WEST VIRGINIA UNIVERSITY HOSPITALS

WEST VIRGINIA UNIVERSITY HEALTH

SYSTEM

POLICY AND PROCEDURE MANUAL

Policy V.116S

1st Effective 08/23/2021

Revised 01/21/2022, 11/09/21, 1/19/22

Reviewed 01/21/2022

COVID-19 VACCINATION PROGRAM

SCOPE:

All West Virginia University Health System (WVUHS) Entities*

* West Virginia University Health System adopts this policy and procedure for WVU Hospitals, Inc.; Summersville

Regional Medical Center; WVUHS Home Care, LLC; WVUHS Medical Group; Reynolds Memorial Hospital;

Berkeley Medical Center; Jefferson Medical Center; Potomac Valley Hospital of W.Va., Inc.; United Summit

Center; United Hospital Center, Inc.; Wheeling Hospital, Inc.; Barnesville Hospital Association; United Physician’s

Care, Inc.; St. Joseph’s Hospital of Buckhannon, Inc.; Camden-Clark Memorial Hospital Corporation; Camden-

Clark Physician Corporation; Braxton County Memorial Hospital, Inc.; Jackson General Hospital; Wetzel County

Hospital; Uniontown Hospital; Allied Health Services, Inc.; West Virginia United Insurance Services, Inc.;

Accountable Care Organization of West Virginia, LLC(ACO); AHS, LLC; and Gateway Home Health Care, LLC

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PURPOSE:

The purpose of this policy is to protect the health and safety of patients, healthcare personnel, the families of patients

and healthcare personnel, and the community as a whole from COVID-19 infection through vaccination. The

purpose of this policy is to provide information to WVUHS healthcare workers regarding the requirements of the

COVID-19 vaccination. Administration of the COVID-19 vaccine can help to reduce the risk of COVID-19

infection, prevent transmission of COVID-19 from healthcare workers to others, especially persons at high risk of

complications, and reduce personnel absenteeism during community outbreaks.

DEFINITION:

For purposes of this policy, healthcare workers (“HCWs”) is defined as all employees (including those without

direct patient care responsibilities and those working remotely) and all physicians, licensed independent

practitioners, residents, volunteers, students, trainees, and contracted workers/vendors caring for patients or

providing related services on any of WVUHS’s premises.

“HCW” does not include non-employees who:

(1) exclusively provide telehealth or telemedicine services offsite and who do not have any direct contact

with patients or staff;

(2) provide support services for the entity that are performed exclusively offsite and who do not have any

direct contact with patients or staff; or

(3) infrequently provide ad hoc non-health care services on site for limited periods (such as annual elevator

inspection, delivery and repair personnel).

Note: In determining whether a non-employee is excluded from the definition of HCW, entities should consider (a)

frequency of presence, (b) services provided, and (c) proximity to patients and staff. For example, a plumber who

makes an emergency repair in an empty restroom or service area and correctly wears a mask for the entirety of the

visit would not be required to be vaccinated. On the other hand, a crew working on a construction project whose

members use shared facilities (restrooms, cafeteria, break rooms) during their breaks would be subject to the vaccine

requirement due to the fact that they are regularly using the same common areas used by staff, patients, and visitors.

COVID-19 is defined as a respiratory disease caused by SARS-CoV-2, a new coronavirus discovered in 2019. The

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virus is thought to spread mainly from person to person through respiratory droplets produced when an infected

person coughs, sneezes, or talks. Some people who are infected may not have symptoms. For people who have

symptoms, illness can range from mild to severe. Adults 65 years and older and people of any age with underlying

medical conditions are at higher risk for severe illness.

POLICY:

It is the policy of WVUHS to require all HCWs to receive the COVID-19 vaccination. COVID-19 vaccination is a

requirement of working at WVUHS. Exceptions for HCWs who have medical contraindications or religious reasons

that prevent them from obtaining the COVID-19 vaccination must be approved by Employee Health and the

Medical and Religious Exemption Review Committees.

This policy is based on guidance from the Centers for Disease Control and Prevention (CDC) and the Equal

Employment Opportunity Commission and is designed to comply with all applicable federal, state, and local laws.

Compliance with this policy is a condition of continued employment. Please read this policy carefully.

PROCEDURE:

Information About COVID-19 Vaccines

The CDC has promoted the benefits and safety of approved COVID-19 vaccines. According to the CDC:

• COVID-19 vaccines currently approved or in development in the US do not contain the COVID-19 virus

and will not make you sick with COVID-19.

• Getting the COVID-19 vaccine will not make you test positive for COVID-19.

• COVID-19 vaccinations have been shown to be highly effective at preventing you from getting sick with

COVID-19 and experiencing the most severe consequence of the disease.

