DQA Webinar - COVID-19 Health Care Staff Vaccination Rule - Tuesday, November 23, 2021

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Division of Quality Assurance: Assisted Living

Attn: DQA Regulated Providers

DQA Webinar - COVID-19 Health Care Staff Vaccination Rule - Tuesday, November 23, 2021

On November 4, 2021, the Centers for Medicare & Medicaid Services (CMS) announced new emergency rules that require all healthcare providers and supplies, that participate in a federally certified Medicare and Medicaid program under Medicare Conditions of Participation (COP), Conditions of Coverage or Requirements for Participation, to develop a plan/process to vaccinate all staff with a first dose or single dose vaccine by December 6, 2021. All eligible staff must be fully vaccinated by January 4, 2022.

The federal emergency rule does not apply to providers that are certified through the Wisconsin Medicaid program and are not federally certified under the Medicare and Medicaid program under Medicare Conditions of Participation (COP), Conditions of Coverage or Requirements for Participation.

CMS has provided additional information in a FAQ document: CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule Frequently Asked Questions.

The Division of Quality Assurance will host a webinar on Tuesday, November 23, from 10 a.m.-12 p.m., and provide information about the federal COVID-19 health care staff vaccination rule and answer your questions.


Submit questions you would like addressed at the webinar by emailing them to DHSWebmailDQA@dhs.wisconsin.gov by 12 p.m. on November 18, 2021.

To Join:
Join Zoom Meeting 
Meeting ID: 161 564 3039
Passcode: 029203

Or by Phone: (669)254-5252 or (646)828-7666
Webinar ID: 161 564 3039

The federal emergency regulations apply to the following Medicare and Medicaid-certified providers/suppliers:

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

Staff covered under this requirement:

The vaccination requirement applies to eligible staff working at a facility that participates in the Medicare and Medicaid programs, regardless of clinical responsibility or patient contact. This includes:

  • Facility employees
  • Licensed practitioners
  • Students
  • Trainees
  • Volunteers
  • Individuals who provide care, treatment or other services for the facility and/or its patients under contract or other arrangements

The federal emergency regulations do not apply to:

  • Adult Day Service
  • Assisted Living Facilities
  • Community Support Programs
  • Comprehensive Community Services
  • Home and Community-Based Services
  • Outpatient mental health, behavioral health, and alcohol and other drug use disorder (AODA) clinics
  • Personal Care Agencies
  • Physician’s offices

DQA Review

CMS expects state survey agencies to conduct onsite compliance reviews of the requirements during recertification surveys and complaint surveys. Surveyors will check to determine if a facility has met the three basic requirements:

  1. Having a process or plan for vaccinating all eligible staff
  2. Having a process or plan for providing exemptions and accommodations for those who are exempt
  3. Having a process or plan for tracking and documenting staff vaccinations.

Surveyors will review the facility’s vaccine policies, the number of resident and staff COVID-19 cases over the last 4 weeks and list of staff and their vaccination status. This information will be used to determine the compliance of the provider or supplier with these requirements.

Links to the CMS November 4, 2021, presentation, Omnibus COVID-19 Health Care Staff Vaccination Rule

To view the slides, visit here.
To view the video, visit here.