CMS Staff Vaccination Rule: Phase 2 Deadline is Feb. 28

Posted on February 24, 2022 by Jonathan Lips

Implementation of the CMS staff vaccination mandate continues in full swing, with the Phase 2 compliance deadline arriving on Monday, Feb. 28.

As of that date, the requirement is for 100% of staff to 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
• Been granted a qualifying exemption; or
• A temporary delay as recommended by the CDC, the facility is compliant under the rule.

Regarding exemptions, the Phase 2 requirement is that a staff member has been granted a qualifying exemption, not simply that they have requested one.

Surveyors will review for compliance with this requirement on all initial certification, standard recertification surveys, as well as all complaint surveys. A facility not at 100% compliance will be cited (F888) by MDH, but CMS is still exercising some enforcement discretion. According to CMS guidance, a facility above 90% and has a plan to achieve a 100% staff vaccination rate within 30 days would not be subject to an enforcement action.

Last week, the Minnesota Department of Health (MDH) announced that it is increasing the level of standard recertification surveys this month, aiming to have each survey team complete an average of two to three recertifications per month.

For those who may not have accessed these materials yet, note that CMS has posted several resources that help prepare for surveyor investigation of compliance with the vaccine mandate:

• The agency has developed a COVID-19 Staff Vaccination Status for Providers matrix to present this information. It directs facilities either to complete the CMS form itself or to provide a list containing the same information as the form would include. This form also includes instructions for how surveyors should determine compliance with the vaccination mandate, including verification of NHSN data and calculating the percentage of vaccinated staff.
• As a companion to the Vaccination Status matrix, CMS has also created a spreadsheet that allows surveyors and facilities to make specific calculations for the comparison to NHSN data and for staff who are partially or fully vaccinated, have exemption requests pending, have been granted exemptions, or who are temporarily delaying vaccination according to CDC guidelines.
• Consistent with its guidance relating to the mandate, CMS has posted a revised version of its infection control survey tool (CMS-20054), now labeled Infection Prevention, Control & Immunizations (Jan. 2022), with three new critical elements relating to F888.
• CMS has also updated the Entrance Conference Worksheet to note that a facility will need to provide the following information within four hours of entrance: a numbered list of resident cases of confirmed COVID-19 over the last four weeks that indicates whether any resident cases resulted in hospitalization or death; COVID-19 Healthcare Staff Vaccination Policies and Procedures; and COVID-19 Staff Vaccination Matrix (Note: Facilities may complete the COVID-19 Vaccination Matrix for Staff or provide a list containing the same information as required in the staff matrix).

We have posted links to the items described above on our COVID-19 Information and Resources webpage.

Providers may also access all of these items through this CMS Nursing Homes web page's downloads section. Scroll to the "Survey Resources with Staff Vaccine Documents (02-22-2022) (ZIP)" link, download and open the folder, then sort the files by date to identify the new materials.

Please contact Jonathan Lips or Kari Everson with any questions concerning the vaccine mandate.