HospitalInspections.org

Based on review of QSO memo 22-09-ALL Revised Attachment D, policy review, staff vaccination document review, and staff interview, the facility had a vaccination rate of 99.5% and failed to ensure all staff are fully vaccinated for COVID-19, except for those who have been granted exemptions and failed to ensure staff specified in paragraph (g)(1) 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. This affected 35 of 7782 staff members (Staff D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, CC, DD, FF, GG, II, JJ, KK, LL, MM, NN, and QQ). The facility census was 425.

Findings include:

Review of QSO memo 22-09-ALL Revised Attachment D revealed that within 60 days following the issuance of the applicable memorandum the facility demonstrates 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple vaccine series) or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Centers for Disease Control (CDC). Policies and procedures must include, at a minimum, a process for ensuring all staff specified in paragraph (g)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by CDC, due to clinical precautions and considerations) 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.

Review of the facility policy titled, Vaccine Program for Employees, effective 02/25/22, revealed new employees must be fully vaccinated or receive an approved exemption(s) prior to their start date or within the timeframes required by MHS.

The policy did not define the timeframes.

Review of the Active Employee Roster with Vaccination or Exemption Status report revealed 11 employees were partially vaccinated (Staff O, P, Q, R, S, T, U, V, W, X, and Y), 11 employees had pending exemptions (Staff D, E, F, G, H, I, J, K, L, M, and N), and 13 employees were listed as record pending, no vaccination record and no exemption on file, (Staff Z, AA, CC, DD, FF, GG, II, JJ, KK, LL, MM, NN, and QQ).

The 11 employees who were partially vaccinated and the 13 employees with a record pending were identified as having worked between 02/06/22 and 05/14/22.

On 06/01/22 at 1:00 PM, Staff C was interviewed. Staff C verified that the staff listed on the Active Employee Roster with Vaccination or Exemption Status report as partially vaccinated, pending exemption, or record pending were still in process. Staff C stated each of these categories had timeframes associated with them, were being tracked, and they were working diligently with the staff to get the documentation needed.

Staff C also did not define the timeframes.