CMS: Vaccination Expectations for Surveyors Performing Federal Oversight

The Centers for Medicare and Medicaid Services (CMS) has issued memo QSO-22-10-ALL to all State Survey Agencies, requiring onsite surveyors – including CLIA and Life Safety surveyors – to be fully vaccinated for COVID-19 or have an acceptable medical or religious exemption.

For surveyors with an accepted exemption, they must take extra precautions while onsite during survey “as determined and documented by the state (such as mandatory testing, limitation to conducting survey activities that limit patient/resident contact such as record review, limitation to conducting offsite activities, or re-assignment or work modification).” All surveyors are expected to use appropriate PPE while surveying.

State Survey Agencies are responsible for compliance with this expectation. Therefore, certified providers and suppliers are still not permitted to ask surveyors for proof of their vaccination status as a precondition for entry.

However, you may ask surveyors their vaccination status should a resident request to only have vaccinated visitors. In this unique case, the surveyor should be informed the resident does not want unvaccinated visitors so the unvaccinated surveyor can interview a different resident. If the surveyor declines to answer, facilities should then assume they are unvaccinated for purposes of interacting with residents requesting such limitation. However, the surveyor must still be allowed to enter the facility.

NYSHFA/NYSCAL CONTACTS:

Jackie Pappalardi, RN, BSN
Executive Director
518-462-4800 x16

Lisa Volk, RN, B.P.S., LNHA
Director, Clinical & Quality Services
518-462-4800 x15