Failure to Offer and Document COVID-19 Vaccination for Staff
Penalty
Summary
The facility failed to follow its own COVID-19 Vaccination policy, dated 7/15/21, which requires an infection control program that reduces the incidence of COVID-19 by offering immunization to all employees and residents, unless medically contraindicated or already immunized, and by maintaining documentation that staff received education on vaccine benefits and risks and were offered the vaccine or information on obtaining it. During an interview and record review, the Infection Preventionist/Assistant DON (an LPN) confirmed that the facility did not have documentation showing that employees were offered the COVID-19 vaccine and stated that employees were not being offered the vaccine by the facility and that they were not aware this was a requirement. The CMS Form 671, signed by the Administrator in Training, documented that 44 residents resided in the facility at the time of the survey. This deficiency was identified based on the lack of documented evidence that staff were provided COVID-19 vaccine education and offers of vaccination, as required by the facility’s written policy and applicable CMS expectations, and the admission by facility leadership that employees were not being offered the COVID-19 vaccine through the facility.
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