Ftag of the Week – F888 COVID-19 Vaccination of Facility Staff (Pt. 2)

Welcome back to the CMSCG Blog. In this post, we will continue our “Ftag of the Week” for F888 COVID-19 Vaccination of Facility Staff. In Part 1 of this series, we outlined the requirements for the newest Infection Control Ftag, including all the required elements of the COVID-19 vaccination policy and procedures that nursing homes are expected to have in place. In this post, we will review the guidance to surveyors for F888 since surveyors will be taking a different approach to investigating compliance with this requirement.

CMS QSO-22-07-ALL was issued on December 28, 2021, and surveyors will begin surveying for compliance 30 days after that date, January 27, 2022. Given that the United States Supreme Court upheld the vaccine mandate yesterday, January 13, 2022, all states will be required to become compliant with this regulation. You can view the Centers for Medicare & Medicaid Services (CMS) media statement on this ruling here.


EDIT: On January 14, 2022, CMS clarified in new guidance that the timeframes set out in CMS-QSO-22-07-ALL do not apply to the states that were part of the injunction that was lifted on January 13, 2022. That means those states will have a different compliance date than the states that were not part of the injunction. States will a different compliance date include: Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Utah, West Virginia and Wyoming. Stay tuned for an update on the CMSCG Blog regarding the newly issued guidance from CMS.


Acceptable Compliance Rate

The compliance threshold for facility staff vaccination rates under this requirement is 100%.

Compliance Timeframes to be Aware of

While CMS is requiring that all nursing home staff have received the appropriate number of COVID-19 vaccine doses within certain timeframes, non-compliance with the 100% compliance rate will generally result in facilities being provided with the opportunity to come back into compliance. Let’s look at what CMS expects for compliance:

Within 30 Days

Providers are expected to have all the required Policies and Procedures in place and implemented for staff vaccination. If a provider can show that all required elements of the P&P are in place to ensure that all facility staff (unless exempt/delayed), regardless of clinical responsibility or direct contact with residents, are vaccinated for COVID-19, then things can go one of two ways:

  1. If the provider has all the required components of the P&P in place, and 100% of the staff has received at least one dose of vaccine or have an exemption/pending request for exemption or are identified as someone with a temporary delay, then the provider is in compliance.
  2. If the provider has all the required components of the P&P in place, but less than 100% of staff have received at least one dose of COVID-19 vaccine, or have an exemption/pending request for exemption, then the provider is not in compliance with the rule.

If the provider is not compliant with the standard, here’s what happens next.

  • The facility will receive notice of non-compliance via a CMS-2567 with a citation at F888.
    • If the facility is above 80% vaccination rate and has a plan to achieve a 100% staff vaccination rate within 60 days, no enforcement action will be taken.
    • If a facility exceeds the threshold, but the State believes there is a threat to patient health and safety, then the State will work with CMS to determine next steps.
    • If a facility fails to meet the outlined parameters, then it could be subject to additional enforcement actions. These enforcement actions may vary based on the deficiency findings and can include Plan of Correction, Civil Monetary Penalties (CMPs), payment denials and even termination.
Within 60 Days

Within 60 days of the QSO Memo being published (60 days after December 28, 2021), the expectations change. If a provider can show that it has P&P in place to ensure all facility staff (except those exempted as noted above) are vaccinated for COVID-19 but less than 100% of staff has received at least one dose of a single-dose vaccine or all of the doses of a multiple-vaccine series, or have an exemption/ delay, then the facility is not in compliance with the requirements.

  • If the provider is at the 90% or above vaccination rate and has a plan in place to achieve 100% compliance within 30 days, then the facility would not be subject to an enforcement action.

As noted above, CMS expects States to work with CMS for some instances, and in others, the facilities could be subject to multiple enforcement actions.

Within 90 Days

At 90 days, CMS is giving less wiggle room. 90 days after December 28, 2021, any facility that fails to maintain compliance with the 100% compliance standard may be subject to enforcement action. This means that facilities need to work quickly to avoid enforcements.

Surveying for Compliance

Surveyors will be reviewing the facility’s P&P to ensure all required elements are included. Those elements must show how your facility will ensure that staff are fully vaccinated against COVID-19, how you will ensure staff have received at least one dose of vaccine prior to providing care to residents, and what additional precautions will be used for staff who are fully vaccinated. The P&P also needs to consider how tracking and documentation of all this information will be completed, and must address how requests for exemptions or temporary delays to vaccination will be handled. Don’t forget – you also need to have a contingency plan in place in the event that staff are not fully vaccinated.

Don’t forget – you also need to have a contingency plan in place in the event that staff are not fully vaccinated.

CMSCG cannot remind you too many times – these requirements need to be in place within 30 days of December 28, 2021 for [states that were not part of the injunction] (edited based on newly released guidance). Additionally, surveyors will use the Infection Prevention, Control & Immunizations Facility Task to determine if the facility is compliant with the requirements for COVID-19 vaccination of staff. Surveyors are directed to focus their investigations on facility staff who are regularly providing services to the facility.


View CMS QSO-22-07-ALL here and to view the specific requirements for long-term care facilities, click here to view Attachment A. If you arrived here looking for the requirements for any other provider type, you can view the full list of attachments here.


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