03/10/2022

Survey Tip of the Week: Vaccine Mandate Contingency Plan

The vaccine mandate requires facilities to have a contingency plan policy. Details on how F-tag 888 has been cited in Ohio was shared on the March 9 STAT webinar. During the call it was discussed that the policy must address what actions the facility will take when staff decline vaccination and do not quality for an exemption. Although facilities may not currently be able to implement a contingency plan, the facility will be cited if a policy for a contingency plan is not in place. The nursing home regulation §483.80(i)(3)(x) Contingency Plans states:

Facilities are required to have contingency plans for staff who are not fully vaccinated. Contingency plans should include actions that the facility would take when staff have indicated that they will not get vaccinated and do not qualify for an exemption. Contingency plans should also address staff who are not fully vaccinated due to an exemption or temporary delay in vaccination, such as through the additional precautions required at §483.80(i)(3)(iii). Facilities should prioritize contingency plans for those staff that have obtained no doses of any vaccine over staff that have received a single dose of a multi-dose vaccine. For example, contingency plans could include a deadline for staff to have obtained their first dose of a multi-dose vaccine. The plans should also indicate the actions the facility will take if the deadline is not met, such as actively seeking replacement staff through advertising or obtaining temporary vaccinated staff until permanent vaccinated replacements can be found.

Surveyors are instructed to review records and interview staff to confirm the facility has implemented their contingency plan, if needed, by:

• Verifying the actions taken for staff who would not get vaccinated and did not qualify for an exemption.
• Asking when a deadline to receive the first dose of a vaccine was given and confirming the date.
• Identifying what actions were taken if the deadline has passed.

LeadingAge Ohio encourages facilities to review the CMS Long-Term Care Surveyor Training found on the QSEP training webpage.

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 April 13 call at 10:00am.

As Ohio’s annual survey process continues, 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.