Long-Term Care Survey Alert

Published on Sun Oct 23, 2005 PDF

Be on the lookout for new survey guidance.

If your flu and pneumoccocal immunization program falls short, roll up your sleeves and make some quality improvements before the Centers for Medicare & Medicaid Services rolls out a new set of F tags. CMS published a final rule in October requiring facilities serving Medicare or Medicaid patients to provide all residents flu and pneumococcal vaccination, unless contraindicated or the resident/responsible party refuses.

New survey interpretive guidance will address the finalized immunization requirement, which is only one aspect of a facility's infection control, said Susan Joslin, RN, PhD, a nurse consultant for CMS during a recent CMS Webcast. Joslin recommended facilities review their infection control efforts with more than immunizations in mind. For example, also look at strategies for monitoring and tracking infection, handwashing, aseptic techniques, isolation precautions--and risk assessment for communicable disease for residents and employees, Joslin advised.

Using the new guidance, surveyors may look to see if a facility's immunization program does the following, said Joslin:

• Includes a process for obtaining immunization history for new admissions and current residents. For example, Stella Maris nursing facility keeps a running immunization record on new admissions and current residents. The interdisciplinary team meets with the family at the first care plan meeting and gathers information for the immunization forms, said Webcast presenter Stephanie Gramling, RN, a nurse at the facility in Timonium, MD.

• Identifies residents who are eligible to receive the flu and pneumococcal immunizations and those who may have contraindications to receiving them.

• Tracks residents who refuse the vaccine or those whose immunizations are pending or delayed.

• Includes procedures to respond to delays in receiving vaccines or vaccine shortages.

Editor's note: CMS will post an advance copy of the guidance at www.cms.hhs.gov/medicaid/survey-certletters.asp.