Revisions to CMS Survey Process for COVID-19 Vaccination Announced

On June 14, 2022, the Centers for Medicare and Medicaid Services (CMS) announced changes regarding how compliance with the Omnibus COVID-19 vaccination requirement for staff will be reviewed. In a new QSO Memo, “Surveys for compliance with Omnibus COVID-19 Health Care Staff Vaccination Requirements,” the Agency announced that surveying for healthcare staff vaccination will continue during initial surveys as well as recertification surveys, but will only occur in response to an allegation of non-compliance related to the requirement. This means that a facility will only be surveyed regarding its efforts to ensure staff are vaccinated as the result of a complaint, whereas in the original guidance, surveyors would need to check on all surveys.

Changes to Interpretive Guidance Coming

CMS also plans to revise the Interpretive Guidance (IG) for QSO 22-11-ALL, “Revised Guidance for the Interim Final Rule – Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination” (initially issued in January 2022 and revised in April 2022). The initial IG had directed surveyors to issue high-level deficiencies when surveying for compliance with the requirements. CMS states in the new Memo that it will revise the guidance to surveyors to recognize good faith efforts of providers to get staff vaccinated and to “more fully evaluate” whether a deficiency rises to the level of actual harm versus potential harm by considering the COVID-19 community transmission rate. The good news in this Memo is that CMS directs State Agencies to reach out to CMS if surveyors are considering citing providers at Immediate Jeopardy (IJ), Condition or Actual Harm levels, so this may give some relief to facilities struggling to achieve 100% vaccination rates. However, with this type of directive, the implication is that many facilities have probably found themselves in an IJ situation or receiving Actual Harm-level citations due to the initial Interpretive Guidance and now CMS is trying to reign in surveyors who have been heavy-handed in their citations. Hopefully the adjustments to the requirements will provide smoother sailing for facilities who are doing their best to protect their residents and staff.

Read the June 14, 2022 QSO Memo (QSO-22-17-ALL) here for more details.

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