Position Statements

Background:

The Centers for Medicare and Medicaid Services (CMS) now require that Healthcare Workers receive vaccination against COVID-19 as a condition of employment in skilled nursing facilities (SNFs). Employees/practitioners may request exemptions from such vaccine mandates for medical or sincerely held religious reasons. As all skilled nursing facilities are required to have a medical director, it is likely that this individual will be involved in evaluating such requests.

Position:

It is the position of Post-Acute and Long-Term Care Medical Association (PALTmed) that, to maximize the opportunity for medical directors to make decisions on the validity of medical exemption requests, SNFs should use a standardized Medical Exemption Request form and that such forms:

  • List the acceptable medical exemptions at the top of the form to eliminate the opportunity for free-texting and/or making a blanket statement that the individual should be exempted.
  • Include the duration of the requested exemption (even if it is indefinite/permanent).
  • Include a statement that the practitioner who is signing the medical exemption is in an ongoing professional relationship with the individual seeking exemption, has a thorough knowledge of the condition being listed, and has not been engaged solely for the purpose of providing the exemption.
  • Do NOT include the question of religious exemptions so as not to put that issue in the jurisdiction of the medical director.

Acceptable medical exemptions include:

  1. Severe adverse reaction (e.g., anaphylaxis, myocarditis) after a previous dose of or to a component of the COVID- 19 Vaccine, including polyethylene glycol (PEG)*
  2. Active myocarditis – staff may delay vaccination until myocarditis has fully resolved.
  3. Active COVID-19 infection – vaccination should be delayed until staff member is fully recovered from infection and no longer in isolation.
  4. Monoclonal antibodies within the past 90 days, or 30 days if given prophylactically.

*If an individual has a documented allergy to Polyethylene Glycol, they can receive the Johnson & Johnson (J&J) vaccine instead, with the understanding that the CDC endorsed ACIP’s recommendation expressing a clinical preference for the mRNA COVID-19 vaccine over the J&J vaccine based on evidence regarding vaccine effectiveness, vaccine safety and rare adverse events. ACIP reaffirmed that receiving any vaccine is better than being unvaccinated. Individuals who are unable or unwilling to receive an mRNA vaccine will continue to have access to Johnson & Johnson’s COVID-19 vaccine. The recent ACIP recommendation on the J&J vaccine is here: https://www.cdc.gov/media/releases/2021/s1216-covid-19-vaccines.html and a summary document from CDC is here: https://www.cdc.gov/vaccines/covid-19/downloads/summaryinterim-clinical-considerations.pdf

As with any allergic or adverse reaction, the nature of the reaction should be clearly documented by the practitioner signing the medical exemption.

NOTE: Pregnancy or trying to conceive is not a reason for medical exemption. There is no evidence that any of the FDA authorized COVID vaccines impact fertility. The risk of severe illness and death due to infection with COVID-19 during pregnancy is high, therefore the CDC recommends vaccination during pregnancy for all individuals who do not have other reasons for exemption. There is no evidence of increased risk of adverse events during pregnancy with COVID vaccination. PALTmed recommends continuing education for staff members requesting exemption due to trying to conceive or with active pregnancy. 

For Staff who Meet Exemption:

PALTmed recommends that the facility put forth specific guidelines by which unvaccinated exempt staff must abide to continue direct care of residents. Exempt staff should sign a document consenting to abide by precautions or face disciplinary action. The guidelines may include regular testing, mandatory specified PPE, or required quarantine after exposure to SARS-CoV-2 (see template).

NOTE: Larger systems with multiple facilities may consider seeking legal and infectious disease counsel to form a “vaccine exemption advisory board” to objectively review these requests and recommend denial or approval. If a facility is part of a larger corporate system, consider a central review of exemptions through this mechanism to avoid inconsistency across sites. 

If staff would like to speak to someone about COVID-19 vaccination during pregnancy, they can contact MotherToBaby, a CDC resource whose experts are available to answer questions in English or Spanish by phone or chat. The free and confidential service is available Monday–Friday, 8am–5pm (local time). To reach MotherToBaby: Call 1-866-626-6847 https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html

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Note: Effective August 13, 2024, AMDA - The Society for Post-Acute and Long-Term Care Medicine is now Post-Acute and Long-Term Care Medical Association (PALTmed).