Nursing Facility Staff Vaccinations, Boosters, and Shortages After Vaccination Deadlines Passed

Over one in five COVID-19 deaths has been in a long-term care facility since the start of the pandemic. Due to the disproportionate impact of COVID-19 on this population early in the pandemic, vaccinations of nursing facility residents and staff were a high priority when the vaccine rollout began in Winter 2020-2021. Since then, the Centers for Medicare and Medicaid Services (CMS) has implemented a health care worker vaccination mandate, which does not include booster shots, for nursing facilities and other providers that participate in Medicare and/or Medicaid. Although some states sued to challenge this rule, the Supreme Court allowed the mandate to take effect while those cases are resolved by the lower courts.

This analysis uses nursing facility-level data reported by the federal government to track the increase in vaccination rates among nursing facility staff nationally and by state between August 2021 (when the vaccine mandate was first announced) and March 27^th, 2022 (after the vaccine deadline for health workers had passed in all states), building on a previous data note. Additionally, this analysis provides state-level information on booster rates among nursing home staff and the prevalence of staffing shortages after all vaccination deadlines had passed. Approximately 14,700 nursing facilities (or about 97% of all nursing facilities) are included in this analysis, and at least 95% of facilities in each state reported reliable data. See methods for more details.

While this analysis does not directly attribute the increase in vaccination rates to the mandate, since many factors could affect these measures, the trends are nonetheless helpful for understanding the impact of different policies on rates of infections, hospitalization, and deaths attributable to COVID over time. Key findings from our analysis include:

• Vaccination Rates: Nursing facility staff vaccination rates increased nationally by 25 percentage points, from 63% to 88%, between August 2021 and March 2022 (Figures 1 and 2). As of March 2022, 12% of nursing facilities nationally reported 100% staff vaccination rates, and 39% of facilities reported rates over 90% but less than 100% (Figure 3). The remaining 49% of facilities reported rates of 90% or below. These data cannot be used to estimate the share of facilities in each state that comply with the mandate since data do not account for vaccine exemptions.
• Booster Rates: As of March 2022, the national booster rate for nursing facility staff was 44%, ranging from 93% in MA to 24% in FL, MO, and MS (Figure 4). While the federal mandate does not explicitly require booster shots, five states (CT, MA, NJ, NY, and CA) that reported a greater than 30-percentage point increase in booster rates from January 2022 to March 2022, as well as some of the highest booster rates in March 2022, had state-level booster mandates during this time period. Nationally, about one-third of facilities reported booster rates among nursing facility staff higher than 50%, while another one-third of facilities reported booster rates under 25% (Figure 5).
• Staff Shortages: More than one in four (28%) of nursing facilities nationally reported staffing shortages as of March 2022 ranging from 63% in AK to 3% in CA (Figure 6). Staffing shortages peaked nationally during the Omicron wave, with nearly one in three facilities reporting a shortage in January 2022. Staffing shortage rates have fallen since then from 33%, and remained relatively stable through March 2022, even after the implementation of the vaccine mandate.

Vaccine Mandate: Requirements and Litigation

In mid-August 2021, the Biden Administration announced that nursing facility staff would be required to be vaccinated against COVID-19 as a condition of participation in the Medicare and Medicaid programs. CMS released the interim final rule establishing the new vaccination requirement in November 2021. Due to litigation, facilities in different states had different deadlines to comply with the new rule. CMS guidance requires 100% of staff in nursing facilities to have completed their vaccinations or have a pending or approved exemption by February 28^th in 25 states plus D.C.; by March 15^th in 24 states; and by March 21^st in the remaining state, Texas.

CMS released a series of guidance with details on enforcement and implementation timelines for facilities to comply with the mandate. After the mandate became effective in all states, including in states that sued to challenge it, the substantive provisions of the guidance were the same for all states, except that the effective dates differed, as explained above. Under this guidance, CMS established three difference enforcement action thresholds:

• Within 30 days after the relevant guidance was issued: 100% of staff must have received at least one dose of COVID-19 vaccine, or have a pending or approved exemption, or a CDC-recommended delay. A facility that is above 80% and has a plan to achieve a 100% staff vaccination rate within 60 days is not be subject to additional enforcement action.
• Within 60 days after the relevant guidance was issued: 100% of staff must have received all necessary doses of the COVID-19 vaccine series, or have a pending or approved exemption, or a CDC-recommended delay.  A facility that is above 90% and has a plan to achieve a 100% staff vaccination rate within 30 days is not be subject to additional enforcement action.
• Within 90 days after the relevant guidance was issued: Facilities that do not comply with the 100% standard may be subject to enforcement action.

Nursing facilities that do not achieve compliance could be subject to enforcement through a number of mechanisms. CMS states that federal and state surveyors will begin surveying facilities for compliance with the rule as part of initial certification, standard recertification or reaccreditation, and complaint surveys 30 days following the issuance of the guidance. Facilities that do not achieve the 100% standard may be subject to enforcement through actions such as civil monetary penalties, denial of payments, and termination of participation from the Medicare and Medicaid programs. CMS in the guidance emphasizes that their “primary goal is to bring health care facilities into compliance” and termination would likely occur “only after providing a facility with an opportunity to make corrections and come into compliance.”

