HospitalInspections.org

Based on interview and document review, the facility failed to develop and implement policy and procedures to ensure that all staff are fully vaccinated for COVID-19 resulting in the potential for poor outcomes for all 165 patients receiving services at the facility.

Findings include:

At 0935 on 02/02/22, during review of document titled, "Policy and Procedures, #112, Covid-19 Health Care Staff Vaccination" (Rev. 02/02/22, "Draft until approved"), it was revealed that the policy failed to; (1.) Provide processes for staff to request medical or religious exemptions from Covid-19 vaccination mandates (2.) Provide a process for ensuring that all documentation, which confirms clinical contraindications to COVID-19 vaccines, has been signed and dated by a Licensed Independent Practitioner. (3) Provide 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 for COVID-19. (4.) Provide 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 (5.) Provide contingency plans for staff who are not fully vaccinated for COVID-19.

On 02/02/22 at 0900, an interview was conducted with the Director of Quality (Staff B). Staff B was queried 'if the facility had written policy and procedure for the vaccination of staff against Covid-19', Staff B replied, "I just wrote it this morning. The office assistant is formatting it right now. Staff were receiving emails for directions on vaccination requirements." Staff B was then asked, 'what is the process for staff to request medical exemption from Covid-19 vaccination' to which Staff B stated, " We don't have a written process. It's 'learn as you go', honestly. The request process was put into place a week before the January 27 deadline. The Central Office makes the employee go online and fill out a 'CS (Civil Service) 1668 Disability Accommodation Request by Employee' form. Physicians are refusing to sign them because the physician doesn't feel the person is Disabled." Staff B was then questioned regarding the process for staff to request 'religious exemption' status from Covid-19 vaccination. Staff B stated, "I'm not sure they have a form for that. The process would be the same, they file the same form as they would for medical exemption.".