HospitalInspections.org

Based on observation, review of facility documents, and staff interview (EMP), it was determined that the governing body failed to ensure that the contracted service for environmental services was provided in an effective manner.

Findings include:

1. On March 8, 2022, an escorted tour of the facility with EMP1 revealed the following:

10:35-10:59am: A tour of E8 Rooms 809-825 with EMP1, EMP4, and EMP5 revealed sinks outside of rooms E812, E815, E817, and outside of the medication room located across from nurses' station had a buildup of an unknown substance on sink heads, around the sinks, and in the corners of the counters around the sinks. The colors of the buildup varied from white, yellow, black, pink, and green. This tour also revealed dust, eraser, remnants, and crumbs on a computer workstation outside of E813, empty hand sanitizer outside of room E814, and small dead bugs and dust on a window ledge outside of room E815. An open, uncovered garbage can was found in a hallway that visitors and patients have access to outside of the conference room.

11:00-11:15am: A tour of E8 Rooms 801-808 and 826-834 with EMP1, EMP4, and EMP5 revealed sinks outside of rooms E802, E805, E828, and the sink in front of the nurses' station on that side had a buildup of an unknown substance on sink heads, around the sinks, and in the corners of the counters around sinks. The colors of the buildup varied from white, yellow, black, pink, and green. The tour also revealed layers of dust in nurses' station on this side, specifically on the counters where glucometers are held. At the sink across from the nurses' station on this side, there was a double outlet with the top outlet covered by cream colored tape. Unknown to staff as to why it was covered. Unknown to facilities personnel as to why it was covered. Dust was also layered and falling off the cactus sink in the hallway next to the Omnicell.
The connecting hallway in the back of the unit is obstructed by a stretcher on the right side of the hallway and two Welsh Allyn VS machines on the right. In addition, the storage alcove, on the left is spilling into the hallway and contains the following: linen cart; empty soiled linen hamper, a stainless steel cart and five workstations on wheels.
11:18am: There are three light fixtures on the ceiling outside of the elevators on E9. The middle and right light fixtures had dark spots in them that were unknown bugs or dirt. Also observed dust and small dead bugs on the window ledge. EMP1 confirmed the above.
11:19am: E9 computers on wheels were observed to be covered in a layer of dust that discolored the bottom of them to a gray/black color. EMP1 confirmed the above.
11:36am: Observed dust and small dead bugs on window ledge outside of elevators on E7. Infection Control Permit for construction expired 12/31/2021. EMP1 and EMP6 confirmed the above.
11:53am-12:20pm: A tour of the MICU located on E7 with EMP1, EMP6, EMP8, and EMP9 revealed heavy layers of dust on things such as supply carts, window ledges, storage/disposal bins, on top of hand sanitizer dispensers, computers on wheels, door handles (push handles), and on computer workstations outside of patient rooms. Build up around the sink outside of room E734 that appeared white to yellow in color. Clumps of dust on the floor in the corners of the unit as well as under a black cart labeled "PAPRS ", supply carts, under sinks, and under workstations. There were various pieces of trash on the floor of the unit. An unknown dried substance was observed on the top of various supply carts. There was a procedure cart outside of room E725 that was found unlocked but not being used.
In addition, biohazardous and regular trash bins/carts are noted to be full inside the soiled utility room in the MICU. EMP6 states that trash is picked up by EVS once in the AM and once in the PM.
There was not a designated space for soiled equipment as dirty posey alarms and IV poles were located on the top shelf above the sink. Baer huggers were located (1 each) on the right and left side of the sink. A soiled potty chair was on the right side of the soiled utility room next to a broken chair and a broken recliner.
EMP6 stated he just "tried" to keep a clear path through the soiled utility room.
The cord coil from the medical grade extension cord between rooms 731 and 732 were full of dust clumps.
12:24pm: Clumps of dust were observed on the window ledge outside of E elevators on the second floor. Below the ledge there was also a bench that was heavily stained with unknown substances. EMP1 confirmed.
2. On March 8, 2022, at approximately 1:00pm, EMP16 explained the quality control process for the environmental services team which includes 15 room inspections per manager per week (total of 45 inspections per week), management rounding, and assuring cycle cleaning per the cycle logs. In addition, there is a quarterly business plan review between the contractor and hospital senior leadership. EMP16 also explained that the quality focus for the department has been to improve HCAHPS scores.
3. On March 8, 2022, a review of the Master Services Agreement with the contracted entity, dated 12.4.19, Article 1, EVS Services, 1.3 " Cleaning Specifications- The EVS Services will be performed in accordance with the cleaning specifications attached hereto as Exhibit A-1-(a) "
Review of Exhibit A-1-(a), on March 8, 2022, reveals the following:
Dust/sweep halls, lobbies, picture frames, hand rails, etc., all surfaces daily and as needed. Frequency- As needed M/W/F.
Trash- regular, biohazard, and hazardous waste in all locations including administrative offices, work rooms and break rooms. Frequency- 3 times daily. On March 8, 2022, EMP16 explained that trash pick up and disposal takes approximately 15 minutes per unit. There is one employee assigned to trash pick up on each tower.
Procedural areas- high/low dust including vents. Frequency- daily.
4. On March 8, 2022, a review of POL-5126102, Quality and Performance Improvement Plan- CY- 2022 (Approved: 01/18/2022) was reviewed.

