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CMS Survival Guide

By Danielle Bearden | Director of Human Resources

[Ed. Note: A pair of federal court decisions issued in late November have effectively blocked this CMS vaccine mandate rule from taking effect. On November 29, a federal judge in Missouri temporarily blocked CMS from enforcing its COVID-19 mandate in Alaska, Arkansas, Iowa, Kansas, Missouri, Nebraska, New Hampshire, North Dakota, South Dakota, and Wyoming. And then on November 30, a Louisiana federal court took one giant step further and blocked the rule from taking effect in any healthcare facility across the country not covered by the Missouri decision. We recommend reading about these two decisions for a game plan on how your organization should proceed.]

If you are a Medicare or Medicaid Provider and have not already done so, we recommend you move quickly yet prudently to implement a process to ensure compliance with the Rule. First and foremost, confirm which rules apply to you, whether it is the CMS Rule, OSHA’s ETS for large employers, federal contractor requirements, or if you are not a Medicare or Medicaid provider, OSHA’s Healthcare ETS.

If you are indeed covered by the CMS Rule, the following five steps, described in further detail here, are important parts of a successful plan:

  1. Adopt systems and procedures to determine and safeguard all information regarding employees’ vaccination status;
  2. Communicate applicable policies and procedures to everyone who may work on-site, including but not limited the particulars of your vaccine requirement and the process for requesting exemptions;
  3. Develop a non-discriminatory, streamlined process to handle vaccine accommodation requests;
  4. Review and confirm additional COVID-19 precautions that will be applicable to individuals who are granted accommodations; and
  5. Prepare to respond to some inevitable pushback and complaints, as well as likely on-site CMS inspections, by communicating clearly and maintaining detailed records of your processes.

If you have already implemented a mandatory vaccine policy, ensure it aligns with the requirements discussed; if so, certainly continue to follow, using available resources such as employee education and clinics, to ensure vaccination of all employees.


Danielle Bearden is a dynamic HR professional, currently serving as the Director of Human Resources at Lever1, planning, developing, and directing the administration of all HR functions within the Lever1 Human Resources Department. She has over 15 years of experience in all areas of Human Resources including strategic planning, total rewards, performance management, employee wellness and safety, HR compliance and labor relations.