COVID-19 CMS Vaccination Requirements - CMS Definition of 'Fully Vaccinated'
What does it mean to be fully vaccinated?
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.
Staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The CMS requirements for vaccine completion rates does not include the 14-day waiting period as identified by CDC for full vaccination. Rather these requirements are considered met with the completed vaccine series (i.e., one dose of a single dose vaccine, or final dose of a multi-dose vaccine series). Please refer to the CMS QSO Ref: QSO-22-07-ALL document available on the CMS website regarding the phased and level of deficiency guidelines.
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.
Staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The CMS requirements for vaccine completion rates does not include the 14-day waiting period as identified by CDC for full vaccination. Rather these requirements are considered met with the completed vaccine series (i.e., one dose of a single dose vaccine, or final dose of a multi-dose vaccine series). Please refer to the CMS QSO Ref: QSO-22-07-ALL document available on the CMS website regarding the phased and level of deficiency guidelines.
At the time of survey, organizations must be prepared to demonstrate that the process used for validating vaccination status included viewing an acceptable proof of vaccination document. Each organization determines how this information will be documented. Examples of acceptable documents may include, but not limited to:
- CDC COVID-19 vaccination record card (or a legible photo of the card)
- Documentation of vaccination from a health care provider or electronic health record
- State immunization information system record.
NOTE: Simply viewing or obtaining a letter of attestation or signature attesting to receiving the vaccination is not acceptable.
For additional information, please visit the following CMS website:
Manual:
Ambulatory
Chapter:
Leadership LD
New or updated requirements last added: January 28, 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 28, 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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