Nursing homes are increasingly hiring housekeepers, waitresses and residents’ own relatives as temporary nurse’s aides after they learn how to feed, bathe and care for elderly and disabled residents in a free eight-hour “crash course” online.
The course has attracted thousands of applicants since the Centers for Medicare and Medicaid Services waived the minimum 75-hour training requirements for nurse’s aides in March to address “potential staffing shortages” in nursing homes, and it is generating new debate over safety in the homes that have been the coronavirus’ most vulnerable targets.
Approximately 38,000 people have earned online certificates as “temporary nurse’s aides” through the new course offered by the American Health Care Association, which represents the bulk of the nation’s 15,000-plus nursing homes.
The course, one of several online, is permitted as a means of acquiring temporary nurse’s aide certification in at least eight states, including West Virginia, hard-hit New York and New Jersey, while several other states are pairing the course with additional requirements.
The recruiting effort is unfolding as unemployment claims are soaring to highs unseen since the Great Depression and the Trump administration is preparing to direct nearly $5 billion into nursing homes battered by the virus, partly to shore up their staff.
Watchdogs warn that having inexperienced staffers care for the 1.4 million residents could be a recipe for harm. But nursing homes say they are desperate for help as COVID-19 has sidelined and even killed staffers and created an urgent need for reinforcements.
“The training program came about because we saw an immediate need early on in this crisis to allow an influx of staff, should staff become ill from this virus,” Holly Harmon, AHCA’s vice president of quality, regulatory and clinical services. “Obviously we’re under an unprecedented time with this pandemic.”
CMS, which regulates the nation’s nursing homes, does not have statistics on COVID-related staffing shortages and infections in the facilities, partly because it began collecting the data last week. Kaiserm care facilities account for more than 35,000 of the 100,000 COVID-19 related deaths.
Nurse’s aides typically handle the most intimate and labor-intensive tasks in nursing homes that house people with conditions such as Alzheimer’s disease, heart disease and broken hips. Federal regulations require at least 75 hours of classroom and hands-on training for certified nursing aides. Many states require more.
A CMS official said the agency waived the minimum training hours to provide “maximum flexibility” to the nursing-home industry during the pandemic, and emphasized that the homes are still responsible for hiring capable aides with clean backgrounds who can “demonstrate competency.” Supervisors must observe their performance on the job.
“In other words, while some facilities may choose to hire aides that have completed the 8 hour training class . . . the facility is still required to ensure residents’ needs are met, and are accountable for ensuring their health and safety,” the agency said in a statement. “This includes adhering to the effective infection prevention and control standards to prevent the spread of COVID-19.”
Elder advocates fear the abbreviated training regimen could endanger nursing-home residents. A mistake while feeding or moving a frail resident can prove fatal, and the close contact inside the facilities can spread the virus.
“This is a total joke,” said Brian Lee, executive director of Families for Better Care and a former state ombudsman for long-term care facilities in Florida.
“People will die because of this.”
Nursing home leaders say the online classes are a reasonable short-term fix for an extreme situation.
COVID-19 has sickened and killed thousands of residents and some staff, leaving some nursing homes with skeleton crews. And more staffers are needed for the coronavirus’ new precautions. Workers deliver meals to residents in their rooms to avoid spreading the virus in dining halls. They check vital signs several times a day, and they help increasingly isolated residents chat with their loved ones online. Many homes say they hope to beef up their staff in case another outbreak sidelines them.
“The fact of the matter is, this is not a normal virus,” said Robyn Stone, senior vice president at LeadingAge, which represents nonprofit nursing homes and other providers, and unveiled its own free nine-hour online training class in mid-May. “This is not a normal infection control effort. This is a much more intensive effort that requires a lot more staff.”
The American Health Care Association offers a “compacted” version of a typical training that “prioritizes those care areas that are most critical right now,” Harmon said.
Using videos and written materials, the online class covers a nurse’s aide’s typical duties, such as feeding and bathing residents, cleaning dentures, shaving and clipping nails, dressing and undressing, infection control and prevention, moving residents from the bed to a chair or other locations, taking them to the bathroom, and caring for the dying.
The course also teaches aides to properly wash their hands to prevent infections, and address emergencies such as choking. Applicants must answer 40 of 50 questions correctly to pass the final assessment, a score of 80 percent.
“You’re getting basically a crash course in all the classroom training, and then the burden falls on the RN to really follow up with the competencies,” said Jan Siegal, the director of quality, clinical and regulatory services at the Health Care Association of New Jersey.
