HospitalInspections.org

Based in interview and record review, the Facility failed to develop and implement policies and procedures to assure that all staff are fully vaccinated for COVID-19.

Per record review on 4/14/22 and 4/15/22, the Facility had protocols for COVID-19 testing, the proper wearing of PPE, symptom monitoring, and an algorithm for monitoring staff after an exposure. There was no evidence that the Facility had a process to ensure additional precautions to mitigate the transmission and spread of COVID-19 for all staff who were not fully vaccinated; a process for tracking and securely documenting the COVID-19 vaccination status of all staff; A process for tracking and securely documenting the COVID-19 vaccination status of any staff who had obtained any booster doses; A process by which staff may request an exemption based on applicable Federal Law and a way to track and securely document the information; a process that ensured documentation of medical exemptions were signed and dated by a licensed practitioner with the recognized clinical contraindications to COVID-19 vaccinations; a process for ensuring the tracking and secure documentation of the vaccination status of staff for whom a vaccination must be temporarily delayed; and contingency plans for staff who were not fully vaccinated for COVID-19.

Per interview with the Director of Regulatory Affairs and Manager of Infection Prevention on 4/14/22 and 4/15/22, the Director stated that as they only hire fully vaccinated staff, S/he felt that the Facility did not need to develop a policy to ensure that all staff are fully vaccinated for COVID-19. The Director confirmed that they have no formal process for tracking staff immunizations, and that the process is handled informally between S/he and another administrator.