Current through Register Vol. 48, No. 9, September 27, 2024
A. All
facilities shall conduct an annual tuberculosis risk assessment in accordance
with CDC guidelines to determine the appropriateness and frequency of
tuberculosis screening and other tuberculosis related measures to be
taken.
B. The risk classification,
such as low risk or medium risk, shall be used as part of the risk assessment
to determine the need for an ongoing TB screening program for staff and
residents and the frequency of screening. A risk classification shall be
determined for the entire facility. In certain settings, such as, healthcare
organizations that encompass multiple sites or types of services, specific
areas defined by geography, functional units, resident population, job type, or
location within the setting, may have separate risk classifications.
C. Staff Tuberculin Skin Testing.
1. Tuberculosis Status. Prior to date of hire
or initial resident contact, the tuberculosis status of direct care staff shall
be determined in the following manner in accordance with the applicable risk
classification:
2. Low Risk:
a. Baseline two-step Tuberculin Skin Test
(TST) or a single Blood Assay for Mycobacterium tuberculosis
(BAMT): All staff, within three (3) months prior to contact with
residents, unless there is a documented TST or a BAMT result during the
previous twelve (12) months. If a newly employed staff has had a documented
negative TST or a BAMT result within the previous twelve (12) months, a single
TST (or the single BAMT) can be administered to serve as the
baseline.
b. Periodic TST or BAMT
is not required.
c. Post-exposure
TST or a BAMT for staff upon unprotected exposure to M.
tuberculosis: Perform a contact investigation when unprotected
exposure is identified. Administer one (1) TST or a BAMT as soon as possible to
all staff who have had unprotected exposure to an infectious TB case or
suspect. If the TST or the BAMT result is negative, administer another TST or a
BAMT eight to twelve (8 to 12) weeks after that exposure to M.
tuberculosis ended.
3. Medium Risk:
a. Baseline two-step TST or a single BAMT:
All staff, within three (3) months prior to contact with residents, unless
there is a documented TST or a BAMT result during the previous twelve (12)
months. If a newly employed staff has had a documented negative TST or a BAMT
result within the previous twelve (12) months, a single TST, or the single
BAMT, can be administered to serve as the baseline.
b. Periodic testing (with TST or BAMT):
Annually, of all staff who have risk of TB exposure and who have previous
documented negative results. Instead of participating in periodic testing,
staff with documented TB infection (positive TST or BAMT) shall receive a
symptom screen annually. This screen shall be accomplished by educating the
staff about symptoms of TB disease, including the staff responses, documenting
the questioning of the staff about the presence of symptoms of TB disease, and
instructing the staff to report any such symptoms immediately to the
Administrator. Treatment for latent TB infection (LTBI) shall be considered in
accordance with CDC and Department guidelines and, if recommended, treatment
completion shall be encouraged.
c.
Post-exposure TST or a BAMT for staff upon unprotected exposure to M.
tuberculosis: Perform a contact investigation when unprotected
exposure is identified. Administer one (1) TST or a BAMT as soon as possible to
all staff who have had unprotected exposure to an infectious TB case or
suspect. If the TST or the BAMT result is negative, administer another TST or a
BAMT eight to twelve (8 to 12) weeks after that exposure to M.
tuberculosis ended.
4. Baseline Positive or Newly Positive Test
Result:
a. Staff with a baseline positive or
newly positive test result for M. tuberculosis infection, such
as TST or BAMT, or documentation of treatment for latent TB infection (LTBI) or
TB disease or signs or symptoms of tuberculosis, such as, cough, weight loss,
night sweats, fever, shall have a chest radiograph performed immediately to
exclude TB disease, or evaluate an interpretable copy taken within the previous
three (3) months. These staff members shall be evaluated for the need for
treatment of TB disease or latent TB infection (LTBI) and shall be encouraged
to follow the recommendations made by a physician with TB expertise, such as
the Department's TB Control program.
b. Staff with positive TST results,
regardless of when that conversion was first documented, shall document that
conversion, document a subsequent negative chest radiograph, and receive a
negative assessment for signs and symptoms of TB before they may be hired or
admitted, as appropriate.
c. Staff
who are known or suspected to have TB disease shall be excluded from work,
required to undergo evaluation by a physician, and permitted to return to work
only with approval by the Department TB Control program. Repeat chest
radiographs are not required unless symptoms or signs of TB disease develop or
unless recommended by a physician.
D. Resident Tuberculosis Screening
Procedures.
1. Residents shall have evidence
of a two-step tuberculin (TST) skin test. If the resident has a documented
negative tuberculin skin test (at least single-step) within the previous twelve
(12) months, the resident shall have only one (1) tuberculin skin test to
establish a baseline status.
2.
Residents shall have at least the first step within thirty (30) days prior to
admission and no later than forty-eight (48) hours after admission pursuant to
the physical examination as specified in Section 1100.
3. Residents with Positive Tuberculosis
Results.
a. Residents with a baseline positive
or newly positive test result for M. tuberculosis infection,
such as a TST or blood assay for Mycobacterium tuberculosis
(BAMT), or documentation of treatment for latent TB infection (LTBI)
or TB disease or signs or symptoms of tuberculosis, for example, cough, weight
loss, night sweats, or fever, shall have a chest radiograph performed
immediately to exclude TB disease, or evaluate an interpretable copy taken
within the previous three (3) months. Routine repeat chest radiographs are not
required unless symptoms or signs of TB disease develop or unless recommended
by a physician. These residents shall be evaluated for the need for treatment
of TB disease or LTBI and shall be encouraged to follow the recommendations
made by a physician with TB expertise, such as the Department's TB Control
program.
b. Residents known or
suspected to have TB disease shall be transferred from the facility if the
facility does not have an Airborne Infection Isolation room in accordance with
Section 101.C, required to undergo evaluation by a physician, and permitted to
return to the facility only upon consultation with the Department's TB Control
program.