HospitalInspections.org

Based on record review and interview, the facility failed to ensure that a documentation system is in place to determine the vaccination (and/or exemption) status for COVID-19 for all staff who are employed at the facility in 1 of 4 staff categories (contracted independent providers).

Finding include:

A review of facility policy titled, "COVID-19 Illness Prevention" #3101 last revision date 09/22/2021 revealed, "The COVID-19 vaccine will be required for all ThedaCare team members and providers, as well as anyone who works inside facilities including independent affiliated providers and medical staff members, contractors, volunteers and students. Full vaccination is required by November 22, 2021, meaning the complete two-dose series for Pfizer or Moderna, or one dose for Johnson & Johnson. Limited exemptions for specific medical or religious reasons will be considered...ThedaCare requires that, in the absence of granted medical or religious exemption, team members and other staff receive the COVID-19 vaccine. ThedaCare will communicate to team members and other staff the availability and requirements for vaccination. If you receive the COVID-19 vaccination outside a ThedaCare work environment, you are required to provide proof of vaccination to your leader of Employee Health."

During an interview with Senior Vice President of Operations I stated, "I am very confident due to conversations during meetings, the hospital staff including medical staff is over 95% with the vaccine compliance policy however we just don't have a process in place to account for the documentation of the independent medical providers." Senior Vice President of Operations I stated, the facility is in the midst of creating a system to maintain the physicians' status with vaccinations."

During a review of facility documentation of COVID-19 vaccination, there were 1,890 confirmed, Employees, Independent Providers, Privileged Providers and Students total. There was 1,538 total staff with confirmed documentation of completion of the vaccination or approved exemptions (81%).

During a review of facility documentation of COVID-19 vaccination, there was 413 independent medical providers that come into the hospital, however the facility only received confirmed documentation that 61 of the providers have documented that they have received the COVID-19 vaccination.