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WESTERN MENTAL HEALTH INSTITUTE
COVID-19 Vaccination of Facility Staff
Tag No.: A0792
Based on document review, policy review, and interview, the facility failed to develop and implement policies and procedures to ensure all staff were fully vaccinated for COVID-19.
The findings included:
1. Review of the facility staff vaccination log provided during the entrance conference, revealed 31.9 % of staff remained unvaccinated.
2. Review of the facility's policy "Covid-19 Vaccination Information" undated revealed, " ...Employees...Beginning in December 2020, all...employees are offered vaccination with the [named] vaccine. Consenting employees may receive both full doses...All employees are screened upon hire for Covid vaccination status. If new hires have not had the Covid vaccine, they are offered the...upon hire..."
3. During an interview in the conference room on 3/22/2022 at 1:30 PM, the Chief Executive Officer verified the facility did not have a formalized policy at this time to address exemptions, a process for mitigation for staff who were not fully vaccinated, a process for new hires who were not fully vaccinated or a process to achieve a 100% staff vaccination rate.