CMS revised its guidance for all provider-types for assessing and maintaining compliance with the COVID-19 staff vaccination regulatory requirements.

• QSO-23-02-ALL replaces and consolidates information from QSO 22-07-ALL Revised, QSO 22-09-ALL Revised, and QSO 22-11-ALL Revised.

Zooming in: The changes, which apply to all states, include: 

• ​Lowering the levels of scope and severity when citing noncompliance.  
  • ​F888 will be cited at severity level 1, with a scope of widespread, or “C.” Noncompliance is based on the failure to implement policies and procedures at 483.80(i)(3)(ii). 
  • Situations indicating egregious noncompliance (more than 50 percent of staff being unvaccinated (unless exempted, or temporarily delayed), and/or no policies or procedures as required, should be cited at severity level 2, with a scope of widespread, or “F.” 
• ​Facilities that are noncompliant (vaccination rates under 100 percent) but have implemented a plan to achieve a 100 percent staff vaccination rate would not be subject to an enforcement action.  
• Streamlining of the process for additional precautions by providing facilities with the discretion to choose which additional precautions to implement that align with the intent of the regulation which is intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated. 
• Removing NHSN data review. Surveyors have the discretion to verify the accuracy of NHSN data on surveys based on a complaint report or if concerns are identified. 
• Adding good faith effort examples which show facilities attempt to correct noncompliance.