Every finding on record at St Mary's Hospital(Hospice Department)

Based on a review of personnel files, policies, and procedures and an interview with the agencys administrative staff, the hospice agencys administration failed to comply with other federal regulatory requirements for obtaining mandatory Hepatitis B declinations from its employees. This did not occur for 5 out of 9 employee files reviewed. --- Findings included: On 07/10/2023, a review of the employee files revealed no documentary evidence that 5 out of 9 employees were offered Hepatitis B (a serious liver infection) vaccinations as required by federal regulation, nor was a declination form completed by the employee. On 7/11/2023, a review of the agencys policy titled ";Associate Occupational Vaccinations" states: ";Associates whose jobs include potential exposure to blood-borne pathogens must be offered the vaccine series (Hepatitis B Vaccine) within 10 working days of beginning their assignment. If any Associate declines the series, a declination must be signed and documented in OHM". Hepatitis B Vaccine Declination (Mandatory) is from Occupational Safety Health Administration (OSHA), standard number 1910.1030 App A.