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CMS Updates Guidance for Vaccination Mandate

Published on

February 18, 2022
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New information has become available for health care facilities on how they need to stay compliant with a new vaccine mandate.

The Centers for Medicare & Medicaid Services (CMS) has imposed additional requirements on long-term care and skilled nursing providers – as well as guidance for surveyors – when surveying compliance with its vaccination mandate.

The mandate covers facilities that receive Medicare or Medicaid funding.

Surveyors from government agencies who are tasked with determining a health care organization’s compliance level began their analysis process on January 27. On that date, long-term care and skilled nursing providers were required to have the following in place:

  • A mandatory vaccination policy and procedure, including all required components such as tracking staff vaccinations, documenting medical and religious exemptions, etc.
  • 100% staff vaccination. That includes all staff with at least one dose of COVID-19 vaccine. Those who have a pending request for a qualifying exemption and those who have been granted a qualifying exemption are not counted toward the 100% vaccination. Also, CMS will not enforce the rule if the facility is at 80% compliance but has a plan to reach 100% compliance within 60 days.


Under the CMS’s guidance, new facility responsibilities include:

  • Matrix system: CMS has created a COVID-19 staff matrix system to gather vaccination data. The software charts the number of staff and their vaccination status, the number of pending and granted exemptions and the number of CDC-recognized delays. Staff are categorized by title, position, direct vs. contracted hires and assigned work-area location. This matrix must be completed by the facility within four hours of the survey.
  • Information: CMS updated the Entrance Conference Worksheet to require the facility create a numbered list of COVID-19 confirmed, resident cases within the prior four weeks, and a designation of whether any resident cases resulted in hospitalization or death.
  • Review: National Healthcare Safety Network data to prepare for the surveyor review.


Surveyor responsibilities include:

  • Review: The surveyor can examine the facility’s infection prevention and control program, COVID-19 vaccination policies and procedures, antibiotic stewardship program, and influenza, pneumococcal and COVID-19 for residents and staff, and COVID-19 staff vaccination matrix. Surveyors should calculate the percentage of vaccinations using the matrix and compare the data with the National Healthcare Safety Network.
  • Test: Sample five residents for influenza, pneumococcal and COVID-19 immunization.
  • Interview: Select eight staff, two vaccinated and six unvaccinated, to ensure their accuracy with the matrix. Three of the six unvaccinated should be without exemptions, one have received a religious exemption, one should have received medical exemption, and one should be a CDC-recommended delay in vaccination. The sample size will not change if a member of a category does not exist.


If your facility has any questions about the new information for the CMS’s vaccination mandate, please contact any member of the Barley Snyder Employment Practice GroupHealth Care Industry Group or Senior Living Industry Group.

DISCLAIMER: The information in this alert should not be construed as legal advice to be relied upon nor to create an attorney/client relationship. Please note that the reader’s or an industry’s specific situation or circumstances will vary and, thus, for example, an approach that is advisable in one industry may not be appropriate in another industry. If you have questions about your situation or about how to apply information contained in this alert to your situation or industry, you should reach out to an attorney.

The views expressed in this alert are those of the individual author and do not necessarily reflect the views of the firm or the firm’s clients. The response to the COVID-19 pandemic is particularly challenging, evolving and, in many cases, can be controversial. Any views expressed in this alert are not intended to advocate for or endorse a particular governmental response to the pandemic.


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