Contact UsCall 1-888-742-4621

TJC & CMS News Blog
Information for Hospitals

CMS COVID-19 Staff Vaccination Requirements

Feb 20, 2022 by
, BH Organizations, Hospitals

CMS COVID-19 Staff Vaccination Requirements Illustration

As an Accrediting Organization (AO) for CMS, TJC is now surveying deemed status organizations for compliance with the CMS COVID-19 staff vaccination requirements. Specifically, TJC is surveying to the CMS Omnibus COVID-19 Health Care Staff Vaccination interim final rule. This rule is now applicable in all 50 states.

Which Staff Require Vaccination?

The categories of staff requiring vaccination are facility employees, licensed practitioners, students, trainees, volunteers, and contracted staff. The rule doesn’t apply to full-time telehealth workers or remote employees.

TJC Survey Process

So, what’s the best way to prepare for this review during survey? First, be aware of the documents surveyors will request. These are as follows:

  • Overall COVID vaccination rate of eligible staff
  • A list of all staff, including positions/title, including COVID vaccination status
  • All policies regarding health care staff COVID vaccinations
  • Policies for COVID vaccination exemptions
  • Policies for COVID vaccination requirements
  • Policies for mitigation of unvaccinated staff
  • List of newly hired staff in last 60 days

A few key points: The timelines for compliance differ for the original 25 states where it was effective vs. the next 24 states and, finally, the state of Texas. TJC reviews this in detail in their FAQ How is compliance with the CMS COVID vaccination requirement determined?

Also, exemptions for clinical contraindications must be from an LIP. In addition, surveyors will not assess the appropriateness of clinical contraindications or religious exemptions. They’ll only evaluate that the documentation is complete.

Lastly, vaccination is the only option. The regulation does not include a testing option in lieu of vaccination.

TJC Scoring

Surveyors will score compliance with the CMS COVID-19 Staff Vaccination Requirements in the Leadership chapter under LD.04.01.01 EP 2: “The hospital provides care, treatment, and services in accordance with licensure requirements, laws, and rules and regulations.”

Thus far, we’ve seen findings for vaccination rates under 100%. For example: “The hospital was not in compliance with the CMS COVID-19 staff vaccination requirements as evidenced by a vaccination rate of 90%.”

Other findings have been for unvaccinated contractors and vendors.

CMS Guidance re Scoring

CMS has provided the following guidance on scoring the level of deficiency for hospitals’ compliance with the staff vaccination requirements

Immediate Jeopardy

  • 40% or more of staff remain unvaccinated creating a likelihood of serious harm OR
  • Did not meet the 100% staff vaccination rate standard ; observations of noncompliant infection control practices by staff (e.g., staff failed to properly don PPE) and one or more components of the policies and procedures were not developed or implemented.

Condition Level Deficiency

  • Did not meet the 100% staff vaccination rate standard and one or more components of the policies and procedures were not developed and implemented. OR
  • 21-39% of staff remain unvaccinated creating a likelihood of serious harm.

Standard Level Deficiency

  • 100% of staff are vaccinated and all new staff have received at least one dose and one or more components of the policies and procedures were not developed and implemented. OR
  • Did not meet the 100% staff vaccination rate standard, but are making good faith efforts toward vaccine compliance.

Joint Commission FAQs

TJC has published several very helpful FAQs that provide details re the CMS rule and how surveyors will evaluate compliance during surveys. Be sure to read the following:

Barrins & Associates Consultation

As we conduct our Mock Surveys and Continuous Readiness Consultations we’re educating our clients on the CMS COVID-19 staff vaccination requirements. Specifically, how Joint Commission surveyors will review compliance. We’ll also share survey results in this area so we can learn from each other’s experience and develop best practices.