Rule/Regulation Violated:
A. A manager shall ensure that:
8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis:
a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and
b. As specified in R9-10-113;
Evidence/Findings:
Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB), as specified in Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i), for five of five sampled personnel members. The deficient practice posed a potential TB infection risk to residents.
Findings include:
1. A.A.C. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specific in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)..."
2. A review of the CDC website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." The web page indicated two-step testing involves an initial TST, and if negative, a second TST administered one to three weeks after the initial TST.
3. A review of E5's personnel records (hired in 2023) revealed documentation of completed initial TSTs for employee. However, there was no documentation of a second completed TST for E5 available for review.
4. In an interview, E1 acknowledged documentation of evidence of freedom from infectious TB, as specified in A.A.C. R9-10-113(B)(1)(a)(i), for E5 was not available for review.
Summary:
The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00188144, AZ00193810, AZ00197416, and AZ00201873, conducted on June 11, 2024: