Angi Livingston

In addition to tracking and submitting extensive COVID-19 data to NHSN weekly and providing numerous data requests to surveyors, facilities now have to dedicate resources to populating a COVID-19 Staff Vaccination Status Roster during survey. 

Providers must worry about being cited for any discrepancies between the roster and their NHSN submissions, along with being held responsible on the citation severity side for the number of cases and deaths in their facility.

CMS updated the long-term care survey process to include surveying for compliance with staff vaccination requirements. The updated process includes off-site review of the NHSN data for facilities that are in a state that implements or enforces COVID-19 vaccination of facility staff.

Current NHSN reporting requirements include each facility tracking and documenting each staff member’s (following the CMS’ broad definition of “staff”) vaccination status to include the identification of the specific vaccine and booster received, dates of all doses received, date of next scheduled dose, exemptions and temporary delays on an ongoing basis.  

Keeping track of staff vaccination status is like the old saying “trying to herd a room full of cats”. The additional time and resources would be much better spent on providing quality care to our residents. Instead, CMS has found another way to divert facility staff and resources from resident care.

To determine facility compliance, CMS created a COVID-19 Staff Vaccination Status Roster for the facility to complete within four hours of the on-site survey. The matrix identifies all individual staff (direct hire, contract, other), title, position, assigned work area, vaccinated/not vaccinated and reason.

According to the surveyor guidance for reviewing the populated matrix, “If the surveyor determines that the information presented to the surveyor is incorrect (and NHSN is correct), or both sources are incorrect, this likely demonstrates the facility’s failure to have a process for tracking and securely documenting the COVID-19 vaccination status for all staff [per §483.80(i)(3)(iv)], and F-888 should be cited.”

Considering the high staff turnover data recently made public by CMS along with the agency staffing use that is rampant during the staffing crisis, it is hard to imagine facility vaccination rates will remain steady or “correct” between the lagged NHSN data submission and the survey date review.

Non-compliance with F888 due to the facility not meeting the required staff vaccination threshold of 100% or having data discrepancies will result in additional enforcement actions, i.e., plans of correction, civil monetary penalties, denial of payment, termination, etc. 

As of January 16th, more than 90% of skilled nursing facilities were below the required 100% staff vaccination rate. Under the new scope and severity grid for citing F888, the estimated scope potential based on the latest staff vaccination data from NHSN is as follows:

  • Isolated: 68% of providers*
  • Pattern: 20.3% of providers
  • Widespread: 11.7% of providers

*If all policies and procedures are appropriately developed and implemented, otherwise will be cited as widespread.

If a facility is under 100% staff vaccination with three or more cases and one COVID-19 related hospitalization or death, they can be cited at immediate jeopardy for F888 even if all infection control policies and procedures are in place. Providers are required by CMS to allow unvaccinated visitors (and residents) access to the facility, and additionally vaccinated individuals can still contract and spread COVID-19. 

Why is the facility is being held responsible for these uncontrollable external factors? What is CMS accomplishing with this new citation and potential remedies? Providers are suffocating under all of these layers.

Angi Livingston, MHA, BSN, RN, is a Senior Consultant at Formation Healthcare.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.