Failure to Post COVID-19 Vaccination Signage
Penalty
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 are available. This deficiency was identified during a Recertification Survey conducted from March 1, 2025, to March 7, 2025. The Dear Administrator Letter #23-15, dated March 13, 2023, required facilities to post such signage at points of entry, exit, and in each residential hallway. However, during observations conducted between March 4, 2025, and March 6, 2025, no signage was found in the lobby, hallways, or resident units. Interviews with facility staff revealed a lack of awareness and oversight regarding the signage requirement. The Infection Preventionist admitted to not posting the signage and was unaware of the need to do so. The Director of Nursing mentioned that the notifications had been posted previously but were removed approximately two years ago during renovations. The Administrator confirmed that COVID-19 vaccines are offered to residents and staff but could not explain the absence of the required signage.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Action: a. Administrator and Director of Nursing reviewed Covid-19 Comprehensive Policy and Procedure on 3/6/25. b. Administrator created and posted Covid-19 Vaccination signage available in lobby and on all units throughout the facility. c. Administrator in-serviced DNS and Infection Preventionist, and gave DNS and Infection Preventionist 1:1 educational counseling on signage posting regarding Covid-19 vaccine being available. II. Identification: a. On 3/6/25 Administrator and DNS reviewed signage on all units. b. Necessary Covid-19 vaccination signage noted missing. c. The facility respectfully states that all identified issues have been corrected. III. Systematic Changes: a. The Director of Nursing and Administrator reviewed and updated the Covid-19 Comprehensive policy and procedure to include posting of mandatory vaccination signage. b. DON in-serviced Infection Preventionist on 3/6/25. IV. Monitoring: a. Director of Nursing and Infection Preventionist created an audit to ensure Covid-19 vaccination signage is posted conspicuously throughout the facility. b. Administrator and DON will monitor all updates to Covid protocols by CDC and NYS. Any necessary signage will be added to policy and audit. Audits will be done quarterly for 1 year. Audits with negative findings will have immediate corrective action and reported to the Administrator for review and follow up. c. Audit findings will be presented to the QA committee quarterly by the Director of Nursing / designee. V. Responsibility: a. The Director of Nursing will be responsible to ensure correction of this deficiency.