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State of California—Health and Human Services Agency
California Department of Public Health

AFL 06-34
November 9, 2006

Skilled Nursing Facilities
Intermediate Care Facilities
Intermediate Care Facilities-Developmentally Disabled
Intermediate Care Facilities-Developmentally Disabled-Habilitative
Intermediate Care Facilities-Developmentally Disabled-Nursing
Correctional Treatment Centers
Facility Administrators
Infection Control Professionals

Standing Orders for Influenza Pneumococcal Immunizations

BACKGROUND: The Department of Health Services, Licensing and Certification program is issuing this letter to address recent legislation regarding the administration of Influenza and Pneumococcal immunizations to facility residents aged 50 or older by licensed professional caregivers.

This letter is intended to provide guidance for the provision and administration of these immunizations medications utilizing standing orders and without patient-specific orders in skilled nursing facilities (SNF), nursing facilities (NF) and intermediate care facilities (ICF). Previous legislation and guidance included:

  • Assembly Bill 691, signed into law in April 30, 2004, required all long term care facilities to offer influenza and pneumococcal immunizations to all resident in these facilities.
  • Long term care facilities serving Medicare and Medicaid (Medi-Cal) residents now must provide immunization against influenza and pneumococcal disease to all residents if they want to continue in those programs, in accordance to a federal rule passed in October 7, 2005 and as outlined in the AFL 20-31(dated November 18, 2002.
  • Standing orders are allowable in General Acute Care Hospitals, per California Code of Regulations (CCR), Title 22, Section 70263(h)-(h)(4), but prohibited in long term care facilities.

Assembly Bill 1711, signed into law in August of 2005, provided that influenza and pneumococcal immunizations pursuant to standing orders without patient-specific orders are permitted if the following criteria are met:

  1. The skilled nursing facility medical director, as defined in Section 72305 of Title 22 of the California Code of Regulations, has approved
    the immunization standing orders established by the facility.
  2. The standing orders meet the recommendations of the Advisory Committee on Immunization Practices (ACIP) of the federal Centers
    for Disease Control and Prevention.

Effective immediately, long term care facilities are encouraged to establish policies and procedures to implement the mandates of Health and Safety Code 1261.3 added by Assembly Bill 1711.

If you have questions about this letter, you may contact the Department of Public Health (CDPH), Licensing and Certification Program, Eric Creer at (916) 552-873-21. If you have any questions concerning the immunizations, you may contact Jon Rosenberg, M.D., of CDHS, Division of Communicable Disease Control at (510) 540-3233.


Original signed by Kathleen Billingsley

Kathleen Billingsley, R.N.
Deputy Director
Licensing and Certification Program

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