HospitalInspections.org

Based on interview and document review, it was determined the facility's policies and procedures failed to ensure that all staff are fully vaccinated or have been granted exemptions for COVID-19 for one (1) out of twenty (20) staff reviewed. The facility also failed to have a process for tracking and documenting the COVID-19 vaccination of all students who provide services within the facility.

The findings include:

On 03/02/22 at 4:14 pm, the surveyor conducted a live video and audio conference call with Staff Member #1 (Vice President) and Staff Member #14 (Associate Vice President of Human Resource Operations). The surveyor reviewed the COVID-19 tracking log of all staff who provide on-site facility services during this time.

The surveyor counted thirty (30) educational programs that provide greater than thirteen hundred (1,300) students with active privileges to provide on-site services with the facility.

The surveyor observed that students who were not associated with the facility-associated school (Virginia Commonwealth University) did not have a COVID-19 vaccination or exemption status.

The surveyor acquired the facility policy titled, "Vaccination Policy HR. EM. 016" (with last effective date of 01/27/22) from Staff Member #2 (Regulatory Affairs Manager) in the afternoon at 03/02/22.

The policy reads, "The non-employed team members' employer (ex. Contingent workers, volunteers, and student workers) must demonstrate compliance with vaccination or improved exemption. Those team members must present the documentation to the appropriate external agency or vendor."

Following questioning of this policy excerpt, Staff Member #14 stated that these outside employers have attested that their students are either fully-vaccinated or have an approved exemption.

During conference call, Staff Member #14 added that although the facility does not necessarily know the COVID-19 vaccination and exemption status of all students associated with the aforementioned educational programs, they must abide by the facility contract agreement that requires compliance with The Centers for Medicare and Medicaid Services (CMS) Omnibus COVID-19 Healthcare Vaccination Rule.

While on conference call with Staff Member #1 and Staff Member #14, the surveyor randomly reviewed the vaccination and exemption status of twenty (20) individuals providing care, including associate staff, contracted employees, vendors, volunteers, and students.

The surveyor observed Staff Member #17, a contracted employee who serves as an on-site Supply Chain Technician, was not fully vaccinated with an approved COVID-19 vaccination. More specifically, the surveyor observed Staff Member #17 received only one (1) of two (2) doses of the Pfizer COVID-19 vaccine on 03/01/2022, without any additional documentation supporting a need for a temporary delay, or an approved medical or religious exemption.

The surveyor verbalized both aforementioned concerns with Staff Member #1, Staff Member #2, and Staff Member #14 at approximately 5:30 pm on 03/02/22.