Be aware! There’s a new Joint Commission COVID-19 staff vaccination standard effective July 1, 2022. The new standard  is in the Infection Control chapter: IC.02.04.02.

This Joint Commission standard mirrors the recent CMS COVID-19 staff vaccination requirements which we covered in an earlier post. It requires staff to be fully vaccinated.

Questions from organizations re the new Joint Commission COVID-19 staff vaccination standard

Who does the new COVID-19 staff vaccination standard apply to?

If your organization uses Joint Commission accreditation for CMS deemed status, this new standard applies to you. Indeed, that includes the majority of psychiatric hospitals since most use their TJC accreditation for CMS deemed status.

Which staff need to be vaccinated?

“Staff” includes employees, licensed practitioners, student, trainees, and volunteers. It also includes  individuals who provide patient care, treatment, or other services via contract.

Are any staff  not required to be vaccinated?

Yes, two categories of staff are not required to be vaccinated. First, those who provide exclusively telehealth services outside of the hospital and, thus, don’t have direct patient or staff contact.

Second, staff who provide services for the hospital outside of the hospital setting. For example, staff who work exclusively from home.

What’s the definition of fully vaccinated?

Fully vaccinated means staff have completed a primary vaccination series for COVID-19. That means they’ve had either a single-dose vaccine or all required doses of a multidose vaccine.

However, there is provision for new staff to begin providing patient care prior to being fully vaccinated. TJC recently released an FAQ on new staff or contractors that are not fully vaccinated.

Specifically, these new staff must have either a single dose vaccine or the first dose of a multidose vaccination series before they provide patient care. In addition, the hospital must use precautions for these staff until they’re fully vaccinated.

As an example, they could require these staff to wear N-95 masks. Another option could be weekly testing. Or, assigning them to non-patient care functions until they’re fully vaccinated.

Are there any exemptions to the Joint Commission COVID-19 staff vaccination requirements?

Staff can request an exemption based on applicable federal law or clinical contraindications. A Licensed Independent Practitioner (practicing within their scope of practice) must confirm the clinical contraindications.

How will Joint Commission surveyors review compliance?  

First, surveyors will likely request the following documents:

• A list of all staff and their COVID vaccination status
• List of newly hired staff in last 60 days
• Overall COVID vaccination rate of eligible staff
• Policies for COVID vaccination requirements
• Policies for COVID vaccination exemptions
• Policies for mitigation of unvaccinated staff

Next, they’ll review this material to determine your level of compliance. Currently, surveyors score compliance 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.”

Come July 1st, they’ll score compliance under the new Infection Control standard. It’s likely that, depending on the level of compliance, they may also score it under the Leadership standard.

Joint Commission FAQs

When the CMS staff vaccination requirements came out, TJC published several very helpful FAQs. These  are relevant for the new Joint Commission standard since it’s based on the CMS requirements. So, be sure to check out the following:

• COVID-19 CMS Vaccination Requirements -Applicable Entities
• COVID-19 CMS Vaccination Requirements -Applicable Staff
• COVID-19 CMS Vaccination Requirements -CMS Definition of ‘Fully Vaccinated’
• COVID-19 CMS Vaccination Requirements -Exemptions
• COVID-19 CMS Vaccination Requirements -Good Faith Efforts
• COVID-19 CMS Vaccination Requirements -Required Documents, Policies and Procedures
• COVID-19 CMS Vaccination Requirements -Determination of Compliance

Barrins & Associates Consultation 

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