HospitalInspections.org

Based on interview, review of medical exemption documentation regarding Employee 1, review of staff lists, review of P&Ps, and review of other documentation, it was determined the hospital failed to fully develop clearly written and implemented staff Covid-19 vaccination P&Ps in the following areas:
* P&Ps did not ensure all appropriate staff were vaccinated for Covid-19 as the hospital permitted vaccine attestations for contracted staff and other staff.
* P&Ps did not ensure tracking, monitoring and securely documenting vaccination status of all staff including contracted staff, non-employed staff, volunteers, and students; and staff for whom vaccination must be temporarily delayed.
* P&Ps did not ensure tracking, monitoring and securely documenting information provided by staff who had requested, and the hospital granted, an exemption from the vaccination requirements.
* P&Ps did not ensure medical exemptions from Covid-19 vaccination were signed and dated by a licensed practitioner who was not the individual requesting exemption; and who was acting within their scope of practice; and information specifying which of the authorized COVID-19 vaccines were clinically contraindicated for staff to receive, and the recognized clinical contraindications.

Findings include:

1. The P&P titled "Covid-19 Vaccination Policy (ASANTE)," dated effective 09/23/2021 was reviewed and reflected:

* "This policy applies to all Asante employees, volunteers, students, Contractors and Non-Employed Providers."

* "Proof of Vaccination means documentation provided by a tribal, federal, state or local government, or a health care provider, that includes an individual's name, date of birth, type of Covid-19 vaccination given, date or dates given ... the name/location of the health care provider or site where the vaccine was administered. Documentation may include but is not limited to a COVID-19 vaccination record card or a copy or digital picture of the vaccination record card, or a print-out from the Oregon Health Authority's immunization registry."

* "Contractors means personnel or representatives of organizations with which Asante has contracted who perform services at an Asante Worksite and who, in connection with performing those services, enters a building or structure occupied by Asante employees or patients, including but not limited to servicing equipment, engaging in construction or repairs, providing clinical or sales support or providing care (including contracted staff, third-party vendors, registry, etc.). Contractors does not include Non-Employed Practitioners, as defined below."

* "Fully Vaccinated means two weeks after completing the entire recommended series of vaccination with a vaccine approved or authorized by the FDA (including on an emergency use basis) to prevent COVID-19, including any recommended boosters. For example, a person would be Fully Vaccinated two weeks after receiving a second dose of the Pfizer or Moderna COVID-19 vaccine ... "

* "Contractors ... Contractors must be Fully Vaccinated, or they will not be permitted to enter an Asante Worksite ... Each organization with which Asante has contracted to perform services at an Asante Worksite must collect and maintain a record of COVID-19 vaccination status for all employees, agents and representatives who will be onsite at any Asante facility. The record must include appropriate Proof of Vaccination. Each organization will be required to validate the vaccination status of its employees and representatives at the request of Asante."

* "Asante's policy is to require either proof of COVID-19 vaccination or an exception approved by Asante for all employees, volunteers, students, Contractors and Non-Employed Practitioners and to maintain a record of vaccination status for those persons."

* "Record of Vaccination Status ... Asante will collect and maintain a record of COVID-19 vaccination status for all employees, students, volunteers, Non-Employed Practitioners and Contractors. Records will be collected annually or as needed, to be determined by Asante. For non-employees, the record may consist of validation of vaccination by the person's employer or school."

2. Regarding contracted (traveler) staff:

The hospital's P&Ps were not fully developed and implemented; and processes were unclear, and did not provide assurance traveler staff under contract were vaccinated for Covid-19. Examples included:

2. a. Regarding traveler staff under contract, the P&P titled "Covid-19 Vaccination Policy (ASANTE)," dated effective 09/23/2021 reflected:
* "Contractors ... Contractors must be Fully Vaccinated, or they will not be permitted to enter an Asante Worksite ... Each organization with which Asante has contracted to perform services at an Asante Worksite must collect and maintain a record of COVID-19 vaccination status for all employees, agents and representatives who will be onsite at any Asante facility. The record must include appropriate Proof of Vaccination. Each organization will be required to validate the vaccination status of its employees and representatives at the request of Asante."

