CMS Issues Mandatory Vaccine Survey Guidance

CMS Posts Update – Surveys for compliance with Omnibus COVID-19 Health Care Staff Vaccination Requirements
CMS’s Quality, Safety & Oversight Group posted a Memo on June 14, 2022, which provides guidance for survey oversight of the staff vaccination requirement for Medicare and Medicaid certified providers and suppliers. (QSO-22-17-ALL)

The staff vaccination requirement for all CMS-certified providers and suppliers has been in effect (in all states) since February 20, 2022. CMS reports that nearly 12,000 providers and suppliers have been surveyed for compliance with the requirement and to date, 95.0% of those providers and suppliers surveyed by states have been found to be in substantial compliance with this requirement.

Survey oversight:

  • State Survey Agencies (SAs) and Accrediting Organizations (AOs) will now only be expected to perform compliance reviews of the staff vaccination requirement during initial and recertification surveys and in response to specific complaint allegations that allege non-compliance with the staff vaccination requirement.
  • SAs and AOs are no longer expected to perform these reviews on every survey.
  • Accrediting Organizations retain the authority to exceed Medicare requirements, per their accreditation standards.

Note: SAs may expand any survey to include vaccination requirement compliance for non-deemed providers and suppliers and those deemed by AOs with CMS-approved programs.

Immediate Jeopardy
CMS is also reviewing the Memo, Guidance for the Interim Final Rule – Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination (QSO-22-11 ALL-Injunction Lifted) to update the interpretive guidance explaining 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.