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Guidance Issued for CMS Surveyors

Situation Report | January 31, 2022

The Centers for Medicare and Medicaid Services (CMS) has issued guidance to state Survey Agency Directors about the vaccine status and procedures for state surveyors.

CMS advises that surveyors who are not fully vaccinated (unless vaccination is medically contraindicated or the individual is legally entitled to a reasonable accommodation under federal civil rights laws because they have a disability or sincerely held religious beliefs, practices, or observances that conflict with the vaccination requirement) should not participate as part of the onsite survey team performing federal oversight of certified providers and suppliers (including accreditation surveys performed under an Accrediting Organization’s (AO’s) deeming authority).

Unvaccinated personnel may be used, at the state survey agency’s or AO’s discretion, for offsite survey or enforcement activities.

The state survey agencies and AOs are ultimately responsible for compliance with CMS’s vaccine expectations. Therefore, certified providers and suppliers are not permitted to ask surveyors for proof of their vaccination status as a precondition for entry. Providers and suppliers may have questions about the process a state or AO is using to implement this guidance, including verification of surveyor vaccination, mitigation expectations for unvaccinated staff with approved exemptions, and ensuring proper tracking of vaccination status. Those questions should be addressed to the state survey agency or AO.

CMS encourages state survey agencies and AOs to proactively communicate with providers and suppliers about their efforts to implement this guidance.