HospitalInspections.org

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Item #1 - Vaccination of Staff

Based on document review and review of the hospital policy and procedure, the Critical Access Hospital failed to fully implement policies and procedures for COVID-19 vaccination of the hospital staff.

Failure to fully implement COVID-19 vaccination processes and procedures for the healthcare staff risks transmission of COVID-19 to patients, staff, and visitors.

Findings included:

1. Document review of the hospital's policy and procedure titled, "COVID-19 Vaccination Requirement," PolicyStat # 10358408, last revised 08/21, showed all health care workers in a health care setting in Washington State to be fully vaccinated for COVID-19 subject only to disability and religious exemption.

2. On 03/02/22, Surveyor #1 reviewed the hospital's COVID-19 vaccine tracking spreadsheet. The review showed that 81 out of 108 hospital staff were fully vaccinated for COVID-19. Thirteen staff members had an approved medical or non-medical exemption requests on file. Fourteen staff members had a pending exemption request on file with no action taken at the time of the review. Using the CMS Staff Vaccination Formula and Table, Surveyor #1 calculated the hospital's overall staff vaccination rate at 87.03 percent.

Item #2 - Approval of Exemption Requests

Based on document review, interview, and review of the hospital policy and procedure, the Critical Access Hospital failed to implement policies and procedures for staff requests for non-medical exemption and/or accommodations from COVID-19 vaccination for 14 of 25 staff files reviewed.

Failure to evaluate staff requests for exemption or accommodation for COVID-19 vaccination in a timely manner risks transmission of COVID-19 to patients, staff, and visitors.

Findings included:

1. Document review of the hospital's policy and procedure titled, "COVID-19 Vaccination Requirement," PolicyStat # 10358408, last revised 08/21, showed that the hospital will review the requests for exemption in a timely manner and coordinate any clarifications as quickly as possible.

2. On 03/02/22, Surveyor #1 reviewed 25 non-medical exemption requests that were identified from the hospital's COVID-19 vaccine tracking spreadsheet. The review showed 13 of the 25 files reviewed had an official approval form attached to the staff request for exemption. The other 14 files reviewed showed no official approval form attached to the staff request for exemption.

3. 03/03/22 at 11:00 AM, Surveyor #1 and #3 interviewed the Human Resources Manager (Staff #304) about the current status of the 14 hospital staff requests for exemption. Staff #304 confirmed that they did not follow the hospital's process to formally approve the 14 staff requests for exemption.

Item #3 - Tracking Booster Vaccination Status of Staff

Based on document review, interview, and review of the hospital policy and procedure, the Critical Access Hospital failed to develop and implement policies and procedures which tracked COVID-19 vaccination status of any staff who had received a booster dose as recommended by CDC.

Failure to develop and implement a tracking process for staff who receive a booster dose of COVID-19 risks delays in infection control outbreak investigations and transmission of COVID-19 disease to patients, staff, and visitors.

Findings included:

1. Document review of the hospital's policy and procedure titled, "COVID-19 Vaccination Requirement," PolicyStat # 10358408, last revised 08/21, showed that the hospital will maintain all records of COVID-19 vaccinations and exemptions.

2. On 03/03/22 at 8:15 AM, Surveyors #1 and #3 interviewed the Chief Executive Officer (Staff #303), Human Resource Manager (Staff #304), the Infection Control/Employee Health Manager (Staff #305), and the Chief Nursing Officer (Staff #306) about the COVID-19 vaccine mandate processes and procedures. Surveyor #3 asked Staff #305 if the hospital had a policy which addressed COVID-19 vaccine booster doses for staff. Staff #305 stated there was no policy currently in place. An email had been sent to staff informing them that booster doses were available but was not currently tracking those individuals who had received a booster dose.

3. On 03/03/22, Surveyor #1 and #3 reviewed the hospital's COVID-19 vaccine tracking spreadsheet. The review showed no column which tracked or documented those individuals which had received a COVID-19 booster vaccination.

Item #4 - Contingency Plan for Unvaccinated Staff

Based on interview and review of the hospital policy and procedure, the Critical Access Hospital failed to implement contingency plans that required additional precautions to mitigate the spread of COVID-19 diseases for unvaccinated staff who were granted an approved exemption.

Failure to implement contingency measures for unvaccinated staff who were granted an approved exemption risks transmission of COVID-19 to patients, staff, and visitors.

Findings included:

1. Document review of the hospital's policy and procedure titled, "COVID-19 Vaccination Requirement," PolicyStat # 10358408, last revised 08/21, showed that those individuals with approved exemptions will comply with all job restrictions, safety protocols, and safety requirements as directed for compliance with reasonable accommodations. Staff will wear appropriate personal protective equipment (PPE) specified for non-vaccinated applicable individuals for the period of time designated by management and/or infection control.

2. On 03/03/22 at 8:15 AM, Surveyors #1 and #3 interviewed the Chief Executive Officer (Staff #303), Human Resource Manager (Staff #304), the Infection Control/Employee Health Manager (Staff #305), and the Chief Nursing Officer (Staff #306) about the COVID-19 vaccine mandate processes and procedures. Surveyor #3 asked Staff #305 if the hospital contingency plan contain any additional precautions that non-vaccinated staff must take. Staff #305 indicated that there are no additional measures or actions required for non-vaccinated staff. All staff are required to wear masks, socially distance themselves, and wear appropriate PPE when indicated. There is no additional education or restrictions provided to non-vaccinated staff.

3. On 03/03/22 between 9:00 AM and 11:00 AM, Surveyor #3 interviewed a Registered Nurse (Staff #302) with an approved exemption about any precautions or special considerations she must take when caring for patients. Staff #302 stated she was not instructed to take any additional precautions and was to follow the same processes that vaccinated staff take when caring for patients.
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