CMS Relaxes Frequency of Inspection for Vaccination Requirement Compliance

Posted on June 16, 2022 by LeadingAge

This week, CMS announced that survey oversight of the staff vaccination mandate for Medicare and Medicaid-certified providers and suppliers will continue to be performed during initial and recertification surveys but will now only be performed in response to complaints alleging non-compliance with this requirement, not all complaint surveys. This news comes after CMS determined that 95% of nearly 12,000 providers and suppliers surveyed by states have been in substantial compliance with this requirement.

CMS is also reviewing QSO-22-11 to update the interpretive guidance describing Immediate Jeopardy, determinations to ensure that deficiency citations recognize good-faith efforts by providers 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 are directed to reach out to their CMS regional office if considering citing vaccine requirements at immediate jeopardy.

On a different topic, CMS has also extended regulatory flexibility relating to emergency preparedness exercises.

Under CMS regulations, nursing facilities must conduct two emergency preparedness testing exercises annually, alternating between full-scale functional exercises and exercises of choice (mock drill, table-top exercise, workshop). However, if a facility experiences an actual natural or man-made emergency that requires activation of its emergency plan, the provider will be exempt from its next full-scale community-based exercise or individual, facility-based functional exercise following the onset of the actual event.

CMS recently issued a revised memorandum QSO-20-41-All to confirm that if a facility is still operating under a currently activated emergency plan during its specified 12-month cycle of testing exercises, any currently activated emergency plan will be recognized by surveyors as having met the full-scale exercise requirement for that 12-month cycle. The updated guidance only applies if a facility is still currently operating under its activated emergency plan or reactivated its emergency plan for COVID-19 in 2021 or 2022. See the memorandum for additional details, including documentation examples to establish that a facility is operating under an activated emergency plan.