Corrective Action Planned: Management acknowledges the finding related to the lack of formal policies or procedures in place requiring independent review or approval of vaccine inventory reconciliations prior to submission of the Vaccine Order Form during the time of the audit. 1. Inventory Reconcil...
Corrective Action Planned: Management acknowledges the finding related to the lack of formal policies or procedures in place requiring independent review or approval of vaccine inventory reconciliations prior to submission of the Vaccine Order Form during the time of the audit. 1. Inventory Reconciliation Workflow and System Controls The State of Connecticut utilizes CT WiZ, a centralized vaccine ordering and supply management system. To maintain ordering privileges, the program enforces a strict regulatory safeguard: inventory must be fully reconciled every two weeks. Failure to complete this reconciliation triggers an automated, hard stop within CT WiZ, preventing any additional vaccine orders from being placed. To ensure absolute accuracy and data integrity, our practice executes a standardized, threepart reconciliation process that typically leverages a dual-provider verification model: • Part 1: Physical Count (Floor Staff): Clinical nurses on the floor conduct a manual, physical inventory of all vaccine doses, cross-referencing exact lot numbers and expiration dates. • Part 2: Electronic Health Record Alignment (Coordinator): The designated Vaccine Coordinator reviews the physical counts against the electronic Lot Manager log within Epic to identify and resolve any administrative discrepancies. • Part 3: State System Data Entry (Coordinator): The verified quantities are formally submitted into the CT WiZ portal to complete the biweekly cycle and clear the system for subsequent orders. Staffing Redundancy: While a single coordinator may occasionally manage all three steps if cross-covering the floor, the workflow is deliberately structured to divide tasks between floor nurses (physical counts) and site coordinators (via EMR reconciliation and CT WiZ entry). 2. Vaccine Oversight Team Vaccine operations are managed through a centralized leadership structure with site-specific accountability to ensure consistent oversight at clinic locations. Vaccine operations may be managed by a senior nurse practice manager, practice manager, lead nurse or a backup coordinator. This triad ensures continuous coverage, strict adherence to ordering schedules, and immediate troubleshooting for storage or inventory alerts. 3. Storage, Handling, and Annual Training Compliance In alignment with state oversight expectations and the strict guidelines governing CVP asset management, cold-chain integrity and proper handling are heavily protected. To mitigate risk and standardize knowledge across all care teams, the following educational requirements are mandated: • Mandatory Annual Training: All rostered nursing personnel - including core staff, float pool, and per diem nurses - are strictly required to complete annual training modules dedicated to CVP guidelines and CDC Storage and Handling. • Verification of Competency: Training must be completed through the official CDC TRAIN platform, and employees must submit their earned certificates of completion to clinical leadership to be maintained on file for audit readiness. Name(s) of Contact Person(s) Responsible for Corrective Action: Matthew Farr, VP Ambulatory Operations, Cynthia O’Brien, Senior Nurse Manager Practice Operations Anticipated Completion Date: 01/01/2026