HospitalInspections.org

Based on observations, interviews and record review, it was determined that the CAH failed to comply with the Life Safety From Fire requirements as indicated on the attached Life Safety from Fire CMS 2567 SOD report.

Findings include:

1. Refer to the findings on the Life Safety from Fire CMS 2567 SOD report.

Based on observations, interview, documentation in 1 of 12 employee and contract staff TB screening records (Staff 42), and review of infection control P&Ps it was determined that the hospital failed to ensure that infection prevention policies and procedures related to TB screening had been fully implemented as TB screening for all staff was not conducted in accordance with hospital P&Ps.

Findings included:

1. The P&P titled "Caregiver Health - Tuberculosis (TB) Evaluation and Screening," dated as approved 03/30/2022, was reviewed. It included the following requirements:
* "It is the policy of SCHS to establish a standard of practice for [TB] screening to ensure quality and safe Infection Prevention practices for SCHS caregivers, volunteers, and students ... This is a policy that applies to all St. Charles system caregivers at time of hire ... This policy exists to meet regulatory requirements for the evaluation and screening for M. tuberculosis for all health care personnel (HCP)."
* "All Caregivers are to complete a baseline TB screening by [IGRA] testing upon hire. Testing, symptom review and risk assessment to be completed by caregiver health nurse."
* "A previously documented negative IGRA (Quantiferon gold or T-Spot) from an alternate facility within one year from date of hire is acceptable. A negative Tuberculin Skin Test or PPD is not considered acceptable documentation and an IGRA will be ordered by caregiver health."

2. Documentation for caregiver Staff 42 reflected they were credentialed and privileged to provide services at the hospital as a member of the medical staff effective 04/04/2023. TB screening documentation contained in electronic medical staff credential files and dated 01/03/2023 contained incomplete information about their TB screening history. On a printed copy of an electronic medical staff "attestation form" the following question was asked: "If you have had a positive tuberculin skin test in the past, please complete the following." The response selected by Staff 42 was "N/A - have never tested positive." There was no other information documented including what type of TB screening testing was conducted previously and the dates testing was conducted. There was no documentation that the caregiver had received a "baseline TB screening by [IGRA] testing upon hire" in accordance with the P&P described under Finding 1 above.

3. During interview with staff that included the CHS, QM staff, and Administrator on 06/28/2023 at approximately 1450 they confirmed that there was no other TB screening documentation to reflect that Staff 42 had received TB screening in accordance with the hospital's P&P. They further confirmed that the TB screening P&P applied to all employee and contract staff, including medical staff.