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COVID Vaccination Compliance Review

COVID Vaccination Compliance Review

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.

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Accreditation, Certification, Compliance Personalized Wellness, Point-of-Care Services