Performance Measurement Network

Question: Covid Vaccine Audit


I have a questions regarding the interim final rule on covid-19 healthcare staff vaccination. I see that its required for the following entities:

Ambulatory Surgery Centers Critical Access Hospitals Home Health Agencies Home Infusion Therapy Suppliers Hospices Hospitals

As a healthcare staffing agency that staffs these facilities, are we also then required to audit on the vaccine?


There is no performance measure for Healthcare Staffing Services that assesses employees of the firm vaccination status. Similarly, Health Care Staffing Services standards are not being updated based on the COVID-19 health care staff vaccination interim final rule from CMS.

Health care staffing agencies should be prepared that their clients will likely expect vaccinations for any agency staff placed on assignment with their organizations. When that is the case the staffing agency should be checking the vaccination status for any employee they are placing with a client that has such a requirement. Joint Commission reviewers will not audit for such vaccinations unless it is an agency requirement per policy, or contract requirement of a client.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: HCSS,

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