HospitalInspections.org

Based on interview and facility document review, it was determined that the facility's COVID-19 staff vaccination policy failed to meet the standard of the regulation.

The findings included:

The facility's policy titled, COVID-19 Vaccinations, effective October 26, 2021 was reviewed in conjunction with staff COVID-19 vaccination documentation on 3/7/2022 through 3/9/2022. The facility's policy failed to contain the following required items:

1.) A process for ensuring implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19;

2.) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (g)(1) of the regulation;

3.) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by CDC;

4.) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the hospital has granted, an exemption from the staff COVID-19 requirements;

5.) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and

6.) Contingency plans for staff who are not fully vaccinated for COVID-19.

An interview was conducted with Staff Member (SM) #3 regarding the COVID-19 staff vaccination requirements and policy. SM #3 provided the surveyor with a list of the staff and their vaccination status, a list of physician's and their vaccination status, a list of vendors, students and volunteers, and the percentage of vaccinated employees. SM #3 explained how a student's vaccination status is verified and explained the verification process for contractors and vendors. The surveyor and SM #3 discussed the facility's policy and acknowledged that it did not contain all of the required items.

The information was reviewed again during the exit conference on 3/9/2022. SM #3 said the facility had already begun the process of updating the policy.