CMS Issues Revised QSO's for Assessing COVID-19 Vaccine Compliance

Updated: Apr 11

On April 5, 2022 the CMS Quality, Safety & Oversight Group and Survey & Operations Group issued a series of three QSO’s which revised QSO-22-11-ALL, QSO-22-09-ALL, and QSO-22-07-ALL. The QSO’s are designed to provide guidance and survey procedures for assessing and maintaining compliance with an interim final rule (IFC) published by CMS on November 05, 2021 which sets forth requirements regarding COVID-19 vaccine immunization of staff among Medicare- and Medicaid-certified providers and suppliers. These revised QSO’s help state surveyors determine the severity of a COVID-19 vaccine immunization noncompliance deficiency finding at a facility when assigning a citation level.



Each revised QSO says there are different enforcement action thresholds depending on the amount of time which has elapsed from the date of the revised QSO issuance. For example, each revised QSO says that if, within 30 days after the revised QSO is issued, a facility demonstrates that policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19 and 100% of staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted qualifying exemption, or identified as having a temporary delay as recommended by the CDC, then the facility is compliant under the IFC.


On the other hand, if within 30 days a facility shows that less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, then the facility is non-compliant under the IFC.


Each revised QSO also sets forth enforcement action thresholds for 60 days and says that facilities failing to maintain compliance with the 100% COVID-19 vaccine immunization standard within 90 days of the revised QSO’s issuance may be subject to enforcement actions.

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