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That memo whas been rescinded.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.

Surveys for Compliance with Omnibus COVID-19 Health Care Staff Vaccination Requirements

This is an update to a NAHC Report article published on June 15, 2022.

Previously, NAHC reported that the Centers for Medicare & Medicaid Services (CMS) posted memo QSO-22-17-ALL containing new instructions for surveys for compliance with Omnibus COVID-19 Health Care Staff Vaccination Requirements. CMS previously issued guidance and survey procedures to survey entities for assessing and maintaining compliance with the regulatory requirements for vaccination.

Under the previous guidance, federal, state and Accreditation Organization (AO) surveyors were to assess for compliance with the vaccination requirements at surveys for initial certification, standard recertification or reaccreditation, and complaint surveys.

Effective immediately, surveyors will continue to survey for compliance with the vaccination requirements during initial and recertification surveys, but will now only survey for compliance in response to complaints alleging non-compliance with this requirement (not all complaint surveys). NAHC received clarification from CMS that any complaint survey addressing infection control and not just the COVID-19 vaccination requirements specifically, will include a review of the provider’s compliance with the vaccination requirements.  Since these requirements became effective earlier this year, 95% of the nearly 12,000 providers that have been surveyed by states are in compliance with the requirements.

This most recent memo also instructs state survey agencies to reach out to their CMS Location if they are considering citing vaccine requirements at immediate jeopardy, Condition or actual harm levels. CMS is reviewing its previous interpretive guidance describing Immediate Jeopardy, Condition-level and actual harm determinations to ensure that deficiency citations recognize good faith efforts by providers/suppliers and to more fully evaluate harm or potential harm to patients/residents by considering trends in COVID-19 rates in the community.  Stay tuned to NAHC Report for more information on these updates as they become available.

Surveys for Compliance with Omnibus COVID-19 Health Care Staff Vaccination Requirements

This is an update to a NAHC Report article published on June 15, 2022. Previously, NAHC reported that the Centers for Medicare & Medicaid Services (CMS) posted memo QSO-22-17-ALL containing new instructions for surveys for compliance with Omnibus COVID-19 Health Care Staff Vaccination Requirements. CMS previously issued guidance and survey procedures to survey entities for assessing and maintaining…

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.

Surveys for Compliance with Omnibus COVID-19 Health Care Staff Vaccination Requirements

This is an update to a NAHC Report article published on June 15, 2022.

Previously, NAHC reported that the Centers for Medicare & Medicaid Services (CMS) posted memo QSO-22-17-ALL containing new instructions for surveys for compliance with Omnibus COVID-19 Health Care Staff Vaccination Requirements. CMS previously issued guidance and survey procedures to survey entities for assessing and maintaining compliance with the regulatory requirements for vaccination.

Under the previous guidance, federal, state and Accreditation Organization (AO) surveyors were to assess for compliance with the vaccination requirements at surveys for initial certification, standard recertification or reaccreditation, and complaint surveys.

Effective immediately, surveyors will continue to survey for compliance with the vaccination requirements during initial and recertification surveys, but will now only survey for compliance in response to complaints alleging non-compliance with this requirement (not all complaint surveys). NAHC received clarification from CMS that any complaint survey addressing infection control and not just the COVID-19 vaccination requirements specifically, will include a review of the provider’s compliance with the vaccination requirements.  Since these requirements became effective earlier this year, 95% of the nearly 12,000 providers that have been surveyed by states are in compliance with the requirements.

This most recent memo also instructs state survey agencies to reach out to their CMS Location if they are considering citing vaccine requirements at immediate jeopardy, Condition or actual harm levels. CMS is reviewing its previous interpretive guidance describing Immediate Jeopardy, Condition-level and actual harm determinations to ensure that deficiency citations recognize good faith efforts by providers/suppliers and to more fully evaluate harm or potential harm to patients/residents by considering trends in COVID-19 rates in the community.  Stay tuned to NAHC Report for more information on these updates as they become available.