HospitalInspections.org

Item #1 Hospital's Vaccination Exemption Requirements

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure that contracted staff with an approved COVID vaccination exemption status were fit tested for an N95 mask as required by hospital's policy.

Failure to follow hospital's policy for N95 fit testing for contracted staff that have an approved COVID vaccination exemption places, patients, staff, and visitors at an increased risk of illness.

Findings included:

1. Document review of the hospital's policy titled, "Employee Health and Wellness" policy number 11405, effective date 02/08/22, showed contractors with an approved medical or religious exemption to the COVID vaccination will be required to wear a fit-tested N95 mask while indoors at the hospital, clinics, or other campus locations. The policy also indicated fit testing performed elsewhere is acceptable if written documentation is provided and that the testing demonstrates fitting to a mask stocked by the hospital.

2. On 3/23/22 at 11:00 AM Surveyor #1 interviewed a contracted staff member (Staff #101) about accommodations for an approved COVID vaccinantion exemption status. Staff #101 indicated he received education and was required to wear the hospital's N95 mask. Surveyor #1 asked staff #101 if he was fit tested for the N95 mask that he was wearing (3M 9205). Staff #101 said no, he indicated that he had been fit tested before at other facilities but not for the one he was wearing.

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Item #2 Additional Precautions/Contingency Plan

Based on document review and interview, the Critical Access Hospital (CAH) failed to address in the hospital's policy any additional safety precautions for staff who received only one dose of a multi-dose Covid vaccination series.

Failure to provide any additional safety precautions for staff who had only received one dose of a multi-dose Covid vaccination, places patients, staff, and visitors at risk of illness.


Findings included:

1. Document review of hospital's policy titled, "Procedure to Ensure Compliance with Mandatory Employee COVID Vaccinations" no policy number, no date, part (6) stated, "If the employee has received at least one dose of a vaccine and has an appointment to receive the second dose, they may be given a temporary fit for duty status."

2. On 03/23/22 at 12:45 PM Surveyor #1 interviewed the CEO (Staff #102) regarding hospital's policy for staff who have not completed covid vaccination series. Staff #102 indicated if staff have completed 1 of the 2 multi-dose Covid Vaccine Series they are considered "fit for duty". Surveyor #1 asked about any additional precautions for staff who have not completed their Covid vaccinations series. Staff #102 indicated that staff did not need any additional precautions. Surveyor #1 indicated during the exit that the policy as written does not meet CMS Guidance for the Interim Final Rule - Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination which indicated if staff is not fully vaccinated then additional precautions are required.
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