On Dec. 28, CMS released QSO-22-07-ALL Guidance for the Interim Final Rule that was released on Nov. 5, 2021 that established requirements regarding COVID-19 vaccine immunization of staff. The guidance and survey procedures included in this memo currently does not apply to the following states, who are part of lawsuits that continue to have injunctions: Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Texas, Utah, West Virginia and Wyoming. Key guidance included in the memo includes:
- By January 27, 2022, facilities are required to have implemented:
- Policies and procedures for ensuring all facility staff, regardless of clinical responsibility or resident contact are vaccinated for COVID-19; and
- 100% of staff have received at least one dose of a COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC.
- By Feb. 28, 2022 providers must have implemented:
- Policies and procedures for ensuring all facility staff, regardless of clinical responsibility or resident contact are vaccinated for COVID-19, including all required components of the policies and procedures specified below (e.g., related to tracking staff vaccinations, documenting medical and religious exemptions, etc.); and
- 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple vaccine series) or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the CDC.
- Between Jan. 27th and Feb. 28th providers that are out of compliance with the 100% first dose portion of the rule will receive notice of non-compliance with the 100% standard. A facility that is above 80% first dose vaccination and has a plan to achieve a 100% staff vaccination rate within 60 days will not be subject to an enforcement action.
- After Feb. 28th, those that have not achieved a 100% staff vaccination rate will receive a notice of non-compliance. A facility that is above 90% and has a plan to achieve a 100% staff vaccination rate within 30 days would not be subject to an enforcement action.
- By March 28th, 2022, facilities failing to maintain compliance with the 100% standard may be subject to enforcement action.
- By January 27, 2022, facilities are required to have implemented:
Beginning on January 27, 2022, Surveyors will begin to include these provisions in surveys.
- Surveyors will be evaluating NHSN vaccination data prior to coming onsite and compare the NHSN vaccination rates to the internally tracked facility vaccination rates.
- If > 10% difference is noted between the two rates , the provider could be cited under the F888 tag for failure to properly track and report vaccination rates. Surveyors may still cite under F888 if the 80% or 90% vaccination rates have been achieved if they can show that a danger to residents still exists.
- Surveyors will not evaluate specific requests for a religious exemption, nor the facility’s acceptance or denial of the request. Instead, surveyors will review the facility process to ensure it is an effective means for staff to request a religious exemption for a sincerely held religious belief.
- Surveyors will be evaluating NHSN vaccination data prior to coming onsite and compare the NHSN vaccination rates to the internally tracked facility vaccination rates.
In addition to QSO-22-07-ALL, CMS also released a supplemental attachment to be used in conjunction with the Guidance for the Interim Final Rule, a staff vaccination requirements decision tree graphic, and a FAQ document.
