Updated guidance for the Interim Final Rule – Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccine Immunization Requirements. It provides survey procedures for assessing and maintaining compliance. It replaces QSO 22-07-ALL. It has revised interpretive guidance in attachment A. CMS-20054 IPC & Immunization has been revised. No revised AFL yet.

CMS expects all providers’ and suppliers’ staff to have received the appropriate number of doses of the primary vaccine series unless exempted as required by law, or delayed as recommended by CDC. Facility staff vaccination rates under 100% of unexcepted staff constitute noncompliance under the rule. Non-compliance does not necessarily lead to termination, and facilities will generally be given opportunities to return to compliance. For example, a facility that is noncompliant and has implemented a plan to achieve a 100% staff vaccination rate would not be subject to an enforcement action. Consistent with CMS’s existing enforcement processes, this guidance will help surveyors determine the severity of a noncompliance deficiency finding at a facility when assigning a citation level.

CDC NHSN Data Verification: Surveyors have the discretion to verify the accuracy of NHSN data on surveys based on a complaint report or if concerns are identified. We note that CMS and CDC conduct quality checks of facility NHSN data submissions each week in an effort to identify trends or indicators of data reporting issues. Procedures for conducting this review may be found in the Surveyor Resources folder and LTCSP procedure guide.

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