Prevalence of Nursing Assistant Training and Certification Programs Within Nursing Homes, 1997–2007

Recent studies have shown that nursing homes (NHs) make strategic choices about where to invest resources and that these choices are often shaped by the NH’s environment (Castle, 2003; Davis, Brannon, Zinn, & Mor, 2001; Weech-Maldonado, Qaseem, & Mkanta, 2009; Zinn, Mor, Feng & Intrator, 2007). The environment includes the state and federal policies that govern provision of care and also the other organizations found in the environment, such as competitors and resource providers (Rosko, Chilingerian, Zinn, & Aaronson, 1995). One choice that NHs make is whether to provide nurse aide training and competency evaluation programs (NATCEPs) to those wanting to become certified nursing assistants (CNAs). CNAs provide 80%–90% of the care in NHs, so the quality of care residents receive is largely dependent on their skills (Riggs & Rantz, 2001). Therefore, the federal government mandates that all CNAs receive at least 75 hr of training and be certified before beginning work in Medicare/Medicaid certified NHs (Federal Register 42 Part 483, 1991). This policy became effective in 1991, and information about whether NHs were providing NATCEPs in-house began to be collected as part of the annual survey process in 1997. NHs that do not provide this training in-house must hire CNAs who have been trained elsewhere. A number of environmental factors, therefore, may affect a NH’s choice of whether to provide an NATCEP, including state policies related to the initial approval and ongoing monitoring of the NATCEP and the availability of CNAs trained elsewhere. NHs likely base the strategic choice of whether to provide an NATCEP on both the availability of internal resources and these environmental factors. NHs that provide NATCEPs are reimbursed by the state Medicaid program. However, in most cases, NHs are not reimbursed for the full cost of the program because states have imposed limits on the cost of the programs or reimburse facilities based on the proportion of their residents who are covered by Medicaid (i.e., the proportion of the NATCEP cost NHs are reimbursed for is equal to the proportion of total patient days that were paid for by Medicaid; Centers for Medicare and Medicaid Services [CMS], 2001). Nursing assistants who receive their training outside NHs are supposed to be reimbursed for their training by any NH that hires them within a year of passing the certification exam (Federal Register 42 Part 483, 1991). In most states, NATCEPs can be provided in a number of settings, including NHs, community colleges, high schools, vocational–technical schools, and proprietary training facilities. State policies govern NATCEP content requirements, and many states have also increased the number of hours of training required. States are responsible for approving and monitoring the NATCEPs, and most states follow the federal regulation requiring that programs be reviewed and approved every 2 years (Office of the Inspector General, 2002). In addition, states must enforce the federal regulation that stipulates that any NH receiving a deficiency-related sanction (as the result of a failed annual survey) may not provide an NATCEP for 2 years (Federal Register 42 Part 483, 1991). Although the 2004 National Nursing Assistant Survey (NNAS) gathered data on where CNAs received their NATCEP training, no previous research has examined the availability of NATCEP training in the NH or other settings. The purpose of this study was to describe how the prevalence of NATCEPs provided in the NH setting changed between 1997 and 2007, to explore the environmental factors that may be influencing the prevalence of these programs, and to examine how the changing prevalence of NH-based NATCEPs may be affecting those considering CNA work.