HospitalInspections.org

Based on interview and document review, the facility failed to ensure vaccination policies and procedures contained direction regarding additional infection control precautions for staff who were exempt from the COVID-19 vaccine in order to mitigate the spread of COVID-19 prior to staff providing any care, treatment, or other services for the facility and/or its patients.

Findings include:

On 3/10/22, the COVID-19 Staff Vaccination Instructions for Providers matrix provided by the facility indicated the facility employed 7249 staff. Of those, 6888 were partially or fully vaccinated, 361 staff were granted a religious or non-medical exemption. This was an 100% vaccination rate.

On 3/10/22, at 1:37 p.m. regulatory and accreditation program manager (RAPM) stated the facility had not directed additional infection control precautions, including additional testing, for staff who were exempt from the COVID-19 vaccine. RAPM stated the facility protocol included wearing a surgical source control mask and eye protection, and these requirements were the same for vaccinated and non-vaccinated staff members. RAPM further stated she had reviewed the CMS Hospital Attachment QSO-22-07-ALL memo dated 12/30/21, which indicated the hospital was required to implement additional infection control precautions for those staff who had not received the COVID-19 vaccination and had been granted a medical and or religious exemption. RAPM stated the hospital's current practice and policy was not in line with CMS guidance related to mitigating the spread of COVID-19 related to unvaccinated staff members.

On 3/10/22, at 8:05 a.m. radiology technician (RT)-A was interviewed and stated she was granted an exemption from the COVID-19 vaccine. RT-A stated she was not directed to utilize any additional infection control precautions. RT-A stated she was only required to wear a surgical mask and eye protection, which was the same personal protective equipment (PPE) requirement for all staff regardless of vaccination status.

On 3/10/2022, at 9:10 a.m. the director of employee health (DEH) and manager of employee health (MEH) were interviewed. DEH stated the current practice for employees who had been granted either a medical or religious exemption to receiving the COVID-19 vaccine included wearing a source control surgical mask and eye protection while providing cares. DEH stated there was not a concern related to PPE supplies, and the hospital had an adequate supply of COVID-19 testing supplies. MEH verified no additional infection control precautions were in place related to mitigating the spread of Covid-19 for those employees who had been granted a religious and or medical exemption.

The facility policy HealthPartners Colleague Vaccination Program Policy and Information Guide updated 1/17/22, directed colleagues with approved exemptions for certain required vaccines will wear medical grade PPE face masks and follow additional identified infection prevention and control standards, and other additional health and safety precautions identified by HealthPartners to mitigate the transmission and spread of disease.