Inadequate Pneumococcal Vaccine Protocols for Employees
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the lack of compliance with pneumococcal vaccine protocols for eight out of ten employees reviewed. Specifically, the facility did not determine eligibility for the pneumococcal vaccine, provide education on its risks and benefits, or offer the vaccine annually to all employees who have direct care and/or close contact with residents. Documentation was missing for Employee F regarding vaccine eligibility and education. Employees D, A, and B were last offered the vaccine in 2020 and 2022, respectively, but declined it. Additionally, the consent/declination forms for Employees E, H, I, and J were not dated or signed by a facility representative, indicating a lack of proper documentation and attestation that the vaccine was offered and education provided. During interviews, the Infection Preventionist and the Administrator admitted to being unaware of the requirement to offer the pneumococcal vaccine annually to all employees. This oversight indicates a need for revision in the facility's policy and procedure to ensure compliance with New York State Department of Health regulations.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 I210 Corrective Action- To assure the facility determines eligibility for the pneumococcal vaccine, provides education on the risks/benefits of the pneumococcal vaccine, and offers the vaccine to all employees annually. 1. Employees (A-J) will have their eligibility for the Pneumococcal Vaccination determined, and if able, they will be offered, educated on, and have consent/declination forms signed. Those who are eligible and have consented, will have the vaccination administered. 2. All employees at the facility have the potential to be affected by this practice. The facility will complete a full house audit of staff. The audit will include eligibility, and if able, education, consent/declinations, and administration of the Pneumococcal vaccine (if appropriate). 3. The facility’s pneumococcal vaccination policy for employees will be reviewed and revised (if necessary). All Registered Nurses and HR staff in the facility will be reeducated on this policy. 4. To ensure prevention of future deficit in this practice, the Staff Educator/Designee will perform 10 audits per month for 3 months, then as needed based on the audit findings. Audits will verify that eligibility, and if able, education, consent/declinations, and administration of the Pneumococcal vaccine. The Director of Nursing will monitor this process and review the results monthly at QAPI meetings. If continued improvement is needed, the Committee may make further recommendations. The Director of Nursing will assume overall responsibility for correction of F I210.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
