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Updated CMS vaccine mandate guidance stresses contractor compliance

Make sure contracted staff are compliant with CMS’ vaccine requirement and that these contractors can provide proof of vaccination.

CMS updated its guidance to surveyors on Tuesday, April 5, 2022, making it clear that contractor compliance is a high priority during survey reviews of vaccine documentation.

The new guidance notes that surveyors should review the agency’s process for how it ensures that contracted staff are compliant with the vaccination requirement.

CMS is also setting minimum standards for the surveyor’s review of staff documentation. The review should be based on the agency’s list of employee vaccination status, and include:

  • A minimum of six direct care or patient engagement staff, including contracted staff working at the time of the survey. Four should be vaccinated, one should be logged as not fully vaccinated and one should have a medical exemption or temporary delay in vaccination.
  • Two contracted direct care staff should be among the six (or more) sampled and the surveyor should sample at least two additional contracted staff: one vaccinated and one unvaccinated or exempt.

As previously stated in the guidance, surveyors are expected to review the agency’s records to verify the documentation for those employees listed as vaccinated and conduct follow up interviews to address discrepancies.

CMS adds in the update that “failure for contract staff to provide evidence of vaccination status reflects noncompliance and should be cited.”

The update also clarifies that:

  • Agencies can decide its own additional precautions that unvaccinated staff should take, and that CMS’ examples for agencies and surveyors aren’t requirements.
  • A “temporary delay” in vaccination can include those staff who have to wait due to an acute illness COVID-19 or isolation due to COVID-19.
  • Staff on extended leave (due to suspension, family leave, workers compensation leave, etc.) should not be counted when measuring compliance with the standard.

See the entire update at https://go.cms.gov/3KsBItm.