Center for Improvement in Healthcare Quality Newsletter
February 2022

News You Can Use

February Compliance Tip of the Month – Complying with the COVID Vaccine Mandate

As most of you know by now, the Supreme Court upheld the HHS mandate that staff and contract workers employed in healthcare organizations must be fully vaccinated against the COVID-19 virus or been granted a medical or religious exemption. Organizations will be surveyed by both accrediting organizations and CMS for compliance effective January 27, 2022
Accrediting organizations (AO’) have until February 5, 2022 to submit their proposed standards and survey procedures addressing the mandate to CMS for approval. Until approval is granted, CMS expects AO’ to use the CMS standards and survey procedure to cite organizations that are non-compliant to the mandate requirements.

Proposed CIHQ Standard

IC-13: COVID Vaccination of Organization Staff
The organization must develop and implement policies and procedures to ensure that all staff are fully vaccinated against COVID-19.
Note 1: For purposes of this standard, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine.
Note 2: This standard does not apply to the following:
  • 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.
  • 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.
  • Staff who provide limited and infrequent services to the organization and do not have expected contact with patients (e.g., elevator servicing personnel, landscapers, etc.)
  1. 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:
    • Hospital employees.
    • Licensed practitioners.
    • Students, trainees, and volunteers; and
    • 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 must include a process for ensuring all staff (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the hospital and/or its patients.
  3. The policies and procedures must include a process for ensuring that all staff are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations.
  4. The policies and procedures must include 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.
  5. The policies and procedures must include a process for tracking and securely documenting the COVID-19 vaccination status of all staff.
  6. The policies and procedures must include 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.
  7. The policies and procedures must include a process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law.
  8. The policies and procedures must include a process for tracking and securely documenting information provided by those staff who have requested, and for whom the hospital has granted, an exemption from the staff COVID-19 vaccination requirements.
  9. The policies and procedures must include a process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which 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, and for further ensuring that such documentation contains:
    • All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and
    • A statement by the authenticating practitioner recommending that the staff member be exempted from the hospital’s COVID-19 vaccination requirements for staff based on the recognized clinical contraindications.
  10. The policies and procedures must include a process for ensuring the tracking and secure 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.
  11. The policies and procedures must include a process for contingency plans for staff who are not fully vaccinated for COVID-19.
The proposed CIHQ standards is exactly the same as the current CMS requirements under Condition of Participation for Infection Prevention & Control at § 482.42(g).

How will the Mandate Requirement be Surveyed?

CIHQ will follow CMS’ procedure when assessing compliance during accreditation surveys. This procedure was sent in a memo dated 1/14/22 to all accredited organizations participating in Medicare and is available on your organization’s CIHQ intranet site. Key activities will include:
  1. Reviewing your organization’s policies to assure that they align with the vaccine mandate requirements
  2. Asking for a list of all staff, their title, position, and vaccination status (i.e., fully vaccinated, unvaccinated)
  3. For those staff who are unvaccinated, surveyors will ask for evidence of the following:
    1. Documentation of a medical or religious exemption, or the need to temporarily delay vaccination due to an acceptable circumstance (e.g., recent COVID exposure, etc.)
    2. Evidence that if the staff person is permitted to continue working, that there is a plan in place to mitigate the risk of catching or transmitting the virus.
  4. Assessing compliance with COVID mitigation strategies such as mask wearing, isolation practices, screening procedures, etc.
Be sure to watch the “What’s New” for policies and tools to assist you in your compliance.

CIHQ has Joined the Texas Organization of Rural & Community Hospitals (TORCH)

CIHQ is proud to announce our Corporate Membership with the Texas Organization of Rural & Community Hospitals (TORCH) whose vision is to provide rural Texas access to the highest quality healthcare. The mission of TORCH is to be the voice and advocate for rural and community hospitals, and to provide leadership in addressing needs and issues that arise. We believe this partnership will serve CIHQ and TORCH through shared values of providing the best customer service, using data as a basis for setting policy and improving outcomes, and an open dialogue. CIHQ and TORCH strive to be prepared for changes, maintain growth and to build strategic relationships that enhance effectiveness.
Stop by and see CIHQ at Booth 105 during the TORCH Spring Conference & Trade Show in Dallas, April 19-21, 2022. This distinctive event is the premiere source for quality education and networking for rural hospital leaders and decision makers in Texas. Learn about current issues, reinforce old relationships, and build new ones, show your support for rural and community hospitals.