HospitalInspections.org

Based on record review and interview, the facility failed to ensure that all staff had 100% compliance in COVID-19 vaccination (and/or exemption) status for all staff who are employed at the facility in 1 of 6 staff categories (facility staff).

Finding include:

A review of facility policy titled "Influenza and COVID-19 Vaccination Program" with a revision date of 2/23/2022 was reviewed. This document revealed "DEFINITIONS:...IV. Staff: All SSM employees, medical or profession staff, fellows, residents, students, instructors of academic affiliates, onsite volunteers, Contracted Personnel. Contracted Personnel are defined as on-site purchased service/vendor representative/temporary agency personnel/personnel with other arrangements, working within an SSM property and/or engaged in person with other staff or patients...PROCESS:...II. All staff must receive the SSM COVID-19 Required Vaccine or have an approved medical exemption, religious exemption, or Temporary Delay of COVID-19 Vaccine prior to performing work. A. This policy does not apply to: 1. Contracted personnel who infrequently provide ad hoc non-health care services (e.g., delivery, repairs and inspection) or whose tasks are performed outdoors (e.g., groundskeeping). 2. Contracted personnel who exclusively provide telehealth or telemedicine services outside of the hospital setting and who do not have any direct contact with patients and other staff. 3. Contracted personal who provide support services for the hospital that are performed exclusively outside of the hospital setting and who do not have any direct contact with patients and other staff. III. New Staff:..B. COVID-19: New staff must receive 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 or have an approved medical exemption, religious exemption, or Temporary Delay of COVID-19 Vaccine by their start date...VII. Recordkeeping A. Records will be maintained documenting vaccinations, boosters, exemptions, and COVID-19 temporary delays. VIII. Compliance: A. Staff who are not compliant with this policy will not be permitted to work. 1. The staff member's leader, institution or employer is responsible for ensuring compliance with this policy. 2. Employees who are not compliant with this policy will be placed on unpaid administrative leave until compliance is achieved. The employee will receive the next level of corrective action, at a minimum a written warning. 1. Employees who are not complaint with this policy by one month after the start of administrative leave will be dismissed and/or their medical staff membership or clinical privileges will be revoked. 2. Employees on approved leave of absence (e.g., FMLA, military) must be in compliance with this policy prior to returning to work."

During a review of facility documentation of COVID-19 vaccination there was a total of 2412 staff under the facility CCN #. Under the category of facility staff there was a total of 3 staff listed that had received 1 dose of COVID-19 vaccine and had been eligible for the second dose but had not received it. Lead Cook O had received first dose (of a 2 dose vaccine) on 1/22/2021 (14 months ago) and has never gotten the second dose. Surgical Technologist P had received first dose (of a 2 dose vaccine) on 8/8/2021 (7 months ago) and has never gotten the second dose. Clinical Partner Liaison Q had received first dose (of a 2 dose vaccine) on 2/21/2022 (6 weeks ago) and has never gotten the second dose. This gives the facility a vaccination compliance rate of 99.9%.

There was documentation for each of the 3 staff that the facility reached out to their managers to get vaccine status and/or ensure that these 3 employees receieved their second dose of vaccine.

This vaccination rate for staff of 99.9% was confirmed on 4/4/2022 at 4:15 PM with Employee Relations Director I, Employee Regulatory Manager J, Senior HR (Human Resources) Leader K, Regulatory Manager L, System Director M, Chief Nursing Officer B and Regulatory Specialist A.