While the vaccine mandate is in effect, litigation challenging the new rule is ongoing. Although cases in Texas and Florida were dismissed after the Supreme Court allowed the rule to take effect, cases in Missouri and Louisiana are still pending. The Missouri case is now back at the district court for a decision about whether to permanently block the rule, while the Louisiana case is currently at the 5^th Circuit Court of Appeals, awaiting an expected return to the district court. Although the Supreme Court decided that the federal government has authority to issue the rule, the states in both active cases are now seeking to amend their complaints to add new claims that were not part of their arguments at the Supreme Court.

Missouri now argues that the rule is arbitrary and capricious since the Omicron variant has replaced the Delta variant, which was prevalent when the rule was issued. Louisiana now argues that requiring state surveyors to enforce the rule violates the “anti-commandeering doctrine” and also challenges subsequent CMS guidance that indicates that state surveyors should be vaccinated. In both the Missouri and Louisiana cases, the district court judges have indicated that they are likely to allow the states to add these new claims, which raises the possibility that the rule could be blocked again – decisions that likely would be appealed.

Nursing Facility Staff Vaccinations

Nursing facility staff vaccination rates increased nationally by 25 percentage points (63% to 88%) between August 2021 (when the vaccine mandate for health workers was initially announced) and March 2022, the deadlines for compliance with the mandate in all states (Figure 1).  While a number of factors may have influenced the rise in vaccination rates, it appears that the vaccine mandate contributed to increases in staff vaccination rates.

By the end of March 2022, after vaccine mandate deadlines had passed in all states, vaccination rates for nursing facility staff varied widely by state, ranging from 76% in Montana to 99% in five states (NY, RI, DC, ME, and MA) (Appendix Table 1). Previous analysis found similar state variation in nursing facility staff vaccination rates prior to the mandate deadlines, which CMS cited as a factor leading to the adoption of the rule. While state variation in vaccination rates has persisted since the deadlines passed, all states reported an increase in staff vaccination rates after the vaccination deadlines passed (Figure 2).

The increase in staff vaccination rates also varied across states between August 2021 and March 2022, ranging from a 37-percentage point increase in Georgia to a nine-percentage point increase in Hawaii (Figure 2). Nursing facilities in ten states reported a 30-percentage point or greater increase between August 2021 and March 2022, while facilities in five states reported an increase of 15 percentage points or less in same time period (Figure 2). This variation may be partially attributed to some states reporting high baseline vaccination rates, such as Hawaii (89%) and California (82%), while other states such as Georgia and Louisiana reported lower rates (48% and 52%, respectively).

After all vaccination deadlines had passed by the end of March 2022, 12% of facilities reported a staff vaccination rate of 100% and 39% of facilities reported staff vaccination rates greater than 90% but less than 100%. The remaining 49% of facilities reported rates of 90% or lower (Figure 3). The share of facilities reporting universal staff vaccination rates ranged from 56% of facilities in Rhode Island to 0% of facilities in Wyoming. The share of facilities reporting near-universal rates of vaccination (91-99%) ranges from 82% of facilities in Connecticut to 16% of facilities in Oklahoma. 24% of nursing facilities reported vaccination rates between 81-90% and roughly the same share (25%) reported a staff vaccination rates of 80% or lower.

It is difficult to assess compliance with the mandate based on these data. The federal data includes the number of staff who report medical contraindications to the COVID-19 vaccine, but does not track other potential exemptions, such as religious exemptions or CDC-recommended delays. Additionally, it is not clear whether all staff with a reported medical contraindication fall under the umbrella of “approved exemptions”. A ProPublica investigation found that nearly 20,000 nursing facility workers, or about one percent of nursing facility staff, claimed a medical exemption for vaccines and an additional 164,000, or about nine percent, declined to get the vaccine for another reason, which could include a religious objection.

Nursing Facility Staff Boosters

The national booster rate for nursing facility staff was 44% as of March 2022 (Figure 4).  Though booster shots have been cited as crucial protection against serious illness and death due to COVID-19, the CMS rule does not require staff to receive booster shots. The CDC began recommending boosters for nursing home residents in September 2021, after data indicated that vaccinations become less effective over time, especially among older adults.  Staff booster rates in nursing facilities increased 17 percentage points (27% to 44%) between mid-January 2022 and March 2022, after vaccination deadlines had passed. January 2022 was chosen as the comparison time period since it is five months after the vaccine mandate was announced, aligning with CDC’s recommendations to receive a booster shot five months after most initial vaccine regimens.  

