TJC, CMS issue guidance on COVID-19 vaccine requirement

by A.J. Plunkett (

Update your policies on vaccines and make sure the changes are approved before your next survey now that CMS, The Joint Commission (TJC), and the other accrediting organizations are going forward with enforcing the Biden administration’s requirement for healthcare workers to be fully vaccinated against COVID-19.

“There should be clear procedures for capturing staff’s vaccine status and capturing the exemption requests. For large organizations that will be an undertaking itself,” say Jennifer Cowel, RN, MHSA, CEO of Patton Healthcare Consulting and a former Joint Commission executive and nurse surveyor.

She also recommends being able to show your facility’s progress on vaccine compliance and that you are acting quickly on staff exemption requests. The first deadline for implementation is January 27.

Both CMS and TJC quickly published guidance late last week on how they would enforce the vaccine requirement after the Supreme Court lifted injunctions from lower courts that halted the enforcement in 25 states impacted by lawsuits.

Both indicated that enforcement would be part of regularly scheduled surveys or complaint surveys.

According to CMS’ information about enforcement at hospitals, “Surveyors will begin surveying for compliance 30 days after the issuance of the QSO-22-09-ALL memorandum, through a full survey for recertification or reaccreditation, federal initial surveys, or a complaint survey. Surveyors will be guided to focus on the vaccination status and hospital policies to address vaccination for staff that regularly work in the hospital (e.g., weekly), using a phased-in approach as described.”

QSO-22-09-ALL from CMS’ Quality, Safety and Oversight Group, was published on January 14, and includes a note that the information applies to all states not covered under earlier memos, except for Texas, which has a separate legal challenge.

Meanwhile, Florida state officials have warned hospitals in the state not to enforce the federal requirement. Hospital officials there have said they are still working out how the state order will impact the federal mandate. In its original interim final rule, CMS cited regulations that federal mandates would supersede local orders.

The CMS guidance published on January 14 largely mirrors a similar memo issued on December 28, which is the guidance TJC based it’s enforcement rules on, said the accrediting organization  in an FAQ.

“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.”

CMS has said hospitals and other healthcare providers covered under the interim final rule will have 30 days after the publication of the guidance memo to show that all staff have either had at least one dose of the vaccine or been approved for a religious or medical exemption. Those providers have another 30 days to show that staff are full vaccinated or have an exemption.

CMS has also said it would work with facilities that have a substantial plan in progress to comply with the vaccine requirement.

While nursing homes and some other providers first face civil penalties, all providers who do not comply could see their Medicare and Medicare funding terminated, says CMS.

The new guidance may seem daunting, but hospitals have largely been implementing the requirements anyway, says Steven MacArthur, a senior safety consultant with The Greeley Company in Danvers, Massachusetts.

Hospitals “just need to review the specifics of their implementation plan and plug any holes that might exist. The plan and the practices related to the plan have to match up—which is true of any and every implementation plan, including enforcing consequences,” he notes.

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CMS, COVID-19, Joint Commission