| 6400.151(c)(2) | Staff #1 received a TB test on 08/06/18 and not again until 09/02/20. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | PROVIDER PLAN OF CORRECTION
DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING.
1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY:
Hope Enterprises will ensure Staff #1 has a current tuberculin skin test completed on or before 09/02/2022 and every 2 years thereafter. Hope Enterprises will provide a written reminder to Staff #1 of the need for tuberculin skin testing 1 month prior to due date. Documentation will be maintained and available for on-site review.
2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS:
Hope Enterprises will review 100% of staff records to ensure tuberculin skin testing is completed every 2 years. Hope Enterprises will provide a written reminder of the need for tuberculin skin testing to each staff member found to be within 1 month of his or her Tuberculin skin testing due date. If any staff member is found to be past the 2 year due date for tuberculin skin testing, Hope will require proof of tuberculin skin testing with negative test results or, if positive, initial chest x-ray with results noted prior to returning to work. Documentation will be maintained and available for on-site review.
3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR:
Hope Enterprises will retrain all staff on the requirement to have a Tuberculin skin testing completed every 2 years. Hope Enterprises will update its policies to provide that a complete physical examination, including Tuberculin skin testing, is required to work in a licensed residential facility. Hope will update its policies to include a written reminder of the need for tuberculin skin testing to each staff member 1 month prior to due date. Documentation will be maintained and available for on-site review. |
05/31/2021
| Implemented |