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F0867
F

Repeat Deficiency in Immunization Compliance Due to Ineffective QAPI Monitoring

Franklin, Minnesota Survey Completed on 05-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively maintained ongoing compliance regarding immunization requirements, resulting in a repeat citation for influenza and pneumococcal immunizations. Specifically, review of records showed that three out of five residents reviewed for immunizations were not offered or provided the pneumococcal vaccine series as recommended by the CDC. Additionally, the Quality Assessment and Assurance (QAA) committee meeting minutes from April 2024 through May 2025 did not include ongoing data or monitoring related to this repeat citation, despite the facility's policy stating that performance improvement activities should be monitored for effectiveness and sustainability.

See complete original report
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