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CMS Revises Survey Guidance on COVID-19 Vaccination Requirements

For CEOs, CNOs, compliance officers, human resources executives

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The Centers for Medicare & Medicaid Services (CMS) has issued revised surveyor guidance on its final rule requiring COVID-19 vaccination for health care staff.  

CMS clarifies that hospitals must provide surveyors with their process for ensuring contracted staff are compliant with the vaccination requirement and says that failure of contract staff to provide evidence of vaccination status reflects noncompliance. Further, CMS specifies that contractors should examine documentation for a sample of a minimum of six direct care/patient engagement staff, of whom four should be vaccinated staff or contractors and two should be unvaccinated staff or contractors (including one who is not fully vaccinated and one with a medical exemption or temporary delay). CMS also specifies that surveyors should choose a sample of at least two contracted staff (one vaccinated and one unvaccinated or exempt) who are not included in those direct care contracted staff outlined above. 

In addition, CMS clarifies that surveying for staff vaccination requirements is not required on Life Safety Code (LSC)-only complaints or LSC-only follow-up surveys, and refines its definition of temporarily delayed vaccination.