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Based on a review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to have active hospital-wide programs for the surveillance, prevention, and control infectious diseases as evidence by failure to develop and implement policies and procedures to ensure that all staff were fully vaccinated for Covid-19 as evident by the failure to implement nine of ten components of the vaccine mandate (A-0792).

Based on a review of facility documents and staff interviews (EMP), it was determined that the facility failed to develop and implement policies and procedures to ensure that all staff were fully vaccinated for Covid-19 as evident by the failure to implement nine of ten components of the vaccine mandate.


Findings include:

A review of the facility's COVID-19 Vaccination Program Policy, dated February 4, 2022, states the following:

"Covered Individuals wo are not included in the submission requirements of Article V, Sections, B or C above (i.e. individuals performing services at a Covered Facility through a vendor, supplier, or other entity under a third-party contract, including but not limited to a master services or other agreement with a UPMC-affiliate entity) are required to submit proof of vaccination or exemption request as outlined below.

Primary non-employed staff groups include, but are not limited to:

Students: Each academic institution shall be responsible for maintaining and managing student vaccination records and approved medical or religious exceptions to ensure compliance with this policy. Students engaged in clinical rotation or otherwise providing services at a UPMC affiliated entity in conjunction with an educational program shall submit proof of vaccination or exemption request directly to their academic institutions.

Vendors: Each vendor shall be responsible for compiling, maintaining, and managing proof of vaccination records and approved medical or religious exceptions for its own employees, sub-contractors, or other individuals covered by this policy to ensure compliance with the requirement set forth herein."

1. A review of facility documents revealed that there were no policies or processes in place for ensuring students and vendors have received, at a minimum, a single-dose Covid-19 vaccine, or the first dose of the primary vaccination series for a multi-dose Covid-19 vaccine prior to staff providing any care, treatment, or other services for the hospital and/or its patients.

2. A review of facility documents revealed that there were no policies or processes in place for ensuring students and vendors were fully vaccinated for Covid-19, except for those who have been granted exceptions to the vaccination requirements, or those for whom Covid-19 vaccination must be temporarily delayed.

3. A review of facility documents revealed that there were no policies or processes in place for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of Covid-19, for students and vendors who are not fully vaccinated for COVID-19.

4. A review of facility documents revealed that there were no policies or processes in place for tracking and securely documenting the COIVD-19 vaccination status of students and vendors.

5. A review of facility documents revealed that there were no policies or processes in place for tracking and securely documenting the COVID-19 vaccination status of students and vendors who have obtained any booster doses as recommended by CDC.

6. A review of facility documents revealed that there were no policies or processes in place by which students and vendors may request an exception from the staff COVID-19 vaccination requirements.

7. A review of facility documents revealed that there were no policies or processes in place for tracking and securely documenting information provided by students and vendors who have requested an exception from the staff COVID-19 vaccination requirements.

8. A review of facility documents revealed that there were no policies or processes in place for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19, and which supports students and vendors request for medical exemptions from vaccination, had been signed and dated by a licensed practitioner, who was not the individual requesting the exception, and who was acting within their respective scope of practice.

9. A review of facility documents revealed that there were no policies or processes in place for ensuring the tracking and secure documentation of the vaccination status of students and vendors for whom COVID-19 vaccination must be temporarily delayed, due to clinical precautions and considerations.

On March 18, 2022, at 1:45 PM, EMP1 explained that the faclity could obtain vaccination and exemption information of students from the academic institution, upon request. Additionally, EMP1 explained that the facility could obtain vaccination and exemption information of vendors from a "contractors' [web]site."

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure the maintenance of recognized national standards of clinical practice in one of 10 medical records reviewed (MR1).
Findings include:

On March 17, 2022, policy HS-OR0001* states, "Prevention of Wrong Site, Wrong Procedure and Wrong Person Surgery or Invasive Procedure: Surgical Cases" (Last Updated- July 1, 2021). Section F. "Time Out" (Immediately Prior to the Procedure) states: "1. The RN circulator will verify the patient's identity orally with the patient (if possible) and with the surgical team by comparing the name on the patient's identification band (if accessible), medical record and/or patient label. 3. Active communication among all members of the surgical team/procedure team consistently initiated by a designated member of the team is used to confirm: ...procedural site, laterality, patient position, procedure site is marked and is visible ...4. The "Time Out" is an active process and is to be conducted in the location where the procedure will be done and immediately prior to the start of the procedure. Everyone will suspend other duties. 6. Should any discrepancies be identified during the "Time Out," a "Condition Stop" will be called and the procedure will not proceed until the discrepancy has been resolved."

1.On March 17, 2022, a review of MR1 revealed that the surgical time out was completed and documented and that the surgical team failed to confirm procedure site, laterality, and visualize the procedure mark prior to initation of the procedure.

On March 17, 2022, the above findings were confirmed by EMP2 at 1:39PM, and confirmed by EMP3 at 1:45PM.