The state of Iowa has agreed to temporarily waive training requirements for nurse aides who deliver much of the hands-on care in nursing homes.

The waivers were issued by the director of the Iowa Department of Inspections and Appeals two weeks ago in response to a request from industry lobbyists. They will be in effect at least until the end of the federally declared state of emergency caused by the COVID-19 pandemic.

The waivers have the effect of extending some of the regulatory relief granted to nursing homes last year by Gov. Kim Reynolds during the initial stages of the pandemic. The regulatory relief comes at a time when the governor has declined to reinstate some of the mitigation efforts — business and school closings, limits on public gatherings, restrictions on hours of operation, etc. — intended to slow the spread of the virus.

“This is so wrong in so many ways,” said John Hale, a consultant and advocate for Iowa’s elderly. He said some of the training standards that are being waived are already “woefully out of date and woefully inadequate,” having been established more than 30 years ago at a time when nursing home residents had less complex needs.

“At the beginning of the COVID crisis that played out in horrible ways in nursing homes, it was popular for employers and elected officials to call these front-line workers ‘essential,'” Hale said. “Pledges were made to honor them and their heroic efforts. This rule-waiving in no way does that. Rather, it sends the message that it’s business as usual in the industry, and that when push comes to shove, shortcuts will be taken and essential workers and the residents they care for will deal with the consequences.”

In approving the industry’s request for the waivers, Department of Inspections and Appeals Director Larry Johnson Jr. said that under the circumstances, forcing nursing homes to comply with the existing regulations “would pose an undue hardship on licensed health care facilities.” Johnson also said approving the waivers will still provide “substantially equal protection of public health, safety, and welfare.”

DIA is the state agency that licenses, regulates and oversees Iowa’s nursing homes. The waivers approved by Johnson apply to regulations aimed at direct caregivers in those homes:

Training courses: The requirement that a nurse aide who has not completed a 75-hour training program participate in a structured, on-the-job training program lasting 20 hours is waived, but only to the extent that the worker has completed at least 20 hours of the 75-hour course.

Tests and examinations: The requirement that a nurse aide who has received training outside of a state-approved program pass an exam is waived. Although an aide must still “demonstrate competency in skills and techniques necessary to care for residents,” the rules don’t specify how that competency would be demonstrated.

Medications: The requirement that a person certified as a medication aide by another state complete a state-approved competency exam is waived to the extent that the individual is “able to demonstrate competency.”

Waivers amount to proclamation extension

In March 2020, Reynolds issued the first of several proclamations of disaster emergency, temporarily suspending various laws and regulations that applied to Iowa businesses after finding that compliance with such regulations would hinder Iowa’s response to the COVID-19 pandemic.

At the same time, federal authorities moved in a similar direction, with the U.S. Department of Health and Human Services suspending the ban on nursing homes employing anyone for more than four months unless the worker met certain training and certification requirements.

The governor’s regulatory relief for nursing homes was set to expire Aug. 22, and the Iowa Healthcare Association, a lobbying organization that represents 360 care facilities in the state, felt she was not going to renew it. In an effort to effectively extend the provisions of the proclamation without the governor’s involvement, the association went directly to Johnson, the head of the state inspections agency, and requested the regulatory waivers.

On Aug. 16, Johnson agreed to the request. Three days later, the governor issued a proclamation extending the same set of waivers. They are expected to remain in place at least until similar federal waivers are ended, which is not likely to occur until 2022.

According to the association, even before pandemic, Iowa nursing homes had trouble attracting workers, and when COVID-19 hit, the workforce issue became a full-blown crisis. Since then, Iowa homes have employed 2,100 “temporary nurse aides,” or TNAs, to help meet residents’ needs. With the new waivers now in place, the homes can continue to employ the lesser-trained TNAs.

“Facilities have been operating with the use of Temporary Nurse Aides for over 16 months, since the beginning of the public health emergency,” IHA President and CEO Brent Willett told Johnson in requesting the waivers. “Providers of long-term care services and supports have maintained the high quality of care provided due in part to the ability of TNAs to continue meeting resident needs and nurse oversight of the temporary nurses’ aides.”

Hale said the state’s decision to waive the enforcement of rules that are already inadequate to protect Iowans “boggles the mind,” and he questioned what steps DIA took to validate the industry’s claims that resident care has improved in Iowa.

Staff training has long been an issue

Although nurse aides deliver much of the hands-on case in nursing homes, they are also among the least trained and poorly compensated workers in the health care field. In nursing homes, the competency and training of even the licensed professionals — registered nurses, licensed practical nurses and administrative staff ± are often the subject of state inspection reports.

Recently, DIA inspectors questioned the training of registered nurses, LPNs and others at the Altoona Nursing & Rehabilitation Center, where a woman died after suffering an apparent heart attack.

The state inspectors said a registered nurse at the home initiated chest compressions and CPR, but with the resident still in bed rather than on a hard surface. After a few minutes, the nurse grew tired and asked a licensed practical nurse who was in the room to take over. The LPN allegedly responded to the request by saying “she was tired, didn’t feel well and didn’t want to do CPR,” inspectors reported.

State waives training requirements for nursing home staff