Menu of State Long-Term Care Facility Influenza Vaccination Laws

Flu can be a serious disease that can lead to hospitalization and sometimes even death; anyone can get very sick from flu, including people who are otherwise healthy.⁶ Flu is primarily a community-based infection that is transmitted in households and community settings.⁷ Each year, 5% to 20% of US residents get the flu. Deaths associated with flu are most frequent among older adults.⁸ During the 1976–2007 flu seasons, an estimated yearly average of 21,098 flu-related deaths occurred among adults aged ≥65 years, corresponding to 90% of estimated annual average deaths across all age groups.⁹

Healthcare-associated infections, which can include flu,¹⁰ are “infections that occur during the course of healthcare delivery.”¹¹ In healthcare settings, flu can be spread by healthcare workers passing germs from hands or clothes to other workers or to patients.¹² The Advisory Committee on Immunization Practices recommends annual flu vaccination for all healthcare personnel to reduce flu-related morbidity and mortality among both healthcare personnel and their patients.¹³ Vaccination of healthcare providers has been associated with reduced work absenteeism and with fewer deaths among nursing home patients and elderly hospitalized patients.¹⁴ Flu vaccine coverage rates for healthcare workers in long-term care settings are often lower than in other healthcare facilities, such as hospitals and ambulatory care facilities.¹⁵ Yet in long-term care facilities, where residents are often aged 65 years or older, vaccination among healthcare workers is particularly important because flu vaccine effectiveness can be lower in elderly populations.¹⁶

Twenty-four states establish flu vaccination requirements for long-term care facility healthcare workers,¹⁷ and 32 states establish requirements for long-term care facility patients.¹⁸ This menu assesses and gives examples of state laws that expressly establish flu vaccination requirements for long-term care facility healthcare workers and patients.¹⁹ Specifically, it reviews these laws based on the facilities and individuals the requirements apply to, type of requirement, and the exemptions permitted under the law. Because of these range of categories, each law can be assessed from different angles. In many cases, a single law specifies the applicable healthcare facility and also identifies whether the law applies to all or particular patient populations or to all or particular employee populations.

CDC recommends that all adults receive the flu vaccine annually. To learn more, visit CDC’s Vaccine Information for Adults web page for information about this and other recommended vaccines.

Long-term care facilities “provide a variety of services, both medical and personal care, to people who are unable to manage independently in the community.”²⁰ Examples of long-term care facilities include nursing homes and skilled nursing facilities, among others.²¹ These laws establish requirements based on the long-term care facility type and the type of vaccination requirements. In addition, some state laws allow for vaccination exemptions.

Examples by Long-Term Care Facility Type

Twenty-fourstates’ flu vaccination provisions expressly reference long-term care facilities or apply to various healthcare facilities that are considered long-term care facilities.²²

All Long-Term Care Facilities

• Kentucky law states that “[e]very long-term care facility shall require each employee to be immunized against . . . influenza virus.”²³
• In Missouri, “all long-term care facilities . . . shall assist their health care workers, volunteers, and other employees who have direct contact with residents in obtaining the vaccination for the influenza virus by either offering the vaccination in the facility or providing information as to how they may independently obtain the vaccination.”²⁴

Specific Long-Term Care Facilities

• Under Georgia law, “[e]ach nursing home shall annually offer on site to its health care workers and other employees who have direct contact with patients, at no cost, vaccinations for the influenza virus.”²⁵
• New Hampshire law requires that “each . . . residential care facility . . . licensed under this chapter shall provide to its consenting employees annual immunizations against influenza.”²⁶

Examples by Healthcare Worker Type

All Healthcare Workers

Eighteen states have flu vaccination requirements for all healthcare workers in long-term care facilities.²⁷

• Under Arkansas law, “[e]ach nursing home facility in this state shall . . . [d]ocument and report annually immunizations against . . . [i]nfluenza virus for . . . full-time and part-time employees . . . .”²⁸

Healthcare Workers with Occupational Exposure

California is the only state that explicitly establishes flu vaccination requirements for long-term care facility healthcare workers with occupational exposure.²⁹

