HospitalInspections.org

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Based on document review and interview the Critical Access Hospital (CAH) failed to implement a process that meets CMS COVID-19 Health Care Staff Vaccination requirements for contracted employees.

Failure to verify and document vaccination or exemption status of contracted staff members risk unvaccinated staff providing patient care or other services to the CAH which could lead to patient, staff, or visitor infection and associated negative health outcomes.

Reference: CMS; Critical Access Hospitals (CAH) Attachment QSO-22-07-ALL "Staff" refers to individuals who provide any care, treatment, or other services for the CAH and/or its patients, including employees; licensed practitioners; adult students, trainees, and volunteers; and individuals who provide care, treatment, or other services for the CAH and/or its patients, under contract or by other arrangement.


Findings included:

1. Document review of hospital's policy and procedure titled, "Washington State Covid-19 Vaccination Requirement" and "Vendor Declaration of Vaccination Status form" no policy number, no date, showed that vendors/suppliers must submit a Declaration of Vaccination Status form by 10/18/21 which indicated that the employer has verified proof of vaccination status of their own employees. The form also states that the hospital at anytime may request proof of vaccine verification from contractors.

2. On 03/16/22 between the hours of 8 AM and 12:00 PM Surveyor #1 interviewed the Employee Health Manager (Staff #101) regarding the process for vaccination verifications for contracted employees. Staff #101 provided a hospital policy which indicated that vendors/supplier must submit a Declaration of Vaccination Status form to ensure that their employees are fully vaccinated. Surveyor #1 requested to see "Agility's" (Biomedical Vendor) Declaration of Vaccination form. Staff #101 showed documentation that the form was emailed to the Vendor on 09/23/21 and a follow up email was sent on 10/06/21 to remind the vendor to return the Declaration of Vaccination form to the hospital. Staff #101 confirmed that the Declaration of Vaccination form was not returned to the hospital.
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