HospitalInspections.org

Based on the review of policy and procedure, facility documents, and interviews, it was determined that the facility failed to ensure:

1. the hospital's policies for COVID-19 vaccination of hospital staff were comprehensive; and

2. the hospital tested unvaccinated or incompletely vaccinated staff weekly for COVID-19.

These deficient practices have the potential risk for the spread of COVID-19 in the facility.

Findings include:

1. The following policies and procedures were reviewed during the survey.

COVID-19 MANDATORY VACCINATION-BEHAVIORAL HEALTH DIVISION, revision date 03/01/2022
COVID-19 MANDATORY VACCINATION-BEHAVIORAL HEALTH DIVISION-CONTINGENCY PLAN ADDENDUM, effective date 03/01/2022
ACCOMMODATIONS OF RELIGIOUS BELIEFS, effective date 12/06/2021
COVID-19 MANDATORY VACCINATION OR TESTING POLICY, effective date 12/06/2021
MANDATORY COVID-19 VACCINATION REQUIREMENTS AND COVID-19 MITIGATION PRECAUTIONS, revision date 01/20/2022
VALLEY HOSPITAL COVID-19 PLAN, 03/30/2022
Pandemic Virus (COVID-19) Response Plan for Behavioral Health, 03/30/2022

The hospital policies for COVID-19 vaccination of staff revealed that processes were not developed and/or implemented for the following.

1. The facility policies on staff vaccination requirements did not include a process to ensure staff obtain recommended booster doses or define when staff is considered fully vaccinated.

2. The facility policies on staff vaccination requirements did not include a process for tracking and documenting information confirming recognized clinical contraindications to COVID-19 vaccines provided by staff who have requested and been granted a medical exemption to vaccination.

3. The facility policies on staff vaccination requirements, testing requirements, and contingency plan contained conflicting information regarding testing requirements for unvaccinated staff.

Employee #6 confirmed on 06/29/2022 that the hospital's policies for COVID-19 vaccination of staff did not include the required processes as listed above.

2. The facility policy "COVID-19 MANDATORY VACCINATION OR TESTING POLICY, effective date 12/06/2021 requires: "...Requirements for Unvaccinated or Incompletely Vaccinated Employees...Asymptomatic unvaccinated or incompletely vaccinated employees are required to undergo diagnostic screening testing for COVID-19. These employees must also wear a face covering at the workplace at all times with limited exceptions noted below...Employees must be tested with either PCR testing or antigen testing weekly (at least once every seven days) for COVID-19...The facility should designate one HR contact and backup designee to receive and track all test results. Records of COVID-19 test results are considered to be employee medical records and must be maintained in the employee's confidential Medical File...."

Employee #6 confirmed on 06/29/2022 that the hospital employee COVID vaccine tracking document has not been tracked and monitored since the HR director left the facility in March 2022. Additionally, Employee #6 confirmed that the facility policy for weekly testing of unvaccinated or incompletely vaccinated employees was not implemented.