• California law states that “[t]he employer shall establish, implement, and maintain effective procedures for providing vaccinations against seasonal influenza to all employees with occupational exposure.”³⁰

Healthcare Workers with Direct Patient Contact

Five states explicitly establish flu vaccination requirements for long-term care facility healthcare workers with direct patient contact.³¹

• Per South Carolina law, “[d]irect care staff and residents shall have an annual influenza vaccination . . . .”³²
• Texas law states that “[t]he executive commissioner by rule shall require nursing homes to offer, in accordance with an immunization schedule adopted in department rules . . . influenza vaccine . . . to staff who are in contact with elderly residents.”³³

Examples by Requirement Type

State vaccination laws for healthcare workers in long-term care facilities include assessment requirements, administrative offer requirements, administrative ensure requirements, and surgical mask requirements.

Assessment

Nineteen states have flu vaccination assessment requirements for healthcare workers in long-term care facilities.³⁴

• New York law requires that nursing homes “document the influenza vaccination status of all personnel for the current influenza season in each individual’s personnel record or other appropriate record.”³⁵
• Under Utah law, long-term care facilities must report “the total number of healthcare workers and the number of those workers who are documented to have received an influenza vaccine for the current influenza season.”³⁶

Administrative Offer

Twenty states require long-term care facilities to offer flu vaccination to healthcare workers.³⁷

• Oklahoma law requires that nursing facilities “shall document evidence of the offering of annual vaccination against influenza for each . . .  employee.”³⁸
• Per Maine law, “[a] nursing facility or licensed assisted living facility shall adopt a facility policy that recommends and offers annual immunizations against influenza to all personnel who provide direct care to residents of the facility.”³⁹

Administrative Ensure

Sixteen states require long-term care facilities to ensure that healthcare workers are vaccinated against flu.⁴⁰

• Under South Carolina law, nursing home “[d]irect care staff . . . shall have an annual influenza vaccination unless the vaccine is medically contraindicated or the person is offered the vaccination and declined.”⁴¹
• District of Columbia law requires nursing facility employees to “undergo immunization for influenza virus.”⁴²

Surgical Mask

Three states require long-term care facility healthcare workers to wear surgical masks during flu season if they have been exempted from or declined vaccination.⁴³

• Colorado law states that long-term care facilities shall ensure that “each healthcare worker who does not have proof of immunization wears a surgical or procedure mask during influenza season when in direct contact with patients and in common areas as specified by the licensee’s policy.”⁴⁴
• In Rhode Island, healthcare workers who are not immunized are “required during any declared period in which flu is widespread—as part of his or her professional licensing obligation—to wear a surgical face mask for the duration of each direct patient contact in the performance of his or her duties.”⁴⁵

Examples by Exemption Type

States with flu vaccination requirements often explicitly permit exemptions from these requirements in certain circumstances,⁴⁶ such as when vaccination is medically contraindicated or when it violates a person’s religious or philosophical beliefs.⁴⁷

Medical

Twenty-two states permit medical exemptions for vaccination requirements,⁴⁸ although even where not explicitly exempted by law, it is likely that employees with a medically contraindicated condition are not required to be vaccinated.

• Employees in long-term care facilities in Massachusetts are not required to be vaccinated for flu if “the vaccine is medically contraindicated, which means that administration of influenza vaccine to that individual would likely be detrimental to the individual’s health.”⁴⁹
• Per Texas law, nursing facilities “must offer influenza vaccinations to . . . employees in contact with residents, unless the vaccination is medically contraindicated by a physician . . . .”⁵⁰

Religious

Thirteen states permit religious exemptions for flu vaccination requirements for long-term care facility healthcare workers.⁵¹

• Under Alabama law, long-term care facility employees are not required to receive the flu vaccine “if the vaccine is against the individual’s religious beliefs.”⁵²
• North Carolina states that nursing homes must “require . . . employees to be immunized against influenza virus,” but “[n]o individual shall be required to receive vaccine under this section if the vaccine is . . . against the individual’s religious beliefs. . . .”⁵³

