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Based on review of QSO Memo 22-09-ALL Revised Attachment D, review of facility policy, review of facility COVID-19 vaccination records, and staff interview, the facility failed to implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 and failed to implement their process for ensuring 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 facility's percentage of vaccinated staff for COVID-19 was 83.1%. The facility census was 78.

Findings include:

Review of QSO memo 22-09-ALL Revised Attachment D, dated 01/14/22, revealed within 90 days of issuance of this memorandum, 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple vaccine series) or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Centers for Disease Control and Prevention (CDC). The memo also stated the hospital must develop and implement policies and procedures and the policies and procedures must include, at a minimum, a process for ensuring 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.

Review of the facility policy titled, COVID Mandate Vaccination Policy, effective 02/15/22, revealed all facility staff are required to have received at least one dose of a Food and Drug Administration (FDA) authorized COVID-19 vaccine by: January 27, 2022 for Florida facilities/February 13, 2022 for Ohio and Louisiana facilities and the final dose of a primary vaccination series by February 26, 2022 for Florida facilities/March 15, 2022 for Ohio and Louisiana facilities. The policy also stated that staff who receive an exemption to the COVID-19 vaccine will be subject to additional precautions to mitigate the transmission and spread of COVID-19 which includes: weekly testing will be done for exempted staff and staff who have not completed their primary vaccination series, until the regulatory requirement has been met; staff who have not completed their primary vaccination series are required to use a NIOSH approved N95 fit tested or equivalent mask for source control, regardless of whether they are providing direct care to or otherwise interacting with patients.

Review of the hospital's Employee Roster revealed there were 154 current employees. Review of the data provided by the Human Resources Director of the vaccination status for employees revealed there were 40 fully vaccinated staff, one staff member who received one dose of the vaccine, 87 staff with non-medical exemptions, one staff with a temporary delay and 25 staff without a documented status. The facility vaccination rate was calculated at 83.1 %. Review of the facility's infection control policy and procedure titled, Covid Mandate Vaccination Policy, effective date 02/15/22, revealed a section titled Additional Precautions and Contingency Plans for Unvaccinated Staff. Review of this section revealed staff who receive an exemption to the COVID-19 vaccination will be subject to additional precautions to mitigate the transmission and spread of COVID-19, which included: weekly testing, adhering to universal source control and physical distancing measures in areas that are restricted from patient access, and use of a NIOSH (National Institute for Occupational Safety and Health) approved N95 fit tested or equivalent mask for source control, regardless of whether they are providing direct care to or otherwise interacting with patients.

Interview with Staff G on 05/03/22 at 1:39 PM confirmed the facility vaccination rate was not meeting 100% compliance. Staff G provided the numerical data of employee vaccinations and confirmed unvaccinated staff had been working at the facility despite the facility policy's guidance that required all staff to be compliant by 03/15/22.

Random observations and interviews with eight staff, Staff H, I. J, K, L, M, N, and O, on 05/03/22 revealed the staff were exempted or had not been vaccinated. None of the eight staff wore N95 masks and only three of the eight staff, Staff M, N and O, stated in interviews that they were tested weekly because they were agency staff and were tested based on agency protocol.

Interview with Staff A on 05/03/22 at 2:15 PM confirmed surveyor observations of staff not wearing N95 masks as required in the facility's policy. Staff A confirmed the facility was not in compliance with the Centers for Medicare & Medicaid Services (CMS) mandate.

This deficiency substantiates Substantial Allegation OH00127907.