​The Centers for Medicare and Medicaid Services (CMS) staff vaccination rule requires facilities to take additional precautions for those staff who remain unvaccinated due to a medical/religious exemption or newly hired staff who only have the first dose of the two-dose series. CMS provides a list of additional precautions in QSO memos QSO-22-07-LTC, QSO-22-09-LTC, and QSO-22-11-LTC.

It is important to keep in mind that facilities are not required to follow all the precautions listed by CMS in the QSO memo. However, they should be intentional about establishing appropriate policies around additional precautions and take a layered approach based on risk of COVID-19 transmission to residents they serve. For example, facilities may choose to test all unvaccinated staff at a higher frequency than required by CMS or CDC guidance, but only require unvaccinated staff with direct contact with residents to wear N95 masks.

In addition, facilities may want to reassign unvaccinated frontline caregivers to residents who are not at particularly high risk for negative outcomes due to COVID-19. For example, residents on chronic ventilators or who are severely immunocompromised (such as transplant patients) would have unvaccinated staff reassigned.

Additional precautions facilities should consider based on their resident population in their approach include:

  • Reassigning staff to different work areas or duties, such as:
    • Non-patient care areas.
    • Remote work, where possible.
    • Residents who are not at highest risk (e.g. immunocompromised or unvaccinated).
    • Assignments with limited contact with residents.
  • Test unvaccinated staff at a higher frequency than required by CMS requirements or CDC guidance.
  • Requiring staff to follow additional infection prevention and control precautions, above and beyond CDC guidance. This could include:
    • Adhering to universal source control.
    • Physical distancing measures in all areas of the facility that are restricted from patient access (e.g., staff meeting rooms, kitchen).
    • Requiring staff to use an N95 or higher-level respirator for source control.
It's important that facilities review and understand CDC's Interim IPC Guidance for Nursing Homes to recognize what would be considered an “additional" precaution (e.g., above and beyond what is currently required) versus IPC measures already required of the facility, which in many cases (such as testing and N95 use) hinges on community transmission.

Please contact covid19@ahca.org with any questions.