CMS revises COVID-19 vaccination memos to combine survey instructions as infection rates decline

by A.J. Plunkett (

CMS has combined three earlier Quality, Safety & Oversight Group (QSO) memos on required COVID-19 vaccinations into a single memo, with revisions to note how surveyors should cite noncompliance.

One of the revisions, highlighted in red, notes that “egregious noncompliance” such as more than half the staff unvaccinated, will be cited as a condition level deficiency. Instances of noncompliance where “good faith” efforts to comply are ongoing would only be a standard-level deficiency.

Another highlighted note emphasizes that in all cases, “surveyors should closely investigate infection prevention and control practices to ensure proper practices are in use, such as proper use of personal protective equipment, transmission precautions which reflect current standards of practice, and/or other relevant infection prevention and control practices that are designed to minimize transmission of COVID-19.”

The now 163-page combination memo, QSO-23-02-ALL, includes instructions for survey for all the provider types that previously were attachments to each of the earlier memos.

The hospital information starts on page 36, critical access hospital information on page 96.

It has been almost a year since CMS published its November 2021 interim final rule mandating the vaccination of all healthcare workers against COVID-19, which unleashed several legal challenges and was ultimately upheld and pushed forward.

Because different states were challenging the rule, CMS created three memos to push forward in states where no challenge existed. This combines those memos, which each have also been revised as COVID hospitalization and vaccination rates changed.


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Accreditation, CMS, COVID-19