MDS Alert

Take your best shot at immunizing eligible residents, coding W3.

To protect your residents from pneumococcal disease -- and your facility from lagging vaccination quality measures and related F tags -- stick with this three-point action plan.

Step 1: Know who should receive the vaccination and booster shots. That includes people 65 or older or younger people "living in environments or social settings (e.g. nursing homes and other long-term care facilities) in which risk of invasive pneumococcal disease or complications is increased," according to the RAI manual. People 65 or older should receive a second dose (booster) of vaccine if they received the first dose more than five years earlier when they were under 65 at the time, advises the manual. The CDC also recommends a second dose (booster) for people who are immunocompromised due to various conditions (see the list of conditions in the RAI manual, on the left below). People older than 10 years, including those who are 65 and older, who have any of the conditions spelled out by the RAI manual require the second (booster) dose five years after the first dose. But then they are finished, says Stephanie Mayoryk, RN, CIC, infection control nurse at Levindale Hebrew Geriatric Center and Hospital in Baltimore.

To vaccinate or not vaccinate short-stay residents: Levindale has a "chronic care" population, so it's chosen "to vaccinate everyone" against pneumococcal disease, says Mayoryk. But for short-stay residents under age 65 who aren't immunocompromised, the decision whether to provide the vaccination rests in the hands of the physician, she tells Eli.

Step 2. When in doubt, vaccinate. There are no data documenting reactions more serious than swelling and pain at the injection site in people who received two pneumococcal vaccinations less than five years apart, said Ray Strikas, MD, in a Centers for Medicare & Medicaid Services-sponsored Webcast on influenza and pneumococcal vaccination (www.cms.internetstreaming.com).

Proactive strategy: The admission staff at Levindale obtain the resident's immunization history when he comes into the facility, including talking with the admitting physician, according to the CMS Webcast. If they still can't determine whether a resident has received the vaccine, the facility will try to contact the resident's primary care physician office to see if it has documentation of the vaccination. If there's any question, "we vaccinate," said Susan Levy, MD, medical director for the facility, who presented during the CMS Webcast.

Step 3: Know how the immunization quality measured work and make sure you code the MDS correctly to take credit for vaccinations or exclusions. What you code at W3 determines the publicly reported postacute and chronic care quality measures. The QMs identify the "percent of eligible and willing residents with an up-to-date pneumococcal vaccination."

W3a asks whether the resident's pneumococcal vaccination status is up- to-date (0 = no and 1 = yes). If it isn't up to date, W3b explains the reason (1 = the resident isn't eligible to receive it, 2 = it was offered and declined or 3 = not offered).

Key pointer: Just because a resident has had a pneumococcal vaccination in the past doesn't mean he's up- to-date -- a fact that surveyors could uncover in reviewing a resident's records. "Facilities should have a protocol for evaluating residents to see if the person who's had a pneumococcal vaccination needs a booster," says Nathan Lake, RN, an MDS and long-term care expert in Seattle.

The pneumococcal vaccine QM's numerator includes residents who have an up-to-date vaccination (W3a = 1) within the six-month target period as indicated on the selected MDS target record (assessment or discharge). "The denominator is everyone with a valid MDS assessment or discharge tracking form for that six-month reporting period," says Rena Shephard, RN, RAC-C, MHA, FACDONA, president of RRS Healthcare Consulting in San Diego. Residents are excluded from the measure if the facility offered the vaccination to the resident but he or his responsible party declined it or the resident wasn't eligible to receive it.

If you code W3b as a "1," that would mean "the resident isn't eligible due to an allergic reaction to the vaccine, a physician's order not to immunize" -- or he had an acute febrile illness, "although the facility should vaccinate the person after the illness ends," says Shephard.

Key pointer: Putting a dash for "inability to determine" at W3a and/or W3b won't exclude a resident from the quality measure.