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In Depth: COVID-19 Vaccination for Healthcare Personnel

With a deadline looming and legal action in the news, I thought it admissable to pull together some context, add in some resources, and summarize where we find ourselves in the quest for compliance – and why.
It started on November 4th with an announcement of a new requirement from the Center for Medicare and Medicaid Services (CMS)
In part, it reads:

The Biden-Harris Administration is requiring COVID-19 vaccination of eligible staff at health care facilities that participate in the Medicare and Medicaid programs.

Facilities covered by this regulation must establish a policy ensuring all eligible staff have received the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine prior to providing any care, treatment, or other services by December 6, 2021. All eligible staff must have received the necessary shots to be fully vaccinated – either two doses of Pfizer or Moderna or one dose of Johnson & Johnson – by January 4, 2022. The regulation also provides for exemptions based on recognized medical conditions or religious beliefs, observances, or practices. Facilities must develop a similar process or plan for permitting exemptions in alignment with federal law.

I think it bears mentioning that the rule specifies that all staff must have received the first dose by December 6th and be fully vaccinated by January 4th, I am typing this on December 1st.

The post also includes:

The regulation also provides for exemptions based on recognized medical conditions or religious beliefs, observances, or practices. Facilities must develop a similar process or plan for permitting exemptions in alignment with federal law.

Again, at this late date, this is probably impertinent, but you’ll note that the rule requires a policy on exemptions, which presumably is enacted, and has received applications for exemptions.
The Frequently Asked Questions (FAQs) document (cited below) includes more detail on exemptions.

Q: Are exemptions allowed?
A: CMS requires facilities to allow for exemptions to staff with (as a reasonable accommodation for a disability or a sincerely held religious belief, observance, or practice and for medical 9 reasons. Providers and suppliers should establish exceptions as a part of its policies and procedures and in alignment with Federal law. CMS believes that exemptions could be appropriate in certain limited circumstances, but no exemption should be provided to any staff for whom it is not legally required (under the ADA or Title VII of the Civil Rights Act of 1964) or who requests an exemption solely to evade vaccination.

Q: How will facilities determine if an individual’s request for a religious exemption is valid?
A: CMS encourages facilities to review the Equal Employment Opportunity Commission’s Compliance Manual on Religious Discrimination for more information on religious exemptions.  

Q: Does the regulation include exemptions for staff that show they have COVID-19 antibodies? 
A: No. Staff who have previously had COVID-19 are not exempt from these vaccination requirements. Available evidence indicates that COVID-19 vaccines offer better protection than natural immunity alone and that vaccines, even after prior infection, help prevent reinfections. CDC recommends that all people be vaccinated, regardless of their history of symptomatic or asymptomatic SARS-CoV-2 infection.



Breaking News:

Bloomberg Law posted Vaccine Mandate for Health-Care Workers Halted by Court, which includes this excerpt:

A federal court in Missouri blocked the Biden administration from enforcing a vaccine mandate for health-care workers in 10 states.

Missouri, Nebraska, Arkansas, Kansas, Iowa, Wyoming, Alaska, South Dakota, North Dakota, and New Hampshire aren’t subject to the rule while the injunction stands

The preliminary injunction by the U.S. District Court for the Eastern District of Missouri marks the first victory for opponents of the mandate, which requires health-workers to be vaccinated by Jan. 4, 2022.

The lawsuit is one of four challenges the Centers for Medicare & Medicaid Services faces against the rule. More than half of states are now involved in one of the challenges, which all claim the mandate will exacerbate staffing shortages. A federal judge in Florida declined to block the rule in a separate suit.

Legal observers have said the mandate is on firm footing because the Medicare agency has the right to govern the rules facilities must follow if they want funding. 

I think it’s important to note that the CMS mandate occurs as part of an ongoing effort at encouraging vaccination. Some efforts are based on Federal mandates, including OSHA and those affecting Federal Employees. Others are state requirements, including New York’s. A great many others originated from health systems determination that such a requirement was warranted, and worthy of a policy that resulted in those organizations parting ways with some of their employees (Becker’s has an eye-opening post on the extent that this has come to pass)

The National Rural Hospital Association (NRHA) has been active in this matter as well.

They partnered with Chartis on an important study:

Amidst Delta Surge, Rural Hospital Staff Vaccination Rates Make Little Progress

In the intervening months, the Delta variant has surged across rural communities. By the beginning of September, infection rates had reached levels not seen since the early weeks of January.   News reports detailing staff exhaustion and shortages, intensive care units operating at full capacity, and the suspension of hospital services (e.g., obstetrics) were appearing with increased regularity. This domino effect caused by the Delta variant raises important questions about vaccination rate progress and the extent to which staffing challenges are impacting access to care within rural communities. We conducted a follow-up survey from September 21, 2021 to October 15, 2021 that generated 130 responses from rural hospital leaders nationwide.  Our survey found that:

  • 44 percent of respondents said the percentage of healthcare professionals fully vaccinated is between 50 and 69
  • 75 percent of respondents report that their facility has not mandated COVID vaccines for healthcare professionals
  • 96 percent of respondents said nursing is a role in which they are having difficulty filling
  • Nearly 30 percent indicate that issues related to nurse staffing have resulted in the suspension of services, while another 22 percent say they are considering such action
  • 42 percent say the number one reason for nurse staff departures in 2021 are more financially lucrative opportunities at another hospital


Nearly all our survey respondents (98.5 percent) reported that they are experiencing a staffing shortage. Although the recruitment and retention of staff isn’t a new challenge for rural providers, the pandemic has exacerbated this issue. Asked to identify which roles are proving to be the most difficult to fill, more than 95 percent (96.2 percent) of respondents selected nursing. Ancillary services-related positions was rated second highest (66.2 percent), followed by facilities (28.5 percent)

They composed and shared comments to CMS that specifically address the challenges of the rural healthcare environment.

NRHA has drafted the attached comments in response to the CMS COVID-19 Health Care Staff Vaccination Interim Final Rule requiring covered employers to implement and enforce mandatory vaccination policies as a part of President Biden’s COVID-19 action plan.

NRHA believes it is important for all healthcare workers to be vaccinated, to protect both themselves and the communities they serve.  As rural hospitals and other providers work to comply with the CMS rule, the federal mandate is expected to increase the healthcare workforce shortage resulting in service disruptions at the best and some rural hospitals closing or stopping certain healthcare services at the worst.

NRHA asks the US Department of Health and Human Services to consider the following strategies to combat potential rural workforce shortages:

Provide rural communities facing severe workforce shortages, the option of and funding for, testing of non-vaccinated healthcare professionals. The OSHA ETS outlines a weekly COVID-19 testing regimen as an alternative to compulsory vaccination. Rural providers have noted this incongruity and would like this option, at least in the short term, to keep their employees at the bedside. As a transition, testing could be made available as an option for 6-12 months while rural providers educate their employees to the value of getting vaccinated.

Develop detailed, targeted, and comprehensive rural federal workforce plans to be communicated and implemented to avoid gaps in health care services in rural communities across the country.

Allocate additional COVID-19 Provider Relief Funds or other relief measures to compensate providers closing healthcare services to comply with this federal mandate.
Remove preamble text that suggests regulatory violations resulting in civil monetary penalties and Medicare program termination.

Please reach out to the NRHA Government Affairs team with any questions or concerns.

Carrie Cochran-McClain
National Rural Health Association
Chief Policy Officer
Washington DC

This is a developing story, and we are making a concerted effort to stay abreast of the influx of information from multiple sources.

Please feel free to call or email your comments and questions, and we will do our best to help.

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Paul Hudson, FACHE
Chief Operating Officer