COVID-19 CMS Vaccination Requirements - Good Faith Efforts
Are there any instances in which good faith efforts will be recognized to meet the 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.
CMS expects all providers' and suppliers' staff to have received the appropriate number of doses by the timeframes unless exempted based on recognized clinical contradictions or applicable federal laws or delayed as recommended by CDC. If an organization has not met the dose and timeframe requirements, the following good faith efforts may be taken into consideration when determining the level of deficiency for a finding:
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.
CMS expects all providers' and suppliers' staff to have received the appropriate number of doses by the timeframes unless exempted based on recognized clinical contradictions or applicable federal laws or delayed as recommended by CDC. If an organization has not met the dose and timeframe requirements, the following good faith efforts may be taken into consideration when determining the level of deficiency for a finding:
- If the organization has no or has limited access to vaccine, and the hospital has documented attempts to obtain vaccine access (e.g., contact with health department and pharmacies), and/or
- If the organization provides evidence that they have taken aggressive steps to have all staff vaccinated, such as advertising for new staff, hosting vaccine clinics, etc.
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
Manual:
Ambulatory
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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