(Updated) Are your surveyors vaccinated? Probably, but please don’t ask

UPDATED:  CMS recinded this QSO memo on June 17, 2022, noting that there was confusion with how it should be implemented. 

CMS has officially put out guidance to its own state survey agencies that all its onsite surveyors should be fully vaccinated, and it expects the same of accrediting organizations (AOs).

However, according to Quality, Safety & Oversight Group memo QSO-22-10-ALL, AOs are expected to enforce the requirement among their own surveyors.

“The State Survey Agencies and AOs are ultimately responsible for compliance with this expectation,” according to the memo, which then bolded the next sentence: “Therefore, certified providers and suppliers are not permitted to ask surveyors for proof of their vaccination status as a precondition for entry.”

The January 25 guidance did not indicate what might happen if a hospital or other Medicare certified provider or supplier did ask the question. It did offer an avenue for questions.

“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.”

The guidance also stated that unvaccinated surveyors could participate in any remote or off-site survey activities. And it said state survey agencies should have a process to “by which staff may request exemption from COVID-19 vaccination based on recognized clinical contraindications (https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html#Contraindications) or because they are 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 (https://www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws). This process should clearly identify how an exemption is requested, and to whom the request is made.”

Hospital AOs such as The Joint Commission (TJC), DNV Healthcare, and the Accreditation Commission for Health Care (ACHC), which recently merged with HFAP, have said they require their onsite surveyors to be vaccinated.

A January 25 advisory from DNV acknowledging the renewal of the COVID-19 public health emergency also said the AO would continue to do annual NIAHO surveys remotely but that CMS-required triennial reviews would still be onsite.

However, the AO noted that CMS “continues to rely on the discretion of accreditation organizations to determine whether postponement of an onsite survey is safe and appropriate under the individual facility’s circumstances.”

“DNV-accredited hospitals that expect onsite accreditation or re-accreditation survey through the 2nd quarter of 2022 (generally, with accreditation expiration dates before July 31, 2022) may request postponement of survey,” said the advisory.

To request postponement, a hospital should be “experiencing the following due to COVID-19:

• Inpatient census at or near capacity, or extraordinary ICU utilization
• Inpatient, emergency, or critical care capacity reduced due to COVID-19 related staff shortage
• Shortage of PPE, medical supplies, medications, or vaccines
• Voluntary or mandated discontinuation of elective surgeries
• Emergency department closed or on extended diversion
• Onsite deployment of state or federal disaster medical team, or alternate care site
• Implementation of a state-recognized crisis standards of care program.”

The other AOs have also said they recognize that a hospital or healthcare facility may be experiencing a significant COVID-19 surge and said delays could be requested based on similar requirements.

The CMS guidance with a vaccine requirement for its own surveyors comes five days after its final guidance to hospitals and other healthcare providers caring for COVID-19 patients that all staff facing potential exposure must be vaccinated against the airborne virus.