Philosophical

Twenty-four states permit philosophical exemptions for flu vaccination requirements for long-term care facility healthcare workers.⁵⁴

• Under Pennsylvania law, long-term care facilities “shall request that … employees be immunized for influenza virus,” but “[n]o . . . employee shall be required to receive either the influenza or pneumococcal vaccine if “the employee . . . refuses the vaccine after being fully informed of the health risks of such action.”⁵⁵
• Oregon law requires long-term care facilities to report the “[n]umber of staff with a documented refusal of influenza vaccination during the previous influenza season.”⁵⁶

Examples by Long-Term Care Facility Type

Thirty-two states have flu vaccination provisions that expressly reference long-term care facilities or that apply to various healthcare facilities that are considered long-term care facilities.⁵⁷ These laws establish requirements based on the long-term care facility and patient category and the type of vaccination requirements. In addition, some state laws allow for vaccination exemptions.

All Long-Term Care Facilities

• Alabama law requires that “[a] long term care facility shall document the annual immunization against influenza virus and the immunization against pneumococcal disease for each resident.”⁵⁸
• In New Jersey, long-term care facilities must “document evidence of annual vaccination against influenza for each resident.”⁵⁹

Specific Long-Term Care Facilities

• Illinois law requires “long-term care for under age 22 facilities” to “annually administer or arrange for a vaccination against influenza to each resident.”⁶⁰
• Under North Carolina law, nursing homes “shall require residents and employees to be immunized against influenza virus and shall require residents to also be immunized against pneumococcal disease.”⁶¹

Examples by Patient Type

While many states have vaccination laws that apply to all patients, other states have vaccination laws for patients who are particularly vulnerable to flu.

All Patients

Thirty-two states have flu vaccination laws for all patients.⁶²

• Arkansas requires nursing homes to “[d]ocument and report annually immunizations against . . . [i]nfluenza virus for residents.”⁶³
• Delaware law requires nursing facilities to “have on file evidence of annual vaccination against influenza for all residents.”⁶⁴

Patients Aged 65 Years or Older

Two states have flu vaccination laws for patients aged 65 years or older.⁶⁵

• Under California law, healthcare facilities, including nursing facilities, “shall offer . . . immunizations for influenza and pneumococcal disease to residents, aged 65 years or older, receiving services at the facility.”⁶⁶
• In Texas, nursing homes must “offer . . . influenza vaccine to elderly residents,”⁶⁷ defined as those aged 65 years or older.⁶⁸

Examples by Requirement Type

State vaccination laws for long-term care facility patients include assessment requirements, administrative offer requirements, and administrative ensure requirements.

Assessment

Twenty-one states have flu vaccination assessment requirements for long-term care facility patients.⁶⁹

• Kentucky law requires that “[u]pon admission, the long-term care facility shall . . . [a]ssess the resident’s immunization status for influenza virus.”⁷⁰
• In North Carolina, nursing homes are required to “document the annual immunization against influenza virus . . . for each resident.”⁷¹

Administrative Offer

Twenty-seven states require long-term care facilities to offer flu vaccination to long-term care facility patients.⁷²

• In Michigan, [a]nursing home shall “offer each resident . . . an annual vaccination against influenza.”⁷³
• Nebraska requires its nursing facilities to “offer onsite vaccinations for influenza . . . to all residents and to all inpatients prior to discharge.”⁷⁴

Administrative Ensure

Twenty-three states require long-term care facilities to ensure patients are vaccinated against flu.⁷⁵

• South Carolina law states that “residents shall have an annual influenza vaccination.”⁷⁶
• District of Columbia law requires that nursing facilities “ensure that each resident . . . has either received immunization against influenza virus or has refused such vaccination.”⁷⁷

Examples by Exemption Type

States with patient flu vaccination requirements often explicitly permit exemptions from these requirements in certain circumstances⁷⁸

Medical

Twenty-nine states explicitly permit long-term care facility patients to be exempted from receiving flu vaccination for medical reasons,⁷⁹ although even where not explicitly exempted by law, it is likely that individuals with a medically contraindicated condition are not required to be vaccinated.

