Vaccination Expectations for Surveyors Performing Federal Oversight

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

CMS posted QSO-22-10-ALL (3 pages) with the same title as this blog on Tuesday, January 25, 2022.

The key points of this Memorandum are:

  • Surveyors who are not  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) 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).
  • Surveyors who have a COVID-19 vaccination exemption, as identified above, 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.
  • The State Survey Agencies and AOs are ultimately responsible for compliance with this expectation. Therefore, certified providers and suppliers are not permitted to ask surveyors for proof of their vaccination status as a precondition for entry. Providers and suppliers may have questions about the process a state or AO is using to implement this guidance, including verification of surveyor vaccination, mitigation expectations for unvaccinated staff with approved exemptions, and ensuring proper tracking of vaccination status. Those questions should be addressed to the State Survey Agency or AO. We encourage State Survey Agencies and AOs to proactively communicate with providers and suppliers about their efforts to implement this guidance.