HospitalInspections.org

Based on interview and document review, the facility failed to develop and implement policy and procedures to ensure that all staff were fully vaccinated for COVID-19 resulting in the potential for poor outcomes for all 68 patients receiving services at the facility.
Findings include:

At 1106 on 02/08/22, during review of document "Policy and Procedures, #ADM-Cov-1, Covid-19 Vaccination" (Effective 01/03/22), it was revealed that the policy failed to; (1) Provide a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19. (2.) Provide a process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (3.) Provide contingency plans for staff who are not fully vaccinated for COVID-19.

On 02/08/22 at 1110, an interview was conducted with the Director of Operations (Staff C). Staff C was queried if the facility had written policy and procedure for the vaccination of staff against Covid-19, Staff B replied, "Not a policy per se, just emails. Memos were sent to all employees, and request forms for exemptions." Staff C was then asked, 'Are any unvaccinated staff scheduled or working here today?", to which he stated, "No."

On 02/08/22 at 1300, document titled "PGH EE Vaccination Status 2022" was reviewed with Staff C. This document was an Excel spreadsheet which listed 272 staff members, 42 of which were listed as 'non-vaccinated'. Staff C was again queried if any staff could be working today and he replied, "Forty-two people could be here working today without any vaccinations for Covid-19." Staff C was queried, "This spreadsheet shows many employees who have missed the January 27, 2022, deadline for first-dose of Covid-19 vaccination, do you agree?", to which he replied, "Absolutely. They ae playing a game with the second deadline." Staff C was then asked to identify which 'non-vaccinated' staff were working 'today'. Staff C stated, "A lot of these people were vaccinated at CVS (pharmacy chain) and CVS did not update MICR (Michigan Immunization Care Registry). Give me 15 minutes to update this list."

On 02/08/22 at 1345, Staff C identified two staff members (Staff J and Staff K) as present and available for interview.

On 02/08/22 at 1403, an interview was conducted with Staff J. Staff J was queried, "What is your current Covid-19 vaccination status?", to which she replied, "I am not vaccinated." Staff J was then asked, "Were you given a deadline to get vaccinated or exempted", to which she replied, "I was given a deadline of January 27th. I was sick then." Staff J was then asked, "How were you informed of this deadline?", to which she replied, "I received an email and was told in-person by my supervisor." Staff J was then queried 'What if you missed the deadline?', to which she replied, "You could be suspended or terminated." Staff J was then questioned if 'either of those consequences had occurred?', and she replied, "no."

On 02/08/22 at 1417, an interview was conducted with Staff K. Staff K was queried regarding his status of Covid-19 vaccination, to which he replied, "I am not vaccinated." Staff K was queried if he received notification to be vaccinated by January 27th, 2022, Staff K stated, "I did not. I was sick December 15th (2021) through January 5th (2022). I was stuck at home and had no access to email. Anna (Staff D) called me last week, asking if I was getting vaccinated and letting me know that exemption forms are available." Staff K then stated, "I had antibodies infused." Staff K was queried if the facility was made aware of the antibody infusion, Staff K stated, "They did not know I had antibodies." Staff K was then queried if 'any added work modifications were in place to mitigate the spread of Covid-19, due to his non-vaccination?', to which he replied "no." Staff K was then asked if he was required to wear a 'face-shield and/or a'N-95' mask, to which he replied, "no." Staff K was next questioned if he had any changes to his assigned work duties since January 27, 2022?', to which he replied, " No, I work mostly 5 South, occasionally 4 South and 4 North. We get pulled for staffing shortages." Staff K was then asked, 'Could you be pulled to work the Covid unit?', to which he replied, "yes, if needed."

On 02/08/22 at 1435, Director of Quality (Staff B) was queried 'Who is responsible for the Covid-19 vaccinations program and data?', to which Staff B replied, "(Staff C) and (Staff L) are in charge of the Covid-19 vaccination program."

On 02/08/22 at 1440 an interview was conducted with Infection Control lead (Staff L). Staff L was asked 'who is responsible for tracking Covid-19 vaccinations?', to which Staff L stated, "Myself and HR." Staff L was then questioned about the frequency of updating the spreadsheet, to which she replied, "at least weekly. I do it in 'real-time' also." Staff L was then queried, 'Are unvaccinated / non-exempted employees allowed to work today?', to which she replied, "Currently, yes, until February 28th." Staff L was then asked, 'What is the deadline for non-exempt employees to get at least one shot?', to which she replied, "I believe January 27th or 28th." Staff L was next questioned if 'contingency plans had been prepared to help the facility meet the requirements?', to which she replied, "Agency people are lining up, and all new employees are required to have vaccination upon hire." Staff L was then queried if 'Staff J and Staff K should not be listed as 'Temporary Delay' due to their recent illness and Staff K's antibody infusion?', to which Staff L replied, "If they don't provide me that, I don't know."