Facing No Vaccine Mandate Test Out Option, Nursing Home Operators at Odds On Staff Shortage Fallout

Some nursing home advocacy groups and operators, upon the Thursday release of the Biden administration’s vaccine mandate guidance, say execution will only make the current workforce crisis worse.

Others believe employer-initiated mandates indicate less of a workforce loss, with operators like St. Louis, Mo.-based St. Andrew’s Resources for Seniors System (STARRS) losing less than 2% of its workforce following a self-imposed mandate in October.

“It is a concern of many of our frontline managers, the potential loss of employees,” Bill Holman, incoming CEO of St. Louis, M.O.-based STARRS said. “I think there’s enough short run history here with organizations that had successfully migrated to policy mandating who have not lost as many employees as they may have forecasted upfront.”


By contrast, president of Traylor-Porter Healthcare J. Mark Traylor told Skilled Nursing News he may lose 50-100 employees over the federal mandate, a medical director and other management expected to be among them.

While in favor of the vaccine, Traylor said the unintended workforce consequences will take a toll on resident care. Traylor owns four skilled nursing facilities in Alabama through his company, which currently employs about 450 people.

“You have areas of the country, you have providers that may have a 25 to 30% vaccination rate. I think you will move the needle but you’re not moving the needle to 60, 75%,” said Traylor. “The question is, how do you appropriately care for those patients with limited staff? Is there a team of National Guard or CMS vaccinated employees and nurses and [certified nursing assistants, CNAs] that can come in and help us care for these people?”


Traylor said staff vaccination ranges from 28% to 85% for his facilities.

Missouri currently has the lowest staff vaccination rate at 56.86%, while Alabama sits at 64.12% as of Nov. 4.

CMS clarifies guidance

The Centers for Medicare & Medicaid Services (CMS) held a virtual stakeholder meeting Thursday afternoon to review the guidance — Medicare and Medicaid participating health care facilities, nursing homes included, must have fully vaccinated staff members by Jan. 4, 2022.

The CMS regulation further states that facilities must establish a policy within 30 days, ensuring that staff have received the first dose of a two-dose COVID-19 vaccine or a one-dose vaccine by Dec. 5.

President Joe Biden initially announced a mandate for all nursing home employees in August, but soon after extended it to include any health care provider that receives Medicare or Medicaid funding.

Daily or weekly testing of unvaccinated staff was considered, CMS said in its guidance, but found “vaccination is a more effective infection control measure.” Operators can conduct testing alongside vaccination, but not as a replacement for vaccines.

“This really forces people to make a decision, whether they’re going to continue employment and follow the mandate or not,” said Holman. “When there is an option to do something else, then, in my mind, that weakens the mandate.”

CMS worked with the Occupational Safety and Health Administration (OSHA) to develop guidance. OSHA also issued its vaccine mandate requirements for employers with more than 100 employees on Thursday — this rule allows a test out option, unlike CMS guidance.

In his presentation, Dr. Lee Fleisher said CMS will check for vaccination mandate compliance through recertification and complaint surveys; Fleisher is chief medical officer and director of the Center for Clinical Standards and Quality (CCSQ) for CMS.

Accrediting organizations will be required to update their survey process to include vaccination regulations, Fleisher added.

“Providers out of compliance will be cited based on the level or severity of noncompliance with an opportunity to return to substantial compliance,” Fleisher noted. “CMS has a variety of established enforcement remedies for nursing homes, home health agencies and hospices beginning in 2022. This includes civil monetary penalties, denial of payment and even termination from the Medicare and Medicaid programs as a final measure. The remedy for noncompliance among hospitals and certain other acute and continuing care providers is termination.”

Fleisher was quick to add it was not CMS’ goal to terminate facilities from the Medicare and Medicaid programs, but rather to work with operators to bring them back in compliance as quickly as possible.

The regulation allows for exemptions based on recognized medical conditions or religious beliefs, observances or practices — and the nursing home is required to develop its own process or plan to allow for those exemptions.

Care will suffer, aging services groups say

A hard Jan. 4 deadline requiring full vaccinated staff without provider resources or test out options for unvaccinated workers will push too many people out of the nursing home industry, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) said in a statement.

In turn, resident access to long-term care will be threatened by worker shortage fallout.

“Across the country, access to long term care is becoming strained as providers have no choice but to limit admissions or even close their doors due to workforce shortages,” Mark Parkinson, president and CEO of AHCA/NCAL, said in a statement. “We hope to continue working with the Administration to make the federal vaccine mandate successful while supporting our residents and caregivers.”

Fellow senior care advocacy group LeadingAge echoed AHCA/NCAL’s sentiments, with its president and CEO Katie Smith Sloan expressing concern over the impact on aging services workforces.

“The policy could further complicate staffing issues (including the prospect of additional departures) for our members who are already contending with longstanding workforce challenges exacerbated by the pandemic,” Smith Sloan said in a statement.

The Society for Post-Acute and Long-Term Care (AMDA) said the organization is “pleased” with the guidance lead time of 30 days for a first or only dose of the COVID-19 vaccine, which also happens to be the timeframe to have a plan in place for vaccine implementation, exemptions and accommodations, and documenting and tracking staff vaccinations.

AHCA/NCAL represents more than 14,000 nursing homes and long-term care facilities across the country, providing care to roughly 5 million patients on an annual basis. LeadingAge represents more than 5,000 non-profit aging services providers, and AMDA has over 50,000 medical directors, physicians, nurse practitioners and physicians among its membership.

The vaccine mandate, tied to Medicare and Medicaid participating health care facilities, affects about 76,000 providers and 17 million health care workers, CMS said.

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