This week’s “Ftag of the Week” is F883 Influenza and Pneumococcal Vaccinations, which is part of the Infection Prevention and Control regulatory group that we are reviewing in full on the CMSCG Blog. F883 is a relatively straight-forward regulation, but where facilities are vulnerable is in not having a strong system around thorough documentation. During survey, five residents who may have been included in the sample for other reasons will be reviewed for the administration of these vaccinations. Surveyors will conduct record review and will be looking for the following information.
For both influenza and pneumococcal immunizations, facilities are required to do several things. First, residents/resident representatives must be provided with education on both the benefits and potential side effects risk of the immunization. The resident/representative must be provided with the opportunity to refuse. For influenza, residents must be offered the immunization between October 1 and March 31 on an annual basis unless the resident has already been immunized during that time frame or it is medically contraindicated. The regulatory guidance notes that the Centers for Disease Control (CDC) recommends administering the influenza vaccine when it becomes available rather than on a specific date. Regarding Pneumococcal immunizations, facilities are expected to follow CDC and ACIP (Advisory Committee on Immunization Practices) recommendations. This means facilities need to have a protocol in place for the administration of PPSV23 and PCV13.
What is also required is the following documentation the medical record:
- Documentation that education was provided on benefits/side effects
- Resident either:
- Received the immunization – The resident’s
medical record should show that a vaccine was administered unless there is
documentation of one of the following:
- Did not receive it based on contraindication
- Resident or representative refused
- Resident has already been immunized
- Decision has been made to delay vaccination for a resident on precautions
- Resident is end-stage and receiving palliative/comfort care and has refused
- Received the immunization – The resident’s medical record should show that a vaccine was administered unless there is documentation of one of the following:
The Interpretive Guidance (IG) notes that having an effective immunization program in place requires collaboration with the Medical Director on developing policies for immunizations that reflect current standards of practice. This includes the development and implementation of physician-approved orders for vaccines, include a review of the resident’s medical record for immunization status and possible medical contraindications, information on how education and information will be provided to the resident/representative and a vaccination schedule that includes recording and monitoring of administration that meets acceptable national recommendations.
Remember, the focus of this regulation is to minimize each resident’s risk of acquiring, transmitting or experience complications for either influenza or pneumococcal disease. Lowering your resident population’s risk lowers your staff’s risk, too.