Performance Improvement Oversight Committee (PIOC) (page 2): ' In alignment with the AHN QSV Committee of the Board, this committee is chaired by the Chief Medical Officer and co-chaired by the director of Quality. The committee monitors the development of hospital quality goals, sets priorities concerning quality improvement projects, and measures and analyzes data trends for key quality, safety, and value metrics. By recommending changes in policies and procedures, providing guidance and prioritizing quality improvement work, the committee implements the standards, regulations, and guidelines of the accrediting licensing bodies while supporting continuous improvement efforts to drive the highest quality of patient care. Member ship in PIOC includes representation from medical, nursing, ancillary and administrative staff. PIOC incorporates the following activities and/or hospital functions:
· Quality and performance improvement/outcomes measurement
· Safety (environment of care)..."

"Information gathered is integrated and presented to the PIOC for review and evaluation. Assessment tools include but not limited to:
· AHN Dashboards/WPH Dashboards
· Institute Reports/Departmental
· Quality Improvement Reports
· Team Observations and Feedback
· Regulatory Agency Evaluations
· Patient Experience Survey Results
· Patient Safety Committee Reports
· Staff Input from Safety Surveys "

Based upon a review of Attachment A, PIOC reporting schedule, Facilities was scheduled to report to PIOC on June 15, 2021, and Environmental Services was scheduled to report to PIOC on Sept. 21, 2021. Each department received 10 minutes to update the team on their quality measures for 2021.

Minutes from 14 meetings were reviewed (Jan. 19, 2021 through Feb. 15, 2022) for content.

On June 15, 2021, the update to the PIOC Committee from Facilities Management was regarding the installation of water filling stations throughout the hospital.

On Sept. 21, 2021, the focus of the update to PIOC from Environmental Services focused upon HCAHPS scores for the department and the noted improvement.

Quality, Safety, Value Board meeting minutes were reviewed for November 23, 2021. Minutes include the Safety Management- Performance Management Indicators for the Environment of Care. However, minutes do not include detailed, quantitative data slides. Of note, the entirety of this information is not noted in the PIOC meeting minutes.

