Failure to Conduct TB Screening for New Employee
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.
Penalty
Surveyors found that the facility did not follow its own TB screening policy for new employees. The written policy required a baseline TB status using a 2-step TST for all team members, with specific allowances for recent prior testing. However, one newly hired employee had only a single TST documented and no additional testing, and another newly hired employee had only an older QuantiFERON Gold result with no new TB testing at hire. The HR manager reported she was accepting outside TB test results from within the past year for new hires without further testing, while the NHA and DON stated they expected adherence to the facility’s TB testing policy and CDC recommendations.
The facility failed to conduct pre-employment TB screenings for three newly hired employees, as required by CDC guidelines. Personnel records for a housekeeping staff member, an occupational therapist, and a physical therapist lacked evidence of TB screening prior to their employment, despite the facility's policy mandating such procedures. This deficiency was confirmed by a human resources employee.
The facility did not follow pre-employment TB screening procedures for two newly hired employees, as required by state regulations and CDC guidelines. Employee records showed incomplete TB testing, with one employee having only a one-step skin test and another having an outdated chest x-ray, contrary to the facility's policy.
The facility did not follow CDC guidelines for pre-employment TB screening for a newly hired employee. The deficiency was identified through personnel records and staff interviews, showing non-compliance with the requirement for TB testing upon hire.
The facility failed to follow CDC guidelines for TB screening of newly hired health care personnel. Two newly hired nurse aides did not receive the required pre-employment TB screening, despite providing evidence of prior negative TB tests within 12 months. This deficiency highlights a lapse in the facility's adherence to recommended TB screening procedures.
The facility did not complete pre-employment tuberculin skin testing for five employees, violating CDC guidelines and its own policy. Personnel records lacked documentation of TB tests for an LPN and four RNs, which was confirmed by the Nursing Home Administrator.
Failure to Follow TB Screening Policy for New Employees
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its tuberculosis (TB) screening policy for employees. The facility’s written policy, titled “Respiratory Protection Program Standard” and last reviewed on March 23, 2026, required that a baseline TB status be obtained on all residents, team members, and volunteers, using a 2-step intradermal tuberculin skin test (TST) for initial testing. The policy allowed prior documented 2-step TSTs within the past 12 months to stand as the initial TST, and if more than 12 months had passed since a prior 2-step TST but a 1-step TST had been given in the last 12 months, a one-step test would be given to fulfill the 2-step requirement. Despite this, personnel file reviews showed that the facility did not obtain the required TB testing at the time of hire for certain employees. Employee 9, hired on April 20, 2026, had documentation of only a single 1-step TST dated December 17, 2025, with no additional TB testing in the personnel file at the time of hire to meet the 2-step requirement. Employee 10, hired on January 27, 2026, had documentation of a QuantiFERON Gold TB blood test dated January 27, 2025, which was negative, but there was no record of any additional TB testing at the time of hire. During an interview, the Human Resources Manager (Employee 11) confirmed she was accepting TB test results from outside the facility within the last year for new hires without further testing, in line with what she believed to be facility protocol. In a separate interview, the Nursing Home Administrator and Director of Nursing stated they would expect the facility to follow its current TB testing policy at the time of employment and to follow current CDC recommendations.
Plan Of Correction
1. Employee screenings were corrected to follow current policy for TB testing at time of employment for staff identifier # 9 and #10. 2. Audit of employee files that were hired in the past 3 months completed to ensure current policy for TB testing/screening and CDC guidelines was followed, at time of employment. 3. Education provided to Human Resource Manager on current TB policy and current CDC guidelines for testing/screening of staff at time of employment. 4. Audit of all new hires TB records will be completed X3 months. Audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Failure to Conduct Pre-Employment TB Screening
Penalty
Summary
The facility failed to implement pre-employment screening procedures for Tuberculosis (TB) for three newly hired employees, as required by the Centers for Disease Control and Prevention (CDC) guidelines. The facility's policy mandates that all employees undergo screening for latent tuberculosis infection and active tuberculosis disease using a tuberculosis skin test or interferon gamma release test, along with symptom screening, prior to employment. However, the personnel records for Housekeeping Staff Employee E1, Occupational Therapist Employee E2, and Physical Therapist Employee E3 did not include evidence of such screenings. Housekeeping Staff Employee E1 was hired on February 13, 2025, and worked multiple days in February, March, and April without documented TB screening. Similarly, Occupational Therapist Employee E2, hired on March 3, 2025, and Physical Therapist Employee E3, hired on March 31, 2025, also worked several days in March and April without documented pre-employment TB screenings. During an interview, Human Resources Employee E5 confirmed the facility's failure to conduct the required TB pre-employment screenings for these employees.
