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Memo from Executive Director on Mandatory Staff Vaccinations, Oct. 9, 2021

Location: CO
Title: Memo from Executive Director on Mandatory Staff Vaccinations, Oct. 9, 2021
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MEMORANDUM TO: All Facilities Licensed by the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Services Division 

FROM: Jill Hunsaker Ryan, MPH, Executive Director 

CC: Members of the Colorado Board of Health 

DATE: October 8, 2021 RE: Mandatory Staff Vaccinations as set forth in the Standards for Hospitals and Health Facilities Chapter 2, General Licensure Standards, 6 CCR 1011-1

Thank you for your hard work during these unprecedented times! The COVID-19 pandemic has brought on new and unexpected challenges that have stressed the healthcare industry like no other time in recent memory. It has demonstrated the need for a robust healthcare industry and further emphasized the relationship between various healthcare facility types and the importance of those partnerships. Many strategies have been employed to keep the healthcare system intact and accessible, and to date Colorado healthcare systems have been able to provide the necessary care for those seeking healthcare in Colorado. Over the past year, it has been clear that one strategy gives Colorado the best chance to minimize the impact COVID-19 has on the healthcare system. That strategy is the vaccine. 

On August 30, 2021, the Colorado Board of Health passed an emergency rule that requires vaccination against COVID-19 for all healthcare workers with direct patient contact in all licensed healthcare facilities. The emergency rule went into effect immediately at the time of the hearing and all healthcare workers should have received their first dose of a two dose series or single dose of the single dose Johnson & Johnson vaccine as of October 1, 2021. We have seen impressive results from this requirement, with jumps in vaccination rates among staff across the state in the last few weeks. 

I want to stress that the emergency rule, by law, must be followed by all licensed healthcare facilities. The rule requires a 100% vaccination rate for each facility, but does allow for both medical and religious exemptions. Both types of exemptions must have formal attestations that can be made available to the department for review. Facilities that have approved religious exemptions for their staff must apply to CDPHE for a waiver from the 100% vaccination requirement. Given that high rates of exemptions to vaccination could place patients and staff at risk for exposure to COVID-19, CDPHE will consider this issue when determining whether to grant a waiver and prioritize facilities that have a higher rate of exemptions for infection control inspections. It goes against the rule for staff to be unvaccinated and not have an approved attested exemption on file at the facility. 

The rule also requires reporting on these vaccination rates twice a month. This data is exceedingly important to assure compliance, inform future rulemaking, and must be submitted by every healthcare facility. More information on the rule can be found in the rule language and the accompanying guidance. 

Since the passage of our emergency rule, the federal government announced plans to require vaccination in federally regulated facilities. The details of the federal requirement are not yet available. Given the uncertainty of what the federal requirement will entail, CDPHE will not pursue additional rulemaking at the October 21, 2021, Board of Health meeting but will instead wait to harmonize with the federal rule. We believe this is the most responsible path forward at this time and this pause will allow us to consider the pending federal requirement. 

Additionally, the department will be issuing a temporary waiver from the vaccination requirement for those home care agencies which employ live-in caregivers for the sole purpose of providing care to one or more clients residing in the same household. In many cases these particular caregivers are members of the same family and as such, do not engage or otherwise provide care and services for others outside of their own home. Additional opportunities for flexibility in the rule may exist for unique situations such as this and your ongoing communication with us remains important. If you would like to provide comments or feedback please submit them to 

If you have additional questions about the implementation of this rule, please contact: 

Thank you all for your cooperation in implementing this rule for your facilities and joining us in doing everything you can to protect those seeking healthcare in Colorado