Comfort Care, LLC

Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for two of two personnel sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel. The webpage states, "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing." 3. A review of E1 and E2's personnel record revealed one TB test, risk assessment, and signs and symptoms screening. 4. In an interview, E1 acknowledged that E1 and E2 did not have a second TB test.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by an assisted living facility, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse. Findings include: 1. Record review revealed R2's pre-admission determination, which included whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner. However, this was not completed within 90 days before R2 was admitted to the facility. 2. In an exit interview, findings were discussed with E2 and no additional information was provided.