HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure COVID-19 policies and procedures were followed and implemented as required, potentially placing staff and patients at risk for exposure to COVID-19. As a result, it was determined that the Condition for Participation 42 CFR 482.42, Infection Prevention Control Antibiotic Stewardship, was not met.

Findings include:

1. The Hospital failed to ensure that all Hospital staff were either fully vaccinated or had an approved religious/medical exemption, as required. (A-792 A)

2. The Hospital failed to ensure the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated is in place. (A-792 B)

A. Based on document review and interview, it was determined that for 30 of 3826 staff (approximately 1%), the Hospital failed to ensure that all Hospital staff were either fully vaccinated or had an approved religious/medical exemption, as required.

Findings include:

1. The Hospital's policy titled, "COVID-19 Vaccination Compliance (9/2/2021)" was reviewed on 3/14/2022 and included, "All covered persons are required to be fully vaccinated for COVID-19 or submit a waiver and receive an exemption by a deadline established [by hospital]."

2. On 3/9/2022, the CM'S (Centers for Medicare and Medicaid) Guidance for the Interim Final Rule -Medicare and Medicaid Program; Omnibus COVID-19 Healthcare Staff Vaccination, dated 12/28/2021, was reviewed and included, "Vaccination enforcement... Facility staff vaccination rates under 100% constitute non-compliance under the rule... Within 60 days after the issuance of this memorandum4, if the facility demonstrates that: Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and ... Less than 100% of all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule..."

3. The COVID-19 associate data presented on 3/14/2022 included that 18 associates had no vaccination or exemption data on record, and 12 associates had applied for a medical exemption, but had not been approved as of 3/14/2022.

4. During an interview on 3/15/2022 at approximately 9:00 AM, the Manager of Associate Health (E#4) stated that some of the data has not been submitted into the system. E#4 stated, "I am new to this role and am trying to catch up. The data may be available somewhere, but it is not completed as of now."

5. During an interview on 3/15/2022 at 12:30 PM, Director of Quality (E#5) stated that the Hospital uses the state of Illinois COVID deadline dates as their deadline dates for completion of vaccinations.

B. Based on document review and interview, it was determined that for 5 of 5 (E#6, E#7, E#9, E#10 and E#11)associates reviewed for weekly COVID testing, the Hospital failed to ensure a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated; or a process for tracking and securely documenting the COVID-19 vaccination status of all staff were in place.

Findings include:

1. The Hospital's policy titled, "COVID-19 Vaccination Compliance (9/2/2021)" was reviewed on 3/14/2022 and included, "Routine COVID-19 testing may be required for non-vaccinated employees per state guidelines."

2. An internal e-mail dated 9/16/2021, sent by Hospital Human Resources was reviewed on 3/15/2022 and included, "Per Illinois Governor J.B. Pritzker's guidelines, mandatory testing for all health care workers who are not fully vaccinated require weekly mandatory COVID-19 testing ... Beginning the week of October 3, 2021."

3. The individual weekly testing results of 5 randomly selected non-vaccinated employees were reviewed on 3/15/2022. The following active employees were missing weekly testing as follows:
E#6 (registered nurse - religious exemption) - no testing the week of 1/29/2022
E#7 (environmental services - religious) - no testing the week of 2/27/2022
E#9 ( Wellness Educator - no information on status) - only monthly testing was being done.
E#10 (Sitter - no information on status) - only monthly testing was being done.
E#11 (Patient Care Technician - no information on status) - no testing available

4. During an interview on 3/15/2022 at approximately 9:00 AM, the Manager of Associate Health (E#4) stated that the employees are not compliant with weekly testing. E#4 stated, "I track all the information, but I'm behind."

5. During an interview on 3/15/2022 at 12:30 PM, Director of Quality (E#5) stated that the Hospital uses the state of Illinois COVID testing requirements as their testing requirements for non-vaccinated associates whish requires weekly testing.