Failure to Administer Required Tuberculin Skin Tests to New Employees
Summary
The facility failed to comply with mandatory infection control and sanitation requirements by not administering a two-step Mantoux tuberculin skin test to 7 out of 10 newly hired employees before their first day of employment. This deficiency was identified during a record review and interview conducted by a surveyor. The Director of Nursing (DON) was unable to provide evidence of the required testing for these employees. Additionally, the facility did not have a policy in place for the screening of new employees as per the relevant executive order.
Plan Of Correction
1. Corrective Action of Areas Affected: The facility cannot retroactively correct the identified concerns related to new hires no longer employed by the facility who did not receive the required [R] in accordance to Federal/State regulations. The Staffing Coordinator/HR was re-inserviced on ensuring all new hires obtain a [R] in accordance with federal and State regulations. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The facility conducted an audit of all current employee files to verify the required tuberculosis screening has been completed. Documentation was not present on all employees, and their PPD has been properly administered. 3. Systemic Changes to Prevent Future Occurrences: A new hire checklist has been implemented including tuberculosis screening and other necessary information required upon employment. The Staffing Coordinator/HR is ensuring the required tuberculosis screening has been completed prior to employees beginning Orientation. 4. Monitoring of Corrective Action: The Staffing Coordinator/HR will conduct weekly audits x4 weeks, then monthly x2 months of new hires to verify the required tuberculosis screening has been completed prior to employees beginning Orientation. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Penalty
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