HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the facility failed ensure 100% compliance for the COVID-19 vaccination mandate.

Findings:

Review on March 24, 2022, of the facility policy, "COVID-19 Vaccination Program," last reviewed March 21, 2022, revealed "I. Policy To protect the health and lives of patients, employees, and visitors against COVID-19 and in furtherance of UPMC's compliance efforts with respect to local, state, and federal COVID-19 vaccination mandates, all Covered Individuals, as defined herein, shall be subject to the vaccination requirements set forth in this COVID-19 Vaccination Program. For purposes of this policy individuals are considered to be compliant if they have completed a primary vaccination series for COVID-19 or have an approved medical or religious exemption. The completion of a primary vaccination series for COVID-19 is based on the current federal definition. ... IV. Definitions ... Covered Individual - This vaccination requirement applies to all individuals who regularly and customarily provide services in a Covered Facility, regardless of clinical responsibility or patient contact. The requirement includes all current employees as well as any new employees who provide any care, treatment, or other services at the Covered Facility and/or for its patients. In addition to employees working at a Covered Facility, the mandate also covers volunteers; non-employed personnel who provide care, treatment, or other services at the Covered Facility and/or for its patients under contract or other arrangements; students enrolled in clinical rotations at UPMC-Covered Facilities; non-employed members of any UPMC-affiliated hospital medical staff; and suppliers or vendors who regularly and customarily provide services in a Covered Facility. ...V. Guidelines A. Covered Individuals are required to provide either proof of vaccination or submit a medical or religious exemption request. ..."

Review on March 24, 2022, of facility documentation revealed the total number of staff for the facility was 2578. There was documentation 93 staff were not fully vaccinated or were not granted a medical or religious exemption or temporary delay. There was documentation the facility was 96.39% compliant with the COVID-19 Vaccination Program.

Interview on March 24, 2022, with EMP1, at approximately 1430, confirmed the facility had 2578 staff and 93 staff were not fully vaccinated, or were not granted an exemption or delay. EMP1 confirmed the facility was not in 100% in compliance with the COVID-19 Vaccination Program.