HospitalInspections.org

Based on observation, interviews and review of hospital documents, hospital staff a) failed to include in hospital policy 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 and b) failed to ensure all staff are fully vaccinated for COVID-19, have a pending request for or have been granted an exemption to vaccination, or have a need to temporarily delay vaccination. (291 of 6643 staff were affected)

The findings are:

Review of the hospital's compliance with the "Omnibus Health Care Staff Vaccination rule" was conducted while the surveyor was onsite for a complaint investigation. On 2/23/22, the surveyor asked to be provided with vaccine documentation and hospital policies related to the COVID-19 vaccination rule. The surveyor was provided with a document titled "CMS Covid-19 Vaccination Policy" origin date 11-2021, effective date 11-2021. Review of the provided policy for the required components, failed to find a process for ensuring the implementation of additional precautions for all staff not fully vaccinated. "CMS Covid-19 Vaccination Policy" read in part under C. Accommodation and Exemption Requests; "7. Employees receiving an exemption will be expected to comply with additional precautions intended to mitigate the transmission and spread of Covid-19." Staff #7, #8 and #9 were asked what the additional precautions are and if the additional precautions had been implemented. Staff were unable to provide the surveyor with this information. The surveyor learned during the discussion all staff are required to wear a mask and complete a screening process but no extra precautions are required of those individuals who are not fully vaccinated. Staff #9 stated they (management) would be revising the policy and would begin work on it immediately.

The surveyor was unable to return to the hospital the next day due to unforeseen circumstances and returned to complete the survey on 2/28/22. On 3/1/22, the surveyor was provided with the revised policy which now read in part as follows: "unvaccinated employees will be required to adhere to additional precautions comprising one or more of the following: i. Continued practice of universal masking, including higher level respirator masks for source control, ii. Continued social distancing in non-patient areas, iii. Continued daily attestation of symptom and exposure history prior to coming to work, iv. Regular COVID-19 viral testing based on CDC recommendations." Staff #7 and #9 discussed the revised policy with the surveyor. When asked what additional precautions are in place right now, the surveyor was again told that all employees are wearing masks and screening for COVID symptoms and exposure prior to work. Staff #9 stated the belief was that the hospital had 90 days to be in compliance with the regulation. It was determined during a discussion with Staff #9 they were looking at guidance related to enforcement action. Although the policy had been revised, Staff #9 confirmed unvaccinated employees currently do not take additional precautions.
The surveyor informed Staff #9 and Staff #7 the expectation is for policies and procedures to have been developed and implemented within 30 days of the issue of the memorandum. Prior to the surveyor's exit on 3/1/22, Staff #9 presented the surveyor with a second revision of their policy which contained requirements for additional precautions for unvaccinated employees with an effective date of 3/1/22, to be immediately implemented.

Review of documentation of staff vaccination status provided to the surveyor found the following data: of 6643 total staff; 5913 staff documented as fully vaccinated, 115 staff were partially vaccinated, 322 staff had a documented medical or religious exemption and 2 staff had a temporarily delayed vaccination status. 291 staff remained unvaccinated which resulted in 96% compliance. Hospital staff are actively working toward achieving 100% compliance.

The above issues were discussed on multiple occasions with the management team during the survey and summarized prior to exit on 3/1/22.