CMS will not immediately remove nursing homes from Medicaid and Medicare if they do not adhere to the employee staff vaccination requirement announced last week, administrators said during a call with industry stakeholders on Wednesday.

Instead, CMS will take a stepwise approach to enforcing the mandate. Nursing homes will first be notified they are not in compliance with the regulation, then assessed civil monetary penalties, then denied payment, and ultimately removed from the program if they do not comply.

“Termination is not typically the first action taken. We usually use a progressive pattern of enforcement and remedies,” said Jean Moody-Williams, deputy director of CMS’s Center for Clinical Standards and Quality.

The new requirement is not expected to take effect until September. CMS can’t share details because the agency is still in the rulemaking process, said Evan Shulman, director of CMS’s nursing home division. CMS will accept questions in the meantime.

As of Aug. 8, 62% of nursing home staff were vaccinated. At the state level, the rate ranges from 44% to 88%, according to CMS. The vaccine mandate will affect more than 15,000 nursing homes, which employ about 1.3 million workers and serve about 1.6 million nursing home residents, according to the White House.

A national standard could ameliorate staffing problems at nursing homes with mandates already in place by preventing vaccine-skeptical employees from leaving for workplaces without mandates, Moody-Williams said

“We believe this requirement would really level the playing field,” Moody-Williams said.

President Joe Biden’s administration also announced last week that anyone who had received their COVID-19 vaccine at least eight months prior would be eligible for a booster shot, pending federal approvals, starting the week of Sept. 20.

Healthcare providers, nursing home residents and seniors would be among the first eligible because those groups had early access to the vaccines. Health officials plan to begin delivering booster shots to residents of long-term care facilities next month.

Since the emergence of the delta variant in the U.S., COVID-19 cases among nursing home residents have increased from 319 on June 27 to 2,696 on Aug. 8, with many outbreaks occurring in facilities in states with low staff vaccination rates, according to CMS.

Both CMS and Centers for Disease Control and Prevention data show a strong relationship between the increase of COVID-19 cases among nursing home residents and the rate of vaccination among nursing home workers, the White House said.

There will be significant supply of the vaccines and options for accessing them. said Dr. Nimalie Stone, a CDC epidemiologist. Nursing homes will be able to obtain vaccines from either long-term care pharmacies or retail drugstores.

To keep track of booster shots administered in nursing homes, the CDC has added two new questions to its data collection form. One asks for the cumulative number of residents or healthcare personnel eligible to receive a booster and another asks for the number of those eligible who have received an additional dose or booster.

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