HospitalInspections.org

Based on review of QSO memo 22-09-ALL, Attachment D, review of facility COVID-19 vaccination records, staff interview, and review of the facility policy, the facility failed to ensure 100% of staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted qualifying exemption, or identified as having a temporary delay as recommended by the Centers for Disease Control (CDC). The facility's percentage of vaccinated staff for COVID-19 was 96.2%. This affected 261 of 6813 staff members. The active census was 759.

Findings include:

Review of QSO memo 22-09-ALL, dated 01/14/22, revealed within 60 days of issuance of this memorandum, 100% of staff have received at least one dose of COVID-19 vaccine or have a pending request for, or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Centers for Disease Control and Prevention (CDC).

Review of the policy titled," Covid-19 Vaccine Policy," effective date 02/10/22, revealed all associates and privileged staff must comply with the following: All Associates and Privileged Clinical Staff must obtain the first dose of a COVID-19 vaccine or have a pending exemption request submitted pursuant to the process set forth in Appendix A. " Exemption Process for Associates and Clinical Staff."

Moderna: March 16,2022
Pfizer: March 23, 2022
Johnson & Johnson: April 13, 2022

Associates must obtain the final dose of a COVID-19 Vaccine or have an approved exemption on or before April 14,2022.

Review of staff vaccination tracking on 03/14/22 at 12:20 PM revealed there were no COVID-19 vaccinations or exemptions on file for the following employees:

One staff member for the following job classifications; Clinical Manager Neurodiagnostics, Lab Supervisor, Nurse Administrator, Project Manager, RN Care Manager, IV Specialist, Surgical Tech, Radiation Therapist, MRI Technologist, Physical Therapist Assistant, Pharmacy Tech Support Therapist, Pharmacy Tech, Pharmacy Tech Support Specialist, Psychiatric Tech, Respiratory Tech, Customer Response Rep, Scheduling Coordinator, Program Coordinator EAP, RN Clinical Leader, Substance Abuse Coordinator.

Two staff members for the following job classifications; Safety Aide, Medical Technologist, RN Enterostomal Therapist, Physical Therapist, Histotechnician, Histotechnologist, CT Technologist, Paramedic, Floor Technician, Parking Attendant, Cook, Unit Service Coordinator.

Three staff members for the following job classifications; Licensed Practical Nurse, Supply Chain Tech, Office Specialist.

Four staff members for the following job classifications; Psychiatric Tech, Patient Support Assistant, OR Assistant.

Five staff members for the following job classification; Nutrition Host

Six staff members for the following job classification; Radiology Technologist

Seven staff members for the following job classification; Protective Service Officers

Eight staff members for the following job classification; SPD Techs

Ten staff members for the following job classifications; Technical Laboratory Assistants and Respiratory Therapist

Eleven staff members for the following job classification; Patient Escorts

Thirteen staff members for the following job classification; Food Service Workers

Sixteen staff members for the following job classification; Environmental Services Associates

Fifty four staff members for the following job classification; Patient Support Assistants

Fifty Six staff members for the following job classification; Registered Nurses

Interview with Staff Y on 03/14/22 at 12:20 PM confirmed the staff identified above had not received the COVID-19 vaccination or had an exemption on file. Staff Y stated the facility plan, according to the policy, was that 100% of employees would be vaccinated by 04/13/22 or have exemptions on file.

Staff Y stated if staff had not started the vaccination series or received an exemption, they would be removed from the schedule and/or terminated as per policy. According to policy and procedure those staff who had an approved exemption or temporary delay from the COVID-19 vaccine must comply with continuous masking, even after system wide mandates and government mandates were revoked.