Failure to Conduct TB Screening for New Employee
Penalty
Summary
The facility failed to adhere to its policy regarding tuberculosis (TB) screening for newly hired employees. According to the facility's policy, IM-162 Tuberculosis-Employee Screening, revised on June 14, 2023, each newly hired employee must be screened for TB infection and disease after an employment offer has been made but before the employee begins their duties. However, a review of the personnel records revealed that one of the five employees reviewed, referred to as Employee 1, did not receive the required tuberculin screening within the specified timeframe. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the process is currently being worked on.
Plan Of Correction
1. Facility policy has been reviewed and revised in accordance with state regulations. 2. Employee 1 has had a TB questionnaire completed and signs/symptoms were all negative. 3. Employee 1 had a T-Spot done. 4. NHA will provide education to HR Coordinator regarding TB testing completion before a candidate starts on their job duty assignment. 5. Baseline audit will be completed on employee files to determine compliance with TB screening. 6. NHA or designee will conduct an audit monthly x 2 months on all new hires to ensure all have proper TB documentation before the start date of employment. 7. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.