Expected increased survey scrutiny for unvaccinated agency staff

By Sheila Salisbury-Sizemore RN, BSN SimiTree Senior Manager, Compliance  

Now that the Centers for Medicaid and Medicare Services (CMS has retired the Focused Infection Control (FIC) Survey and mandated a COVID-19 vaccine, your agency can expect surveyors to take a close look at unvaccinated staff on your next survey.

CMS wants surveyors to evaluate an agency’s infection prevention and control by using the existing survey process. Anytime the agency undergoes a survey, whether it’s a routine 36-month survey, a complaint survey, a survey due to the addition of a branch or a survey for any other reason, surveyors are going to look at how well the agency is meeting infection control regulations.

Unvaccinated staff will likely attract the most surveyor scrutiny. Agencies can expect to see unvaccinated staff targeted as a priority to validate compliance and effectiveness of the agency’s policies, procedures, and infection control program.

It's also likely that home visits will be selected based on unvaccinated staff assignments rather than patient assignments.

Be proactive for survey

These changes mean your agency will need to plan ahead for surveyor visits, aggressively monitoring your unvaccinated staff for survey readiness around Medicare’s Conditions of Participation for infection control.

According to survey guidance, surveyors will be looking for a process to ensure that your agency continues to follow all COVID-19 standards in the home, especially by those staff who are unvaccinated or who are not yet fully vaccinated. The surveyor is directed to observe staff providing care to determine compliance with current standards of practice with infection control and prevention.

Some recommendations include:

  • Avoid making high-risk assignments. Your agency is obligated to ensure that patients are receiving care that is safe. The highest-risk scenario would be for an unvaccinated staff member to be assigned to an immunocompromised or unvaccinated patient. Agency leaders should pay close attention to prevent unvaccinated staff from being assigned to high-risk patients.
  • Survey your own staff. Agency leaders should provide observational field visits, announced and unannounced, with unvaccinated field staff to ensure that proper infection control and prevention procedures are followed.
  • Consider survey blind spots. Proper handwashing procedures continue to be an issue for agencies on mock surveys conducted by our team. Most commonly, staff are not washing their hands according to CDC guidance of 20 seconds each time and not allowing adequate time for the hand sanitizer to dry when applied.
  • Follow CDC standards. Make certain your clinicians are following national infection prevention and control standards set out in CDC guidance under “Interim Infection Prevention and Control for Healthcare Personnel During the Coronavirus 2019 (COVID-19) Pandemic.”
  • Research all requirements that apply to your agency. Your state requirements may differ from CMS requirements. Work with your state Department of Health, State Agency, and/or Accrediting Organization (AO) to make certain your agency is following all applicable state rules and regulations in addition to CMS requirements. In most cases, the state Department of Health will have this information available on its web site.
  • Find your experts. With all of the complexities surrounding the mandate, identify your key experts within the organization to guide discussions, coach other leaders and managers related to mandate communication and drive dissemination of information to staff.
  • Be considerate of varying opinions. With the health care staffing crisis upon us, it is vital that leaders approach vaccine mandate communication with a sincere attitude of empathy. Discussions with staff should be grounded in facts and conducted professionally in an environment that is conducive to transparency.
  • Keep patients invested in infection control. Beyond survey concerns, you can improve safety by making sure patients are complying with COVID-19 protocols. It’s important to discuss expected COVID-19 precautions prior to the visit. If the clinician encounters noncompliance with the established safety protocols, reminders should be initiated with continued teaching regarding COVID-19 transmission precautions. If anyone else other than the patient will be in the home during the visit, the clinician should clarify that COVID-19 precautions are expected to be observed by everyone in the home.

Need help with survey readiness?

Minimizing compliance risk and meeting regulatory requirements is an important part of making your organization stronger, healthier, and better able to focus on patient needs.

Our team of former and current surveyors and certified consultants can help your organization with mock surveys, citing everything a surveyor would and providing a corrective action plan.

Sheila Salisbury-Sizemore is a former ACHC surveyor who now serves as Senior Manager of the SimiTree Compliance, Regulatory and Quality team.

Sheila Salisbury Sizemore Simitree Health

By Sheila Salisbury-Sizemore RN, BSN
SimiTree Senior Manager, Compliance


Contact Us

Let's work together to improve the health of your organization. At SimiTree, we balance financial expertise and clinical excellence to help our clients grow. How can we help you? Call us at 866.839.5471 or complete the form below.