HospitalInspections.org

Based on interview, personal record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure two employees (Employee #7 and Employee #8), out of eight employee records reviewed, had Tuberculin Skin Tests (TB skin tests) completed prior to employment.

Findings include:

A review of the facility's policy and procedure, Section XIII "Education and Notifications" revealed "All employees will require a TB Skin Testing during "New Employee Orientation" prior to beginning work, unless previous history of a positive test has been recorded. Employees who test positive will be referred to the Health Department for evaluation. Employees who test positive will not be required to complete a Tuberculosis questionnaire. All employees will complete annual testing or complete the Tuberculosis questionnaire every 11 months."

1. A review of Employee #7's personnel record revealed the employee was hired on 12/30/09. There was no documented evidence that Employee #7 had a TB skin test completed prior to employment or at any time during employment. Furthermore, there was no evidence of a TB questionnaire completed by Employee #7 prior to employment or at any time during employment.

2. A review of Employee #8's personnel record revealed the employee was hired on 07/01/05 . There was no documented evidence that Employee #8 had a TB skin test completed prior to employment or at any time during employment. Furthermore, there was no evidence of a TB questionnaire being completed by Employee #8 prior to employment or at any time during employment.

An interview with the Director of Social Services, on 02/29/12 at 10:20 AM, revealed "that's not what we do" when asked for evidence of completed TB skin tests or completed questionnaires for Employee #7 and Employee #8. No further explanation was provided.