AHCA says on its website that the course is “permitted under special waivers, exceptions, or flexibilities” in Delaware, Indiana, Iowa, Maryland, Nebraska, New Jersey, New York and West Virginia.
The course is also being used in Washington D.C., Alabama, Georgia, Kansas, Mississippi, North Carolina, New Hampshire, Pennsylvania, South Carolina, Tennessee and Virginia, but the association said additional training may be required. Oklahoma offers a 16-hour course for temporary aides.
In New Jersey, where approximately half of the COVID-19 deaths are associated with long-term care facilities, a state health-care association estimated that a third of the facility staff have so far missed work during the pandemic. The Andover Subacute and Rehabilitation Center had 17 bodies pile up one weekend in April, and CMS later fined the facility $220,000 for multiple violations. St. Joseph’s Senior Home in Woodbridge, New Jersey, had to evacuate residents when the Catholic nuns who ran the facility were overwhelmed.
“There are some nurses and RNs who have not had a day off,” said Siegal.
Iowa, Indiana and New Jersey confirmed that they sanctioned the association’s eight-hour class after nursing homes reported staff shortages. The states also require background checks, but Iowa Department of Inspections and Appeals spokeswoman Stefanie Bond said some facilities may hire aides before the background check is complete.
Other states such as New York and Maryland said they did not sanction the online classes but understood that the federal waiver simply granted nursing homes more discretion to hire workers.
“We were looking for all kinds of methods to increase the number of ways that people could work,” said Cheryl Heiks, the executive director of the Delaware Health Care Facilities Association, adding that she has gone on the radio to spread the word that the nurse’s aide position is a “recession-proof job.”
State health officials in Delaware, West Virginia and Nebraska did not respond to inquiries about the online class.
AHCA officials did not know how many people who passed the course have since found jobs inside nursing homes. But state affiliates said many have gotten hired, and their duties can vary by state and facility.
Zach Cattell, president of the Indiana Health Care Association, said a temporary nurse aide’s job duties could include anything listed on AHCA’s website. But in Delaware, Heiks said temporary aides are only performing basic tasks, such as clearing lunch trays, and”definitely not administering medication.”
Rhonda Flanigan, chief people officer for Vetter Health Services, a nonprofit that owns 33 facilities in Nebraska, Iowa, Missouri, Kansas and Wyoming, said they have hired a number of temporary aides to shore up staffing. So far they have had only a few COVID infections, but she said, “One of the things we stressed to our facilities is, ‘You need to be ready.’”
Once hired, she said, the temporary nurse’s aides receive additional on-the-job training in skills such as hand-washing and infection control. Supervisors monitor them closely, and most are helping with basic tasks, such as using the television remote control, Face-timing with their families, reading the Bible or taking meals.
“We’re not leaving them alone,” she said. “We’re not allowing them to do things you would have to have additional training to do.”
Nursing home watchdogs worry that the waiver is another step toward relaxing oversight of an industry that has thrived on low-wage workers — a typical nurse’s assistant earns less than $15 an hour — and often violates federal rules. A government watchdog report last week found that most nursing homes had infection-control deficiencies in recent years.
Yet some states have already granted nursing homes immunity from lawsuits, and Congress is considering a similar move.
It is unclear what the temporary nurse’s aides are paid.
“I’m afraid they’re just taking advantage of the emergency to do the eight hours of training when they know they should have much more training than they do,” said Charlene Harrington, a registered nurse and professor emerita in the Department of Social and Behavioral Sciences at the University of California San Francisco. “They don’t want to invest in the workers.”
Advocates for the elderly say granting greater flexibility to the industry rewards homes that often failed to prepare for the pandemic.
The Life Care Center of Kirkland, home to the nation’s first outbreak, pleaded for help after the coronavirus ravaged the Washington state facility, killing more than 40 people. But later federal inspectors fined the center $611,000 for failing to report the outbreak. Two longtime certified nursing assistants told inspectors they had not been trained to properly sanitize items with bleach wipes.
Industry leaders say some nursing homes receive bad marks, but they believe most are trying their best to confront a deadly and mysterious virus. For months, nursing home workers heroically went to work as the virus killed thousands of residents and some staff, often without the chance to say goodbye to their families.
“It’s terrible and it should not have happened,” Stone said. “Because the truth is, if they had done good testing from the very beginning from at least a month ago or two months ago, we would have mitigated a lot of these deaths and a lot of this horrible stuff that has happened to staff. That is the real tragedy in all of this.”
She said the online classes seek to “set up a flexible system where you still hold people as accountable as possible,” she said. “But it’s very, very difficult to do that in this kind of a situation.”
“It’s an absolute nightmare,” she said.