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Based on interview, review of medical personnel files, review of Kentucky Administrative Regulation (KAR) 902 KAR 20:016, and review of the facility's policy, it was determined the facility failed to ensure its employees received a periodic triennial (every three years) medical examination for eight (8) of eight (8) sampled employees who had been employed for at least three (3) years (Employee #1, #2, #4, #6, #7, #8, #9, and #10).

The findings include:

Review of 902 KAR 20:016 titled, "Hospitals: Operations and Services," effective 08/31/18, revealed in Section 3 (9) (d) for personnel, the hospital shall have an employee health program for the mutual protection of employees and patients, including provisions for preemployment medical examination and follow-up medical examination no less than every three (3) years thereafter for staff who serve patients.

Review of the facility's policy titled, "Employee Health Program," number 6253091, last reviewed and revised 04/2019, revealed the facility's Employee Health Program included 1) an effective screening for communicable disease and health assessment; 2) surveillance of employees to identify high risk employees; 3) coordination with infection control for follow-up on exposures to communicable diseases; 4) written policies, procedures, and protocols for work restrictions and occupational illnesses; and 5) a preventative health program. Specific procedures included 1) a pre-hire physical and communicable disease/immunization assessment; 2) annual surveillance for tuberculosis status, flu vaccine program, and OSHA Respiratory Protection Fit testing program; 3) evaluation of Hepatitis A status for high-risk employees; 4) providing vaccines, free of charge, if needed; and 5) counseling employees on health concerns and illnesses.

1. Review of Employee #1's, a Social Worker, medical file revealed she had a date-of-hire (DOH) of 04/29/96. She had no evidence of any medical examination in her file.

2. Review of Employee #2's, a Pharmacist, medical file revealed she had a DOH of 05/28/00. She had no evidence of any medical examination in her file.

3. Review of Employee #4's, a Registered Nurse (RN), medical file revealed she had a DOH of 08/20/07. Her last medical examination was 07/02/15.

4. Review of Employee #6's, the Emergency Department Director, medical file revealed she had a DOH of 05/13/96. She had no evidence of any medical examination in her file.

5. Review of Employee #7's, an RN, medical file revealed she had a DOH of 08/11/09. She had no evidence of any medical examination in her file.

6. Review of Employee #8's, a Pharmacy Technician, medical file revealed he had a DOH of 08/09/11. His preemployment medical examination, dated 07/25/11, was the only one in his file.

7. Review of Employee #9's, a Respiratory Therapist, medical file revealed she had a DOH at a sister facility of 02/18/13. Her preemployment medical examination, dated 02/05/13, was the only one in her file.

8. Review of Employee #10's, the Infection Preventionist, medical file revealed she had a DOH of 12/16/87. She had no evidence of any medical examination in her file.

Interview with the Market Manager for Employee Health, on 09/05/19 at 2:00 PM, revealed she was unaware of the changes in the KAR that took effect on 08/31/19 with the follow-up medical exam to be done every three (3) years. She stated she believed the periodic medical exam requirement was not specific enough on what components to be included and unnecessary because of the ongoing monitoring of employees for communicable diseases with the annual influenza vaccination and TB evaluation. The Manager also revealed the requirements for employee illness regarding when to be absent from work as well as follow-up on employee illness by the Infection Preventionist were adequate to ensure mutual protection of employees and staff against any communicable disease transmission.