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24 CREE DRIVE

LOCK HAVEN, PA 17745

COVID-19 Vaccination of Facility Staff

Tag No.: A0792

Based on review of facility policy and documentation and staff (EMP) interview, it was determined the facility failed to meet the 100% threshold for the COVID-19 vaccination mandate.

Findings include:

Review on March 23, 2022, of facility policy "COVID-19 Vaccination Program," dated March 21, 2022, revealed "I. Policy To protect the health and lives of patients, employees, and visitors against COVID-19 and in furtherance of UPMC's compliance efforts with respect to local, state, and federal COVID-19 vaccination mandates, all Covered Individuals, as defined herein, shall be subject to the vaccination requirements set forth in this COVID-19 Vaccination Program. For purposes of this policy individuals are considered to be compliant if they have completed a primary vaccination series for COVID-19 or have an approved medical or religious exemption. The completion of a primary vaccination series for COVID-19 is based on the current federal definition. ... IV. Definitions Covered Individual - This vaccination requirement applies to all individuals who regularly and customarily provide services in a Covered Facility, regardless of clinical responsibility or patient contact. The requirement includes all current employees as well as any new employees who provide any care, treatment, or other services at the Covered Facility and/or for its patients. In addition to employees working at a Covered Facility, the mandate also covers volunteers; non-employed personnel who provide care, treatment, or other services at the Covered Facility and/or for its patients under contract or other arrangements; students enrolled in clinical rotations at UPMC-Covered Facilities; non-employed members of any UPMC-affiliated hospital medical staff; and suppliers or vendors who regularly and customarily provide services in a Covered Facility. ...V. Guidelines A. Covered Individuals are required to provide either proof of vaccination or submit a medical or religious exemption request. ..."

Review on March 23, 2022, of facility documentation revealed the total number of staff for the facility was 146. Of that number 112 staff members received all doses of a multi-dose vaccine, one staff member received a single dose vaccine, 24 staff members were granted a religious exemption, and nine staff members had not completed the primary vaccination series for COVID-19. These nine staff members did not have a medical or religious exemption.

Interview on March 23, 2022, with EMP1 confirmed the total number of staff for the facility was 146 with nine members of the staff not in compliance with the COVID-19 vaccine mandate. EMP1 further confirmed the facility's overall compliance with the COVID-19 vaccine mandate is 93.8%.