COVID Vaccination Compliance Review

Posted: March 22, 2022

The article below is excerpted from previously published Did You Know? newsletters. The newsletters are archived for customer reference in Customer Central.

ACHC is surveying certain Medicare-certified organizations for compliance with the COVID-19 vaccination mandate issued by the Centers for Medicare & Medicaid Services (CMS).

The vaccination requirement became effective in all states in January and February. CMS guidance may continue to evolve, and compliance avoids the risk of a condition-level or Immediate Jeopardy finding.

The requirement applies to all initial and reaccreditation surveys and to complaint surveys for organizations participating in the following ACHC deemed-status accreditation programs: Acute Care Hospital, Ambulatory Surgery Center, Critical Access Hospital, Home Health, Home Infusion Therapy, Hospice, and Renal Dialysis.

ACHC Surveyors are reviewing:

• Policies and procedures regarding COVID-19 vaccination(s).
• The tracking process used to log vaccination status of affected personnel.
• The process to ensure confidentiality of the vaccination status of affected personnel.
• Contingency plans for personnel who are not fully vaccinated to mitigate the spread of COVID-19 infections.
• A personnel list of individuals who provide care, treatment, or other services for the organization and/or its patients, under contract or by other arrangement.
  • This list should include the percentage of unvaccinated personnel, excluding those who have approved exemptions.
  • This list should identify personnel who remain unvaccinated due to approved exemptions.
• A sampling of personnel files to verify acceptable proof of vaccination status.
• Documentation for personnel unvaccinated due to a medical contraindication. Documentation includes:
  • Authentication (signature and date) by a physician or an advanced practice provider and including identification of the specific vaccine contraindicated and the recognized clinical reason for contraindication with a statement recommending exemption.