• In Arizona, nursing care institutions must ensure that “vaccinations for influenza and pneumonia are available to each resident . . . unless . . . the vaccination is medically contraindicated.”⁸⁰
• Texas law requires nursing facilities to law “offer influenza vaccinations to residents . . . unless the vaccination is medically contraindicated.”⁸¹

Religious

Thirteen states permit religious exemptions to their flu vaccination requirements for patients in long-term care facilities.⁸²

• North Carolina law requires nursing home residents to be vaccinated for influenza but states that “[n]o individual shall be required to receive vaccine under this section if . . . the vaccine is against the individual’s religious beliefs.”⁸³
• In Pennsylvania, a long-term care facility resident will not “be required to receive either the influenza or pneumococcal vaccine if it is against his religious beliefs.”⁸⁴

Philosophical

Twenty-seven states permit philosophical exemptions to their flu vaccination requirements for patients in long-term care facilities.⁸⁵

• Hawaii law states that “[e]ach resident shall receive age-appropriate immunizations or vaccinations including but not limited to pneumococcal and annual influenza vaccines . . . unless . . . refused by the resident.”⁸⁶
• In South Dakota, nursing facilities “shall arrange for influenza vaccination to be completed annually for all residents . . . [d]ocumentation of vaccination or refusal shall be recorded in the resident’s medical record.”⁸⁷

 

CDC recommends that healthcare workers receive the flu vaccine annually. To learn more, visit the CDC’s Recommended Vaccines for Healthcare Workers web page for information about this and other recommended vaccines.

This document was developed by Hillary Li, JD candidate 2017 at the University of North Carolina School of Law and Fall 2016 extern; Aila Hoss, JD, former Carter Consulting, Inc.; Alexandra Bhatti, JD, MPH, Cherokee Nation Assurance, LLC; and Dawn Pepin, JD, MPH, Cherokee Nation Assurance, LLC, with the Public Health Law Program (PHLP). This document was produced in collaboration with CDC’s National Center for Immunization and Respiratory Diseases. The authors thank Lindsay Culp, JD, MPH, Megan C. Lindley, MPH, and Matthew Penn, JD, MLIS, for their research and editorial assistance.

For further technical assistance with this inventory, please contact phlawprogram@cdc.gov. PHLP provides technical assistance and public health law resources to advance the use of law as a public health tool. PHLP cannot provide legal advice on any issue and cannot represent any individual or entity in any matter. PHLP recommends seeking the advice of an attorney or other qualified professional with questions regarding the application of law to a specific circumstance. The findings and conclusions in this summary are those of the authors and do not necessarily represent the official views of CDC.

This menu includes states laws collected from WestlawNext during September 9–November 8, 2016.

