CMS Updates Nursing Home Survey Tools for Staff Vaccination Mandate

Posted on January 27, 2022 by Jonathan Lips

Thursday, Jan. 27, marks Minnesota's Phase 1 compliance deadline for the CMS staff vaccination rule. Surveyors are now reviewing for nursing home compliance with this requirement on all initial certification, standard recertification surveys, and all complaint surveys, regardless of what issue the complaint involves. 

As inspections relating to these requirements begin, CMS this week posted two new survey tools and updated some existing ones to reflect the mandate. We have posted links to all the items noted in bold below on our COVID-19 Information and Resources webpage.

CMS guidance issued Dec. 28 explains that, as part of the survey process for the vaccine mandate (deficiencies to be cited under new tag F888), surveyors will request from facilities a list of all staff and their vaccination status, among other information. The list must include:

• The percentage of vaccinated staff using the vaccine matrix provided by the survey team; and
• The position or role of each staff member, including staff (facility staff, contracted staff, volunteers, or students) who are or are likely to be in contact with residents or other staff, regardless of frequency.

CMS 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 strongly encourage care centers to review these tools and instructions as part of your survey preparation.

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–Jan. 2022 (01/25/22) (ZIP)" link, download and open the folder, then sort the files by date to identify the new materials.