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Memorial Medical Center COVID-19 Mandatory Vaccination Policy

The Department of Health and Human Services (”DHHS”) and Centers for Medicare and Medicaid Services (“CMS”) issued an emergency interim final rule on November 4, 2021, published in the Federal Register on November 5, 2021, entitled CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule (“CMS Emergency Vaccination Mandate”). This COVID-19 Mandatory Vaccination Policy (“Policy”) is intended to ensure compliance with the CMS Emergency Vaccination Mandate.

A. PURPOSE

The purpose of this Policy is to ensure that Memorial Medical Center (“Hospital”) provides a safe environment that is free of known hazards and prioritizes the health and safety of Hospital’s patients, employees, staff, contractors, students, vendors, volunteers, visitors, and the community at large, and to comply with the CMS Emergency Vaccination Mandate.

Hospital recognizes that vaccination is a vital tool to reduce the presence and severity of COVID-19 cases for anyone seeking health care or working in health care. As information regarding the pandemic and its impact on the work environment is continuously evolving, Hospital reserves the right to modify this Policy at any time, in its sole discretion, with or without notice.

B. SCOPE

This Policy applies to all Eligible Staff working at or for Hospital as defined below, whether or not employed, and whether or not serving in a clinical capacity. This Policy does not apply to staff who work 100% remotely, nor does it apply to visitors without a business purpose (e.g. family members of patients).

C. DEFINITIONS

1. 1. Eligible Staff means all Hospital employees, practitioners with clinical privileges or medical staff appointment, students, trainees, vendors, employees of contracted companies, contracted staff and volunteers. This Policy applies to all staff who work offsite if such staff interact with other Hospital staff or with Hospital patients. However, staff who work for Hospital exclusively via telehealth or tele-work are not “Eligible Staff.”
   2. Fully Vaccinated means that two weeks have passed after completing primary vaccination with a COVID-19 vaccine, with, if applicable, at least the minimum recommended interval between doses. For example, this includes two weeks after a second dose in a Two Dose Vaccine Series, such as the Pfizer or Moderna vaccines, two weeks after a Single Dose Vaccine, such as the Johnson & Johnson vaccine, or two weeks after the second dose of any combination of two doses of different COVID-19 vaccines as part of one primary vaccination series.
   3. Proof of Vaccination means an acceptable document evidencing that an individual has received an approved COVID-19 vaccine. Proof of Vaccination shall include the Eligible Staff member’s name, the type of vaccine administered, the date(s) of administration, and the name of the health care professional(s) or clinic site(s) that administered the vaccine. Acceptable examples of Proof of Vaccination include:
      • The record of vaccination from a health care provider or pharmacy;
      • A copy of the COVID-19 Vaccination Record Card;
      • A copy of medical records documenting the vaccination;
      • A copy of vaccination records from a public health, state, or tribal information system; or
      • A copy of any other official documentation that contains the type of vaccine administered, date(s) of administration, and the name of the health care professional(s) or clinic site(s) administering the vaccine(s).
   4. Single Dose Vaccine means any single dose vaccine regimen approved by the Food and Drug Administration, including under an Emergency Use Approval, for protection against COVID-19. The Johnson & Johnson (also known as the Janssen) vaccine is a Single Dose Vaccine.
   5. Two Dose Vaccine Series means any two dose vaccine regimen approved by the Food and Drug Administration, including under an Emergency Use Approval, for protection against COVID-19. The Pfizer vaccine and the Moderna vaccine are approved Two Dose Vaccine Series.

