Starting a Facility Based CNA Program—Things to Consider

There is a CNA shortage in California. On July 1, 2018 the shortage is going to get worse as the 3.5 staffing ratio goes into effect.

Facility based training has always been a popular method for training large numbers of CNAs quickly. Unfortunately, there are currently only 47 facilities in California that state approval to conduct training programs. Many more SNFs serve as clinical sites for outside schools, but only these 47 can run the full training program in the way that all SNFs used to do.

The purpose of this article is to provide SNFs with some of the background you will need to consider before you decide to start a facility based CNA training program, and to provide you with some shortcuts to get the process started if you decide to proceed.

Regulation

Facility based CNA programs are managed by the California Department of Public Health, Aide and Technician Certification Section, Training Program Review Unit (TPRU). This is a very small unit that has the daunting task of overseeing every aspect of the CNA certification process, including approving training programs, providing regulatory monitoring and oversight of all training in progress, managing the certification testing system, issuing certifications and overseeing renewals, approving all CNA continuing education programs, and running a registry of approximately 200,000 CNAs. The unit consists of a supervisor, 4 Surveyors, and a limited staff of admin personnel. Did I mention that they also oversee the entire Home Health Aide Profession?

This unit can get severely backlogged. The ideal turnaround for a new CNA training program approval is 90 days, but there are currently programs that have been waiting more than 180 days and still have not had their review completed.

The TPRU has done a fantastic job setting up a standardized application process and providing necessary resources on their web site, which can be accessed at: https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/TPRU.aspx#TrainingProgramforms

In addition to the CDPH forms you are required to submit, you will need to develop a comprehensive set of Policies and Procedures to meet state guidelines, submit a training curriculum that meets Title 22 standards, and ensure that you have (and can document) that you have a properly certified instructor.

Once your application has been reviewed you can expect to receive inquiries and/or corrections from the CDPH Surveyor assigned to your application. Once these have been dealt with you will receive an appoint for a site inspection. Once you have passed this, you can expect to receive a training program approval number, at which point you can begin recruiting students and set a class start date.

Student Wages and Staffing Ratios

When you run a facility based CNA programs you are required to hire the students and pay them wages while they are in training, and they cannot be required to pay any part of the program cost. These are OBRA requirements12. The minimum hourly wage for Nurse Assistants in training is whatever your local minimum wage is, plus the amount of legacy wage pass throughs that impact your building.

Student wages, plus costs incurred by your facility in conducting CNA training are listed on your cost report as direct labor costs3.

Student hours spent in classroom and clinical training cannot be counted toward your staffing ratio requirements; their first responsibility during class hours is learning, not resident care. You can never count students who are conducting clinical training in your facility for an outside school in your staffing ratios.

However, as students complete training on specific skills their instructor is required to test their abilities and certify them on those skills. Once a student has been certified on their skills they can then perform them in the capacity of a CAN. For example, if an employer hires students for 40 hours a week, and the class schedule is for 20 hours a week, then the additional 20 hours can be counted in your staffing ratio as CNA time, as long as the students are utilizing skills for which they have been certified. This situation continues up to the point where the students take the State Certification Exam. If they pass they immediately become a CNA, if they don’t pass they can no longer work in a CNA capacity.

Title 22 places a four month time limit on the period a Nurse Assistant can work for a facility. If they have not passed the State Certification Exam at that point they can no longer perform CNA work for that facility4.

Other Alternatives

There have been a variety of ideas that SNFs have employed to find and/or train CNAs that you could consider instead of running your own CNA training program. Here are some highlights:

1. Approach existing local CNA programs and volunteer to serve as a clinical site. These could be private, for profit vocational schools, public education programs (Community College, Adult School, High School ROP), or non-profits (American Red Cross). You can find the latest data on CDPH approved CNA programs at: https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/Certified-Nurse-Assistant-Training-Programs.aspx
2. Enter into partnerships with existing CNA programs. Some employers have business relationships with local training programs through which the employer sponsors students going through training. This can the form of scholarships or forgivable loans. These can be structured so that it ties the student to their sponsors after they graduate. But the students cannot be employed at the employing facility as NAs while they are not in training or it will trigger the OBRA requirement to pay wages during training.
3. Start your own school as a separate business, using your facility as the training site. The most elegant example of this approach was designed by Beverly and Golden Living. They established regional training centers to support clusters of their facilities. The schools were independent subsidiaries of the parent corporation, and also served as staffing registries. They paid for students to go through training, hired them on certification, and assigned them to their company’s facilities in the area or held them in a registry pool. This approach requires standing up a new business, which will require additional regulatory approval from the California Bureau for Private Postsecondary Education.
4. Enter into partnerships with local workforce investment agencies. Organizations like County Workforce Investment Boards, County CalWORKs offices, school districts and other agencies may have access to funding to assist with starting and operating CNA programs. The CAHF Sierra Chapter previously partnered with the Shasta County workforce agency to start a CNA training program in Redding.

Next Steps

However you decide to proceed, it is time to act now. A six month lead time for CNA program approval means that you may, barely, have time to get your own training program in place before the new staffing ratio goes into effect.

Ken Merchant is the principal of Ken Merchant Consulting Services. He is a former QCHF Executive Director and the long time COO of the College of Medical Arts, a chain of vocational schools specializing in CNA training.