HospitalInspections.org

Based on document review and interview, it was determined that for 5 of 539 staff, the Hospital failed to ensure that all Hospital staff were either fully vaccinated or had an approved religious/medical exemption, as required. This has the potential to effect all Patients, Visitors, and Staff serviced at the facility with average daily census of 65.

Findings include:

1. The Hospital's policy titled, "Vaccination and Immunity Validation Program" (effective 2/2/2022), was reviewed on 4/25/2022 at approximately 1:00 PM. The policy required, "E. Required Immunizations: 1.) OSF Mission Partners are required to complete any vaccination series while employed. Mission Partners not in compliance with this policy will be subject to Positive Discipline up to and including termination. 2.) Occupational/Employee Health will monitor compliance and notify the operational leader of any OSF Mission Partner who is not in compliance with this policy."

2. A Frequently Asked Questions publication Titled "Required COVID-19 Vaccinations for Mission Partners" (updated 11/3/2021) addressed to all staff and distributed to all was reviewed on 4/25/2022 at approximately 1:30 PM and included, " ....'Fully Vaccinated' is defined by Illinois executive order as two weeks after receiving the one-dose Johnson & Johnson vaccine or two weeks after receiving the second dose of either of the two-dose vaccines from Moderna and Pfizer."

3. The Hospital's Workforce COVID-19 Vaccination Tracking Sheet (received 4/26/2022) was reviewed on 4/26/2022 at approximately 10:15 AM and indicated that the Hospital had a total of 539 workforce staff (includes contracted staff per the Manager of Employee Health (E#3). Lists of staff that were unvaccinated, partially vaccinated, had approved/pending exemptions, were reviewed and indicated that 5 staff were partially vaccinated with no follow-up noted for completing vaccination doses.

4. An interview was conducted with the Manager of Employee Health (E#3) on 4/26/2022, at approximately 10:30 AM. E#3 verbally agreed that the 5 staff were considered unvaccinated and that the staff "must have fell through the cracks". E#3 also confirmed that the 5 staff were currently continuing to actively care for patients and stated, "We will pull these colleagues into the office and follow-up with them."