Daystar Senior Living, LLC

Based on documentation review and interview, the health care institution's chief administrative officer failed to ensure the health care institution established, documented, and implemented tuberculosis infection control activities that: were consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments. Findings include: 1. A review of "https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm" revealed a report published May 17, 2019. The report stated "All U.S. health care personnel should have baseline TB screening, including an individual risk assessment (Box), which is necessary for interpreting any test result. The 2005 guidelines state that baseline test results provide a basis for comparison in the event of a potential or known exposure to M. tuberculosis, facilitate detection and treatment of LTBI or TB disease in health care personnel before placement, and reduce the risk to patients and other health care personnel (1). The risk assessment and symptom evaluation help guide decisions when interpreting test results..." 2. A review of "https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm" on September 14, 2023, revealed education on "TB Screening and Testing of Health Care Personnel" updated on August 30, 2022. The website stated "Baseline Testing: Two-Step Test; If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used..." 3. A review of E3's personnel record revealed evidence of baseline screening and a Mantoux tuberculin skin test dated July 20, 2023. However, no evidence of two-step testing was documented in E3's personnel records. 4. In an interview, E1 was unable to provide documentation that E3 had the two-step TST testing and the health care institution established, documented, and implemented tuberculosis infection control activities were not consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at htps://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments.