Conversations Blog

Jenny Albertson, NHA

Director of Quality & Regulatory Affairs

Vaccination Mandate FAQs

Q: Has CDPHE created a form they want us to complete for the required reporting of vaccination data?

A: They announced on their most recent LTC Facilities call that they would temporarily be adding this reporting to EMResource and soon will have it added to the reporting system we use for our flu vaccination data.

Q:  Are visitors going to be required to be vaccinated as well?

A:  The Health Department cannot regulate the behavior of visitors or residents.  If they want to be granted the freedoms of fully vaccinated visitors per the RCF Mitigation Guidance, they must provide evidence of vaccination.

Q:  What are our obligations for tracking contractor (therapist, agency staff, etc.) vaccination rates?

A:  We need to obtain and retain vaccination documentation (evidence of vaccination, OR declination and exemption form with routine testing per the RCF Mitigation Guidance) for all who come into our facilities other than visitors.

Q:  Are they required to sign a copy of our vaccination policy?

A:  I do not see any requirement that we inform people of our policy, and I do not believe surveyors will request this.  But given that it is a new policy implemented, I would have it go through QAPI Committee review and approval (including Medical Director and NHA signature), plus staff-wide distribution via education method of your choice.  I would do a front-desk sign-in sheet alongside the COVID screening and ensure all people working in the facility sign off as having reviewed it (cross-check to payroll and agency working list).

Q:  Or are we just to confirm with their employer that they are complying with the new mandate? Must we keep record of contractor vaccination records?

A:  This appears to be the responsibility of the facility to have on file.  I would require it pre-shift for any new agency staff, much like the background check and license verification.  Volunteers for activities, ancillary providers, rounding practitioners, and vendors would also need to keep it on file with the facility.

Q:  Also, if a contractor has a medical or religious exemption, how does that impact our compliance and waiver and reporting requirements?

A:  Since we are required to have evidence of their vaccination status and presumably an exemption reviewed through our facility’s policy, any contractor with a religious exemption would force the facility to submit a waiver for this reason.  The form for this comes out 9/17/21 from the Department, so I hope it will be clear how they want us to capture that information.

Q:  When are single-dose (J&J) vaccinations expected to be administered (9/30 vs. 10/31)?

A:  If you can get folks vaccinated with the J&J by 9/30/2021, that is ideal.  The regulation states they should be given by that date.  The state will not aggressively enforce the regulation until November, but vaccinating outside the required dates could be a risk.

Q:  Since facilities are not permitted to request evidence of vaccination from surveyors when they visit facilities, are surveyors expected to disclose if they are working under a medical/religious exemption and remain unvaccinated?  If so, are the facilities expected to POC test them before they visit or to request a copy of a POC test result done that day?

A:  It is quite likely that ALL survey personnel will be vaccinated and exemptions will not be granted to them.  The Department will let us know whether that is the case.