COVID-19 CMS Vaccination Requirements – New Staff and Contractors
What are the requirements that must be met when bringing on new staff or contractors that may not be fully vaccinated?
Any examples are for illustrative purposes only.
Organizations must have a process for ensuring all eligible staff have received at least a single-dose, or the first dose of a multi-dose COVID-19 vaccine series prior to providing any care, treatment, or other services for the facility and/or its patients. The process must ensure those staff who are not yet fully vaccinated, or who have been granted an exemption or accommodation as authorized by law, or who have a temporary delay, adhere to additional precautions that are intended to mitigate the spread of COVID-19. This requirement is not explicit and does not specify actions that must be taken; there are a variety of actions or job modifications a facility can implement to potentially reduce the risk of COVID-19 transmission examples, including, but not limited to:
New staff or new contractors not fully vaccinated are permitted to start work following one dose of the multi-dose vaccine as long as the facility is using additional precautions to protect patients and staff until that staff member or contractor is able to be fully vaccinated.
Organizations must have a process for ensuring all eligible staff have received at least a single-dose, or the first dose of a multi-dose COVID-19 vaccine series prior to providing any care, treatment, or other services for the facility and/or its patients. The process must ensure those staff who are not yet fully vaccinated, or who have been granted an exemption or accommodation as authorized by law, or who have a temporary delay, adhere to additional precautions that are intended to mitigate the spread of COVID-19. This requirement is not explicit and does not specify actions that must be taken; there are a variety of actions or job modifications a facility can implement to potentially reduce the risk of COVID-19 transmission examples, including, but not limited to:
- Reassigning staff who have not completed their primary vaccination series to non- patient care areas, to duties that can be performed remotely (i.e., telework), or to duties which limit exposure to those most at risk (e.g., assign to patients who are not immunocompromised, unvaccinated).
- Requiring staff who have not completed their primary vaccination series to follow additional, CDC-recommended precautions, such as adhering to universal source control and physical distancing measures in areas that are restricted from patient access (e.g., staff meeting rooms, kitchen), even if the facility or service site is in a county with low to moderate community transmission.
- Requiring at least weekly testing for exempted staff and staff who have not completed their primary vaccination series, until the regulatory requirement is met, regardless of whether the facility or service site is in a county with low to moderate community transmission, in addition to following CDC recommendations for testing unvaccinated in facilities located in counties with substantial to high community transmission.
- Requiring staff who have not completed their primary vaccination series to use a NIOSH- approved N95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients.
The examples above are not all inclusive and represent actions that can be implemented. However, facilities can choose other precautions that align with the intent of the regulation which is intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated.
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
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: April 11, 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: April 11, 2022
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: April 10, 2022
This Standards FAQ was first published on this date.
This page was last updated on April 11, 2022
with update notes of: Reflects new or updated requirements
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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