02/03/2022

Survey Tip of the Week: Staff Vaccinations

The Centers for Medicare & Medicaid Services (CMS) has updated the survey resources in accordance with the staff vaccination mandate on the CMS Nursing Home webpage. The CMS-20054 Infection Prevention, Control & Immunizations (January 2022) survey pathway provides guidance surveyors will use to investigate compliance with the F-tag 888. The pathway covers the policy review, record reviews, observations, and interviews. 

Surveyor guidance for observation and interviews include the following:

Interview sampled staff who are not vaccinated to ensure additional precautions are in place to help prevent the spread of COVID-19. Ask staff: 

• If reassigned: When were you reassigned duties?  

• Are you being tested for COVID-19? If so, how often? 

• Observe staff to determine whether they are using additional CDC-recommended precautions, including using universal source control (use a NIOSH-approved N95 or equivalent or higher-level respirator for source control) and maintaining physical distance including areas that are restricted from resident access (e.g., staff meeting rooms, kitchen) at all times while in the facility. 

• Determine whether other additional precautions are in place to mitigate the transmission of COVID-19. For all sampled staff, determine whether the COVID-19 vaccination documentation includes the following: 

• Screening and eligibility to receive the vaccine(s); and 

• The provision of education related to the COVID-19 vaccines such as the benefits and potential side effects; and offering of the COVID-19 vaccines to staff by the facility per requirements at 42 CFR 483.80(d)(3), F887.

LeadingAge Ohio encourages facilities to utilize the LTC survey pathways to monitor for compliance. The survey pathways can be found on the CMS Nursing Home webpage, under the download section, and within the zip file called LTC Survey Pathways.

For more information about the citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the February 9 call at 10:00AM.

With Ohio annual surveys restarted in January, LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you’d like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.