• COVID-19 vaccines reduce the risk of spreading COVID-19.

• COVID-19 vaccines do not change your DNA.

• COVID-19 vaccinations are an important tool in helping to stop the pandemic.

• COVID-19 vaccines will be free to you, though some charges may be billed to your insurance company.

The CDC has, in the past, advised that fully vaccinated individuals can resume certain pre-pandemic activities in

certain settings without wearing a mask or social distancing, subject to state or local laws or regulations and local

business and employer requirements. An individual is considered fully vaccinated two weeks after the last dose of a

multiple-dose vaccine (e.g. Moderna or Pfizer) or two weeks after a single-dose vaccine (e.g. Johnson & Johnson).

If the CDC or FDA recommends or requires additional doses of any vaccine in order to be fully vaccinated, those

additional doses may be required in order to be considered fully vaccinated and in compliance with this policy.

More information about COVID-19 vaccines and the vaccine approval process is available and frequently updated

on the CDC's website at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/.

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Continued Applicability of Other Infection Control Policies and Protocols

This mandatory vaccination policy is a key part of our overall strategy and commitment to maintaining a safe and

healthy workplace in light of the COVID-19 pandemic. This policy is designed for use together with, and not as a

substitute for, other COVID-19 prevention measures, including WVUHS's:

• COVID-19 Masking Policy for Employees

• Visitation, Building Entrance, and Screening Guidelines During the COVID-19 Pandemic

• Guidelines for Employees with Novel Coronavirus

• COVID-19 Travel Policy

However, fully vaccinated individuals may be exempt from complying with certain COVID-19 prevention

measures, such as face mask or social distancing requirements, in certain settings. For more on those exemptions,

see your local facility’s OSHA COVID-19 Written Program.

We need your full cooperation and compliance with this and other health and safety workplace policies to make

them effective.

Vaccination Requirements

Consistent with the CDC's guidance to prevent the infection and spread of COVID-19, and as an integral part of its

public health and safety measures, WVUHS requires that all HCWs get fully vaccinated against COVID-19 and

show proof of an FDA-approved COVID-19 vaccination by February 28, 2022 at facilities located in Pennsylvania

and Maryland, and by March 15, 2022 for all facilities located in Ohio and West Virginia, unless an exemption from

this policy has been granted as an accommodation or otherwise. For more on the accommodation and exemption

process, see Accommodation and Exemption Requests below.

HCWs who fail to comply with these requirements will be barred from entering the worksite and subject to

corrective action, up to and including termination of employment, subject to reasonable accommodation and other

requirements of applicable federal, state, and local law.

Vaccine Administration

The COVID-19 vaccine will be offered to all HCWs through the System’s hospital Employee Health or Infection

Control Departments. HCWs must be vaccinated by February 28,

2022 at facilities located in Pennsylvania and

Maryland, and by March 15, 2022 for all facilities located in Ohio and West Virginia, and must receive their first

dose of the Moderna or Pfizer vaccine by February 14, 2022.

Proof of Vaccination

HCWs who already have received a vaccine from another health care provider must provide written proof of

vaccination from the vaccine administrator or a CDC-issued vaccination card, including the vaccination place,

date(s), and name, before the deadlines of either February 28 or March 15, 2022 based on their location. Do not

include any medical or genetic information with your proof of vaccination. WVUHS will keep your vaccination

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information confidential.

Accommodation and Exemption Requests

Medical Exemption

In accordance with WVUHS's Reasonable Accommodations Policy, WVUHS provides reasonable accommodations,

absent undue hardship, to qualified individuals with disabilities that enable them to perform their job duties.

Reasonable accommodation may include appropriate adjustment or modifications of employer policies, including

this mandatory COVID-19 Vaccination Program.

HCWs presenting with contraindications listed on the COVID-19 informational statement may be referred to their

primary care physician for written approval prior to vaccination. Contraindications to the COVID-19 vaccination

are the following (CDC Vaccine Safety):

a. People who have a documented history of severe allergic reaction after a previous dose or to a

component of the COVID-19 vaccine.

b. People who have a documented history of severe allergic reaction to a component of each currently

available COVID-19 vaccine.

c. Myocarditis or pericarditis after a first dose of an mRNA COVID-19 vaccine.

d. Another medical condition that will require information in a separate narrative that describes the

exception or deferral until a future date in detail. These requests will be reviewed on a case-by-case basis.

Exemptions for other medical reasons may be available on a case-by-case basis for other medical conditions that are

a contraindication to the COVID-19 vaccine, even if they do not qualify as a disability under federal, state, or local

law. WVUHS will engage in an interactive dialogue to determine whether an exemption is appropriate and can be

granted without imposing an undue hardship on WVUHS or posing a direct threat to the HCW or others in the

workplace. However, WVUHS reserves the right to take any necessary and appropriate steps, including imposing

alternative COVID-19 prevention measures, to ensure that the individual does not pose a direct threat to the health

or safety of others in the workplace.