D. PROCEDURE

1. Mandatory Vaccination Requirements.
   • Phase One. Absent an approved exemption or approved delay, all Eligible Staff are required to have received the first dose of a Two Dose Vaccine Series against COVID-19, or a full dose of a Single Dose Vaccine on or before December 5, 2021. Eligible Staff not in compliance with this Policy must not enter the Hospital or any ancillary buildings unless seeking evaluation or treatment for an emergency medical condition or unless otherwise approved by Hospital, and may be subject to discipline as provided in Section X of this Policy. There is no testing alternative.
   • Phase Two. Absent an approved exemption or approved delay, all Eligible Staff are required to have received the second dose of a Two Dose Vaccine Series against COVID-19 on or before January 4, 2022. Eligible Staff not in compliance with this Policy must not enter the Hospital or any ancillary buildings unless seeking evaluation or treatment for an emergency medical condition or unless otherwise approved by Hospital, and may be subject to discipline as provided in Section X of this Policy. There is no testing alternative.
2. Dissemination of Policy. Hospital will disseminate this Policy and communicate the expectation of compliance and the expected timing of compliance no later than December 5, 2021. The Policy will be made available on the Hospital’s intranet and Hospital’s website (www.ashlandmmc.com). This Policy will be maintained by Human Resources.
3. Obtaining Vaccination.
   • Scheduling. Eligible Staff are responsible for scheduling and attending their own vaccination appointments. Vaccination appointments may be scheduled in any of the following ways:
     • The Hospital’s on-site vaccination clinic when available.
     • Through the Eligible Staff’s medical provider or pharmacy.
     • Through a community-based vaccination clinic.
     • Eligible Staff can find available vaccine appointments through the CDC’s Find COVID-19 Vaccines Tool.
   • Costs. Where necessary, Hospital will make arrangements for shift coverage and transportation costs and will compensate employees at their standard rate for scheduled time off work to obtain the vaccination. In the event there is any other cost associated with receiving COVID-19 vaccination, despite the fact that the government is offering the vaccine without charge to the recipient, the Hospital will incur the reasonable cost of Eligible Staff vaccinations. Requests for assistance with coverage, transportation or reimbursement should be made to the employee’s department head.
4. Eligible Staff Mandatory Reporting.
   • Primary Vaccination. All Eligible Staff are required to report their vaccination status and to provide Proof of Vaccination in accordance with the below table, or alternatively, request and receive a delay or an exemption by December 5, 2021. Eligible Staff must provide truthful and accurate information about their COVID-19 vaccination status. Eligible Staff who do not truthfully and accurately report as required by this Policy will be subject to discipline as provided in Section X herein. The specific vaccination reporting requirements are as follows:

   • Vaccination Status	Reporting Instructions	Reporting Deadline
     Eligible Staff who are fully vaccinated.	Submit Proof of Full Vaccination.	December 5, 2021
     Eligible Staff  Receiving First Dose of a Two Dose Vaccine Series Or Full Dose of a Single Dose Vaccine.	Submit Proof of Vaccination that indicates the first dose.	December 5, 2021
     Eligible Staff Receiving Second Dose of a Two Dose Vaccine Series.	Submit Proof of Vaccination that indicates the second dose.	January 4, 2022
     Eligible Staff who have been granted an exemption or delay.	Submit Exemption Form (medical or religious).	December 5, 2021

