass a certain threshold, even if they are unrelated to the quality of care or are unrelated to the nursing home’s CNA training program.

They would grant CMS greater flexibility in reinstating CNA training programs if providers avoid other major citations and can prove they’ve returned to compliance on past issues.

Nursing homes’ on-site CNA training programs are often free to the job candidate, versus programs at community colleges or other institutions that require entry level workers to invest thousands of dollars before being hired.

A similar measure last year never passed.