2. b. An undated, untitled list of current contracted FocusOne traveler staff with start dates between approximately 08/21/2019 and 02/21/2022 was reviewed:
* The list had a yellow sticky note on it with "ARRMC Focus One Vax Status (travelers)" hand-written on it.
* The list was comprised of approximately 320 staff including RNs, RTs, PTs, CT Techs, SPTs, and Phlebotomists.
* Departments for each staff were recorded and included but were not limited to Critical Care, Emergency Room, Heart Center, OR, NICU, M/S, Med Surg Oncology, Med Surg Neuro/Ortho, Infusion Services, Cath Lab, Behavioral Health, Radiology, Respiratory Therapy, and Laboratory Support Services.
* The vaccination status for more than 200 of the staff under the column "Uploaded Document" was recorded "Attestation." There was no further documentation of vaccine status for those staff, including "Proof of Vaccination" in accordance with the hospital's definition; and therefore no assurance staff were fully vaccinated as defined by CMS.
* The vaccination status for the remaining staff was recorded "Vaccination Card" or "Covid vaccines + Booster." The hospital's P&P did not include a process whereby the hospital ensured those staff were fully vaccinated before being "permitted to enter an Asante Worksite," including how "Proof of Vaccination" was checked and documented, who checked it, and when.

2. c. Two undated lists of current AMN traveler staff under contract were provided. Between the two lists, the following information was provided:
* One list was untitled and the other list had "AMN" in hand writing at the top of the list.
* Staff start dates were between approximately 08/23/2021 and 02/28/2022.
* The lists were comprised of 76 staff including RNs, RTs, PTs, and OTs.
* "Specialty" areas for the staff included but were not limited to ICU, MS, ER, and Outpatient.
* The vaccination status for each of the staff on the lists reflected "Fully Vaccinated" or "Booster;" and "DateFirstDose (sic)," "DateCompleted (sic)" and "DateBoosted (sic)," with corresponding dates for each. However, there was no information that reflected how those dates were obtained, who verified them, including when they were verified with respect to the hospital's P&P that states "Contractors must be Fully Vaccinated, or they will not be permitted to enter an Asante Worksite." Further there was no information that reflected "Proof of Vaccination" as defined by the hospital's P&P, was verified, including who checked it, and when.

2. d. During an interview with VPLO on 03/01/2022 at 0930 regarding contracted FocusOne and AMN traveler staff, he/she stated traveler staff must be 100% vaccinated to come onto hospital property, and "no exceptions allowed." However, he/she stated "We don't maintain [Covid-19 vaccine] records. We just verify by attestation that they are vaccinated." The VPLO stated the hospital could get vaccine records from the staffing agencies "if needed."

2. e. During an interview with the VPLO and VPHR on 03/01/2022 at 1305, they were asked how the hospital ensured FocusOne and AMN traveler staff were vaccinated for Covid-19. They stated this was ensured by language in the FocusOne and AMN contracts.

2. f. The contract with "FocusOne Solutions, LLC," effective date 12/07/2015 was reviewed and reflected an agreement with the hospital for "Professionals for temporary staffing" at the hospital. The contract reflected "Client agrees to provide documentation outlining any specific pre-assignment requirements to comply with the Client's policies and procedures." The language in the contract was broad and generic, and did not ensure staff were vaccinated for Covid-19.

2. g. The contract with "AMN Healthcare, Inc.," effective date 10/27/2021 was reviewed and reflected an agreement with the hospital for "healthcare clinicians" to provide "temporary professional services" at the hospital. "Schedule 2 to Exhibit A-7" attached to the contract reflected the following language. Under "Requirement" it reflected "Covid-19 Vaccine Status," and under "Requirement Description," it reflected "Proof obtained of 1 or 2 vaccines depending on manufacturer or declination obtained prior to start of assignment. If not COIVD (sic) vaccinated, will follow state requirements." The language in the contract was inconsistent with the hospital's P&P. For example, whereas, the hospital's P&P stated "Contractors must be Fully Vaccinated, or they will not be permitted to enter an Asante Worksite," the language in the contract included "declination obtained prior to start of assignment" and "If not [Covid-19] vaccinated ... follow state requirements." It was unclear what these meant with regard to the hospital's P&P that stated contractors must be fully vaccinated before entering the hospital.

2. h. During an interview with the VPQP on 03/03/2022 at 1410, the VPQP stated the hospital had no way to ensure contracted staff who attested to receiving the Covid-19 vaccine were vaccinated, and had received the vaccine prior to starting work in accordance with the hospital's P&P.

