HospitalInspections.org

Based on observation, interviews and review of hospital documents, hospital staff failed to ensure all staff are fully vaccinated for COVID-19, have a pending request for or have been granted an exemption to vaccination, or have a need to temporarily delay vaccination. (18 of 1060 staff are affected).

The findings are:

Review of the hospital's compliance with the "Omnibus Health Care Staff Vaccination rule" was conducted while the surveyor was onsite for an EMTALA complaint investigation. On 3/07/22, the surveyor asked to be provided with vaccine documentation and hospital policies related to the COVID-19 vaccination rule. Review of the provided policy "Mandatory COVID-19 Vaccine Policy" revised 1/18/22 was completed on 3/9/22 with the assistance of Staff #2 and Staff #17. All required minimum components were present in the policy and/or the associated plan. The policy and plan are included in the hospital Emergency Preparedness Plan.

Review of documentation of staff vaccination status provided to the surveyor by Staff #6, found of 1060 staff; 956 staff were documented as fully vaccinated, 86 staff had a documented medical or religious exemption and 4 staff had documented temporarily delayed vaccination . This resulted in 98% compliance. Hospital staff are actively working toward achieving 100% compliance.

The above issues were discussed with staff during the review and summarized prior to exit on 3/10/22.