1. Alexandra Stewart et al. Mandatory Vaccination of Health-Care Personnel: Good Policy, Law, and Outcomes, 53 Jurimetrics J. 341 (Apr. 2013).
2. MC Lindley, GA Horlick, AM Shefer, FE Shaw & M Gorji. Assessing State Immunization Requirements for Healthcare Workers and Patients. Am. j. of preventive med. 32(6), 459–65, 460 (2007).
3. Id.
4. Id.
5. See, e.g., 10 N.Y. Comp. Codes R. & Regs. 2.59; 31 R.I. Code R. 1-22:5.0.
6. Influenza Vaccination Information for Health Care Workers, Centers for Disease Control and Prevention (last visited Jan. 26, 2017).
7. Prevention Strategies for Seasonal Influenza in Healthcare Settings, Centers for Disease Control and Prevention (last visited Jan. 26, 2017).
8. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2016–17 Influenza Season, Centers for Disease Control and Prevention (last visited Jan. 26, 2017).
9. Id.
10. Diseases and Organisms in Healthcare Settings, Centers for Disease Control and Prevention (last visited Oct. 9, 2015).
11. Tara Ramanathan and Matthew Penn, The Emergence of Law to Address Healthcare-Associated Infections, American Health Lawyers Association Connections, 28 (Aug. 2012).
12. Prevention Strategies for Seasonal Influenza in Healthcare Settings, Centers for Disease Control and Prevention (last visited Oct. 13. 2015).
13. Influenza Vaccination Coverage Among Health Care Personnel — United States, 2015–16 Influenza Season, Centers for Disease Control and Prevention (last visited Jan. 26, 2017).
14. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010, Centers for Disease Control and Prevention (last visited Jan. 26, 2017).
15. Carla L. Black, Xin Yue, Sarah W. Ball, et al. Influenza Vaccination Coverage Among Health Care Personnel — United States, 2015–16 Influenza Season. 65(38) Morbidity and Mortality Weekly Report, 1026–31  2016 (stating that “[a]lthough influenza vaccination coverage has increased in all work settings since the 2011–12 season, health care providers in long-term care settings have consistently had lower coverage than health care personnel working in hospital and ambulatory care settings.”)
16. Id. (stating that “[i]nfluenza vaccination among health care personnel in long-term care settings is especially important because influenza vaccine effectiveness is generally lowest in the elderly. In addition, multiple studies have demonstrated that vaccination of health care personnel in long-term care settings confers a health benefit to patients, including reduced risk for mortality.”)
17. Alabama, Arkansas, California, Colorado, Delaware, District of Columbia, Georgia, Illinois, Kentucky, Maine, Maryland, Massachusetts, Missouri, New Hampshire, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, and Utah. See Appendix 1 for citations.
18. Alabama, Arizona, Arkansas, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Kentucky, Maine, Maryland, Michigan, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, and Washington. See Appendix 2 for citations.
19. CDC’s Public Health Law Program (PHLP) conducted a search for state statutes and regulations that establish express influenza vaccination requirements for long-term care facility healthcare workers and patients using WestlawNext, a legal research database. Searches were conducted in all states and the District of Columbia during September 9–November 8, 2016. This assessment did not capture state requirements that incorporate CDC vaccination recommendations by reference. Laws regarding childhood vaccinations, school vaccinations, immunization registries, blood, tissue, and organ donor requirements, post-exposure vaccinations, physician standing orders, and primary care providers and individual healthcare provider requirements to vaccinate patients were not within the scope of this assessment. Laws establishing vaccination requirements as a condition for participation in a health plan were also excluded.
20. Centers for Disease Control and Prevention, Nursing Homes and Assisted Living (Long-Term Care Facilities [LTCFs]), (last visited Feb. 6, 2017). PHLP did not consider the following facilities to be long-term care facilities regardless of the level of nursing care offered: assisted living facilities, substance abuse treatment facilities, rehabilitation facilities, adult day cares, hospice care facilities, home health agencies, health facilities for developmentally disabled persons, rest homes, and group homes.