   • New Staff.
     1. All new Eligible Staff are required to comply with the vaccination requirements outlined in this Policy as soon as practicable and as a condition of the individual’s arrangement with Hospital. Potential new Eligible Staff will be notified of the requirements of this Policy.
     2. New Eligible Staff must submit Proof of Vaccination, written attestation or receive an approval of delayed vaccination or approved medical or religious exemption prior to beginning services for Hospital.
     3. The tracking documentation required in Section IX of this Policy shall be updated immediately for new Eligible Staff.
5. Submission of Proof of Vaccination or Written Attestation Eligible Staff must provide proof of COVID-19 vaccination. Eligible Staff may provide Proof of Vaccination, or, if applicable, provide a signed attestation as provided in Section VI of this Policy. Proof of Vaccination status can be submitted via the following methods:
   • Through the Hospital’s employee health portal, Immuware.
   • Via email to Human Resources or Employee Health staff.
   • In-person at the Human Resources department.
   • Via fax to Human Resources at 715.682.2368.
6. Written Attestation of Vaccination Status.
   • Circumstances Where Written Attestation is Appropriate. Eligible Staff will make best efforts to produce Proof of Vaccination. If an Eligible Staff member is unable to produce Proof of Vaccination despite a good faith effort to do so, the Eligible Staff member may provide a signed and dated statement attesting to their vaccination status.
   • Content of Written Attestation. The attestation must include:
     1. A statement of vaccination status (e.g. fully vaccinated, first dose received) including the type of vaccine administered, the date(s) of administration, and the location where the vaccine was administered.
     2. An explanation of the inability to produce Proof of Vaccination.
     3. The following statement: “I declare (or certify, verify, or state) that this statement about my vaccination status is true and accurate. I understand that knowingly providing false information regarding my vaccination status on this form may subject me to criminal penalties.”
7. Exemptions
   • Eligibility for Exemptions. Eligible Staff may request an exemption from this Policy if the individual has a recognized medical condition for which vaccines are contraindicated (as a reasonable accommodation under the Americans with Disabilities Act) or sincerely held religious beliefs, observances or practices that conflict with the vaccination requirement (established as Title VII of the Civil Rights Act of 1964).
   • Timing of Exemption Request – Current Staff. Requests for exemption must be submitted via Immuware, the hospital’s employee health portal on or before 12 noon on November 19, 2021 for current Eligible Staff. Current unvaccinated Eligible Staff will not be permitted to work after December 5, 2021 until the exemption request has been received and approved. Hospital will make best efforts to approve or deny any exemption requests received by November 19, 2021 prior to December 5, 2021. Requests received between November 19, 2021 and December 5, 2021 will be processed as quickly as possible but the individual may not commence work after December 5, 2021 until the request has been approved.
   • Timing of Exemption Request – Future Staff. Future Eligible Staff will not be able to commence work until the exemption request has been received and approved.
   • Contracted Staff. Hospital may opt to require its contractors to provide Proof of Vaccination, written attestation or evidence of approved exemption for Eligible Staff who provide services to Hospital or its patients through a contracted arrangement, in lieu of Hospital directly managing the vaccination or exemption process for those Eligible Staff. Hospital may accept a contractor’s decision on approval or denial of requested exemptions or delays provided that contractor uses criteria substantially similar to those reflected at Hospital. Contracting organizations will provide proper documentation concerning vaccination or exemption status of Eligible Staff on location. In such circumstances, Hospital will maintain documentation of the representations by the contractors concerning the contracted Eligible Staff as part of the Hospital COVID-19 Documentation process.
   • Medical Exemption.
     1. Requests for exemption based on a medical condition will be submitted using the medical exemption form available on the Hospital portal. Recognized clinical contraindications to the vaccine must be included on the form.
     2. Requests for medical exemption must be authenticated by a licensed medical practitioner who is not the individual requesting the exemption and who is acting within the practitioner’s scope of practice under applicable federal and Wisconsin law.
     3. An individual requesting a medical exemption must submit the completed form to HR staff or upload directly to Immuware.
     4. Hospital may request additional information from the individual submitting the request. The individual must promptly provide or facilitate such information. Failure to do so may result in denial of the request for exemption and may result in discipline in accordance with Section X below.
     5. The Hospital will notify the individual in writing or by electronic mail as to whether or not the request for medical exemption is approved. If not approved, the individual must obtain and report vaccination as otherwise required by this Policy.
     6. The fact that an individual tests positive for COVID-19 antibodies or reports having had COVID-19 previously is not a sufficient basis for an exemption.
   • Religious Exemption
     1. Requests for exemption based on a sincerely held religious belief, practice or observance will be submitted on using the religious exemption form available on the Hospital portal
     2. Individuals must submit the requests for religious exemption to HR staff or upload directly to Immuware.
