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CMS Updates Health Care Personnel Vaccination Mandate Guidance

On April 5th, the Centers for Medicare and Medicaid Services (CMS) issued updated guidance on its health care staff vaccination requirements. The revisions can be found in the general guidance applicable to all covered providers and in the provider-specific memoranda. They principally clarify expectations on survey. Specifically, the updates include:

  • Surveys concerning exclusively Life Safety Code (LSC) complaints or LSC-only follow-up do not require evaluation of staff vaccination compliance.
  • Surveyors may modify the staff vaccination compliance review if the provider was determined to be in substantial compliance within the previous six weeks.
  • Adds to definition of "temporarily delayed vaccination" a known COVID-19 infection until recovery and criteria to discontinue isolation have been met. Recommends a delay under these circumstances.
  • Clarifies that:
    • Facility staff who have been suspended or are on extended leave do not count as unvaccinated staff for determining compliance.
    • The additional precautions requirement for staff who have not completed their primary vaccination series does not specify which actions must be taken. The examples are not all inclusive, and facilities can choose other precautions that are intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated.
  • For nursing homes:
    • For purposes of surveying under tag F888, refers to instructions for sampling contract staff.
    • Failure of contract staff to provide evidence of vaccination status reflects noncompliance and will be cited at F888 under the requirement to have policies and procedures for ensuring that all staff are fully vaccinated, except for those staff who have been granted exemptions or a temporary delay.
    • Good faith efforts to get all staff vaccinated may result in a lower citation.
  • For home health agencies (HHAs) and hospices:
    • Adds requirement for HHAs to provide at the survey entrance conference their process for ensuring that all contract staff are compliant with the vaccination requirement.
    • Delineates staff sampling method for evaluating compliance. 
    • Clarifies that failure for contract staff to provide evidence of vaccination status reflects noncompliance and should be cited under the policies and procedures requirement.

Members are encouraged to read the general guidance document and the memorandum specific to their provider type:

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383