2. i. The hospital's P&P titled "Covid-19 Vaccination Policy (ASANTE)," dated effective 09/23/2021 reflected "All records collected under this policy concerning vaccination status or details (type of vaccine, date of vaccination, etc.) will be maintained and accessed in compliance with applicable policy and law." The P&P did not include a clear process that ensured tracking and securely documenting Covid-19 vaccination information provided by contracted traveler staff, including each staff's role, assigned work area, and how they interacted with patients.

3. Regarding non-employed practitioners:

3. a. Regarding, non-employed practitioners, the P&P titled "Covid-19 Vaccination Policy (ASANTE)," dated effective 09/23/2021 reflected:
* "Non-Employed Practitioners means physicians, advance practice clinicians, and other individuals who are privileged or contracted to provide clinical care at an Asante Worksite, but who are not employed by Asante ... "
* "Asante's policy is to require either proof of COVID-19 vaccination or an exception approved by Asante for all employees, volunteers, students, Contractors and Non-Employed Practitioners and to maintain a record of vaccination status for those persons."
* "Non-Employed Practitioners ... In order to enter an Asante Worksite, Non-Employed Practitioners must be Fully Vaccinated and attest to their vaccination status using the applicable Asante attestation form ... Promptly upon request, each Non-Employed Practitioner must provide Proof of Vaccination."
The P&P was unclear as it stated the hospital required "either proof of COVID-19 vaccination or an exception." However, it also stated non-employed practitioners could "attest to their vaccination" and "upon request ... provide Proof of Vaccination."

3. b. During an interview with VPLO and VPHR on 03/01/2022 at 1315, the following information was provided:
* Non-employed practitioners hired before 10/18/2021 were not required to provide the hospital proof of vaccination. Instead, the hospital permitted those staff to submit an attestation of Covid-19 vaccine status. Only staff hired on 10/18/2021 and after were required to provide the hospital proof of Covid-19 vaccine status.

3. c. The "Covid-19 vaccine attestation form" used by non-employed practitioners referenced above, was reviewed. The attestation form reflected:
* "Per the governor's recent mandate, health care workers are required to be fully vaccinated for COVID-19 by Oct. 18. To ensure Asante is compliant with this mandate, please provide your attestation by completing this form no later than Monday, Oct 4. If you have any questions regarding this requirement, please contact [VPMA] in your facility. Required fields are marked ... "
* "Please attest to one of the following ... " followed by a drop down menu.

3. d. In an email dated 03/01/2022 at 1328 from DMSS, he/she indicated the options in the drop down menu on the Covid-19 vaccine attestation form were:
* "I am fully vaccinated"
* "I am not fully vaccinated, but will be by Oct 18th. I will inform Medical Staff Services when my vaccination has been completed."
* "I do not intend to be vaccinated."

3. e. An undated, untitled list of non-employee medical staff (practitioners) was reviewed and reflected:
* The list had a yellow sticky note on it that reflected "ARRMC Non-Employed Medical Staff."
* The "Initial Appointment" start dates on the list were between approximately 10/05/1979 and 02/24/2022; and the list was comprised of approximately 370 staff including MDs, DOs, PA-Cs, FNP-Cs, DDSs, CNMs, and others.
* Vaccination status information for each staff was recorded under the column "Compliance Type." For approximately 345 of the staff, the vaccination information was recorded "Attestation Received;" and for the remaining staff, "Vaccination Record Received."
For staff with "Attestation Received" recorded, there was no information on the list that reflected what option the practitioners selected from the drop down menu on the Covid-19 attestation form. There was no information in the hospital's P&P that reflected if or how the staff's attestation selection and vaccination status were checked by the hospital, including follow up if staff chose "I am not fully vaccinated ... " or "I do not intend to be vaccinated."

3. f. During an interview with the VPQP on 03/03/2022 at 1410, the VPQP stated the hospital had no way to ensure non-employed practitioner staff who attested to receiving the Covid-19 vaccine had received the vaccine prior to starting work in accordance with the hospital's P&P and the CMS definition for "Fully Vaccinated."

The hospital's Covid-19 vaccination P&P and processes were not fully developed and implemented and did not ensure non-employed practitioner staff were fully vaccinated for Covid-19. Examples included:
* The P&P permitted "attestations" for Covid-19 vaccines for non-employed staff, and therefore did not provide an assurance staff were "fully vaccinated" as defined by CMS.
* For staff who submitted a "Vaccination Record," the P&P did not include a process that ensured non-employed practitioners were "fully vaccinated" including how and when the vaccination records were checked to ensure appropriate "Proof of Vaccination" was received prior to the staff "entering an Asante Worksite."

