09/11/2025
Survey Tip of the Week: Vaccination Schedule
According to the State Operations Manual Appendix PP, F883, facilities must have an effective immunization program. This program must include collaboration with the medical director to develop resident care policies for immunization(s) that reflect current standards of practice and that include the vaccination schedule including mechanisms for recording and monitoring for administration of vaccines in accordance with national recommendations.
Facilities must also track residents’ vaccination histories to ensure new vaccine recommendations are offered to eligible residents. To support a resident’s right to make informed choices, facilities are responsible for providing residents or their representatives with education on the benefits and potential side effects of immunizations.
CMS requires facilities to follow the CDC and ACIP recommendations for vaccines. For up-to-date information on indications and timing of pneumococcal vaccines, CMS states facilities should refer to CDC’s ACIP Vaccine Recommendations and Guidelines website located at:
Facilities should also routinely monitor compliance using the surveyor guidance outlined in the State Operations Manual Appendix PP.