Based on a review of facility documents, medical records (MR), and interview with facility staff (EMP), it was determined that the licensed nurses who provide services in the hospital failed to evaluate the nursing care for each patient for five out of ten medical records reviewed (MR1, MR2, MR3, MR4, and MR5).
Findings include:
Review of facility policy on March 9, 2022, titled "POL-4442507 Critical Care Electronic Health Record Documentation," last revised May 1, 2021, revealed, "...Administration: ...2. Head to Toe Doc Flowsheet: a. Full systems assessment to be documented...every 4 hours...The nurse can only document unchanged assessments on their own initial assessment...e. Braden Score - document a score every shift...4. Activity/Daily Cares...b. Reposition/turn - document a minimum of every 2 hours ...".
On March 9, 2022, a review of MR1, admission date November 17, 2021, was completed. Patient was admitted with existing left inner buttock pressure injury and foot wound. Patient developed a pressure injury to their inferior penis, which was first assessed on 11/27/2021. When reviewing flowsheets, a sample from November 18-20, 2021, was reviewed. The facility failed to document reposition/turn a minimum of every two hours on 11/18/2021 day and night shift, 11/19/2021 day and night shift, and 11/20/2021 day and night shift. The facility also failed to document a Braden Score on 11/18/2021, night shift.
On March 9, 2022, a review of MR2, admission date November 26, 2021, was completed. Patient was admitted with an existing pressure injury to their coccyx and venous ulcers on bilateral legs. Patient developed a pressure injury to their medial nose, which was first assessed on 12/06/2021. When reviewing flowsheets, a sample from November 27-29, 2021, was reviewed. The facility failed to document reposition/turn a minimum of every two hours on 11/27/2021 day and night shift, 11/28/2021 day and night shift, and 11/29, 2021 day and night shift. The facility also failed to document a Braden Score on 11/28/2021 day shift.
On March 9, 2022, a review of MR3, admission date November 17, 2021, was completed. Patient was admitted with no pre-existing pressure injuries or wounds. Patient developed three over the course of their stay to their chin, which was first assessed on 11/20/2021, their perineum, which was first assessed on 12/04/2021, and their left arm, which was first assessed on 12/10/2021. When reviewing flowsheets, a sample from November 18-20, 2021, was reviewed. The facility failed to document reposition/turn a minimum of every two hours on 11/18/2021 day and night shift, 11/19/2021 day and night shift, and 11/20/2021 day and night shift.
On March 10, 2022, a review of MR4, admission date December 10, 2021, was completed. Patient was admitted with no pre-existing pressure injuries or wounds. Patient developed a pressure injury to their chin, which was first assessed on 12/13/2021. When reviewing flowsheets, a sample from December 10-12, 2021, was reviewed. The facility failed to document reposition/turn a minimum of every two hours on 12/10/2021 night shift, 12/11/2021 day and night shift, and 12/12/2021 day and night shift.
On March 10, 2022, a review of MR5, admission date of January 29, 2022, was completed. Patient was admitted with no pre-existing pressure injuries or wounds. Patient developed a pressure injury to their coccyx during their stay, which was first assessed on 02/01/2022. When reviewing flowsheets, a sample from January 29-31, 2022, was reviewed. The facility failed to document reposition/turn a minimum of every two hours on 01/29/2022 day and night shift, 01/30/2022 day and night shift, and 01/31/2022 day and night shift. The facility failed to document a full systems assessment every four hours on 01/29/2022 day shift. And the facility failed to document a Braden Score on 01/29/2022 night shift.
Findings confirmed by EMP25.

Based on review of facility documents, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to document a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs for three out of five medical records (MR1, MR3, and MR4).
Findings include:
Review of facility policy on March 9, 2022, titled, "POL-4446334 Pressure Injury Prevention and Treatment Guidelines," last revised on September 1, 2021, revealed, "...3. Patients with intact skin identified at risk with a Braden Score less than or equal to 18 will have a Prevention Plan of Care initiated and documented by the nurse ...".
On March 9, 2022, a review of MR1, admission date November 17, 2021, was completed. Patient was admitted with existing left inner buttock pressure injury and foot wound. Patient developed a pressure injury to their inferior penis, which was first assessed on 11/27/2021. The facility failed to document a care plan for skin.
On March 9, 2022, a review of MR3, admission date November 17, 2021, was completed. Patient was admitted with no pre-existing pressure injuries or wounds. Patient developed three over the course of their stay to their chin, which was first assessed on 11/20/2021, their perineum, which was first assessed on 12/04/2021, and their left arm, which was first assessed on 12/10/2021. The facility failed to document a care plan for skin.
On March 10, 2022, a review of MR4, admission date December 10, 2021, was completed. Patient was admitted with no pre-existing pressure injuries or wounds. Patient developed a pressure injury to their chin, which was first assessed on 12/13/2021. The facility failed to document a care plan for skin.
Findings confirmed by EMP25.

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 maintain a clean and sanitary environment free of dust, dirt, and debris and failed to resolve the pest presence in the facility (A-0750); and 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 observations, review of facility documents, and interview with staff (EMP), it was determined that the facility failed to maintain a clean and sanitary environment free of dust, dirt, and debris and failed to resolve the pest presence in the facility.

Findings include:

A review of the facility's 2021 Infection Prevention Plan stated, "Appropriate working conditions and practices are established by using knowledge of infection prevention principles to educate staff, design appropriate work environments, purchase appropriate equipment and supplies, clean and disinfect areas and equipment, and monitor the implementation of the processes and policies. Infection prevention is a dynamic process. Regular evaluation of the environment for work practices and hazards is required to maintain a current relevant infection prevention and control program. the program is updated annually and as needed to respond to identified risk, hazards and regulatory complaisance issues."

On March 8, 2022, a tour was conduct with EMP1. The following were observed:

10:25am: Infection Control Permit for construction outside of E8 elevators revealed an expiration date of 12/31/2021. Holes in tape holding up barrier plastic were also observed and confirmed by EMP1.

10:30am: Door to dialysis storage on E8 found to be open to public and confirmed by EMP1.