3. g. The hospital's Covid-19 P&P did not include a process for tracking and securely documenting Covid-19 vaccination information provided by non-employed practitioners including each staff's role, assigned work area, and how they interacted with patients.

4. Regarding volunteers:

The hospital's P&Ps were not fully developed and implemented; and processes were unclear and inconsistent. Examples included but were not limited to:

4. a. Regarding volunteers, the P&P titled "Covid-19 Vaccination Policy (ASANTE)," dated effective 09/23/2021 reflected:
* "Volunteers ... Volunteers who enter an Asante Worksite must submit documentation demonstrating they are Fully Vaccinated (i.e., Proof of Vaccination), or they will not be permitted to enter." There was no other information about volunteers in the P&P. Although the P&P required volunteers provide proof of vaccination to enter the hospital, there was no information in the P&P that described how this was accomplished, including who was responsible; when and how it occurred; and how vaccine information was collected, documented and tracked by the hospital.

4. b. A document that included volunteers titled "Non Employee List," dated "As of: 2/28/2022" was provided in response to a request for a list of all staff and their vaccination status, including staff who are in direct contact with patients, regardless of frequency, and hire date. The list included volunteers with "Last Hire Date" between approximately 04/25/2011 to 02/07/2022. The list included 12 "Chaplain ARRMC (Spiritual Care)" volunteers, 145 "Volunteer ARRMC" volunteers, and other volunteers.

4. c. Another document that included volunteers was provided. The document dated as "Updated 3/3/2022" was untitled and included staff "Vaccinated" and "Unvaccinated" information. It reflected the hospital had 223 volunteers for whom it reflected 100% were vaccinated, and 0.00% were unvaccinated.

4. d. During an interview on 03/04/2022 beginning at 1120 with the VPQP, VPHR, and DRM the following information was provided related to volunteers:
* The hospital has two groups of volunteers. Each group has a coordinator who tracks their respective volunteers' Covid-19 vaccine status. One coordinator uses a database and the other has a spreadsheet. Regarding tracking the vaccine status of volunteers, the VPHR stated "It's outside our hospital database."
* Regarding proof of Covid-19 vaccine status, the VPHR stated some volunteers provide vaccine records while others provide an "attestation."
* The staff confirmed there were no P&Ps regarding Covid-19 vaccine processes for volunteers. "We are unable to find a policy specifically related to volunteers."

4. e. The hospital's Covid-19 vaccination P&P did not include a clear process for tracking and securely documenting Covid-19 vaccination information provided by volunteers including each volunteer's role, assigned work area, and how they interacted with patients.

5. Regarding students:

The hospital's P&Ps were not fully developed and implemented; and processes were unclear and inconsistent: Examples included but were not limited to:

5. a. Regarding students, the P&P titled "Covid-19 Vaccination Policy (ASANTE)," dated effective 09/23/2021 reflected:
* "Students ... In order to enter an Asante Worksite, students must be Fully Vaccinated ... Each contracted school (or its students, as requested by Asante) must submit documentation demonstrating the student is Fully Vaccinated (i.e., Proof of Vaccination). Contracted schools must coordinate and effectuate collection and provision to Asante of vaccination documentation."
* "Asante will collect and maintain a record of Covid-19 vaccination status for all ... students ... Records will be collected annually or as needed, to be determined by Asante. For non-employees, the record may consist of validation of vaccination by the person's employer or school."
There was no other information about students in the P&P. Although the P&P required students provide proof of vaccination in order to enter the hospital, there was no other information in the P&P that described how this was accomplished, including who was responsible; and how vaccine information was collected, documented and tracked by the hospital.

5. b. A document that included students titled "Non Employee List," dated "As of: 2/28/2022" was provided in response to a request for a list of all staff and their vaccination status, including staff who are in direct contact with patients, regardless of frequency, and hire date. The list included 33 students with "Last Hire Date" between approximately 07/24/2017 and 03/27/2022 (sic). The list did not include vaccination status for the students.

5. c. Another document that included students was provided. The document dated as "Updated 3/3/2022" was untitled and included staff "Vaccinated" and "Unvaccinated" information. It reflected the hospital had 102 students for whom it reflected 100% were vaccinated, and 0.00% were unvaccinated.

