CMS Issues Vaccination Expectations for Surveyors Performing Federal Oversight

The Centers for Medicare & Medicaid Services (CMS) is expanding its instructions regarding criteria for surveyors when entering provider and supplier locations, in a new memo, QSO-22-10-ALLVaccination Expectations for Surveyors Performing Federal Oversight.

CMS states that surveyors who are not fully vaccinated (unless vaccination is medically contraindicated or the individual is legally entitled to  reasonable accommodation under federal civil rights laws because they have a disability or sincerely held religious beliefs, practices, or observances that conflict with the vaccination requirement) should not participate as part of the onsite survey team performing federal oversight of certified providers and suppliers (including accreditation surveys performed under an AO’s deeming authority).  Unvaccinated personnel may be used, at the State Survey Agency’s (SA’s) or Accrediting Organization’s (AO’s) discretion, for offsite survey or enforcement activities.

Many SAs and AOs have already implemented their own such requirements, but CMS has made it an official requirement,  effective February 24, 2022.

In addition, CMS now instructs survey entities that current performance and timeliness standards for State Survey Agencies and AOs remain, and consideration will not be provided for failures to meet these expectations due to a lack of vaccinated surveyors to complete the mandated workload. Providers can expect that surveys will be conducted regardless of the current COVID-19 pandemic. Depending on the status of surveyor vaccination, how the survey is conducted may be different. For instance, all or a portion of the survey may be completed via desk review instead of in person.

CMS stressed in the memo that certified providers and suppliers are not permitted to ask surveyors for proof of their vaccination status as a precondition for entry. CMS is requiring that state survey agencies and AOs have a process by which staff may request exemption from COVID-19 vaccination based on recognized clinical contraindications or because they are legally entitled to a reasonable accommodation under federal civil rights laws because they have a disability or sincerely held religious beliefs, practices, or observances that conflict with the vaccination requirement. This is consistent with the CMS vaccine requirements for certified providers.

Surveyors who have a COVID-19 vaccination exemption may continue surveying while observing additional safeguards, as determined and documented by the state (such as mandatory testing, limitation to conducting survey activities that limit patient/resident contact such as record review, limitation to conducting offsite activities, or re-assignment or work modification). All surveyors are expected to use appropriate PPE while surveying.