As was reported recently, CMS issued QSO 22-07-ALL, which outlines the staff vaccination rules for skilled nursing facilities and that the surveyor training slides were available.

We’d like to highlight a few more details. The surveyor training indicates a phase in program for compliance. The ultimate expectation is 100% compliance with the vaccine mandate but indicates some flexibility in penalty implementation as follows:

• Day 30 (1/27/22) – Day 59 – The facility is considered compliant if it demonstrates that all policies and procedures are developed and implemented and 100% of staff have received at least one dose of vaccine, or has a pending request for, or have been granted an exemption, or has a CDC-approved temporarily delayed vaccination.
  • If the facility demonstrates 80-90% the facility is considered non-compliant and will be cited using F-888. If the facility is above 80% and has a plan to achieve 100% vaccination rate within 60 days, they would not be subject to an enforcement action.
  • Facilities with less than 80% of staff who have received at least one dose of vaccine, or have a pending request for, or have been granted an exemption, or a temporary delayed vaccination, the facility is noncompliant and will be cited at F-888 and could be subject to additional enforcement actions.
• Day 60 – Day 89 – Facilities are expected to be 100% compliant with the requirements.
  • If the facility has less than 100% compliance with the vaccine mandate, the facility is non-compliant
  • If the facility is above 90% and has a plan to achieve 100% vaccination within 30 days, they would not be subject to an enforcement action.
  • If the facility is less than 90%, they will be cited at F-888 and they could be subject to additional enforcement actions.
• After 90 days – the following diagram shows how compliance will be calculated, Anything below 100% compliance will result in noncompliance and enforcement action.

Page 14 of the Attachment A of QSO 22-06-ALL also identifies the survey process, the number of employee records to be reviewed (including staff and contract staff) and how scope and severity will be identified.

Additional Resources:

• CMS-20054 Infection Prevention Control and Immunization January 2022
• FIC survey Entrance Conference worksheet
• Staff Formulas for F888
• Staff Matrix for F888 only

If you have any questions, please contact Rick Abrams, Jena Jackson, or Jim Stoa. Please be sure to contact WHCA/WiCAL immediately if you experience a significant exodus of employees due to the vaccine mandate and are experiencing a crisis staffing shortage.