5. d. During an interview on 03/01/2022 at 1305 with the VPLO and VPHR, they were asked how they ensured students were vaccinated before entering the facility. The following information was provided:
* For some students, the hospital's contract with the school that provided the students, stipulated that "all hospital vaccine policies will be followed."
* For other students, the hospital's contract with the school that provided the students, included an "attestation" completed by the school, that indicated the students it provided would be vaccinated.

5. e. During an interview on 03/04/2022 beginning at 1120 with the VPQP, VPHR, and DRM the following information was provided related to students:
* The hospital does not keep Covid-19 vaccine records for students. The student's school attests they'll verify students' vaccine status and maintain vaccine records and the hospital can ask for the records "if we need them."
* The hospital does not check student Covid-19 vaccine records or verify vaccination status.

5. f. The hospital's Covid-19 vaccination P&P did not include a process for tracking and securely documenting Covid-19 vaccination information provided by students including each student's role, assigned work area, and how they interacted with patients.

6. Regarding medical exemptions:

The hospital's P&Ps were unclear and not fully developed regarding medical exemptions from staff Covid-19 vaccine. Examples included:

6. a. The P&P titled "Covid-19 Vaccination Policy (ASANTE)," dated effective 09/23/2021 was reviewed and reflected:
* "Employees may request an exception from the vaccination requirement based on ... A permanent or temporary physical or mental impairment that prevents the individual from receiving a COVID-19 vaccination, or ... Exception requests must be submitted on a properly completed COVID-19 Vaccine Religious/Medical Exception Form."
* Although the P&P referenced a Medical Exception Form, it did not include a process that ensured licensed practitioners who signed medical exemption forms were acting within their scope of practice; did not ensure information specifying which of the authorized COVID-19 vaccines were clinically contraindicated for the staff member to receive; and did not ensure documentation of recognized clinical reasons for the contraindications, including consideration of the following CMS definition for clinical contraindications:
- "'Clinical contraindication' refers to conditions or risks that precludes the administration of a treatment or intervention. With regard to recognized clinical contraindications to receiving a COVID-19 vaccine, facilities should refer to the CDC informational document, Summary Document for Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States, accessed at https://www.cdc.gov/vaccines/covid-19/downloads/summary-interim-clinical-considerations.pdf. For COVID-19 vaccines, according to the CDC, a vaccine is clinically contraindicated if an individual has a severe allergic reaction (e.g., anaphylaxis) after a previous dose or to component of the COVID-19 vaccine or an immediate (within 4 hours of exposure) allergic reaction of any severity to a previous dose or known (diagnosed) allergy to a component of the vaccine."

6. b. A "Covid -19 Vaccine Medical Exception Request Form" for Employee 1 was reviewed and reflected:
* The form was signed by the employee and dated 09/02/2021.
* "I am requesting an exception from the Covid-19 vaccination requirement on the basis of a diagnosed physical or mental condition that limits my ability to receive the Covid-19 vaccination, as certified by my medical provider below."
* "The patient should not receive the COVID-19 vaccination due to a medical condition. What is the medical condition that prevents them from receiving the COVID-19 vaccination?" This was followed by "Pregnancy."
* "Is the medical condition temporary? If yes, what is the expected duration?" This was followed by "yes, 24 months."
* "Please describe how this medical condition impacts their ability to receive the COVID-19 vaccination." This was followed by "undetermined health risks to developing fetus and breast fed infant."
* "The patient may not receive a certain type of COVID-19 vaccination. The patient may receive a vaccination manufactured by." This was followed by "none."
* "The patient may receive a COVID-19 vaccination." This was followed by "No."
* "I certify the above information to be true and accurate. This was followed by an illegible first and last name, and no credentials written in the space for "Printed name of medical provider:" and an illegible signature, and no credentials in the space for "Signature of medical provider:"
Although the hospital granted the employee a medical exemption, there was no documentation on the form or the hospital's P&Ps that ensured the person who signed the form was a licensed practitioner acting within their scope of practice; or that the CMS definition for clinical contraindications was considered prior to granting the medical exemption.

6. c. The P&P titled "Immune Status Program (ASANTE)," dated effective 09/27/2021 reflected:
* "Employee health will maintain records for ... Covid -19 vaccine for all employees, including medical exceptions." The hospital's P&P did not include a process for tracking and securely documenting information provided by staff who requested, and the hospital granted a medical exemption from the staff Covid-19 vaccination.

