Failure to Post COVID-19 Vaccination Signage
Summary
The facility was cited for failing to ensure conspicuous signage was posted throughout the facility to remind residents and staff that COVID-19 vaccinations were available. This deficiency was identified during a Recertification Survey conducted from December 12, 2024, to December 19, 2024. The Dear Administrator Letter #23-15, dated in 2023, required facilities to post such signage at entry and exit points and in each residential hallway. However, observations during the survey revealed that no signage was present in the lobby, hallways, or resident units. The facility's policy for COVID-19 vaccination for healthcare personnel, dated January 31, 2024, did not include procedures for posting signage. Interviews with facility staff revealed a lack of awareness regarding the ongoing requirement to post COVID-19 vaccination signage. The Infection Preventionist stated that the signage had been removed during facility renovations and was unaware of the continued requirement. The Director of Nursing also confirmed the removal of the signage following the lifting of the mask mandate and was not aware that the signage needed to remain posted. The Administrator acknowledged that while the facility provided COVID-19 vaccinations, they were not aware that the signage had to be maintained, as they had only circulated flu vaccine signage.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 Immediate corrective Action: On 12/19/24, signage announcing the availability of the COVID-19 vaccination was printed and posted in highly visible locations within the building, including all entryways, lobby, hallways, time clocks, and resident units. Element 2 All residents have the potential to be affected by this practice. All residents' representatives/family contacts will receive a message through the Care Connect messaging system informing them of the availability of the COVID-19 vaccine. The Activities Department will inform all residents currently residing in the building of the availability of the COVID-19 vaccine. Element 3 The facility updated the infection control policy to include a requirement for posting of COVID-19 vaccination signage. The policy outlines the specific locations for signage placement and a procedure for routine checks to ensure compliance. Element 4 The Infection Preventionist or designee will conduct weekly environmental rounds for 3 months to ensure signage is posted. The Results of the environmental rounds will be reported to the Administrator monthly. The Infection Preventionist will report the findings of the audit to the QAPI Committee for the 1st quarter of 2025. QAPI Committee will decide if further action is required. Element 5 Completion Date: (MONTH) 19, 2024 Person Responsible: Infection Preventionist or designee.
Penalty
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