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CMS Compliance


To all UTHSC employees, trainees, and students working or training in a hospital or clinic:

Based on the recent U.S. Supreme Court rulings, our partner hospital systems and clinical sites are mandated to implement the COVID-19 immunization and masking requirements imposed by the Centers for Medicare & Medicaid Services (CMS) Mandate. All UTHSC employees, trainees, and students are obligated to follow the rules and guidelines of partner hospitals and practice plan clinics when in their facilities for work or clinical training. It is likely that most of you are already in compliance.

The timelines for compliance are very short. Under CMS rules, all hospital staff must receive the initial vaccine dose (whether Pfizer, Moderna or Johnson & Johnson) on or before TODAY, January 27, 2022, and be fully vaccinated by February 28, 2022, unless an exemption or temporary deferral applies in accordance with federal law. We recognize that this short deadline is not ideal, but because of the complicated nature of this subject and the frequent updates, we are trying to make sure these communications have been carefully reviewed. We apologize for the short notice.

Compliance Process: Please understand that failure to meet these requirements may result in the hospital or clinical partner excluding you from their worksite.

  • All employees who have work assignments in a hospital (full or part time; all roles including clinical, teaching, or staff support) must upload proof of their COVID-19 vaccination status to: https://irisweb.tennessee.edu/irj/portal
    • click “Employee Self-Service”
    • click “Personal Information”
    • click “Covid-19 Vaccination Verification”
  • Students who participate in clinical training as part of their academic program are required to upload their proof of COVID-19 immunization to Verified Credentials.

Accommodation Process: Some of the hospital systems (VA and Regional One Health) have announced that they will accept requests for religious or medical accommodations. Please follow this process to request an accommodation directly from those hospitals in seeking accommodation as they are independent from the university:

The hospital or clinic operator has the ultimate discretion to grant or deny such a request, as well as grant or deny access to its facilities.

Currently, UTHSC is not in the position to review or grant any religious or medical exemption requests because we are not mandating vaccination. In the future, a hospital or clinical site may ask the university to assist in reviewing accommodation requests and more information will be provided at that time. Although the university will make a good-faith evaluation based upon the applicable laws and regulations, the hospital/clinical site has the ultimate discretion to grant or deny this request, as well as grant or deny access to its facilities.

Non-Compliance with Hospital/Clinical Site Policy: If you do not comply with a hospital/clinical site immunization requirement, you will put yourself at risk of not meeting employment or academic requirements. Remember that although the university is not mandating that you be vaccinated, it is your responsibility to show up for work or clinical training.

  • For employees (including faculty, staff, and residents/trainees), failure to comply with an essential job function, such as attendance, will result in action under HR0505-Attendance Policy and other applicable policies. You will then be subject to a period of unpaid leave during which you will be given two weeks to reflect on your situation and finalize your individual decision.
  • For trainees/students, exclusion from the hospital/clinical site will result in denial of academic credit for those missed courses or rotations. Further, if your ability to progress is impaired your continued enrollment would be subject to review and potential withdrawal.

We appreciate your patience as we navigate this pandemic and the changing requirements. As noted in the January 21, 2022 Campus Mask Update, our goal is to keep our faculty, staff, and students as safe as possible. Thank you in advance for your cooperation.

Steve Schwab, MD