CMS Rescinds QSO-20-31-ALL and Releases QSO-23-10-NH

The Centers for Medicare & Medicaid Services (CMS) announced that it is rescinding its QSO Memo, “Revised COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality Improvement Activities in Nursing Homes,” effective March 30, 2023.

This Memo is rescinded – CMS directs readers to QSO-23-10-NH for information related to “Strengthened Enhanced Enforcement for Infection Control Deficiencies” which applies to all applicable enforcement actions for survey cycle start dates of March 30, 2023. Any enforcement actions that were in place for survey cycle start dates prior to this date are subject to the enforcement guidance in this Memo (QSO-20-31-ALL) as it was still in effect for those surveys.

What’s the New Guidance?

When CMS rescinded the above QSO Memo, it also released a new Memo related to enforcement and quality improvement in nursing homes, so don’t think that survey & certification activities have also been rescinded. Instead, they have been clarified in the newly released QSO-23-10-NH, “Strengthened Enhanced Enforcement for Infection Control Deficiencies and Quality Improvement Activities in Nursing Homes,” dated March 30, 2023.

Let’s look at the guidance related to infection control citations.

Revised Enhanced Enforcement for Infection Control Deficiencies

F880 Citations Identified at Level 2 Scope/Severity

If a facility is cited at F880 Infection Prevention and Control at a S/S: of D, E or F and F887 (any S/S), the following will occur:

  • Directed Plan of Correction that includes Root Cause Analyses and working with a QIO or another qualified consultant
  • Discretionary Denial of Payment for New Admissions (DPNA) with a 30-day notice period to achieve substantial compliance

Note – If a facility is cited at F880 Infection Prevention and Control (S/S: D, E or F) and F887 at S/S of Actual Harm or Immediate Jeopardy (G-K), additional remedies may be applied to this scenario.

F800 Infection Prevention and Control Citations Identified at Scope/Severity of Actual Harm (Level 3 – G, H or I)

If a facility is cited at F880 at a S/S of Actual Harm (S/S G, H or I), the following will be required:

  • Directed Plan of Correction that includes Root Causes Analyses and working with a QIO or hiring an Infection Control Consultant to develop and implement a corrective action plan
  • Discretionary Denial of Payment for New Admissions (DPNA) with a 15-day notice period to achieve substantial compliance
  • Civil Monetary Penalty (CMP) imposed according to the CMP Analytic Tool with a 10% increase adjustment
F880 Citations Identified at Level 4 – Immediate Jeopardy (S/S of J, K or L)

If a facility is cited at F880 Infection Prevention and Control at a S/S of Immediate Jeopardy (J, K or L), the following will be required:

  • Directed Plan of Correction that includes Root Cause Analyses and working with a QIO or hiring an Infection Control Consultant to develop and implement a corrective action plan
  • Discretionary Denial of Payment for New Admissions (DPNA) with a 15-day notice period to achieve substantial compliance
  • Civil Monetary Penalty (CMP) imposed according to the CMP Analytic Tool with a 20% increase adjustment

View the 3/30/2023 QSO-23-10-NH here.


Need help with a Directed Plan of Correction or required to hire an Infection Control Consultant? CMS Compliance Group, Inc. can help. Fill out the contact form below or call 631.692.4422 for more information.

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