HospitalInspections.org

Based upon a reveiw of facility documents and interview (EMP) it was determined that the facility failed to provide adequate competency review and training for the power injector in the cardiac catheterization lab.

Findings:
1. Review of equipment service report, WO-00710348 (Serial Number: 300149; Model no: 60726793) reveals the piece of equipment was first placed into service on Aug. 23, 2018.
2. Review of annual competency training for staff in the cardiac catheterization lab reveals that competency for the power injector was not a component of the 2021 annual competency for the staff in the cardiac cath lab.
3. On March 16, 2022 at 10:52am, EMP4 confirmed that the staff did not have training/annual competency on the power injector in 2021.

Based upon a review of facility documents and interview (EMP) it was determined that the facility failed to establish policies and procedures regarding outpatient nursing services, establishing criteria for outpatient nursing services, established standards of practice for outpatient nursing services, and alternative staffing plans for outpatient nursing services.


The facility was unable provide nursing policies and procedures establishing which outpatient departments, are not required to have a registered nurse present. There is no evidence of nursing policy or procedure that identifies criteria, general level of acuity and the established standards of practice. The policies and procedures were requested but not provided These findings were confirmed by EMP1 on March 16, 2022 at 1:.30pm .

Based on a review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to have active hospital-wide programs for the surveillance, prevention, and control infectious diseases as evidence by failure to develop and implement policies and procedures to ensure that all staff were fully vaccinated for Covid-19 as evident by the failure to implement nine of ten components of the vaccine mandate (A-0792).

Based on a review of facility documents and staff interviews (EMP), it was determined that the facility failed to develop and implement policies and procedures to ensure that all staff were fully vaccinated for Covid-19 as evident by the failure to implement nine of ten components of the vaccine mandate.


Findings include:

A review of the facility's COVID-19 Vaccination Policy, last revised November 10, 2021, revealed, "Administration: As of November 1, 2021, all new hires will be required to provide proof of vaccination documentation demonstrating fully vaccinated status or an approved accommodation prior to their first day of employment. Active employees without an approved accommodation were required to have their first dose of their Covid-19 vaccination by January 28, 2022 and must be fully vaccinated and provided proof of vaccination documentation by February 28, 2022. Employees returning to work from an approved continuous leave of absence are expected to take steps to comply with this policy within 14 calendar days of returning to work. All employees are responsible to attest to their vaccination status. Employees are required to upload proof of vaccination documentation. There records of vaccinations will be maintained by Employee Health. Such records will not be included in the employee's personnel files. Contracted and Embedded Workforce Personnel (including independent contractor and agency staff) are expected to comply with this policy; however, will not be required to upload proof of vaccination. Accommodation Requests: Employees may be exempted from being fully vaccinated with an approved accommodation due to qualifying medical conditions or an approved religious accommodation. Temporary medical accommodations may be provided until the employee is medically cleared and, at which time, are provided with a reasonable amount of time to comply with this policy. Employees who are seeking a medical accommodation or religious accommodation will need to follow the request process via HR Services > HR Topics > Employee Resources > Employee Accommodations. In addition to Employees receiving a notice of approved accommodation, Employee Health will also mark the employee's accommodation as approved in the Employee Health record. Employees who are approved for an accommodation will be deemed unvaccinated for the purpose of adhering to the PPE and Masking requirements, or other requirements the Company may establish."

A review of facility documents revealed that there were no policies or processes in place for ensuring contracted and embedded workforce personnel (including independent contractor and agency staff) have received, at a minimum, a single-dose Covid-19 vaccine, or the first dose of the primary vaccination series for a multi-dose Covid-19 vaccine prior to staff providing any care, treatment, or other services for the hospital and/or its patients.

A review of facility documents revealed that there were no policies or processes in place for ensuring contracted and embedded workforce personnel (including independent contractor and agency staff) were fully vaccinated for Covid-19, except for those who have been granted exceptions to the vaccination requirements, or those for whom Covid-19 vaccination must be temporarily delayed.

A review of the facility's Employee Vaccination Status document revealed that only Allegheny General Hospital employees were included in Covid 19 vaccination tracking. Further review revealed that the tracking did not include students, trainees, volunteers, and individuals who provide care, treatment, or other services for the hospital and/or its patients, under contract or by other arrangement.

A review of the facility's Employee Vaccination Status document revealed that only Allegheny General Hospital employees were included in Covid 19 vaccination tracking of individuals who have obtained any booster dose as recommended by CDC. Further review revealed that the tracking did not include students, trainees, volunteers, and individuals who provide care, treatment, or other services for the hospital and/or its patients, under contract or by other arrangement.

A review of facility documents revealed that there were no policies or processes in place for which contracted and embedded workforce personnel (including independent contractor and agency staff) may request an exemption from the staff Covid-19 vaccination requirements.

A review of facility documents revealed that there were no policies or processes in place for tracking and securely documenting information provided by contracted and embedded workforce personnel (including independent contractor and agency staff) who have requested, and for whom the hospital has granted, an exception from the staff Covid-19 vaccination requirements.

A review of facility documents revealed that there were no policies or processes in place for ensuring that all documentation, which confirms recognized clinical contraindications to Covid-19 vaccines, and which supports contracted and embedded workforce personnel ' s (including independent contractor and agency staff) request for medical exemptions from vaccination, had been signed and dated by a licensed practitioner, who was not the individual requesting the exception, and who was acting within their respective scope of practice.

A review of facility documents revealed that there were no policies or processes in place for ensuring the tracking and secure documentation of the vaccination status of contracted and embedded workforce personnel (including independent contractor and agency staff) for whom Covid-19 vaccination must be temporarily delayed, due to clinical precautions and considerations.

A review of facility documents revealed that there were no policies or processes in place for ensuring a contingency plan for contracted and embedded workforce personnel (including independent contractor and agency staff) who are not fully vaccination for Covid-19.

During an interview on March 16, 2022, EMP1 confirmed that contracted and embedded workforce personnel, independend contractors, and agency staff are expected to comply with the facility's Covid-19 Vaccination Policy, however not required to upload into the facility's system proof of vaccination.