Medicare Compliance & Reimbursement

Document carefully when residents refuse shots.

Long-term care providers may want to greet this flu season with a pen in one hand and a needle in the other. Effective immediately, nursing homes must either immunize residents for influenza and pneumococcal disease when medically appropriate or document refusals.

That's the final word from the Centers for Medicare and Medicaid Services, which on Oct. 7 made good on its pledge to make stringent immunization standards a condition of participation for Medicare and Medicaid.

To participate in the programs, nursing homes are now required to ensure that residents receive both influenza and pneumococcal immunizations when medically appropriate.
 
"[The feds] are sending the right message," says Paul Drinka of the American Medical Directors Association. But the timing may be particularly tough for nursing homes, which already face a slew of changes related to Medicare participation, from CMS' expedited review appeals program to Medicare Part D.

Note these exceptions: The resident or the resident's representative can refuse the shots, reminds Drinka. Also exempt are those who cannot receive the vaccines for medical reasons. But it's up to the staff to carefully document such cases. Fail to, and you could face costly citations or even a loss of certification.

Specifically, the rule requires that long-term care facilities ensure that each resident is:

• offered flu immunization annually;

• immunized against influenza unless medically contraindicated or when the
resident or the resident's legal representative refuses immunization;

• offered pneumococcal immunization once if there is no history of immunization; and

• immunized against pneumococcal disease unless medically contraindicated or when the resident's legal representatives refuse immunization. The final rule also requires that nursing homes educate the resident or his family about the pros and cons of receiving the vaccines.

"Improving immunization is a key element of our quality improvement strategy--a strategy that is focused on preventing illnesses and complications in the first place," said CMS administrator Mark McClellan in a prepared statement.

McClennan noted that more attention to immunization policies might save facilities money in the long run. "Greater use of flu shots and pneumococcal vaccine in nursing homes is a proven approach to better health and fewer costly complications for one of our most vulnerable groups of beneficiaries."