HCWs who have medical contraindications or disabilities that prevent them from obtaining the COVID-19

vaccination must submit the Medical Exemption Form to Employee Health. All documentation, which confirms

recognized clinical contraindications to COVID-19 vaccines and which supports HCWs’ requests for medical

exemptions from vaccination, must be signed and dated by a licensed practitioner, who is not the individual

requesting the exemption, and who is acting within their respective scope of practice as defined by, and in

accordance with, all applicable State and local laws, and such documentation must contain: (a) All information

specifying which of the authorized or licensed COVID-19 vaccines are clinically contraindicated for the HCW to

receive and the recognized clinical reasons for the contraindications; and (b) A statement by the authenticating

practitioner recommending that the HCW be exempted from the COVID-19 vaccination requirements based on the

recognized clinical contraindications. The request will be reviewed and must be approved by Employee Health and

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the Medical Exemption Review Committee for an exemption to be granted.

Religious Accommodation

In accordance with WVUHS’s Reasonable Accommodations Policy, WVUHS provides reasonable

accommodations, absent undue hardship, to employees with sincerely held religious beliefs, observances, or

practices that conflict with getting vaccinated or receiving the type of vaccine currently available.

HCWs whose religious beliefs prevent them from obtaining the COVID-19 vaccination must submit the Religious

Exemption to Employee Health. The request will be reviewed and must be approved by Employee Health and the

Religious Exemption Review Committee for an exemption to be granted.

Interactive Process

WVUHS will engage in an interactive dialogue with you to determine the precise limitations of your ability to

comply with this mandatory vaccination policy and explore potential reasonable accommodations that could

overcome those limitations. WVUHS encourages employees to suggest specific reasonable accommodations.

However, WVUHS is not required to make the specific accommodation requested and may provide an alternative

effective accommodation, to the extent any reasonable accommodation can be made without imposing an undue

hardship on WVUHS or posing a direct threat to you or others in the workplace.

WVUHS reserves the right to request additional documentation supporting the need for an accommodation or

request for any other exemption. WVUHS will keep confidential any medical information obtained in connection

with your request for a reasonable accommodation or other exemption. [However, we ask that you not provide any

genetic information to WVUHS when responding to a request for additional information or providing proof of

vaccination in compliance with this policy (see GINA Safe Harbor below).

Determinations

WVUHS makes determinations about requested accommodations and exemptions on a case-by-case basis

considering various factors and based on an individualized assessment in each situation. WVUHS strives to make

these determinations expeditiously and in a fair and nondiscriminatory manner and will inform you after we make a

determination. If you have any questions about an accommodation or exemption request you made, please contact

Employee Health or your local Human Resources representative.

GINA Safe Harbor

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by

GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,

except as specifically allowed by this law. To comply with this law, WVUHS asks that you not provide any genetic

information when responding to this request for medical information.

"Genetic information," as defined by GINA, includes:

• An individual's family medical history.

• The results of an individual's or family member's genetic tests.

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• The fact that an individual or an individual's family member sought or received genetic services.

• Genetic information of a fetus carried by an individual or an individual's family member or an embryo

lawfully held by an individual or family member receiving assistive reproductive services.]

Process for Obtaining Vaccine and Proof of Vaccination Status

A Vaccine Information Sheet and informed consent, specific for vaccination against certain COVID-19 viruses,

shall be discussed and all questions answered to the satisfaction of the HCW, and signed by the HCW prior to

vaccination.

Upon receipt of the COVID-19 vaccination, an identifier will be placed on the HCW’s identification badge to

indicate that they have been vaccinated for COVID-19. HCWs must wear the badge identifier from the time they are

vaccinated through the duration as defined by Employee Health or Infection Control departments.

HCWs hired on or after January 31, 2022 must receive at least one dose of the COVID-19 vaccination, submit proof

of prior vaccination, or submit a medical or religious exemption request and receive approval prior to their first day

of employment. All new hires must comply with this policy as of February 28 or March 15, 2022 depending on the

location of the facility.

If a candidate for hire refuses to be vaccinated or submit an exemption request, the offer of employment will be

rescinded. HCWs returning from a leave of absence need to be compliant upon their return (if their return date is after

February 28 or March 15, 2022, depending on work location). If not fully compliant due to extenuating circumstances

during leave, the employer will provide up to 30 days to become fully complaint. HCWs will not be permitted to

return to work until they submit proof of vaccination or have an approved medical or religious exemption request after

February 28 or March 15, 2022. Corrective action will be deferred for no more than 30 days following the HCW’s

release to return to work. All HCWs are encouraged to become vaccinated during their leave whenever possible to

avoid delays in their return.

