Failure to Complete TB Screening for New Employees
Summary
The facility failed to adhere to its tuberculosis (TB) infection control plan by not completing the required TB screening for two employees, identified as Employees 3 and 7. According to the facility's policy, new employees must have either two negative tuberculin skin tests (TSTs) administered not more than three weeks apart or a negative TB blood assay test not more than one year old, along with a completed Baseline TB Individual Risk Assessment and Symptoms Questionnaire. However, the personnel file for Employee 3, who was hired on November 6, 2024, did not contain any documentation of a TST or TB blood assay test prior to hire. Similarly, Employee 7, hired on December 17, 2024, had only one TST documented from a previous employer, dated April 3, 2024, which was negative. There was no additional documentation of a second TST or a TB blood assay test prior to their employment at the facility. During an interview, the Nursing Home Administrator confirmed the lack of documentation and stated that both employees had been removed from the floor and sent for a TB blood assay test, pending negative results before returning to work. The administrator acknowledged the expectation that all new hires should be appropriately screened for TB according to the facility's policy.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for Employee 3 and 7. 2) The Facility removed both employees from the schedule until their TB screening was completed and reviewed. 3) All current employees were reviewed for accurate TB screening requirements. Two: system changes and measures that will be taken: 1) HRA, DON, ADON, Department Heads and Infection Preventionist will be in-serviced on Facility TB policy. 2) Infection Preventionist will review all new employees for correct and accurate TB screening before new employees are allowed to start. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits weekly audits of all new hires for 4 weeks and then monthly for 2 months for accuracy. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
