COVID-19 CMS Vaccination Requirements - Required Documents, Policies and Procedures
What documents are expected to be available at the time of survey?
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.
Required documents to present to surveyors:
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.
Required documents to present to surveyors:
- Overall vaccination rates of staff, excluding exempted staff
- A list of all staff (identifying those hired in the last 60 days), including positions/titles, including vaccination status
- All policies regarding health care staff vaccinations
- A process for tracking and securely documenting the COVID-19 vaccination status of all staff (see FAQ titled 'COVID-19 CMS Vaccination Requirements - Applicable Staff').
- A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC.
- A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable federal law.
- A process for tracking and securely documenting information provided by those staff who have requested, and for whom the organization has granted, an exemption from the staff COVID-19 vaccination requirements based on recognized clinical contraindications or applicable federal laws.
- A process for ensuring that all documentation that confirms recognized clinical contraindications to COVID-19 vaccines and supports staff requests for medical exemptions from vaccination has been signed and dated by a licensed practitioner who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local laws. Such documentation contains:
- All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive
- The recognized clinical reasons for the contraindications
- A statement by the authenticating practitioner recommending that the staff member be exempted from the organization's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications. NOTE: Surveyors only evaluate that the documentation is complete; they do not assess the appropriateness of clinical contraindications.
- A process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19.
- A process for ensuring the tracking and securing documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19 and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment.
- Contingency plans for staff who are not fully vaccinated for COVID-19.
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:
Home Care
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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