Consequences of Non-Compliance

WVUHS employees who fail to receive the COVID-19 vaccination or obtain an approved exemption by the due date

will be barred from work premises and will receive a Documented Counseling or their next step in the Corrective

Action process. Failure to comply with this requirement may also impact the staff member’s bonus eligibility

(where applicable), tuition benefit eligibility, and could impact the ability to transfer to another position within

WVUHS. Failure to receive the COVID-19 vaccination or obtain an approved exemption by the 7th day from the

deadline will result in the employee receiving a final written warning with clear communication that the employee

will have considered to have voluntarily terminated from their position if COVID-19 vaccination or an approved

exemption is not obtained as of 4:30 p.m. on the 14th day from the determined COVID-19 vaccination deadline.

Volunteers who fail to receive the COVID-19 vaccine by the date determined annually will not be permitted to

volunteer on WVUHS premises. Faculty and residents should refer to their medical staff by-laws and/or other

applicable policies for consequences of failure to receive the vaccination or receive an approved exemption.

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Masking

In an effort to prevent the transmission of COVID-19, HCWs who receive an approved medical or religious

exemption will be required to mask with a NIOSH approved N95 mask or equivalent or higher-level respirator for

source control at all times and may be required to take other protective measures. Exempted HCWs will be required

to wear a NIOSH approved N95 mask or equivalent or higher-level respirator for source control at all times while

working on any WVUHS owned or leased premises. Exempted HCWs who fail to comply with the masking

requirement will be issued corrective action, up to and including termination. HCWs who have failed to receive the

COVID-19 vaccination or obtain an approved exemption will also be required to wear a NIOSH approved N95 mask

or equivalent or higher-level respirator for source control at all times while working on any WVUHS owned or

leased premises. HCWs who fail to comply with the masking requirement will be issued corrective action, up to and

including termination. Masks that are not fit tested cannot be worn into a patient’s room with COVID-19, a PUI for

COVID-19, or any other airborne disease. Employees must be fit-tested before the NIOSH N95 mask will be issued.

A new mask will be needed weekly, or as recommended by the CDC, and whenever the mask becomes moistened,

soiled, torn, or otherwise contaminated. Failure to comply with the masking requirement will result in corrective

action, up to and including termination.

The local WVUHS facilities will provide each exempted HCW with NIOSH N95 masks or equivalent higher-level

respirator to wear. Employees are not permitted to alter the masks from the original state produced by the

manufacturer. Employees may only wear masks approved by management, and must wear the mask appropriately to

cover the mouth and nose.

HCWs who work at multiple locations within WVUHS will be required to follow the NIOSH N95 or equivalent

higher-level respirator masking requirements at all locations where they are currently working. It is the HCW’s

responsibility to communicate to local department management that he/she has been exempted from the COVID-19

vaccine and to comply with the NIOSH N95 or equivalent or higher-level respirator masking requirements.

Exempted employees who fail to comply with masking requirements while working at another WVUHS entity

hospital or location will be subject to corrective action, up to and including termination.

Vaccine Shortage

In the event of a COVID-19 vaccination shortage, the vaccine will be offered to HCWs based on job functions and

risk of exposure and transmission. Those HCWs who provide direct patient care and have the greatest risk of

exposure and transmission will be given priority for vaccination and will be held to the mandatory standard.

Contingency Plan

For HCWs that are not fully vaccinated, there is a contingency plan in place to address those not fully vaccinated

due to indicating that they will not receive the vaccine. Process is outlined in Consequences for Non-Compliance.

HCWs that are not fully vaccinated due to a medical, religious exemption or an approved temporary delay in

vaccination will be required to be compliant with additional precautions of N95 masking as described in the

Masking section of this policy. Contingency plans also include posting additional jobs to recruit new or temporary

or agency HCWs until permanent vaccinated replacements can be found.

CROSS REFERENCES:

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CORRECTIVE ACTION AND DISCHARGE - V.230S

WVUHS Reasonable Accommodations Policy - V.105S

WVUHS COVID-19 Masking Policy for Employees – VI.035S

WVUHS Visitation, Building Entrance, and Screening Guidelines During the COVID-19 Pandemic – VI.037

WVUHS Guidelines for Employees with Novel Coronavirus –V.112S

WVUHS COVID-19 Travel Policy – V.113S

Centers for Disease Control and Prevention: https://www.cdc.gov/coronavirus/2019-

ncov/vaccines/recommendations/underlying-conditions.html

The Joint Commission E-Manual, Infection Prevention and Control Chapter