Operators Urge CMS to Reconsider Winding Down Essential Waivers as SNF Recovery Varies

Nursing home operators were able to tell the Centers for Medicare & Medicaid Services (CMS) directly how much certain waivers helped their organizations during the pandemic, with the temporary nurse aide (TNA) and three-day stay waivers being the most beneficial.

SNF industry leaders also made their case for extending waivers or making some permanent during a CMS listening session on emergency preparedness, reminding the agency that recovery looks drastically different across the country.

A seemingly arbitrary cutoff, like with the TNA program, hurts operators that may not have the resources to turn TNAs into certified nursing assistants (CNAs), according to Crystal Bowens, associate vice president of regulatory services at the American Health Care Association (AHCA).

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While there has been no word on whether CMS will make the three-day stay waiver permanent in any capacity, the agency did initially set out to sunset the TNA program in April with an Oct. 7 deadline. CMS cited long-term care survey findings linking resident weight loss, depression and pressure ulcers to the “lack of certain minimum standards,” according to a memo issued at the time.

The waiver allowed TNAs to work longer on the front lines prior to taking their certification exam.

Most recently in August CMS said facilities may have additional time for TNAs to gain their certifications. Operators would need to prove that TNAs were enrolled or signed up for training or testing but unable to be accommodated by that geographic area’s Nurse Aide Training and Competency Evaluation Program (NATCEP).

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“Ending some of these waivers all at the same time I don’t think is helpful for providers,” Bowens said.

Varying recovery timeframes

Leaders in the sector believe CMS is making an assumption that all providers are in the same position in terms of recovery when that isn’t the case for those in the nursing home industry.

Many facilities are still in recovery mode and in need of the TNA program to increase net hires while reducing agency use, Bowens said.

“We’re all on tenterhooks a little bit right now to see how that transition is playing out between TNA to CNA certification, as there are so many backlogs in in different states,” said Jodi Eyigor, director of nursing home quality and policy for LeadingAge. “We’re hopeful that CMS is working with states and that we can work with our states and with our members to get folks through that process to be sure that they can be certified to continue working.”

Even members of Congress are speaking up, urging CMS to support states and TNAs amid the ongoing workforce shortage. A bipartisan group of lawmakers, led by Congressman Brett Guthrie of Kentucky sent a letter to CMS last week requesting the agency’s support of House Resolution 7744.

Otherwise known as the Building America’s Healthcare Workforce Act, the legislation would extend waiver flexibilities for 24 months after the Covid-19 public health emergency (PHE) ends.

Wanda Prince, chief compliance and strategy officer for Brickyard Healthcare, said TNAs were the people that “came running to the fire” when the industry was seeing a mass exodus of staff.

“We continue to utilize these individuals and we are very concerned that we will not be able to get all of them through the certification process before the waiver expires in early October,” added Prince, referring to the original deadline of Oct. 7.

Other topics CMS asked about included developing and implementing emergency preparedness plans, what resources were utilized to inform such plans and how facilities recovered from emergency events.

Waivers freed up clinicians, beds

Eyigor said that overall, waivers helped nursing home clinical staff work at the top of their license and increased the number of staff able to treat patients.

Diana Wiggins, an administrator for Autumn Lake Healthcare at Riverview in Maryland, said the waivers made a “tremendous difference” in giving the facility flexibility during the emergency, and getting people care more quickly.

Telehealth waivers also helped keep patients where they needed to be, she said, and not sent out necessarily during an emergency.

The three-day stay waiver specifically made it easier to get patients in for SNF care from the community, Eyigor said, or get long-term care patients to receive SNF care without having to go to the hospital first.

Suspension of the three-day stay requirement allows Medicare patients to be discharged to a skilled nursing facility without having to stay at a hospital for at least three days.

“This of course helped free up beds in acute care settings … skilled nursing facilities could provide the care to the individuals that we admitted with the [three-day stay] waiver,” added Prince. The Brickyard representative called on CMS to consider keeping this waiver in some capacity.

Streamlined waivers in future

While waivers tied to the Covid-19 public health emergency have been helpful, operators would like to see more of a streamlined approach to rollout, Ron Nunziato said during the call. Nunziato is senior director of policy and regulatory affairs for the Health Care Council of Illinois.

“There has to be a way that the agencies that are involved in this can coordinate their approach so that the facilities and providers get one set of documents of recommendations or guidance or regulations to follow,” Nunziato said.

The most recent example was when the CDC came out with an updated vaccination policy, he said, referring to recommendations made two weeks ago for Covid boosters that add the Omicron BA.4 and BA.5 spike protein components to vaccine composition.

At that point, CMS had not changed its approach or published anything regarding the policy, nor had the local or state health departments.

“You guys have to … be more coordinated because we have different people telling us different things as we move forward through this,” he said.

Lisa Parker, a manager at CMS, said the agency will take Tuesday’s feedback, along with feedback from other listening sessions, as they evaluate existing regulations and waivers.

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