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

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

CMS posted QSO-22-17-ALL the afternoon of Tuesday, June 14, 2022 with the same title as this blog.

Note the change from previous survey oversight – 2nd bullet above and verbiage from the QSO below.

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

While we are seeing a significant increase in COVID-19 cases in parts of the country — driven by the highly transmissible Omicron subvariants — hospitalizations and deaths currently remain relatively low nationwide. This is a testament to the tools and protections in place today, particularly the work that federal, state, local, and private partners have done to get over 220 million people vaccinated and over 100 million boosted.

While State Survey Agencies (SAs) may expand any survey to include vaccination requirement compliance for non-deemed providers and suppliers and those deemed by Accrediting Organizations with CMS-approved programs (AOs) (with authorization from the appropriate CMS location), SAs and 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. This reduction in survey frequency is in keeping with the normal process for oversight of any Medicare requirement, and is supported by the high rates of compliance in initial surveys.

Accrediting Organizations retain the authority to exceed Medicare requirements, per their accreditation standards.

CMS is also reviewing QSO-22-11 to update the 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. State Survey Agencies should reach out to their CMS Location if they are considering citing vaccine requirements at immediate jeopardy, Condition or actual harm levels.”

QSO-22-11 is found here but has not yet been revised since April 5, 2022. I’ll be watching and posting a notification when CMS makes that available.