News COVID-19 Announcements

New & Revised Standards

By January 14, 2022 No Comments

New & Revised Standards – COVID-19 Vaccination Requirements & Director Role Clarification

New Standards - COVID-19 Vaccination Requirements

  •  Medicare mandate: Facility staff must be vaccinated for COVID-19
  • Impacted programs: CMS ASC, OPT, and RHC in 25 states

Revised Standards –Director Role Clarification

  •  New optional position identified by AAAASF standards: Facility Director
  •  Impacted programs: OBS, OBP, OMS, PD, CMS ASC, International Surgical, International Dental

Anticipated implementation date for above: March 1, 2022

New Standards - COVID-19 Vaccination Requirements

This is a follow-up to the announcement from November 10, 2021, “CMS Announces New Regulations Regarding Vaccination Status in Healthcare Settings”.

Per Medicare (CMS) mandate, AAAASF has created new standards which will apply to Medicare-deemed ASCs, OPTs, and RHCs as accredited by AAAASF. The new standards can be read here. CMS surveyor guidance published here, AAAASF specific surveyor guidance will follow.

These draft documents are under review by federal regulators. AAAASF tentatively anticipates that the new standards will be approved and go into effect for surveys occurring on March 1, 2022 and beyond.

According to the January 13, 2022, Supreme Court Ruling, these standards will also apply in Washington DC, all US territories, and all US states with the exception of Texas, which is subject to ongoing litigation. Timelines for compliance may be modified only for states that were part of the January 13 ruling. We are still awaiting updated guidance from CMS, so please check with AAAASF if you are unsure of the timeline for any facility you are surveying.

AAAASF will publish follow-up notices and guidance as this situation continues to evolve.

Please review CMS’s QSO memo and attachments for impacted facilities for additional information.

Revised Standards – Director Role Clarification

After feedback from facilities and surveyors, AAAASF has made some simple changes to differentiate better between a Medical Director and a Facility Director in our standards. To continue this process, our upcoming full review of the standards will better define all roles, responsibilities, and titles.

Please note, the Medical Director and Facility Director may be the same individual as stated in standard 11-B-2. However, the revised standards provide the flexibility to delegate tasks to an appropriately credentialed provider other than the Medical Director.

These revised standards impact all AAAASF non-Medicare facilities (including Surgical, Procedural, OMS, Pediatric Dentistry, International Surgical, and International Dental) and AAAASF CMS ASCs. The revised standards can be read here.

AAAASF tentatively anticipates the revised standards will go into effect for surveys occurring on March 1, 2022, and beyond.

Should you have any questions related to the above or other standards, please email us at

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