COVID-19 CMS Vaccination Requirements - Applicable Staff
Which individuals must comply with the CMS COVID Vaccination requirements?
Any examples are for illustrative purposes only.
Beginning January 27, 2022 for applicable deemed program surveys in progress on that day, The Joint Commission will begin surveying to the COVID–19 Health Care Staff Vaccination interim final rule published by the Centers for Medicare & Medicaid Services in the November 5, 2021 Federal Register and additional guidance posted on 12/28/2021 in the original 25 states, District of Columbia and territories. The CMS COVID-19 vaccination requirements apply to organizations that elect to use Joint Commission accreditation for deemed status purposes.
As a result of the U.S. Supreme Court's decision on January 13, 2022, health care organizations in the 24 states that were not previously subject to the Omnibus Health Care Staff Vaccination rule now are. Additionally, health care organizations in these 24 states need to demonstrate compliance utilizing the phased-in approach per the timelines specified in the Center for Medicare & Medicaid Services' memorandum issued January 14, 2022. Ref: QSO-22-09-ALL memorandum.
On January 20, 2022, CMS published in the QSO-22-11-ALL memorandum that the state of Texas not previously subject to the Omnibus Health Care Staff Vaccination rule now apply. Health care organizations in the state of Texas need to demonstrate compliance utilizing the phased-in approach per the timelines specified in the Center for Medicare & Medicaid Services' memorandum issued January 20, 2022.
The vaccination requirements apply to all eligible staff, both current and new, working at a facility regardless of clinical responsibility or patient contact, including:
There may be many infrequent services and tasks performed in or for an organization that is conducted by "one-off" vendors, volunteers, and professionals. Organizations are not required to ensure the vaccination of individuals who very infrequently provide ad hoc non-healthcare services (such as generator testing, equipment maintenance, etc), or services that are performed exclusively off-site, not at or adjacent to any site of patient care (such as accounting services), but they may choose to extend COVID-19 vaccination requirements to them if feasible. Organizations should consider the frequency of presence, services provided, and proximity to patients and staff.
For additional information, please visit the following CMS website:
CMS: Guidance for the Interim Final Rule - Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination
Beginning January 27, 2022 for applicable deemed program surveys in progress on that day, The Joint Commission will begin surveying to the COVID–19 Health Care Staff Vaccination interim final rule published by the Centers for Medicare & Medicaid Services in the November 5, 2021 Federal Register and additional guidance posted on 12/28/2021 in the original 25 states, District of Columbia and territories. The CMS COVID-19 vaccination requirements apply to organizations that elect to use Joint Commission accreditation for deemed status purposes.
As a result of the U.S. Supreme Court's decision on January 13, 2022, health care organizations in the 24 states that were not previously subject to the Omnibus Health Care Staff Vaccination rule now are. Additionally, health care organizations in these 24 states need to demonstrate compliance utilizing the phased-in approach per the timelines specified in the Center for Medicare & Medicaid Services' memorandum issued January 14, 2022. Ref: QSO-22-09-ALL memorandum.
On January 20, 2022, CMS published in the QSO-22-11-ALL memorandum that the state of Texas not previously subject to the Omnibus Health Care Staff Vaccination rule now apply. Health care organizations in the state of Texas need to demonstrate compliance utilizing the phased-in approach per the timelines specified in the Center for Medicare & Medicaid Services' memorandum issued January 20, 2022.
The vaccination requirements apply to all eligible staff, both current and new, working at a facility regardless of clinical responsibility or patient contact, including:
- Facility Employees
- Licensed Practitioners
- Students
- Trainees
- Volunteers
- Contracted Staff
- Staff who perform duties offsite (e.g., home health, home infusion therapy, etc.) and to individuals who enter a CMS regulated facility (Example: A physician with privileges in a hospital who is admitting and/or treating patients onsite)
The regulation does not apply to full-time telehealth workers or remote employees.
There may be many infrequent services and tasks performed in or for an organization that is conducted by "one-off" vendors, volunteers, and professionals. Organizations are not required to ensure the vaccination of individuals who very infrequently provide ad hoc non-healthcare services (such as generator testing, equipment maintenance, etc), or services that are performed exclusively off-site, not at or adjacent to any site of patient care (such as accounting services), but they may choose to extend COVID-19 vaccination requirements to them if feasible. Organizations should consider the frequency of presence, services provided, and proximity to patients and staff.
For additional information, please visit the following CMS website:
Manual:
Critical Access Hospital
Chapter:
Leadership LD
New or updated requirements last added: January 25, 2022.
New or updated requirements may be based on revisions to current accreditation requirements, regulatory changes, and/or an updated interpretation in response to industry changes. Substantive changes to accreditation requirements are also published in the Perspective Newsletter that is available to all Joint Commission accredited organizations.
Last reviewed by Standards Interpretation: January 25, 2022
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: January 14, 2022
This Standards FAQ was first published on this date.
This page was last updated on April 11, 2022
with update notes of: Editorial changes only
Types of changes and an explanation of change type:
Editorial changes only: Format changes only. No changes to content. |
Review only, FAQ is current: Periodic review completed, no changes to content. |
Reflects new or updated requirements: Changes represent new or revised requirements.
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