10:35-10:59am: A tour of E8 Rooms 809-825 with EMP1, EMP4, and EMP5 revealed sinks outside of rooms E812, E815, E817, and outside of the medication room located across from nurses' station had a buildup of an unknown substance on sink heads, around the sinks, and in the corners of the counters around the sinks. The colors of the buildup varied from white, yellow, black, pink, and green. This tour also revealed dust, eraser, remnants, and crumbs on a computer workstation outside of E813, empty hand sanitizer outside of room E814, and small dead bugs and dust on a window ledge outside of room E815. An open, uncovered garbage can was found in a hallway that visitors and patients have access to outside of the conference room.

11:00-11:15am: A tour of E8 Rooms 801-808 and 826-834 with EMP1, EMP4, and EMP5 revealed sinks outside of rooms E802, E805, E828, and the sink in front of the nurses' station on that side had a buildup of an unknown substance on sink heads, around the sinks, and in the corners of the counters around sinks. The colors of the buildup varied from white, yellow, black, pink, and green. The tour also revealed layers of dust in nurses' station on this side, specifically on the counters where glucometers are held. At the sink across from the nurses' station on this side, there was a double outlet with the top outlet covered by cream colored tape. Unknown to staff as to why it was covered. Unknown to facilities personnel as to why it was covered. Dust was also layered and falling off the cactus sink in the hallway next to the Omnicell.

11:18am: There were three light fixtures on the ceiling outside of the elevators on E9. The middle and right light fixtures had dark spots in them that were unknown bugs or dirt. Also observed dust and small dead bugs on the window ledge, which was confirmed by EMP1.

11:19am: E9 computers on wheels were observed to be covered in a layer of dust that discolored the bottom of them to a gray/black color and confirmed by EMP1.

11:35am: Footboard to a Hill Rom bed found in hallway of E9 elevators. EMP6 reports that, all beds on that unit use Stryker beds. Infection Control Permit for construction expired 12/31/2021. EMP1 confirmed the above.

11:36am: Observed dust and small dead bugs on window ledge outside of elevators on E7. Infection Control Permit for construction expired 12/31/2021. EMP1 and EMP6 confirmed the above.

11:38am: MICU manager's office, which is located directly outside of the doors to the MICU in an unrestricted hallway that patients, staff, and visitors have access to, was found to have the door propped open and the computer unlocked while the office was unattended. Unsecured bottles of what appeared to be OTC medications were also observed left out on shelf of desk. EMP1 and EMP6 confirmed the above.

11:53am-12:20pm: A tour of the MICU located on E7 with EMP1, EMP6, EMP8, and EMP9 revealed heavy layers of dust on things such as supply carts, window ledges, storage/disposal bins, on top of hand sanitizer dispensers, computers on wheels, door handles (push handles), and on computer workstations outside of patient rooms. Build up around the sink outside of room E734 that appeared white to yellow in color. Clumps of dust on the floor in the corners of the unit as well as under a black cart labeled "PAPRS", supply carts, under sinks, and under workstations. There were various pieces of trash on the floor of the unit. An unknown dried substance was observed on the top of various supply carts. There was a procedure cart outside of room E725 that was found unlocked but not being used.

12:24pm: Clumps of dust were observed on the window ledge outside of E elevators on the second floor. Below the ledge there was also a bench that was heavily stained with unknown substances. EMP1 confirmed the above.

During a tour of the ground floor on March 8, 2022, between 10:25 AM and 11:45 AM, the following were observed:
· One dead roach on the floor in the hallway across room GR707.
· Two dead roaches on the floor in the corner of the hallway near room GR707.
· A full can of garbage without a lid, outside of GR702A.
· One dead roach on the floor across room GR414.
· One dead roach across room GR703. In addition, one apple core, one M & M candy wrapper, and one pop bottle were also noted to be on the floor.
· One dead roach across room GR701.
· A mouse dropping (feces) on the floor, across GR414.
· Several mouse droppings were noted on the floor of the hallway, in the corner, across room GR400.
· A sticky trap with a dead mouse was noted across GR222.
· A mayonnaise packet, sunflower seed shells, 2 Pepsi bottles, 15 blue gloves which appear to have been used, one Reese's candy wrapper, a Twizzler candy wrapper, and pieces of a blue plastic bag were noted under the pipes in the pipe room.
· An open space measuring about ¼ to ½ inch was noted at the bottom of the closed movable (garage-type) door in the mobile PET scan area of the MRI Department. The doorway to this room is located near GR603.

EMP13 witnessed and confirmed the above during the facility tour on March 8, 2022, between 10:25 AM and 11:45 AM.

