Regulatory Update

COVID-19 Vaccine Mandate Guidance Revised by CMS

Polaris Group Profile
Polaris Group
April 14, 2022
March 14, 2023
Polaris Group Profile
Polaris Group
March 14, 2023

Learn more about the newest CMS vaccine mandate guidelines and how they affect your community by reading our latest blog.

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COVID-19 Vaccine Mandate Guidance Revised by CMS

CMS recently issued a revised attachment to the memorandum regarding guidance for long-term care and skilled nursing facility COVID-19 health care staff vaccination. This attachment relates to F888 Infection Control; Vaccination of facility staff related to temporarily delayed vaccinations. In this attachment, CMS temporarily “deferred” required vaccinations due to clinical considerations including known COVID-19 infection until recovery from the acute illness (if symptoms were present) and criteria to discontinue isolation have been met as recommended by the CDC.

CMS also added a note under the compliance survey indicating that facility staff who have been suspended or are on extended leave such as a Family and Medical Leave Act (FMLA) leave or Worker’s Compensation Leave, would not count as unvaccinated staff for determining compliance with this requirement. This means that facilities will need to work closely with their HR departments to monitor employees on leave and their vaccination status.  

There are several additions to the survey process updates for tag F888.  

1. Contracted staff: To determine compliance, surveyors will request the facility’s COVID-19 vaccination policies and procedures, the number of resident and staff COVID-19 cases over the last 4 weeks, a list of all staff including contracted staff, their vaccination status, and information on how the facility ensures that their contracted staff are compliant with the vaccination requirement. Failure to provide evidence of vaccination status of contract staff will reflect non-compliance and facilities will receive a F888 citation. Of note, Surveyors may modify the staff vaccination compliance review if the facility was determined to be in substantial compliance with this requirement within the previous six weeks.  

2. Life Safety Code (LSC): For LSC-only complaints or LSC-only follow up surveys, staff vaccination requirements are not required to be invested.  

3. Good Faith: In the Good Faith Effort section, CMS provided clarification regarding procedures for surveyors. CMS provided an example of a facility where staff vaccination rates were at 90% or more without a resident outbreak in the previous 4 weeks where all policies and procedures were developed and implemented. Generally, this would be cited at a “D” but if the facility provides evidence that it has made a good faith effort by taking aggressive steps to get all staff vaccinated, surveyors may lower the citation to an “A”.

To learn more about how Polaris Group Consulting can help your facility stay in compliance with ever-changing CMS regulations, contact the Polaris Group today.  

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