The Joint Commission recently announced elimination of the requirement for a 90% flu vaccination goal effective January 1, 2021. Currently, Infection Control standard IC.02.04.01 Element of Performance # 5 requires organizations to set “incremental influenza vaccination goals, consistent with achieving the 90% rate established in the National Influenza Initiatives for 2020.”

Rationale for this change is that in August the Health and Human Services Dept. removed the 90% goal in its publication “Healthy People 2030”.

Joint Commission Flu Vaccination Requirements

Although the 90% vaccination goal is being eliminated, it’s important to note the rest of the Joint Commission flu vaccination requirements remain in effect.

In its announcement, TJC stated “Organizations should continue to strive to increase compliance with influenza vaccinations and take action to improve vaccination rates. Moving forward, The Joint Commission will not score noncompliance if the organization has not reached 90%. Instead, we will review that organizations have a goal to improve influenza vaccination rates and have leadership support and processes in place to support achievement of these goals.” 

So, exactly what are the Joint Commission flu vaccination requirements that remain in effect? Specifically, you must do the following:

• Establish an annual flu vaccination program for staff and Licensed Independent Practitioners (LIPs.)
• Educate staff and LIPs about flu vaccine.
• For hospitals: Provide flu vaccination at sites and times accessible to LIPs and staff. (Note: The Behavioral Health standards allow organizations to facilitate staff obtaining the vaccine offsite.)
• Include in your Infection Control Plan the goal of improving flu vaccination rates.
• Have a written description of the methodology used to determine flu vaccination rates.
• Evaluate reasons why staff declined the flu vaccination.
• Improve your vaccination rates according to your established goals at least annually.
• Provide flu vaccination rate data to key stakeholders at least annually.

Thus, although TJC has removed the 90% goal per se, the requirements for a full-fledged flu vaccination program are very much still in effect. Notably, this includes setting your own goals to improve vaccination rates and collecting data to measure those goals.

Joint Commission Flu Vaccination: Survey Findings 

Several survey findings over the past few years have, indeed, been for organizations not establishing the 90% goal. As a result of the upcoming change, surveyors will no longer cite noncompliance for this issue.

At the same time, we caution you not to do away with goal-setting altogether for your flu vaccination program. Indeed, EP # 8 (in both the Hospital and Behavioral Health manuals) refers to goal setting.

Specifically, it states: “The hospital/organization improves its vaccination rates according to its established goals at least annually.” Clearly, surveyors will expect you to set reasonable goals based on your current performance and ongoing improvement efforts.

Joint Commission Survey Findings: Infection Control 

So, what other Infection Control findings are high on the radar for psychiatric hospitals and behavioral health organizations? Our database tells us the following topics have been frequent survey findings over the past few years:

• Observations of inadequate hand hygiene by nursing staff
• Lack of appropriate cleaning of medical supplies (e.g. glucometers)
• No high level disinfection for medical instruments (nail clippers, tissue snippers, and callus shavers)
• Expired medical supplies in the medication room
• Not including PHP/IOP and outpatient programs in the hospital’s Infection Control Plan
• Observations of unsanitary conditions in the kitchen and food storage areas
• Lack of an annual evaluation of the Infection Control Plan
• Lack of prioritization of infection risks in the Infection Control Plan

In addition, as TJC resumes surveys amidst the COVID-19 pandemic, they are, understandably, focused heavily on infection control issues. See more detail in our recent post Joint Commission Surveys: Infection Control Focus.

CMS Focus on Infection Control

Since the COVID-19 pandemic hit, we’ve had several of our psychiatric hospital clients undergo Infection Control Complaint Surveys by the State Survey Agency on behalf of CMS. These surveys are reportedly very intense.

For more info on the scope of these infection control surveys, see the following documents included in the CMS announcement on Suspension of Survey Activities on March 4, 2020:

• Attachment A- Survey Planning in Facilities with Active or Suspected Cases of COVID-19 Cases. This describes how surveyors conduct these infection control surveys.
• Attachment B- Infection Prevention, Control & Immunizations. This is the evaluation tool that surveyors use to score the facility’s compliance.

These tools give valuable insight to how CMS is scrutinizing hospitals in response to COVID-19 related complaints.

Barrins & Associates Consultation

We’re now conducting our Mock Survey and Continuous Readiness Consultations both virtually and onsite. As always, we’re prepared to support your ongoing compliance and survey readiness even in these challenging times!