10/09/2025

You Asked… We Answered…

You Asked: If our facility offers the flu vaccine but a resident refuses, what else do surveyors expect to see in the record?

We Answered:
Even when residents decline immunizations, documentation must still show that the facility met all requirements under F883 (Influenza and Pneumococcal Immunizations). Recent survey findings in Ohio have cited providers not because residents refused vaccination—but because education and follow-up were missing from the record.

According to CMS Appendix PP, surveyors will look for clear evidence that the resident or representative received education about the benefits and potential side effects of the vaccine before making a decision. The record must document whether the vaccine was offered within the required timeframe (October through March for influenza) and include the reason for refusal or medical contraindication. If the vaccine was temporarily unavailable, surveyors also expect documentation showing that the facility notified the resident or representative and reordered the vaccine promptly.

For practical steps and examples shared during the session, access the October STAT on Immunizations On Demand webinar on the LeadingAge Ohio Learning Center.

View the CDC’s guidance on the 2025/2026 flu season here.