7. Regarding temporarily delayed vaccinations.

7. a. Hospital Covid-19 vaccination P&Ps provided were reviewed and did not include a process for tracking and securely documenting vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed.

8. Regarding tracking and securely documenting Covid-19 vaccination status, temporarily delayed vaccinations, and exemptions.

8. a. During interview with the VPHR on 03/03/2022 beginning at 1505, the VPHR was asked to provide a P&P that ensured secure documentation, monitoring, and tracking of staff vaccination and exemption status. The following 2 policies were provided:
* "Information Privacy & Security Policy (ASANTE)," dated as approved on "03/01/2019;" and
* "Personnel Files Access to Records (ASANTE)," dated as approved "09/12/2019."
Neither policy provided specific processes or procedures on how staff Covid-19 vaccination, or exemption status would be securely tracked and maintained by the hospital. Generalized statements such as "It is critically important to maintain patient confidentiality, as well as maintain confidentiality about Asante employees ... to all sensitive information (verbal, paper and electronic) related to the operation of Asante including, but not limited to ... Other personal information related to our patients or employees ..." and "The following documents will not be placed in the personnel file ... Medical findings obtained at the time of employment or during employment. Those records are maintained in Employee Health." The P&Ps did not reflect how "personal information", or "medical findings" were securely, stored, maintained or accessed. In addition, the P&Ps did not include a process for tracking and securely documenting temporarily delayed vaccination status.

8. b. The hospital provided two lists regarding staff with medical exemptions. However, the lists contained unclear information. For example:
* An untitled, undated spreadsheet of current employees was provided and reviewed. It reflected several columns which included: "Employee_Name," "Vaccinated Status," "Fully Vaccinated Date," "Vaccine Completion Date," "Religious Exception," "Medical Exception," and "Attendance Exception." The list reflected 12 staff had a "Medical Exception" for whom the "Vaccinated Status" was recorded as "Incomplete" for 3 staff and "Unknown" for 9 staff. There was no further documentation of vaccine status for any of those 12 staff, and therefore it was unclear what their vaccination status was (e.g., temporarily delayed vaccination, clinical contraindication, or other, etc.).
* Another list provided regarding medical exemptions was a 6-page, undated spreadsheet with a handwritten title of "Exceptions & FMLA." It was reviewed and reflected several columns, including "Employee_Name," "Religious Exception," and "Medical Exception." The list reflected 12 staff had a "Medical Exception," for whom 2 staff were on "Remote work" each with a corresponding remote work timeframe; and 10 staff were on "Leave as an Accommodation" each with a corresponding leave period. There was no documentation on how those dates were determined. For example, 8 staff had the same "Leave as an Accommodation Date: 10/18/2021 - 3/26/2022."

8. c. The P&P titled "Immune Status Program," dated as approved on "09/27/2021," was reviewed and reflected "Responsibilities ... Employee Health will maintain records for: ... COVID-19 vaccine for all employees, including medical exceptions. Religious exceptions related to COVID-19 vaccinations will be maintained confidentially by Human Resources."

8. d. During an interview with VPQP on 03/03/2022 at 1545, the following information was provided regarding tracking and securely documenting medical and religious exemptions:
* "Exceptions are kept on a separate spreadsheet and only HR and Legal have access to that spreadsheet." When religious exceptions are reviewed by the committee, staff names, title and job area are redacted by HR and Legal. Supporting documents are on the server and only accessible by HR and Legal. Medical exceptions "are managed by HR and secured" electronically on the server.
* The P&P "Immune Status Program" was reviewed with the VPQP, and he/she confirmed that the process of securing both medical and religious exceptions was not reflected in the P&P as described during the interview.

8. e. Regarding tracking, monitoring, and securely documenting the vaccination status of staff who received boosters:
During an observation of the Covid-19 electronic tracking system with the VPQP and the DRM on 03/03/2022 beginning at 1410, it was observed that the system included Covid-19 booster information for some staff and flagged "overdue" boosters. However, during the observation the VPQP stated that the hospital was "promoting boosters" but was not tracking boosters.

8. f. Review of the following P&Ps reflected they did not include a process for tracking and securely documenting Covid-19 vaccination status of staff who have received boosters:
* "Covid-19 Vaccination Policy (ASANTE)," dated effective 09/23/2021; and
* "Immune Status Program," dated as approved on "09/27/2021."

8. g. Regarding tracking, monitoring and securely documenting vaccination status refer also to findings 2, 3, 4, 5, 6 and 7.






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