No slow start for TJC enforcing vaccine requirements

by A.J. Plunkett (

The Joint Commission (TJC) surveyors have been true to their promise to begin surveying to the new COVID-19 vaccine requirement as soon as it became effective, and hospitals are already being scored for non-compliance.

“They are not doing a slow start on this,” warns Jennifer Cowel, a former TJC survey executive and CEO of Patton Healthcare Consulting.

Make sure to include any vendors on the list of individuals who are vaccinated if they meet the CMS requirement to be vaccinated, says Cowel, noting that at least one hospital was scored because of a single missing vendor.

Surveyors with TJC are looking at vaccination rates and will score a hospital if it is not 100% compliant in the states where the newest Conditions of Participation (CoPs) outlining vaccination expectations are already effective.

Hospitals in those states were to ensure that staff had at least one vaccine shot by January 27, and both by February 28.

The deadlines for vaccination are staggered according to when CMS published memos outlining the schedule for states following a delay in implementation in some states because of legal injunctions that were subsequently lifted by the Supreme Court.

In general, unless the staffer has been granted a qualifying exemption or has a pending request, hospitals will be scored if any required staff remain unvaccinated. However, TJC and other accrediting organizations have said they are following CMS instructions that facilities who are above 80% compliant on the first-shot requirement and have a plan for 100% vaccination within 60 days “will not be subject to additional enforcement action.”

“States should work with their CMS location for cases that exceed these thresholds, yet pose a threat to patient health and safety,” according to CMS. “Facilities that do not meet these parameters could be subject to additional enforcement actions depending on the severity of the deficiency and the type of facility (e.g., plans of correction, civil monetary penalties, denial of payment, termination, etc.).”

Surveyors have been asking for the following documentation of COVID-19 vaccination policies and procedures to be available at least by 9 a.m. of Day 2 of the survey, but “preferably sooner,” says Cowel:

  • List of all staff and their vaccination status
  • The number of vaccinated staff
  • The percent of vaccinated staff
  • The position or role of each staff member, including staff who are in direct contact with residents, patients, providers, clients, regardless of frequency
  • List of staff granted a medical or religious exemption
  • List of staff granted a temporary delay
  • List of staff not vaccinated

Again, remember that the list should include vendors, notes Cowel.

According to CMS, the vaccination requirement applies to the following:

“Regardless of clinical responsibility or patient contact, the policies and

procedures must apply to the following hospital staff, who provide any care,

treatment, or other services for the hospital and/or its patients:

(i) Hospital employees;

(ii) Licensed practitioners;

(iii) Students, trainees, and volunteers; and

(iv) Individuals who provide care, treatment, or other services for the

hospital and/or its patients, under contract or by other arrangement.

(2) The policies and procedures of this section do not apply to the following

hospital staff:

(i) Staff who exclusively provide telehealth or telemedicine services outside of

the hospital setting and who do not have any direct contact with patients and

other staff specified in paragraph (g)(1) of this section; and

(ii) Staff who provide support services for the hospital that are performed

exclusively outside of the hospital setting and who do not have any direct contact with patients and other staff specified in paragraph (g)(1) of this section.”

For more specifics on the requirements, see the hospital attachment to CMS Quality, Safety & Oversight group memo, QSO-22-07-ALL.

For a list of states and deadlines, go here:





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CMS, COVID-19, Joint Commission