Tag: Accrediting Organizations

CMS Updates COVID-19 Guidance for Surveys, Visitation and Testing

The Centers for Medicare & Medicaid Services (CMS) revised the COVID-19 Focused Infection Control (FIC) Survey Tool and visitation restrictions for acute and continuing care (ACC) facilities through a revised QSO-21-08-NLTC memo.  This memo supersedes the instructions in QSO-20-16-Hospice and QSO-20-18-HHA. State survey agencies (SA) and accrediting organizations (AO) have returned to the existing standard…

Vaccination Expectations for Surveyors

The Centers for Medicare & Medicaid Services (CMS) recently updated its vaccination expectations for surveyors.  In January of this year CMS issued a memo (QSO-22-10-ALL) requiring state agency surveyors and accrediting organization (AO) surveyors performing deemed status surveys to not participate in onsite surveys unless fully vaccinated (unless vaccination is medically contraindicated or the individual is 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).

That memo whas been rescinded.

With QSO-22-18-ALL CMS encourages surveyors conducting federal surveys to be vaccinated but does not require it (or an acceptable exemption).  It remains up to the survey entity to implement policies around COVID-19 vaccination (and exemptions).

Previous guidance for surveyors entering nursing homes was provided in QSO-20-39-NH and this guidance remains.  While it is not directly applicable to home health and hospice providers, it may be applicable to some hospice inpatient facilities. Additionally, some state survey agencies and AOs have incorporated this guidance into their policies and procedures. It is expect that home health and hospice providers will not request vaccination status of surveyors or restrict surveyor access based on vaccination status.

Vaccination Expectations for Surveyors

The Centers for Medicare & Medicaid Services (CMS) recently updated its vaccination expectations for surveyors.  In January of this year CMS issued a memo (QSO-22-10-ALL) requiring state agency surveyors and accrediting organization (AO) surveyors performing deemed status surveys to not participate in onsite surveys unless fully vaccinated (unless vaccination is medically contraindicated or the individual…

Vaccination Expectations for Surveyors

The Centers for Medicare & Medicaid Services (CMS) recently updated its vaccination expectations for surveyors.  In January of this year CMS issued a memo (QSO-22-10-ALL) requiring state agency surveyors and accrediting organization (AO) surveyors performing deemed status surveys to not participate in onsite surveys unless fully vaccinated (unless vaccination is medically contraindicated or the individual is 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).

That memo whas been rescinded.

With QSO-22-18-ALL CMS encourages surveyors conducting federal surveys to be vaccinated but does not require it (or an acceptable exemption).  It remains up to the survey entity to implement policies around COVID-19 vaccination (and exemptions).

Previous guidance for surveyors entering nursing homes was provided in QSO-20-39-NH and this guidance remains.  While it is not directly applicable to home health and hospice providers, it may be applicable to some hospice inpatient facilities. Additionally, some state survey agencies and AOs have incorporated this guidance into their policies and procedures. It is expect that home health and hospice providers will not request vaccination status of surveyors or restrict surveyor access based on vaccination status.

CMS Rescinds Focused Infection Control Survey and Visitor Restrictions for Home Health and Hospice Providers

In January 2021, the Centers for Medicare & Medicaid Services (CMS) implemented a revised COVID-19 Focused Infection Control Survey for Acute and Continuing Care (ACC) for providers which included home health and hospice.  This was the focused survey tool that surveyors would use for hospice and home health agency providers for any type of survey being conducted except a complaint survey where the complaint allegation is not related to infection control. At the same time, CMS clarified guidance for screening of individuals entering a health care facility which would include hospice inpatient units. See previous NAHC Report coverage here. Late on February 4, 2022 CMS revised the memo pertaining to the Focused Infection Control (FIC) survey tool and visitor screening.

CMS developed the FIC survey and tool at the beginning of the PHE to help surveyors and facilities absorb the critical infection prevention and control practices for combating COVID-19. CMS believes ACC facilities, including home health and hospice providers, have incorporated COVID-19 management strategies into their infrastructure and operations, and there is no longer a need to continue the required use of the special FIC survey and tool on a national basis. Therefore, CMS is rescinding the survey requirement to conduct FIC surveys.

State Survey Agencies (SAs) and Accrediting Organizations (AOs) should now return to the existing standard survey processes and continue to assess COVID-19 infection prevention and control elements by focusing on the regulatory requirements, while incorporating lessons learned about infection control oversight during the PHE. For example, the Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule guidance requires home health and hospice providers to develop and maintain approved policies and procedures for minimizing transmission of infectious disease that are established based on nationally recognized standards of practice. Surveyors will assess whether those polices are developed appropriately and followed.

While the contents of the FIC survey tool are generally still applicable, if providers wish to continue use of the tool as a template for their own self-assessment CMS encourages them to carefully review the Centers for Disease Control and Prevention (CDC) guidelines as there have been changes to the recommendations since the original tool and update were released (see the “Additional Resource Links” section in the memo linked above for more information on CDC guidelines).

Regarding visitation restrictions CMS stated it recognizes that restricting visitation from family and other loved ones during the COVID-19 pandemic has taken a physical and emotional toll on patients. While the COVID-19 Public Health Emergency (PHE) remains, CMS finds continued federal guidance on visitation restrictions for ACC providers are no longer necessary, which is consistent with the nursing home guidance in QSO-22-39. Facilities should continue to adhere to basic COVID-19 infection prevention principles consistent with national standards of practice.

Providers should note that there may be more prescriptive requirements at the State level for infection control and visitor screening and visitation restrictions. CMS expects health care staff and surveyors (AOs, contractors, Federal, State, and Local) to comply with basic infection control practices such as hand hygiene, wearing masks, and the use of other personal protective equipment, as appropriate for the situation (i.e., standard, contact, airborne, etc).

Surveyors should focus on the regulatory requirements for each provider and supplier type and whether the facility consistently follows processes that are based on national standards of practice. Guidelines produced by the CDC are an example of a source for national standards.

Any COVID-19 infection prevention policy developed by a health care facility to meet the Medicare conditions should be approved by the facility’s governing body, or equivalent group as defined by regulation, before implementation. Health care providers should review their own infection prevention and control policies and practices to prevent the spread of infectious disease and illness, including COVID-19.

Should COVID-19 case rates increase in certain geographic locations, CMS instructs that concerned SAs should strongly consider doing a FIC survey in consultation with the applicable CMS location office.

CMS Rescinds Focused Infection Control Survey and Visitor Restrictions for Home Health and Hospice Providers

In January 2021, the Centers for Medicare & Medicaid Services (CMS) implemented a revised COVID-19 Focused Infection Control Survey for Acute and Continuing Care (ACC) for providers which included home health and hospice.  This was the focused survey tool that surveyors would use for hospice and home health agency providers for any type of survey…

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-ALL, Vaccination 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.

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-ALL, Vaccination 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…

Review of Medicare’s Oversight of Accrediting Organizations

The Centers for Medicare and Medicaid’s (CMS) Quality, Safety, and Oversight Group recently released a memo to all state survey agency directors regarding the FY2017 Report to Congress:  Review of Medicare’s Program Oversight of Accrediting Organizations (AOs) and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) Validation Program. The CMS annual Report to Congress (RTC)…