Noncompliance with TB Testing Requirements for Staff
Penalty
Summary
The facility failed to comply with federal, state, and local regulations regarding tuberculosis (TB) testing for healthcare workers. Record review showed that out of 131 active employees, TB testing records were only provided for 70 employees. Of those, only 23 were in compliance with state and local TB testing guidelines, while 47 had either lapsed TB testing or inconsistent annual testing documentation. The facility was unable to provide TB testing records for the remaining 61 employees. Additionally, the facility did not have facility-specific policies for TB testing available when requested. Interviews revealed that the Infection Preventionist (IP), responsible for ensuring timely TB testing, was on medical leave, and there was no system in place to ensure staff received required TB testing. The DON confirmed the absence of an acting IP and acknowledged the lack of oversight for TB testing compliance. The local health department RN stated that annual TB testing should occur in the same month as the employee's hire date. The Administrator expressed the expectation that all staff follow applicable regulations, but multiple attempts to contact the IP were unsuccessful.