HospitalInspections.org

Based on policy review and staff interview, the facility failed to ensure their policies and procedures included a process for the facility to track and securely document the COVID-19 vaccination status of all staff including students, trainees, volunteers and all individuals who provide care, treatment or other services for the hospital and/or its patients under contract or arrangement. This facility census was 446 patients.

Findings include:

Review of the policy titled, "HR-84 - Vaccination Program for Non-Employed Workforce Members," effective 02/15/22, revealed non-employed workforce members included vendors, contracted workers, volunteers, and students/trainees. These workforce members were required to be fully vaccinated or have an approved exemption as a condition of continued services or training at this facility. The vendor or contractors who employ or retain these workforce members or the education institutions sending students/trainees would be referred to as Covered Entities. The Covered Entities may be required to disclose their vaccination status or provide proof of vaccination at any time. The Covered Entities were responsible for developing and implementing policies and procedures to ensure all individuals assigned to provide services or receive training at this facility were fully vaccinated or have received an approved exemption. The Covered Entity may be required to provide proof at any time. The Covered Entity would be responsible for confirming, assessing, documenting, and monitoring evidence of compliance. The Covered Entity or Covered Workforce Members would be required to maintain documentation of the vaccination status, to proactively notify the facility of any covered exemption, and to provide documentation of compliance with the Vaccination Program to this facility immediately upon request.

During interview on 03/01/22 at 4:00 PM, Staff J stated the contractors would track vaccination status and notify this facility of any exemptions or non-vaccinated workers. The contractors would keep all evidence for vaccinations for their staff and supply it upon request.

During interview on 03/07/22 at 10:00 AM, Staff N verified the contracting organizations would be required to collect and maintain documentation of vaccination status and provide it upon request. The contracting organizations by contract were required to collect the proof of vaccination, track the vaccination status and ensure compliance of their staff.