CMS eases up on COVID-19 vaccination verification during regular surveys

by A.J. Plunkett (

Now that hospitals and other healthcare providers have had time to meet the CMS staff COVID-19 vaccination requirements, CMS is easing up on verification, according to a Quality, Safety and Oversight group memo posted Tuesday afternoon.

However, the memo noted that accrediting organizations were free to “exceed Medicare requirements, per their accreditation standards.”

“Survey oversight of the staff vaccination requirement for Medicare- and Medicaid-certified providers and suppliers will continue to be performed during initial and recertification surveys, but will now only be performed in response to complaints alleging non-compliance with this requirement, not all surveys,” said CMS in QSO-22-17-ALL.

Since the requirement was announced in December 2021, all CMS surveys included a review of how providers were meeting the mandate for staff to either be vaccinated or have a medical or other allowed exemption.

While the mandate allowed exemptions under certain circumstances, it also set out precautions for how or if those staff members would be allowed to interact with other staff or patients.

CMS will revise its previous QSO memo outlining the requirements for each type of provider, QSO-22-11-ALL, “to ensure deficiency determinations reflect good faith efforts implemented by providers and suppliers and incorporate harm or potential harm to patients and residents resulting from any non-compliance.”

The “reduction in survey frequency is in keeping with the normal process for oversight of any Medicare requirement, and is supported by the high rates of compliance in initial surveys,” said CMS.

The new memo also noted that CMS is reviewing interpretive guidance for its surveyors to describe “immediate jeopardy, Condition-level and actual harm determinations to ensure that deficiency citations recognize good faith efforts by providers/suppliers and to more fully evaluate harm or potential harm to patients/residents by considering trends in COVID-19 rates in the community.”

CMS survey agencies that are considering citing vaccine requirements at immediate jeopardy or Condition-level, or where actual harm could be identified, are being instructed to reach out to their CMS regional location.

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