Booster rates for nursing facility staff varied widely across states, ranging from 93% in Massachusetts to 24% in Florida, Missouri, and Mississippi, as of March 2022 (Figure 4). Eight states reported booster rates above 60%, while 13 states reported booster rates below 30%. This wide variation may reflect differences in attitudes or hesitancy about boosters, as well as state and local policies on boosters. Five states (CT, MA, NJ, NY, and CA) reported a greater than 30 percentage point increase in booster rates from January 2022 to March 2022, as well as some of the highest booster rates in the country in March 2022 (an average of 72%, or nearly 30 percentage points higher than the national average). All five of these states had booster mandates during this time period, which may partially explain why these state-level increases are higher than the national increase of 17 percentage points in this time period.

As of the end of March 2022, after all vaccination deadlines had passed, about one-third of nursing facilities nationally reported staff booster rates of over 50%, another third reported rates between 25-50%, and the third of remaining facilities reported rates of under 25% (Figure 5). There is wide state variation in the share of facilities reporting staff boosters of over 50%, ranging from 99% of facilities in Massachusetts to five percent of facilities in Tennessee. Conversely, about 60% of facilities in Florida, Louisiana, and Missouri reported staff booster rates of under 25%, while zero percent of facilities in Massachusetts fall in this category.

Nursing Facility Staffing Shortages

More than one in four (28%) nursing facilities nationally reported staffing shortages as of March 2022 after all vaccination deadlines had passed, ranging from 63% of facilities in Alaska to 3% of facilities in California (Figure 6). State variation in staffing shortages may be attributable to variation in local economies and labor markets and could also be due to differences in the way in which nursing facilities define and report staff shortages. Previous analysis shows that staffing shortages peaked nationally during the Omicron wave, with nearly one in every three facilities reporting a shortage in January 2022. Rates have fallen slightly since then and remained relatively stable through March 2022, even after the implementation of the vaccine mandate. When issuing the vaccine mandate rule, CMS acknowledged that some staff may leave their jobs because they do not want to receive the vaccine, possibly exacerbating staffing shortages, while also citing examples of vaccine mandates that resulted in high rates of compliance and few employee resignations. Data suggest that the vaccine mandate has not exacerbated staffing shortages to the extent initially hypothesized since shortages have actually fallen nationally since January 2022. There are likely a multitude of factors that impact staffing shortages beyond the vaccine mandate.

Looking Ahead

While it is difficult to isolate the impact of the staff vaccination mandate on vaccination rates, booster rates, and staff shortages, the mandate did likely play a role in increased vaccination rates from August 2021 to March 2022. As new COVID-19 variants emerge and make their way into nursing facilities, maximizing vaccination and booster rates among facility staff will help protect against illness and death of residents and staff, and help maintain sufficient staffing levels. The Biden Administration has announced a number of policies to address staffing issues in nursing facilities, including establishing minimum staffing levels for Medicare and Medicaid-certified nursing facilities, supporting state efforts to tie Medicaid reimbursement rates to increases in staff compensation, and launching a national nursing career pathways campaign. The National Academies of Sciences, Engineering, and Medicine also released a comprehensive report on quality of care in nursing facilities and recommended enhanced and updated federal staffing standards as one component of a wide-ranging package of nursing facility reforms. Since the onset of the COVID-19 pandemic, some states have adopted changes to increase state-level minimum staffing requirements. It will be important to watch whether and how lessons from the pandemic are integrated into new federal and state policies to improve nursing facility care quality and protect residents and staff.

Methods

This analysis uses federal data reported weekly by facilities to the CDC’s National Healthcare Safety Network (NHSN) through March 27th, 2022 to align with the week right after all vaccination deadlines had passed. The federal data includes only data on Medicare or Medicaid certified nursing facilities. This analysis therefore does not reflect other long-term care settings, such as assisted living facilities, residential care facilities, group homes, or intermediate care facilities.  These data are updated regularly to reflect revised data from previous weeks, so future versions of this dataset reflecting the same time period may output different values. CMS performs data quality checks to identify facilities that may have entered incorrect data before publishing this data for public download. Facilities that have submitted erroneous data will have an “N” displayed in the column titled “Passed Quality Assurance Check”. Our final sample of nursing facilities in each week of data excludes facilities that CMS flagged in their data quality check, as well as facilities that are missing measures of staff census, staff vaccinations, staff boosters, or staffing shortages, depending on the metric of interest. With these exclusions, each week of data for every metric represents anywhere from 14,800 to 14,900 facilities, or 97-98% of total facilities. Each week of data represents a slightly different set of facilities due to weekly variation in nursing facility reporting. Completed vaccination refers to those who have completed a 2-dose Pfizer, 2-dose Moderna, or a single dose of J&J. Booster data reflect any additional dose of vaccination. Shortage measures reflect any reported shortages among nursing staff (including registered nurses, licensed practical nurses, and vocational nurses), clinical staff (including physicians, physician assistants, and advanced practice nurses), aides (including certified nursing assistants, nurse aides, medication aides, and medication technicians), or other staff (including administrative, custodial, and other environmental service staff).  These measures are asked and reported as binary measures (yes/no) and reflect staffing shortages as of the week of data reporting; therefore, we are unable to determine the magnitude of staffing shortages among nursing facilities that report “yes” to one or more staff positions.

Appendix Table