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THOREK MEMORIAL HOSPITAL
COVID-19 Vaccination of Facility Staff
Tag No.: A0792
Based on document review and interview, it was determined that the Hospital failed to ensure compliance regarding COVID-19 vaccination of all staff, as part of the Hospital's infection prevention and control program. This potentially affected any patient or staff for cross infection.
Findings include:
1. On 3/9/2022, the Facility's policy titled, "COVID-19 Vaccination" (revised on 12/2021) was reviewed and required, "... (The Hospital) has adopted this policy on mandatory vaccination to safeguard the health of our employees from the hazard of COVID-19... Employees must submit an exemption medical certificate from this mandatory vaccination policy if the vaccine is medically contraindicated for them or medical necessity requires a delay in vaccination..."
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 30 days after issuance of this memorandum, if a Facility demonstrates that... Less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exception, or identified as having a temporary delay, as recommended by the CDC, the facility is non-compliant under the rule..."
3. On 3/9/2022, the Hospital's staff vaccination data (undated) was reviewed, and indicated that 98% of staff received one dose of COVID-19 vaccination. There were six (2%) staff who have not received at least one dose of COVID-19 vaccination. Of the six, there was no documentation for the five staff regarding pending request for either medical or religious exemption, or having temporary delay to receive the vaccine.
4. On 3/10/2022, an interview was conducted with E #11 (Chief Nursing Officer). E #11 could not provide documentation regarding either medical or religious exception or having temporary delay for the five staff. E #11 stated, "I don't have it."