Yes, you must open doors to unvaccinated surveyors

by A.J. Plunkett (

Ready or not, yes, you must let surveyors on site at your hospital or other facilities even if they haven’t been vaccinated against COVID-19 yet.

That applies to CMS and all other surveyors acting in their capacity as deeming authorities to ensure patient safety and allow your facility to bill Medicare.

CMS sent out a statement noting that federal and state surveyors must be permitted entry unless they show symptoms of the coronavirus as outlined in earlier infection control guidance regarding surveys.

The statement apparently was in answer to a query from The Joint Commission (TJC), which was acting on the behalf of someone else, according to the Health Facilities Management Insider.

HFM Insider is distributed by the American Hospital Association’s American Society for Health Care Engineering  (ASHE).

The statement from CMS said, “To clarify, Federal and state surveyors are not required to be vaccinated and must be permitted entry into facilities unless they exhibit signs or symptoms of COVID-19. Surveyors should also adhere to the core principles of COVID-19 infection prevention and adhere to any COVID-19 infection prevention requirements set by state law (refer to QSO-20-39-NH). While we recognize this is a NH specific memo, this would also apply to all providers and suppliers.”

That QSO was initially sent out in September but was updated March 10, just before CMS announced it was lifting a temporary moratorium on onsite surveys. TJC also said it was resuming unannounced, onsite surveys, per CMS guidance.

And if anyone in your hospital asks, CMS’ response to the TJC inquiry also notes the regulations that say it has legal authority to ask for any records at any time:

“Medicare or Medicaid providers must grant access to provider records requested by surveyors, pursuant to Section 1864(a) of The Social Security Act (The Act) and Federal regulations at 42 CFR §488.10 and §488.11 to access providers and suppliers with the Requirements of Participation, Conditions of Participation, or Conditions for Coverage. Pursuant to Section 1866 of The Act and 42 CFR §489.53(a)(18), CMS may terminate the Medicare provider agreement of any provider that fails to grant immediate access to records upon a reasonable request to a state survey agency or other authorized entity for the purpose of determining, in accordance with §488.3, whether the provider or supplier meets the applicable requirements, conditions of participation, conditions for coverage, or conditions for certification.”

But also remember that you should make sure the survey team adheres to whatever infection control screening and prevention measures you have in place in response to the COVID-19 pandemic. Because, as always, you can be surveyed against your own policies.



Found in Categories: 
Accreditation, CMS, COVID-19, Survey Preparation