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INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL
COVID-19 Vaccination of Facility Staff
Tag No.: A0792
Based on document review and interview, the facility failed to follow the QSO-22-11-All Memorandum regarding the rate of compliance (85%).
Findings Include:
1. Review of policy titled: F1 facility COVID-19 Vaccination Program, created 08/13/2021, indicated that F1 facility personnel, privileged providers, volunteers, student learners and contracted vendors and workers who access F1 facilities or affiliate locations will be fully vaccinated against COVID-19.
2. Review of QSO-22-11-All Memorandum, revised 04/05/22, indicated that facilities failing to maintain compliance with the 100% standard may be subject to enforcement action.
3. Review of the facility's breakdown of compliance (see below):
Compliant 2944
Exemption 369
Non-compliant 530
Total Employees 3474
Compliance equals 85%
4. Interview on 05/26/22 at approximately 1700 hours with S4, Accreditation and Regulatory Consultant confirmed the numbers listed in above. Confirmed knowledge of issue with the non-compliant number; that number is made up of medical and nursing students and volunteers working inside the F1 facility buildings and affiliates; confirmed there is a process to start to reduce that number in place.