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835 S VAN BUREN ST

GREEN BAY, WI 54301

COVID-19 Vaccination of Facility Staff

Tag No.: A0792

Based on record review and interview the facility failed to follow their contingency plan for staff who are not fully vaccinated for COVID-19 in 1 of 1 COVID-19 Mandatory Vaccination policy.

Findings include:

A review of the facility policy, titled "COVID 19 Vaccination Policy", last updated 04/14/2022, revealed: "...Additional Measures for Unvaccinated Staff...may include...weekly testing...use a NIOSH (National Institute for Occupational Safety and Health) approved N95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients..."

On 06/02/2022 at 10:38 AM during interview with Systems Director of Quality X, when asked what plans are in place to mitigate the spread of COVID-19 for unvaccinated staff, Direct X stated, "We use the current strategies of using universal precautions for all employees, our procedure mask have been effective in the spread." Director X confirmed unvaccinated staff are not being required to do protocol testing and their policy says they "may" put extra precautions in place; Director X confirmed they are "not requiring extra precautions at this time" for the unvaccinated.