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P1700

Failure to Implement Pre-Employment TB Screening

Pittsburgh, Pennsylvania Survey Completed on 02-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement pre-employment tuberculosis (TB) screening procedures for two of five newly hired employees, as required by Pennsylvania State regulations and CDC recommendations. The regulations stipulate that all healthcare personnel should undergo a TB screening upon hire, which includes a baseline individual TB risk assessment, TB symptom evaluation, and a TB test. The facility's policy also mandates that new staff receive two Mantoux TB Skin Tests given two weeks apart unless there is a documented history of a positive TB test. However, the personnel records for Environmental Services Employee E11 and Registered Nurse Supervisor Employee E12 did not meet these requirements. Employee E11's record showed only evidence of a one-step tuberculin skin test, which is insufficient according to the facility's policy. Additionally, Employee E12's record included documentation of a prior positive tuberculin skin test but had a chest x-ray that was over a year old, contrary to the requirement for a chest radiograph at the time of hire unless a recent one is documented. These oversights were identified during a review of personnel records and confirmed in an interview with the Nursing Home Administrator, indicating a lapse in adherence to the established TB screening protocols.

Plan Of Correction

No residents were affected by pre-employment tuberculosis testing issues. Residents may be affected if practice does not change. Human Resources will review employee files to ensure tuberculosis testing was completed on both employees. Human Resources was educated by the director of nursing or designee on the pre-employment tuberculosis policy. The director of nursing or designee will audit new hire charts for pre-employment tuberculosis testing weekly for 4 weeks for compliance. Findings will be reported to the quality assurance and process improvement meetings.

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