CMS mandate for vendors and board tops discussion

Seeley-Swan Hospital District

SEELEY LAKE – At their March 8 meeting, the Seeley-Swan Hospital District discussed the Centers for Medicare & Medicaid Services’ (CMS) requirements as it applies to contractors, vendors and the Hospital District Board of Trustees (Board). Partnership Health Center (PHC) asked the Board to sign a letter acknowledging that the board members entering PHC facilities on official business are vaccinated or have an approved medical or religious exemption. The CMS mandate does not apply to the public.

The CMS Mandate states, “In order to best protect patients, families, caregivers and staff, we are not limiting the vaccination requirements of this IFC to individuals who are present in the facility or at the physical site of patient care based upon frequency. Regardless of frequency of patient contact, the policies and procedures must apply to all staff, including those providing services in home or community settings, who directly provide any care, treatment or other services for the facility and/or its patients, including employees; licensed practitioners; students, trainees and volunteers; and individuals who provide care, treatment or other services for the facility and/or its patients, under contract or other arrangement… This includes administrative staff, facility leadership, volunteer or other fiduciary board members, housekeeping and food services and others… Therefore, any individual that performs their duties at any site of care, or has the potential to have contact with anyone at the site of care, including staff or patients, must be fully vaccinated to reduce the risks of transmission of SARS-CoV-2 and spread of COVID-19.”

As of Jan. 14, anyone that enters a PHC facility on a regular basis that is not a patient, including contractors, vendors and board members, need to be in compliance with the CMS mandate. In an interview following the meeting, PHC Executive Director Laurie Francis said it is PHC’s opinion that since the Seeley-Swan Medical Center is a clinical, medical facility leased to PHC 24/7, compliance would be required for anyone who uses the facility including after hours and on weekends.

Seeley-Swan Medical Center Clinic Manager Georgiann McCoy told the Board she provided a list of vendors to PHC. Letters had been sent to various contractors and other vendors.

In the interview, Francis explained PHC informs vendors and contractors about the CMS rule and asks if their employees can comply. To date, most vendors have said yes and signed the agreement.

“We don’t go in and ask them to show us all their records,” Francis said, “We say thank you.”

However, if someone cannot comply with the agreement, Francis said PHC will make every possible, reasonable accommodation to continue working with vendors, contractors or the Board. PHC can continue to work with them as long as they don’t have to enter the facility.

“We would have to adjust but we would definitely try really hard,” Francis said. “The vendors we work with, we like working with them, we want to continue to work with them and we will be pretty creative to see if we can help continue that relationship.”

It was asked at the meeting how the Health Insurance Portability and Accountability Act (HIPPA) applies to this request for vaccination status.

Francis, in a separate interview, said that HIPPA does not apply because the wording in the CMS mandate asks someone to volunteer his or her health information. If it is volunteered it is no longer considered confidential health information. Francis said that even though it does not fall under the HIPPA rules and privileged health information, PHC would still keep the information confidential.

At the meeting, Berow said it is her understanding that it is the responsibility of the entity signing the agreement to ensure that anyone who comes on site is in compliance.

“I think that the nature of signing [the agreement] is saying that you acknowledge that the mandate applies to you all and you are committed to developing a process that’s in compliance,” Berow said. “We understand that this is absolutely a mandate. In order to be operational and to continue to be able to continue as a solvent business, we have to have that Medicaid and Medicare money. Being non-compliant is not an option for [PHC].”

Vice Chair Bruce Richardson recommended they sign the letter and then they can figure out how to make sure each board member is in compliance.

Chair Twyla Johnson agreed since the board has been meeting virtually for a very long time and she expects that to continue. She recommended signing the letter and then collecting the vaccination status of the board members if they feel comfortable providing her with that information. She would guard the information and ensure that if a board member is not in compliance, they do not enter the Medical Center.

No vote was taken regarding signing the agreement.

In a separate interview, Francis added there is no timeline for the agreement. She assumes that when new board members come on the Hospital District, they will be asked if they can comply with the CMS mandate. It would then be up to the Hospital District to work with the new board member to ensure compliance is met.

The next board meeting is scheduled for April 12 at 5 p.m. via telephone.


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