HospitalInspections.org

Based on interview and document review, it was determined the facility failed to meet the standard of the regulation by not maintaining a policy that addresses all the required components of the regulation, as well as not ensuring all affiliate and non-affiliate staff are in compliance with the COVID-19 staff vaccination rule.

The findings include:

On 04/04/22 at 2:15 pm, the surveyor began reviewing COVID-19 vaccination records and policy and procedures with Staff Member #10 (Employee Health) and Staff Member #12 (Employee Health). The surveyor requested the COVID-19 records for all associate and non-associate staff, including employed staff, vendors, contracted staff, students, and volunteers.

The surveyor received the facility policy titled, "Required Associate Immunization Program," (with effective date of 2/23/22) from Staff Member #12 on 04/04/22 at 3:00 pm. The following are excerpts from the aforementioned policy:

"It is the policy of [facility] for associates and prospective associates to participate in the Associate Immunization Program requirements to ensure the health and safety of all [facility] patients, residents and associates".

"It is the expectation that all non-[facility] associates, contractors, affiliates, volunteers, and students also adhere to these requirements".

"Associates exempt from receiving the COVID vaccine are required to adhere to masking requirements even when the mask mandate is lifted. Additional measures may be implemented as needed."

"Dates of vaccination and deadlines for vaccination and exemption requests will be determined by Associate Health Services and Senior Leadership when vaccine availability becomes known."

"Vaccine Compliance: BSMH will comply [with] all federal and state guidelines. Associates out of compliance with published deadlines without an approved exemption, will be subject to progressive discipline, up to and including termination. Progressive discipline will occur retrospective to the established deadline for COVID vaccine requirement."


The surveyor identified the following components not clearly addressed in the policy:

"Ensure 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. The policy failed to clearly define the process of "additional" precautions used to mitigate the transmission and spread of COVID-19.

"Delineate a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by CDC. The policy did not address the process for tracking and securely documenting the COVID-19 vaccination for any staff who have obtained any booster doses.

"Include a process for tracking and securely documenting of COVID-19 vaccination status for non-associate staff, including vendors, contractors, students, and volunteers.

"Delineate a process for tracking and securely documenting information provided by those staff who have requested, and for who the hospital has granted, an exemption from the staff COVID-19 vaccination requirements. The policy did not address a process for the tracking and secure documentation of the COVID-19 vaccination statuses for all staff who are not fully vaccinated.

"Delineate a process for ensuring the tracking and secure documentation of the vaccination status of staff for who 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

"Delineate and enforce a contingency plan based on the CMS's COVID-19 vaccination deadlines. The facility's policy failed to clearly define the CMS established deadline for COVID vaccine requirement. During conversation with Staff Member #14 (Director of Employee Health) on 04/05/22 at approximately 1:30 pm, Staff Member #14 admitted that the facility did not incorporate the "Phase II" vaccination deadline date as addressed by CMS.


On 04/05/22 at 12:35 pm, the surveyor received the COVID-19 vaccination records for all associate (employed) staff. The surveyor identified there were 1,186 reported staff at facility.

The employee vaccination records indicated that 1,055 staff were fully vaccinated, 102 had approved medical or religious exemptions, and three (3) who met criteria for a temporary delay. The surveyor calculated a total of twenty-six (26) employed staff members who were not in compliance with the regulation.

The surveyor calculated the facility at 97.8% compliance with ensuring all employees were either fully vaccinated, had an approved exemption, or met criteria for a temporary delay.

Additionally, the surveyor sampled 15 random associate and non-associate staff members of varying roles to validate vaccination compliance. During review, both Staff Member #10 and Staff Member #12 confirmed that both Staff Member #15 (surgical technician employee), and Staff Member #16 (contracted agency nurse) did not have evidence of vaccination compliance as indicated by only being partially vaccinated with only a single dose of a multi-dose vaccination (Moderna and Pfizer, respectively).

The surveyor informed the concerns with Staff Member #12, as well as with both Staff Member #10 and Staff Member #14 via a live Zoom video conferencing call in the afternoon of 04/05/22. The staff members verbalized understanding of the surveyor concerns without additional questions.