According to CMS, facilities are required to “ensure that staff who are not yet fully vaccinated, or who have a pending or been granted an exemption, or who have a temporary delay as recommended by the CDC, adhere to additional precautions that are intended to mitigate the spread of COVID-19”. (CMS QSO 22-11-ALL). In this memo, CMS provides a list of possible actions or job modifications a facility can implement as additional precautions for these staff members, which includes, but is not limited to:

      • Reassigning staff to non-patient care areas, remote work, or duties that limit exposure to those most at risk
      • Requiring staff to follow additional CDC-recommended precautions, such as universal source control and physical distancing measures
      • Increased testing
      • Requiring staff to use NIOSH-approved N95 or equivalent or higher-level respirator while in facility

Facilities are not required to follow all the possible actions listed by CMS in the QSO memo, but should establish policies and procedures around additional precautions and take a layered approach based on risk of COVID-19 transmission. When developing your policy and procedures regarding additional precautions for unvaccinated staff, you should review current CDC, CMS, and state guidelines that your facility is required to follow to mitigate the spread of COVID-19 and ensure that the additional precautions you are requiring unvaccinated staff to follow are more restrictive than the precautions currently required.



Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, CPC
Director of Regulatory Services

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