21. See, e.g., Fla. Stat. Ann. § 400.021; Ky. Rev. Stat. Ann. § 216.510; S.C. Code Ann. Regs. 61-17(101)(RR).
22. Alabama, Arkansas, California, Colorado, Delaware, District of Columbia, Georgia, Illinois, Kentucky, Maine, Maryland, Massachusetts, Missouri, New Hampshire, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, and Utah. See Appendix 1 for citations.
23. Ky. Rev. Stat. Ann. § 209.552(3).
24. Mo. Ann. Stat. §§ 198.054.
25. Ga. Code Ann. § 31-7-19(a).
26. N.H. Rev. Stat. Ann. § 151:9-b(IV).
27. Alabama, Arkansas, Colorado, Delaware, District of Columbia, Illinois, Kentucky, Maryland, Massachusetts, New Hampshire, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, and Utah. See Appendix 1 for citations.
28. A.C.A. §20-10-1304
29. California. See Appendix 1 for citations.
30. 8 CCR §5199.
31. Georgia, Maine, Missouri, South Carolina, and Texas. See Appendix 1 for citations.
32. S.C. CODE ANN. REGS. 61-17.
33. TEX. HEALTH & SAFETY CODE ANN. §§ 161.0051.
34. Alabama, Arkansas, California, Colorado, Delaware, District of Columbia, Kentucky, Maine, Maryland, Massachusetts, New Hampshire, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, and Utah. See Appendix 1 for citations.
35. N.Y. Comp. Codes R. & Regs. tit. 10, § 2.59(c).
36. Utah Admin. Code r. R386-705-4.
37. Alabama, California, Colorado, District of Columbia, Georgia, Illinois, Kentucky, Maine, Maryland, Missouri, New Hampshire, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, and Utah. See Appendix 1 for citations.
38. Okla. Admin. Code § 310:675-9-31; 310:675-1-2.
39. Me. Rev. Stat. Ann. tit. 22, § 802(5).
40. Alabama, Arkansas, Colorado, Delaware, District of Columbia, Kentucky, Maryland, Massachusetts, New Hampshire, New York, North Carolina, Pennsylvania, Rhode Island, South Carolina, Tennessee, and Texas. See Appendix 1 for citations.
41. S.C. Code Ann. Regs. 61-17(II)(b).
42. D.C. Mun. Regs. tit. 22-B, §§ 3222.3.
43. Colorado, New York, and Rhode Island. See Appendix 1 for citations.
44. 6 COLO. CODE REGS. 1011-1:II-10.8(B).
45. R.I. Admin. Code 31-1-22:5.3; 31-1-22:2.1(a).
46. See, e.g., 40 Tex. Admin. Code § 19.1601(e)(2)(B); N.C. Gen. Stat. Ann. § 131E-113; 35 Pa. Stat. and Cons. Stat. Ann. §§ 632.3; 632.6(3); Or. Admin. R. 333-018-0127(3). Please note that even where not explicitly exempted by law, it is likely that employees with a medically contraindicated condition are not required to be vaccinated.
47. Philosophical exemptions include exemptions based on philosophical or personal beliefs or allowing the right to decline an immunization.
48. Alabama, Arkansas, California, Colorado, District of Columbia, Illinois, Kentucky, Maine, Maryland, Massachusetts, Missouri, New Hampshire, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, and Utah. See Appendix 1 for citations.
49. 105 Mass. Code Regs. 150.002(D)(f)(1)(a).
50. 40 Tex. Admin. Code § 19.1601(e)(2)(B).
51. Alabama, Arkansas, District of Columbia, Illinois, Kentucky, Maine, Maryland, Massachusetts, New Hampshire, New York, North Carolina, Pennsylvania, and Rhode Island. See Appendix 1 for citations.
52. Ala. Code § 22-21-10(g).
53. N.C. Gen. Stat. Ann. § 131E-113.
54. Alabama, Arkansas, California, Colorado, Delaware, District of Columbia, Georgia, Illinois, Kentucky, Maine, Maryland, Massachusetts, Missouri, New Hampshire, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, and Utah. See Appendix 1 for citations.
55. 35 Pa. Stat. and Cons. Stat. Ann. §§ 632.3; 632.6(3).
56. Or. Admin. R. 333-018-0127(3).
57. Alabama, Arizona, Arkansas, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Kentucky, Maine, Maryland, Michigan, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, and Washington. See Appendix 2 for citations.
58. Ala. Code § 22-21-10(d).
59. N.J. Admin. Code §§ 8:39–19.4(h).
60. Ill. Admin. Code tit. 77, §§ 390.1140(a).
61. N.C. Gen. Stat. Ann. § 131E-113(a).
62. Alabama, Arizona, Arkansas, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Kentucky, Maine, Maryland, Michigan, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, and Washington. See Appendix 2 for citations.
63. Ark. Code Ann. §§ 20-10-1304(b)(3).
64. 16 Del. Admin. Code § 3201-6.3.1.
65. California and Texas. See Appendix 2 for citations.
66. Cal. Health & Safety Code § 120392.2(a).
67. Tex. Health & Safety Code Ann. § 161.0051(c).
