Center for Improvement in Healthcare Quality Newsletter
July 2022

ARS Regulatory Alerts

CIHQ-ARS notifies member organizations of any new or modified accreditation standard, or CMS COP for acute care hospitals. Each alert summarizes the standard / regulation, likely impact to members, and recommends compliance strategies. Whenever possible, alerts are limited to one-page in length so that they can be quickly read and disseminated.

New Regulatory Alert

Alert Date
June 14, 2022
Alert Subject
CMS Relaxes Scope Of Survey Assessments For Covid Vaccine Mandate Compliance
Alert Background
In a letter to State enforcement agencies dated 6/14/22, CMS updated its guidance regarding the assessment of a healthcare facility’s compliance to the COVID vaccine mandate during surveys.
Effective immediately, CMS State Agencies (SA) and Accrediting Organizations (AO) will now only be expected to perform compliance reviews of the staff vaccination requirement during initial and recertification surveys and in response to specific complaint allegations that allege non-compliance with the staff vaccination requirement. SA’ and AO’ are no longer expected to perform these reviews on every survey (e.g., follow-up surveys, extension surveys, etc.)
According to CMS: “The staff vaccination requirement for all CMS-certified providers and suppliers has been in effect (in all states) since February 20, 2022. Nearly 12,000 providers and suppliers have been surveyed for compliance with the requirement. To date, 95.0% of those providers and suppliers surveyed by states have been found to be in substantial compliance with this requirement.”
It is also noted that both SA’ and AO’ retain the ability assess for compliance to the vaccine mandate at during any survey activity if they so choose.
Discussion & Recommendations
To view the discussion & recommendations CIHQ Accredited Hospitals can download this alert in its entirety when logged-in/connected to your facility's CIHQ intranet site. All alerts are archived in the CIHQ intranet site for future access and reference.
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