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Team Newsletter

May 2022

Kelly’s Regulatory News                  

On April 5, 2022, the Centers for Medicare and Medicaid Services (CMS) released “Revised Guidance for the Interim Final Rule – Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination. The revisions to the QSO Memo itself are minimal, but for us, there were updates to Attachment A – LTC, which include updates to F888.

What is in the QSO Memo

First, it is important to note that the QSO Memo states the following:

  • Surveying for staff vaccination is not required on Life Safety Code-only complaints or LSC-only follow-up surveys.
  • Surveyors have the ability to modify the staff vaccination compliance review if the facility was determined to be in substantial compliance with the vaccination requirements within the previous 6 weeks.

F888 – What Has Changed

Vaccination Delays:

The definition of “temporarily delayed vaccination” has been clarified. It now states that a temporarily delayed vaccination is one that is temporarily deferred, as recommended by the CDC, due to clinical considerations, including known COVID-19 infection until recovery from the acute illness (if symptoms were present) and criteria to discontinue isolation have been met.

Do not forget – you need to have a process in place to track the vaccination status of all employees, including ones who were temporarily delayed.

Suspended Staff or Staff on Extended Leave:

The guidance now states that facility staff who have been suspended or are on an extended leave would not count as “unvaccinated” for compliance determination purposes.


One item of particular note in the updated guidance for F888 is in the section that discusses the “additional precautions” a facility should take, including job modifications. The initial version of this document stated the following: “There are a variety of actions or job modifications a facility can implement to potentially reduce the risk of COVID-19 transmission, including, but not limited to” and then provided a list of what many providers assumed were requirements. That section has been revised to note that the actions and job modifications that were listed as “examples” of what a facility could do. Further, there is now a note in the guidance that specifically states that the requirement is not explicit and does not specify which actions must be taken by a facility for staff who are not fully vaccinated (however, Mission Point policy does!).

Updates to the Survey Process

There have been several changes to the guidance for surveyors for F888. These include:

  • When the Review Can be Skipped: Surveyors are now allowed to modify the staff vaccination compliance review if the facility was found in substantial compliance in the previous 6 weeks. If you have a survey with no vaccination compliance issues and then you get another visit within the next six weeks, surveyors can skip the vaccination check. The same goes for the LSC information discussed earlier.
  • Contract Staff: Language has been added to emphasize the vaccination status of contract staff, which is likely due to providers getting caught for not ensuring their contract staff are fully vaccinated. Surveyors are now instructed to request information from the facility regarding how the facility ensures that contract staff are compliant with the vaccination requirement. Specifically, the guidance states: “Failure of contract staff to provide evidence of vaccination status reflects noncompliance and should be cited at F888.” Don’t forget to include those staff, too!
  • Staff Vaccine Matrix: Surveyors can use either the Staff Vaccine Matrix or the list that the facility maintains of its vaccinated staff. This probably makes everyone’s lives easier and the review should go faster, but it is important to make sure you have a continually updated list! That means that you need to assign an “alternate’ who is cross trained to update the list when the primary responsible staff member is absent.

Good-Faith Effort Counts When Choosing Scope/Severity

The section regarding “good faith efforts” has been expanded. Now, an example has been included which notes that if the facility provides evidence of its “aggressive” steps to have all staff vaccinated, that the scope/severity can be adjusted. Per the Interpretive Guidance, if a facility had a 90% vaccination rate and had all the required policies and procedures implemented, that would result in a scope and severity of “D.” If that same facility was also able to provide evidence that it had done everything it could to try to get staff vaccinated, then the scope and severity could be lowered to an “A.” This evidence could include hosting vaccine clinics and advertising for new staff, so ensure you’re documenting everything you have tried to do if you haven’t met the necessary thresholds. COVID-19 continues to play a significant role in day-to-day operations – hoping it will end soon.


Facility Regulatory Check

  • Do not forget – you need to have a process in place to track the vaccination status of all employees, including ones who were temporarily delayed.
  • Please review your contracted staff/vendors to be sure their vaccination status is not missed, and you hold them to the “additional precautions” if not fully vaccinated.
  • Ask HRBP for your Staff Vaccine Matrix on an ongoing basis. Audit to ensure the Matrix is kept up to date.
  • Review the COVID-19 Vaccine Mandate Policy on SharePoint.

Kelly Dines
Vice President of Clinical Operations