68. Tex. Health & Safety Code Ann. § 242.002(5).
69. Alabama, Arkansas, California, Delaware, District of Columbia, Florida, Illinois, Indiana, Kentucky, Maine, Maryland, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, South Dakota, Tennessee, Texas, and Utah. See Appendix 2 for citations.
70. Ky. Rev. Stat. Ann. § 209.552(1)(b).
71. N.C. Gen. Stat. Ann. §§ 131E-113(c).
72. Alabama, Arizona, California, Connecticut, District of Columbia, Florida, Georgia, Illinois, Indiana, Kentucky, Maine, Maryland, Michigan, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Dakota, Texas, Utah, Virginia, and Washington. See Appendix 2 for citations.
73. Mich. Comp. Laws Ann. § 333.21716.
74. Neb. Rev. Stat. Ann. §§ 71-468.
75. Alabama, Arkansas, Connecticut, Delaware, District of Columbia, Florida, Hawaii, Illinois, Indiana, Kentucky, Maine, Maryland, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, and Virginia. See Appendix 2 for citations.
76. S.C. Code Ann. Regs. 61-17(1706)(B)(1).
77. D.C. Mun. Regs. tit. 22-B, § 3222.1.
78. See, e.g., 40 Tex. Admin. Code § 19.1601(e)(2)(B); N.C. Gen. Stat. Ann. § 131E-113; 35 Pa. Stat. and Cons. Stat. Ann. §§ 632.3; 632.6(3); Or. Admin. R. 333-018-0127(3). Please note even where not explicitly exempted by law, it is likely that patients with a medically contraindicated condition are not required to be vaccinated
79. Alabama, Arizona, Arkansas, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Kentucky, Maine, Maryland, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, and Virginia. See Appendix 2 for citations. Please note that even where not explicitly exempted by law it is likely that patients with a medically contraindicated condition are not required to be vaccinated.
80. Ariz. Admin. Code § R9-10-413(B)(5). 40 Tex. Admin. Code § 19.1601 (e)(2)(B).
81. Alabama, Arkansas, Connecticut, District of Columbia, Florida, Indiana, Kentucky, Maryland, New Hampshire, New York, North Carolina, Pennsylvania, and Rhode Island. See Appendix 2 for citations.
82. N.C. Gen. Stat. Ann. § 131E-113(e).
83. 35 Pa. Stat. and Cons. Stat. Ann § 632.6(2).
84. Alabama, Arizona, Arkansas, California, Delaware, District of Columbia, Florida, Hawaii, Illinois, Indiana, Kentucky, Maine, Maryland, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, and Virginia. See Appendix 2 for citations.
85. Haw. Admin. Rules § 11-94.1-42(j).
86. S.D. Admin. R. 44:73:04:09.
87. Please note that even where not explicitly exempted by law it is likely that patients with a medically contraindicated condition are not required to be vaccinated.
88. Philosophical exemptions include exemptions based on philosophical or personal beliefs or allowing the right to decline an immunization.
89. Arkansas law states that each nursing home facility shall “as a condition of his or her employment, require each employee to participate in immunization programs conducted while he or she is employed at the facility.” Ark. Code
90. Ann. § 20-10-1304(b)(2).
91. Colorado law states that “[i]f a licensed healthcare entity demonstrates that it has vaccinated a targeted percentage of its employees in a given year, using its own methodology, it shall be exempt from the [assessment, administrative and surgical mask] requirements.” 6 COLO. CODE REGS. 1011-1:II-10.6.
92. Colorado law states that “[i]f a licensed healthcare entity demonstrates that it has vaccinated a targeted percentage of its employees in a given year, using its own methodology, it shall be exempt from the [assessment, administrative and surgical mask] requirements.” 6 COLO. CODE REGS. 1011-1:II-10.6.
93. Colorado law states that “[i]f a licensed healthcare entity demonstrates that it has vaccinated a targeted percentage of its employees in a given year, using its own methodology, it shall be exempt from the [assessment, administrative and surgical mask] requirements.” 6 COLO. CODE REGS. 1011-1:II-10.6.
94. Colorado law states that “[i]f a licensed healthcare entity demonstrates that it has vaccinated a targeted percentage of its employees in a given year, using its own methodology, it shall be exempt from the [assessment, administrative and surgical mask] requirements.” 6 COLO. CODE REGS. 1011-1:II-10.6.
