COVID-19 CMSVaccination Mandate- The new Standards and CoPsBarbara A McCannChief Quality Officer

The Vaccination Mandate BasicsEffective Nov 5, 2021Enforced (Surveys) Dec 6, 2021 Applies to HHAs, Hospices, and HomeInfusion Therapy Does Not apply to home care (private duty),or DMEPOS, or palliative .unless youcontract with a Medicare-certifiedorganization Civil monetary penalties can be involved Impact estimated at 79,000 health careorganizations, 17M people Estimate among hospitals 30-40% staff notfully vaccinated

Your policy: The following individuals must have at least 1dose of COVID 19 vaccine prior to providing care, treatmentor services to our organization or patients.Staff Employees Licensed PractitionersOther Individuals Students, Trainees VolunteersContracted orArranged Services TherapistsPharmacistsPhysicians, NPsDMEPOS, etc. etc.

Policies and procedures document the process ofverifying vaccination status of eligible individualsWho identifies eligiblestaff and advises themWho documents thedecision, tells theemployeeWhat documents areaccepted as evidence ofvaccination (includingboosters) & howWho follows up toensure 2nd dose of a 2dose series, anddocumentsWho accepts thedocuments, reviews andaccepts or deniesWhere is all thepreceding informationsecurely maintained

Exceptions, Exemptions, Delayed VaccinationTemporary DelayedVaccinationDocumentation of clinicalprecautions, including: Illness secondary toCOVID-19 Received monoclonalantibodies orconvalescent plasmaFederal StateExemptionsExempt due to JobTelehealth or support services Exclusively outside ofsettings where careprovided No direct contact withpatients, families,caregivers, or otherseligible for full vaccination.Medical - 3 specificparameters of statement. Spiritual: Your criteria fora sincerely held belief,practice or observance. Resource: EEOC -updated-covid-19-technicalassistance-0

Policies and procedures document the process of requestingand approval/denial of an exception or exemptionWho receives the request,what documents areaccepted/needed (refer toregulatory language) andhow employee to provideWho accepts thedocuments, reviews andaccepts or denies, and tellsemployee – all documentedDuring the request andreview period– what is yourcontingency planthey aren’t vaccinatedIf accepted, what is thecontingency plan for eachperson-update with anynew mitigation – document!If denied, and individual refusesvaccination, what next? Yourorganization call – rememberthere is no test option.Document!Where is all the precedinginformation, documentationsecurely maintained

The Expected OutcomeAre the processes you put in place working? From a list of employees, licensedpractitioners, students, trainees,volunteers and contracted services, pull asample – Can you show me their vaccination status,and documentation per your policies andprocedures and the standards/regulation? Do you feel confident that those providingcare/treatment services have a least onedose by December 6, or are on acontingency plan waiting for or havingreceived an exception or exemption.

Prepared for the Road Ahead –Now a Regulation What is your process to ensure that nationallyrecognized infection prevention and controlguidelines intended to mitigate the transmission andspread of COVID-19 are implemented and followed?

Caveats & ResourcesThings Change Fast CMS has said there will be surveyor training, interpretation may change. Notadvised of training yet. Surveys of regulations begin December 6 Access to the CMS FAQs – remember questions apply to all types of Medicarecertified facilities, CMS refers to HHAs, hospice, home infusion as‘facilities’ patience is required. 21.pdf Regulations: HHAs: chapterIV-i3 part484 subpartB section484.70Hospice: art- Home Infusion 525 ated-covid-19-technical-assistance-0


CMS has said there will be surveyor training, interpretation may change. Not advised of training yet. Surveys of regulations begin December 6 Access to the CMS FAQs –remember questions apply to all types of Medicare-certified facilities, CMS refers to HHAs, hos