How is compliance with the CMS COVID vaccination requirement determined? 

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, and they will need to establish plans and procedures to ensure their staff are vaccinated based on pending CMS compliance timeline guidance.

Original 25 States
For the original 25 states, District of Columbia and territories, CMS expects all providers' and suppliers' staff to have received the appropriate number of doses by the timeframes unless exempted based on recognized clinical contraindications or applicable federal laws delayed as recommended by CDC. Facility staff vaccination rates under 100% constitute non-compliance.  Health care organizations need to demonstrate compliance utilizing the phased-in approach per the timelines specified in the Center for Medicare & Medicaid Services' memorandum CMS QSO Ref: QSO-22-07-ALL.

NOTE: Vaccination is the only option. The regulation does not include a testing option in lieu of vaccination.    

Next 24 States
For the remaining 24 states, excluding Texas, CMS expects all providers' and suppliers' staff to have received the appropriate number of doses by the timeframes unless exempted based on recognized clinical contraindications or applicable federal laws delayed as recommended by CDC. Facility staff vaccination rates under 100% constitute non-compliance. Health care organizations need to demonstrate compliance utilizing the phased-in approach per the timelines specified in the Center for Medicare & Medicaid Services' memorandum provided in the CMS QSO Ref: QSO-22-09-ALL when evaluating compliance.

Texas
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. 

• Organizations are compliant if, by February 22, 2022, they have established policies and procedures for ensuring that eligible staff are vaccinated, and all staff have received at least one dose, have a pending request for an exemption, have been granted a qualifying exemption, or have been identified as having a temporary delay as recommended by the CDC.
• Organizations are compliant if by March 21, 2022, if all staff have completed the vaccination series (one dose of Johnson & Johnson or two doses of Pfizer or Moderna), have been granted an exemption, or have been identified as having a temporary delay as recommended by the CDC.

NOTE: Vaccination is the only option. The regulation does not include a testing option in lieu of vaccination.  

All sites under the organization's CMS Certification Number(CCN) are required to be in compliance with the Conditions of Participation or Conditions for Coverage (CfC)s; therefore must comply with the vaccination requirements.  

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