COVID-19 Vaccine Mandate Resources

CHA is working diligently to keep members apprised of the most up-to-date information and resources available on state and federal COVID-19 vaccine requirements. For questions or more information, contact Joshua Ewing, CHA vice president of legislative affairs, at [email protected] or 720.330.6061.

State Vaccine Mandate

Sept. 30 Update

On Aug. 30, the State Board of Health convened an emergency rulemaking hearing to discuss the Colorado Department of Public Health and Environment (CDPHE)’s proposed rule – 6 CCR 1011-1 Chapter 2, General Licensure Standards and the COVID-19 Vaccine. The emergency rule requires licensed health care facilities to mandate their personnel (i.e., employees, direct contractors, and support staff) who interact with individuals seeking medical are to receive the COVID-19 vaccine.

After more than an hour of testimony in favor and opposed, the Board voted 6-1 to approve the proposed rule. It is effective immediately. In summary:

  • All health care workers, support staff and direct contractors must have their first COVID-19 dose by Sept. 30, second dose no later than Oct. 31.
  • COVID-19 boosters will be required if recommended by the Advisory Committee on Immunization Practices (ACIP).
  • This applies to all CDPHE-regulated health care facilities.
  • Facilities must maintain documentation of proof of vaccination or medical/religious exemption for each required health care worker.
  • Beginning Oct. 1, facilities must report COVID-19 vaccination rate to CDPHE on the 1st and 15th of every month, in addition to the following list of additional data points:
    • The total number of employees, direct contractors, and support staff, whether or not the individual is subject to the requirements of this part 12.
    • Total number of vaccinated employees, direct contractors, and support staff and the total number of employees, direct contractors, and support staff.
    • Number of medical exemptions claimed by employees, direct contractors, and support staff.
    • Number of religious exemptions claimed by employees, direct contractors, and support staff.
    • Number of employees, direct contractors, and support staff identified by the facility as exempt from the requirements of this part 12.
    • Number of employees, direct contractors, and support staff who have left employment with the facility or agency due to the requirements of this part 12, since the last reporting date.
  • All reported information will be publicly available.

CDPHE also noted that this rule is an emergency rule and that the final rule will look different (including the reporting requirements). CHA testified to ask CDPHE to work with the Association and member hospitals and health systems to ensure flexibility and alignment with similar federal reporting requirements, especially given the short time period in which facilities must come into compliance.

CDPHE also emphasized that the rule applies to facilities, not individuals. It does not determine how facilities implement this mandate – health care facilities are allowed to determine their own policies and procedures needed in order to achieve this mandate. Facilities that cannot meet the 100% vaccination mandate can apply for a waiver.

The new Mandatory Vaccination Waiver Application Form is now available. This can be found under the “Waivers” section of the following webpage –

  • Once completed this specific waiver should be submitted to [email protected]
  • A facility should submit for this waiver when it determines that the 100% vaccination rate cannot be met. This is the case when a facility has 1 or more religious exemptions.
  • Medical exemptions are included in the facility’s 100% vaccination status. If a facility only has staff with medical exemptions, a waiver is not required.
  • Waivers may not be granted for up to 90 days. Once submitted, facilities may operate as if their waiver has been approved. The facility’s mitigation measures described in the waiver application must be used for staff that remains unvaccinated during this time.
  • When reviewing waivers CDPHE may take into consideration the number of staff that are unvaccinated. It is important for facilities to develop comprehensive mitigation plans for all staff that remain unvaccinated.
  • For additional information, feel free to reference the Mandatory Staff Vaccination Guidance

Questions about the implementation of the rule should be directed to the Residential Care Strike Team ([email protected]). Questions about the rule language can be directed to the Health Facilities Policy Team ([email protected]).

Hospitals should be working to prepare for the Oct. 1 and 15 data reporting requirement right now, as it will both provide the state with clarity about the situation on the ground at Colorado hospitals and allow CHA to more effectively advocate for the right flexibilities in the final rule. On Sept. 24, CDPHE announced the release of the COVID-19 Vaccination Reporting function in the Colorado Health Facilities Interactive (COHFI) application. The application is similar to the Flu Vaccination Reporting function.

  • The application will load on Wednesday, Sept. 29, during a regularly scheduled maintenance window.
  • Only COHFI Account Managers will be able to access the COVID Vaccination Reporting application. If you do not have the Manage Users button next the facility name, you will not be able to submit the report. The state is working to add the functionality of being able to assign that role to facility users, but it will not be ready at release.
  • The Vaccination Reporting option will be available for all facilities at launch. If you are not a licensed facility but would still like to report, you will have that option. Only licensed facilities are required to submit reports.
  • Residential care facilities that currently report vaccination rates in EMResource will transition to COHFI reporting by Oct. 1 with other health facility types.

On Oct. 8, CDPHE announced its intention to not request additional rulemaking at the Oct. 21 Board of Health meeting with regards to the state’s health care worker vaccine mandate. Materials from that meeting are available on the Board of Health’s webpage

Federal Vaccine Mandate

Nov. 4 Update

On Nov. 4, the Centers for Medicare and Medicaid Services (CMS) issued an emergency rule requiring all health care workers be vaccinated against COVID-19. According to CMS, the emergency rule is effective Nov. 5, and all eligible staff must be fully vaccinated by Jan. 4, 2022. Exemptions based on recognized medical conditions or religious beliefs, observances, or practices will be allowed, but health care workers will not have an option for testing in lieu of vaccination.

The rule has been posted in the Federal Register and comments are due back to CMS by 5 p.m. on Jan. 3, 2022.  CHA is working to understand the implications this emergency rule will have on the state mandate as the Colorado Department of Public Health and Environment (CDPHE) and the Board of Health work to align the two mandates.