Compliance with the New Vaccine Standard

Now that Critical Access Hospital surveys include a new Accreditation Commission for Health Care (ACHC) Standard for COVID-19 vaccination of healthcare staff and providers, Surveyors are reviewing hospital policies and procedures, lists of all staff and their vaccination status, and individual employee files to ensure staff are fully vaccinated or meet exemption criteria.

The new ACHC Standard, which was established to meet Centers for Medicare & Medicaid Services (CMS) requirements, became effective in all states in January and February. CMS guidance continues to evolve, and compliance is critical to avoid the risk of a condition-level or Immediate Jeopardy finding.

The new ACHC Standard appears as a “Notice of Update” attached to the front of the 2021 edition of Accreditation Requirements for Critical Access Hospitals. When the 2022 edition is released later this year, the standard will be located in Chapter 18 Infection Prevention and Control and Antibiotic Stewardship Programs.

Q&A on Compliance

Who is subject to the COVID-19 vaccination requirement?

Any individual who provides care, treatment, or other services to the CAH and/or its patients is subject to this requirement, regardless of clinical responsibility. Staff who work remotely (100%) and have no interactions with other staff or patients are not subject to the requirements of the regulation. There may be infrequent services conducted by individual vendors, volunteers, or other professionals (e.g., annual elevator inspection), and hospitals are not required to ensure vaccination of these individuals. When evaluating if an individual meets the criteria for this flexibility, hospitals should consider the frequency of presence, services provided, and proximity to patients and other staff.

If staff have exemptions or clinical contraindications, are they included in the vaccination rate calculation?

Yes. When calculating the percentage of compliance, Surveyors will include staff who are fully vaccinated and those staff who have received an exemption or temporary delay.

What should the hospital policy address?

• COVID-19 vaccination is required for all staff.
• A process to track and document the vaccination status of all staff (including recommended booster doses).
• A process for managing exemptions/temporary delays in vaccination.
• Contingency plans for those granted exemptions.
• Infection control mitigation strategies for staff who are unvaccinated due to an approved exemption or temporary delay.

When did ACHC begin surveying under the new standard?

ACHC released notification of the new standard, 18.03.04 Employee Health − COVID-19 Vaccination of CAH Staff, on January 28, 2022. The change became effective for surveys beginning January 27, 2022, in states except Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Utah, West Virginia and Wyoming, where surveys for compliance began on February 14, 2022. In Texas, surveys for compliance began on February 22, 2022.

Important Accreditation Requirements update

The current edition of Accreditation Requirements for Critical Access Hospitals has an important update. CMS requirements for Emergency Preparedness exercises have been revised to be less restrictive, and ACHC Standard 17.03.02 has been edited to reflect this change. Please review the Notice of Update at the front of the 2021 manual of standards to see the revised requirement using your current link to the digital edition. Your Account Advisor can provide this link if you need it to download the updated version.

Here to Help

If you have questions or need more information, please contact your Account Advisor, email customerservice@achc.org, or call (855) 937-2242.

How Healthcare Providers Can Get from P's to Q

Policies, procedures, plans, and programs create quality? Barb Sylvester, RN, MSOLQ, describes how an ACHC quality expert makes the connection. She shares her love of policies and her perspective on the purpose of an ACHC survey. (You might be surprised by what she says is most important.) Listen now to Episode 7: Mind the Gap.

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