CMS Relaxes Frequency of Inspection for Vaccination Requirement Compliance

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.

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