     3. Hospital may request additional information from the individual submitting the request. The individual must promptly provide or facilitate such information. Failure to do so may result in denial of the request for exemption and may result in discipline in accordance with Section X below.
     4. The Hospital will notify the individual in writing or by electronic mail as to whether or not the request for religious exemption is approved. If not approved, the individual must obtain and report vaccination as otherwise required by this Policy.
8. Delay of Vaccination
   • The Hospital will extend the Phase One or Phase Two deadlines for individuals who must delay their vaccination due to legitimate clinical precautions and considerations recognized by the most current version of the CDC guidance.
   • Requests for a delay of vaccination based on clinical considerations will be submitted on the Medical Exemption form (temporary exemption).
   • Requests for a delay of vaccination based on clinical considerations must be authenticated by a licensed medical practitioner who is not the individual requesting the exemption and who is acting within the practitioner’s scope of practice under applicable federal and Wisconsin law.
   • An individual requesting a delay of vaccination for clinical considerations must submit the completed form to HR staff or upload directly to Immuware.
   • Hospital may request additional information from the individual submitting the request. The individual must promptly provide or facilitate such information. Failure to do so will be considered a violation of this Policy.
   • The Hospital will notify the individual in writing or by electronic mail as to whether or not the request for delay is approved. If not approved, the individual must obtain and report vaccination as otherwise required by this Policy.
   • Individuals who are granted an extension of the Phase One and/or Phase Two deadlines for vaccination must make plans to receive appropriate vaccine doses within one week of the date it is safe for them to receive a COVID-19 vaccine and must follow the safeguards specified below.
9. Safeguards.
   • Any individuals who are not vaccinated due to a medical or religious exemption or an approved delay of vaccination are required to:
     • All staff must follow all current masking requirements as outlined by Hospital policy, and
     • If requested by the Hospital, submit to COVID-19 testing periodically.
     • The duration of these requirements will be determined by the Hospital in conjunction with guidance from the CDC, state and federal authorities. Any unvaccinated individual not complying with these safeguard requirements will be subject to discipline pursuant to Section X of this Policy
10. Documentation.
    • COVID-19 Documentation. All records of COVID-19 vaccinations including Proof of Vaccination, written attestations, exemption request forms, exemption approval decisions, delay request forms, delay approval decisions and any related documentation (collectively “COVID-19 Documentation”) will be maintained by Human Resources.
    • Confidentiality. All COVID-19 Documentation will be maintained as confidential (and protected as such under applicable confidentiality law) and will be maintained separately from personnel or other documentation.
11. Tracking.
    • Documentation. Hospital, specifically Human Resources will maintain a record of each Eligible Staff member in Immuware. The information will be provided to government surveyors upon request.
    • Monitoring Progress. Hospital will consult the documentation to identify any Eligible Staff who do not report in accordance with Phase One and Phase Two deadlines and will follow up with each such individual, and impose discipline if indicated in accordance with Section X below.
    • COVID-19 Cases. Hospital, specifically Employee Health and/or Infection Prevention staff will maintain a list of all patient and staff COVID-19 cases over the previous four weeks. This list will be updated at least daily and will be treated as confidential. The list will be provided to government surveyors upon request.
12. Violation of Policy. At Hospital’s discretion, Eligible Staff who fail to comply with this Policy may be subject to discipline up to and including termination of the arrangement with the Eligible Staff member. If an Eligible Staff member falls into more than one of the below categories, the Hospital has discretion as to the mechanism of discipline.
    • Employee Discipline. If an employed Eligible Staff member fails to comply with this Policy (including but not limited to failure to obtain vaccination or failure to report vaccination by the Phase One or Phase Two deadline), the individual will be subject to termination.
    • Credentialed Staff. Those Eligible Staff who hold clinical privileges or medical staff appointment may be subject to restriction, suspension, limitation or revocation of privileges or appointment for failure to comply with this Policy, at the discretion of the Hospital Board of Directors. Such action on this basis is not based on professional competence or conduct and will not entitle the individual to procedural due process rights under the Medical Staff Bylaws.
    • Contracted Staff. Contracted staff who do not comply with this Policy (including but not limited to the Phase One and Phase Two deadlines) will be considered to be in violation of this Policy. At Hospital’s discretion, failure to comply may lead to a termination of the individual’s contract or the arrangement with the individual’s employer, or replacement of the individual under the contract with the individual’s employer such that individual is no longer able to provide services to Hospital or its patients.
    • Students, Trainees, Volunteers, Vendors and Other Non-Employees. Those Eligible Staff who are not employed by the Hospital and who do not hold clinical privileges or medical staff appointment and who violate this Policy may be subject to termination of their arrangement with the Hospital.
    • Post-Termination Presence at Hospital. An Eligible Staff member whose arrangement has been terminated in accordance with this Section may not appear at Hospital or ancillary facilities unless they are a patient or visitor or unless Hospital approves the encounter.