95. Md. Code Ann., Health – General § 19-301 defines “related institutions” as “an organized institution, environment, or home that:(i) Maintains conditions or facilities and equipment to provide domiciliary, personal, or nursing care for 2 or more unrelated individuals who are dependent on the administrator, operator, or proprietor for nursing care or the subsistence of daily living in a safe, sanitary, and healthful environment; and (ii) Admits or retains the individuals for overnight care.” PHLP considered this a long-term care facility.
96. Expires soon.
97. Expires soon.
98. Expires soon.
99. Rhode Island’s statutory code states that “[e]xcept as provided in § 23-17.19-6, every facility in this state shall request that residents and employees be immunized for influenza virus and pneumococcal disease in accordance with this chapter.” 23 R.I. Gen. Laws §§ 17.19-3; 23-17.19-2.23 R.I. Gen. Laws §§ 17.19-3-6 outlines the circumstances for which an employee or resident may be exempt from requirements stated.
100. Note that V.T.C.A., Health & Safety Code § 161.0052 references immunization of “elderly persons” specifically.
101. Includes intermediate care facilities.
102. Please note that even where not explicitly exempted by law it is likely that patients with a medically contraindicated condition are not required to be vaccinated.
103. Philosophical exemptions include exemptions based on philosophical or personal beliefs or allowing the right to decline an immunization.
104. Arkansas law states that each nursing home facility shall “obtain consent from residents or their legal guardians upon admission to participate in all immunization programs that are conducted within the facility while that person is a resident of that facility, and not in violation of the resident’s right to refuse treatment.” Ark. Code Ann. § 20-10-1304(b)(1).
105. Applies to chronic and convalescent nursing homes.
106. Note that 77 Ill. Adm. Code 390.1140 specifically refers to “Long-Term Care for Under Age 22 Facilities” which is defined by Ill. Admin. Code tit. 77, § 390.330 as follows, “Facility, Long-Term Care, for Residents Under 22 Years of Age – when used in this Part is synonymous with a long-term care facility for residents under 22 years of age, which facility provides total habilitative health care to residents who require specialized treatment, training and continuous nursing care because of medical or developmental disabilities.”
107. Applies to patients under 22.
108. Md. Code Ann., Health – General § 19-301 defines “related institutions” as “an organized institution, environment, or home that: (i) Maintains conditions or facilities and equipment to provide domiciliary, personal, or nursing care for 2 or more unrelated individuals who are dependent on the administrator, operator, or proprietor for nursing care or the subsistence of daily living in a safe, sanitary, and healthful environment; and (ii) Admits or retains the individuals for overnight care.” PHLP considered this a long-term care facility.
109. Note that medical exemptions are incorporated by reference in N.H. Code Admin. R. He-P 803.23 where it states that “The licensee shall immunize all consenting residents for influenza and pneumococcal disease and all consenting personnel for influenza in accordance with RSA 151:9-b. . . .” N.H. REV. STAT. ANN. § 151:9-b states that, “[i]mmunization of all consenting patients shall be . . . subject to exemptions for medical contraindications . . . .”
110. Note that religious exemptions are incorporated by reference in N.H. Code Admin. R. He-P 803.23 where it states that “The licensee shall immunize all consenting residents for influenza and pneumococcal disease and all consenting personnel for influenza in accordance with RSA 151:9-b. . . .” N.H. REV. STAT. ANN. § 151:9-b states that, “[i]mmunization of all consenting patients shall be . . . subject to exemptions for. . . religious beliefs.”
111. Expires soon.
112. Expires soon.
113. Ohio Admin. Code 3701-17-13 cites directly to requirements in Ohio Rev. Code Ann. § 3721.041.

Appendix 1: Influenza Vaccination Laws for Healthcare Workers (HCWs) in Long-Term Care Facilities

• Long-Term Care (LTC) Facility Type
• HCW Type
• Requirement Type
• Exemptions

Appendix 2: Influenza Vaccination Laws for Patients in Long-Term Care (LTC) Facilities

• Long-Term Care (LTC) Facility Type
• Patient Type
• Requirement Type
• Exemptions

To see a combined version of these tables, please open the PDF [258 KB] version of the document.