Conversations Blog

Jenny Albertson, NHA

Director of Quality & Regulatory Affairs

Infection Control Pathway Updated to Reflect End of Staff Vaccine Requirement

CMS updated the Infection Control Critical Element (CE) pathway related to the end of the Healthcare Provider COVID-19 Vaccine Mandate announced May 31, 2023.

  • No more surveyor guidance related to F888 (Staff COVID-19 Vaccine).
  • Surveyors now verify compliance with requirements for educating and offering COVID-19 immunization only. Documenting vaccine education for residents and staff is still required.
  • All other areas regarding staff COVID vaccines were removed.
  • The Entrance Conference form no longer includes any staff COVID-19 vaccine requirements, including the need for facilities to maintain a COVID-19 vaccine matrix.

There is also a change, unrelated to the vaccine update. Under “Instructions” for the Interim LTCSP Initial Survey and Certification Process, facilities that are not yet certified should still complete minimum data set (MDS) assessments, despite not being able to submit them until the facility is certified.

The Final Rule was added to the Federal Register, as expected. The rule becomes effective on August 4, 2023.


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