Plan Of Correction
1. No residents experienced adverse effects. Housekeeping Staff Employee E1, Occupational Therapist Employee E2, and Physical Therapist Employee E3 will have their TB testing completed. 2. Two-step TB test administered and signed by licensed nursing staff will be required during the pre-employment process to determine that staff are free from communicable diseases. 3. NHA to educate HR Director/designee on need for two-step TB test administered and signed by licensed nursing staff during the pre-employment process to determine that staff are free from communicable diseases. 4. HR Director/designee to audit new employee orientation folders 1x/week for 4 weeks, then monthly x 2 months.
Failure to Implement Pre-Employment TB Screening
Penalty
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.
Failure to Implement Pre-Employment TB Screening
Penalty
Summary
The facility failed to implement pre-employment tuberculosis (TB) screening procedures for one of five newly hired employees reviewed, identified as Employee 3. According to the Centers for Disease Control and Prevention (CDC) recommendations, all U.S. health care personnel should be screened for TB upon hire using either a TB blood test or a two-step TB skin test. The baseline individual TB risk assessment should be used to interpret the results of these tests. If a previous documented negative TB result is available from less than 12 months before new employment, only a single test is required. The deficiency was identified through a review of select personnel records and staff interviews, indicating non-compliance with the CDC guidelines for TB screening in health care settings.
Plan Of Correction
The facility cannot retroactively obtain a TB result for employee 3. A TB result has since been obtained. A review of current employees hired within the last 6 months was completed to ensure that each had obtained the appropriate TB results prior to beginning employment. The HR Coordinator and representatives from the facilities contracted partners will be educated on ensuring TB surveillance and pre-employment screening. The Administrator or designee will complete audits of all new hires to ensure that each receives the appropriate TB screening prior to employment. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Implement TB Screening for New Hires
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention (CDC) recommendations for tuberculosis (TB) screening and testing for newly hired health care personnel. Specifically, the facility did not implement the required pre-employment TB screening procedures for two of the five newly hired employees reviewed. According to the CDC guidelines, all U.S. health care personnel should be screened for TB upon hire using either a TB blood test or a two-step TB skin test. Additionally, if a previous documented negative TB result is provided within 12 months before new employment, only a single test is required. However, the facility did not follow these guidelines for Employees 2 and 3. Employee 2, a nurse aide, was hired on November 14, 2024, and provided evidence of a negative TB skin test dated March 4, 2024, which was within 12 months of being hired. Despite this, there was no evidence of any further testing, such as a one-step, blood test, or chest x-ray, upon their employment at the facility. Similarly, Employee 3, also a nurse aide, was hired on December 10, 2024, and provided evidence of a prior negative TB blood test dated August 5, 2024, within 12 months of hire. Again, there was no evidence that Employee 3 received any further testing prior to employment with the facility. This lack of adherence to the CDC's TB screening guidelines constitutes a deficiency in the facility's pre-employment screening procedures.
Plan Of Correction
Cited: Employees 2 and 3 will have a full TB screen completed. • Like: HRD/designee will complete a sweep of current staff members to ensure all staff have completed a TB screen. • Educations: NHA/designee will educate the HRD to ensure all staff have completed a TB screen upon hire. • Audits: HRD/designee will audit 5 staff members' files weekly x4 weeks and monthly x 2 months to ensure all staff have completed a TB screen upon hire. Results will be taken through QAPI.
Failure to Conduct Pre-Employment TB Testing
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention (CDC) guidelines for tuberculosis (TB) screening, testing, and surveillance, as evidenced by the lack of pre-employment tuberculin skin testing for five employees. The facility's policy, dated January 11, 2024, mandates that a two-step TB test be completed as part of the health assessment for new employees to ensure they are in good health and capable of performing their job duties. However, a review of personnel records revealed that there was no documentation of completed tuberculin skin tests for Licensed Practical Nurse Employee E1 and Registered Nurse Employees E3, E4, E5, and E6 prior to their employment. During an interview, the Nursing Home Administrator confirmed the facility's failure to conduct the required pre-employment TB testing for these five employees. This oversight indicates a lapse in the facility's compliance with its own health assessment policy and the CDC's recommendations for TB prevention and control. The deficiency was identified through a review of personnel files and interviews with staff, highlighting a systemic issue in the facility's hiring and health assessment processes.
Plan Of Correction
5. Registered Nurse Employee E4 no longer works at the facility. Licensed Practical Nurse Employee E1, Registered Nurse Employee E3, Registered Nurse Employee E5, and Registered Nurse Employee E6's will have tuberculin skin tests completed. 6. The Human Resource Director will audit employee files from the past three months to ensure that tuberculin skin tests were completed prior to employment. 7. The Human Resource Director will be reeducated on the facility policy for Health Assessments for Employees by the Nursing Home Administrator/designee. 8. The Nursing Home Administrator/designee will audit new hires weekly for four weeks and monthly for three months to ensure tuberculin skin tests were completed prior to employment. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
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