Life Amid COVID: Vaccinations

The first U.S. case of the 2019 novel coronavirus, otherwise known as COVID-19, was confirmed in a man from Washington state in January 2020. Since then, our world and the way we function in it has been turned upside down. From wearing masks in public, to staying six feet apart, then isolating at home, to getting a vaccine for the virus…this has changed not only our private lives, but how we have adjusted to the everchanging requirements to be able to continue to work in our daily routines.

Now two years later, we want to examine life among COVID and changes that were made to continue to do the vital role the Medical Staff Professionals play in healthcare organizations.

On November 5, 2021, the Centers for Medicare & Medicaid Services (CMS) issued “CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule” which established COVID-19 Vaccination requirements for the following Medicare or Medicaid providers or suppliers:

• Ambulatory Surgery Centers
• Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services
• Community Mental Health Centers
• Comprehensive Outpatient Rehabilitation Facilities
• Critical Access Hospitals
• End-Stage Renal Disease Facilities
• Home Health Agencies
• Home Infusion Therapy Suppliers
• Hospices
• Hospitals
• Intermediate Care Facilities for Individuals with Intellectual Disabilities
• Long Term Care facilities
• Programs for All-Inclusive Care for the Elderly Organizations (PACE)
• Psychiatric Residential Treatment Facilities (PRTFs)
• Rural Health Clinics/Federally Qualified Health Centers

Phase One requirements included the facilities must have all policies and procedures in place for ensuring staff are fully vaccinated, providing exemptions, and tracking staff vaccinations. Staff at all health care facilities included within the regulation must have received, at a minimum, the first dose of a primary series or a single dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its patients. For Phase One, within 30 days after the guidance is posted, staff at all health care facilities included within the regulation must have received, at a minimum, the first dose of a primary series or a single dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its patients.

Phase Two required that staff must be fully vaccinated (except for those who have been granted exemptions from the COVID-19 vaccine or for those staff whom the COVID-19 vaccination must be temporarily delayed, as recommended by CDC). For Phase Two, within 60 days after the guidance is posted, staff at all health care provider and supplier types included in the regulation must complete the primary vaccination series (except for those who have been granted exemptions from the COVID-19 vaccine or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by CDC).

Per CMS, this vaccination requirement applies to eligible staff working at almost all CMS-certified facilities that participate in the Medicare and Medicaid programs, regardless of clinical responsibility or patient contact. The requirement includes all current staff as well as any new staff who provide any care, treatment, or other services for the facility and/or its patients. This includes facility employees, licensed practitioners, students, trainees, and volunteers. Additionally, this also includes individuals who provide care, treatment, or other services for the facility and/or its patients under contract or other arrangements.

To get a better understanding of how one organization adapted their tracking of the COVID-19 vaccinations, I reached out to Dawn Miller, CPCS, CPMSM, Network Director Medical Staff Services & CVO at Honor Health located in Phoenix, Arizona.

Could you describe how your facility(ies) have implemented these requirements?

With the coordination of our Occupational Health Department and Medical Staff leadership, we have created policies and procedures making it mandatory that all Medical and Allied Health staff submit documentation of being fully vaccinated or approval by the HH COVID Vaccination Committee for exemption. We are tracking the submissions under their Health Status screen, which allows us to report for CMS monthly the compliance and all reporting requirements. We are at 100% compliance and only those providers that meet requirements are being onboarded moving forward.

Have the providers complied?

Yes, we worked with our Medical Staff leadership to produce weekly communications leading up to the deadline date for compliance. Less than 1% of providers were removed from our total staff of 3700, due to non-compliance.

What percentage of the providers have been fully vaccinated?

97% are fully vaccinated and 3% are approved exemptions.

Are both boosters required?

No

How has the facility enforced compliance?

Compliance has been enforced through our credentials policy and the requirement to comply with all Hospital Health requirements. Anytime we have changes we communicate this to the Medical & Allied Health staff with a deadline for compliance and ongoing maintenance, as indicated.

Have providers been suspended if not fully vaccinated?

Yes, we suspended a very small percentage of providers who ultimately went off staff after the allowable 3 months to reinstate lapsed.

Are there other vaccinations required for the providers?

Yes, we require Measles, Mumps, and Rubella (MMR), Hepatitis B (HepB), Varicella (Chickenpox), Flu and COVID Vaccinations. Plus, annual Purified Protein Derivative (PPD) test and/or chest x-ray if positive.

I want to thank Dawn for sharing her input on their facilities’ tracking of the Covid vaccine requirements.