Interview on March 8, 2021, at 10:45 AM, with physician EMP15, revealed that EMP15 has sighted roaches on multiple occassions in the department and that once a roach was stuck between the ceiling tiles. EMP15 also stated that the roaches "live down here with us."

Interview on March 8, 2022, at 10:50AM, with EMP14, revealed that roaches have been seen for all 12 years that EMP14 worked at the facility and that staff are told to run water down the sinks to prevent roaches from coming into the area.

Interview on March 8, at 11:25 AM, with EMP20 revealed that a mouse was seen in their office about two months ago. EMP20 indicated that it was the first time a mouse was seen in their office.

A review of the facility's Infection Prevention and Control Committee meeting minutes for the past 12 months revealed that only once (during the November 16, 2021, meeting) was the pest control issues mentioned during a meeting. However, the facility's 'Pest Sighting Log' revealed multiple sightings of roaches and mice every month for the past 12 months.

During an interview Orkin representative OTH4 explained that they are onsite once a week and rely solely on the 'Pest Sighting Log' to determine where they need to treat for pests, in addition to Orkin observes while onsite. It was further explained that Pestco representatives also rely solely on the 'Pest Sightings Log' for their weekly treatments, in addition to what Pestco observes while onsite.

A review and comparison of the facility's 'Pest Sighting Log' and the facility's 'Incident Log' revealed that in December 2021 and January 2022 there were six mouse sightings that were not included in 'Pest Sighting Log' which Orkin and Pestco representatives were not made aware of and therefore were not areas designated to treat. During an interview EMP16 was unable to explain why the mouse sightings reported on the facility's 'Incident Logs' were not included to the 'Pest Sighting Log'.


During an interview on March 10, 2022, EMP16 explained that the building was a (city) block and that they would never be able to resolve the pest issue because the pipes in the building were too old and eroded. EMP16 agreed that replacing the pipes would probably resolve the pest issue but explained that replacing the pipes would be very costly. It was also explained that the facility's plan is to continue ultilizing the two pest companies once a week to address the pest sightings, but no additional plans were in place to resolve the ongoing sightings of roaches and mice by facility staff and patients.

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. "


An email dated March 9, 2022, from Highmark Health EMP22 was provided to the survey team on March 10, 2022. The email indicated, "AP Vendors - we took a conservative approach to account for any vendors that we paid during the prior 12 months regardless of being a registered user in VendoStat or processing badge access. The resulting list of vendors was sent a communication outlining the COVID-19 vaccination requirements as promulgated by CMS. ........ Any New Badges being issues to vendors/contractors - for any new vendors / contractors requesting badge access to a facility, they will be requested to attest to their understanding of the COVID-19 vaccination requirements." Additionally, the email stated, "Retrospectively - Approached the current vendor population from three directions...... Badge Vendors - Any vendors that possess a badge for access were first evaluated for the need to retain access. Any vendors that did not require full time badges access had their access revoked. For the remaining vendors a communication was sent to them outlining the Covid-19 vaccination requirements as promulgated by CMS. Additionally, an attestation letter was sent to these vendors requiring them to acknowledge their understanding of the requirement."

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 'West Penn Hospital - Employee Vaccination Status' document revealed that only West Penn 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 'West Penn Hospital - Employee Vaccination Status' document revealed that only West Penn 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 with EMP1, it was explained that only hospital employees are required to show proof of vaccination status and that vendors and contractors are not asked for proof of vaccination status. EMP1 further explained that over the next 12 months, as contracts are being renewed, the facility will include information in the contracts regarding the facility's Covid 19 Policy.

During an interview on March 9, 2022, with Orkin contractor EMP29 it was revealed that EMP29 was a contracted employee who was in the facility on a weekly basis. Furthermore, EMP29 confirmed that the facility never asked about his Covid 19 vaccination status.

During an interview on March 9, 2022, with EMP11 it was revealed that EMP11 was a contracted employee and in the facility on a routine basis. Furthermore, EMP11 confirmed that the facility never asked about his Covid 19 vaccination status.

During an interview via Zoom, on March 10, 2022, at 12:15PM, EMP28 indicated that the volunteers and vendors/contractors were not included in the tracking and documentation of the Covid 19 vaccination status of all staff.

During the exit interview on March 10, 2022, at 3:15 PM, Chief Operating Officer (COO) EMP21 indicated that he believes the facility is following the CMS requirements and that having the vendors and contractors sign an attestation is an acceptable method to ensure all staff are fully vaccinated for Covid -19. Additionally, COO EMP21 confirmed that the facility does not obtain information regarding Covid-19 vaccination status or track staff who are vendors and contractors.
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