F883 immunization deficiencies surged in 2024 mock surveys. What do know and what to do in order to align policies with CMS regulations.
CMS developed a Quality in Focus Program as a resource for all long-term care facilities in the country. Efforts are being made to assist the promotion of safe environments within LTC facilities and to educate the general public about why regulations in nursing homes are seemingly strict, rigid and sometimes unreasonable. Using Quality in Focus as the foundation, Polaris Group highlights FTag 883.
A recent analysis of hundreds of Polaris Consultants' mock survey results revealed a surprising trend: F883, covering influenza and pneumococcal immunizations, ranked among the Top 10 FTag citations in 2024. Approximately 35% of Polaris' mock surveys identified deficiencies related to F883, which focuses on reducing the risk of residents acquiring, transmitting, or facing complications from influenza and pneumococcal infections.
Vaccine season is here and it's essential to provide education on the risks and benefits of immunizations, along with obtaining written consent prior to administration. CMS regulations mandate that facilities develop policies and procedures outlining this process, ensuring that these policies align with current standards of practice.
What to know
Annually, residents must be offered the influenza vaccination sometime between October 1st and March 31st unless it is medically contraindicated or if the resident has already been immunized during this period.
- The pneumococcal vaccine is offered every five (5) years, although experts indicate that one to three doses of the pneumococcal vaccine likely provide lifelong protection, based on individual resident situations.
- Resident or resident’s representative must be offered education regarding the benefits and potential side effects of immunization, including written documentation in the medical record.
- There must be written documentation in the medical record that the resident either received the influenza immunization, did not receive it due to medical contraindications, or refusal.
- Residents admitted up until March 31 should be offered the vaccine and may be offered outside the influenza season at the discretion of the facility.
What to do
- Ensure your EMR can record and track immunizations.
- Ensure your nursing staff is trained in providing accurate information regarding the risks and benefits of influenza and pneumococcal immunization.
- Review your immunization program annually at a QAPI meeting. During the review, be sure to discuss any updates and ACIP (Advisory Committee on Immunization Practices) recommendations.
- Ensure physician orders for immunization are part of admission orders and include a mechanism for recording and monitoring for administration of vaccines.
- Connect with Polaris Group for guidance on policy development and education materials.
As leaders in the advancement of the health care continuum, Polaris Group supports public health advice that leads to a reduction in the incidence of vaccine-preventable diseases.
For further information to make sure your facility is meeting all requirements of F883, please reach out to Polaris Group today via our Contact Us page!
