South Carolina Code of Regulations
Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Subchapter 61-84 - Standards for Licensing Community Residential Care Facilities
Sec2 61-84.1700 - INFECTION CONTROL AND ENVIRONMENT
Section 61-84.1700.1702 - Tuberculin Skin Testing (I)

Universal Citation: SC Code Regs 61-84.1700.1702

Current through Register Vol. 48, No. 9, September 27, 2024

A. Tuberculin skin testing is a diagnostic tool for detecting M. tuberculosis infection. A small dose (0.1 mil) of purified protein derivative (PPD) tuberculin is injected just beneath the surface of the skin (by the intradermal Mantoux method), and the area is examined for induration (hard, dense, raised area at the site of the TST administration) forty-eight to seventy-two (48 to 72) hours after the injection (but positive reactions can still be measurable up to a week after administering the TST). The size of the indurated area is measured with a millimeter ruler and the reading is recorded in millimeters, including zero (0) mm to represent no induration. Redness/erythema is insignificant and is not measured or recorded. Authorized healthcare providers are permitted to perform tuberculin skin testing and symptom screening.

B. All facilities shall conduct an annual tuberculosis risk assessment (See Section 101.BBB) in accordance with CDC guidelines (See Section 102.B.16) to determine the appropriateness and frequency of tuberculosis screening and other tuberculosis related measures to be taken.

C. The risk classification, i.e., low risk, medium risk, shall be used as part of the risk assessment to determine the need for an ongoing TB screening program for staff/direct care volunteers and residents and the frequency of screening. A risk classification shall be determined for the entire facility. In certain settings, e.g., healthcare organizations that encompass multiple sites or types of services, specific areas defined by geography, functional units, patient population, job type, or location within the setting may have separate risk classifications.

D. Staff/Direct Care Volunteers/Private Sitters Tuberculin Skin Testing

1. Tuberculosis Status. Prior to date of hire or initial resident contact, the tuberculosis status of staff/direct care volunteer/private sitters 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/direct care volunteers/private sitters (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/direct care volunteer or private sitter 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 and read to serve as the baseline prior to resident contact.

b. Periodic TST or BAMT is not required.

c. Post-exposure TST or a BAMT for staff/direct care volunteers 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/suspect. If the TST or the BAMT result is negative, administer another TST or a BAMT eight to ten (8 to 10) weeks after that exposure to M. tuberculosis ended.

d. Post-exposure TST or a BAMT for private sitters upon unprotected exposure to M. tuberculosis: Written evidence of a contact investigation when unprotected exposure is identified shall be provided to the facility administrator. The private sitter shall provide documentation of a completed single TST or a BAMT prior to resident contact. If the TST or BAMT result is negative, the private sitter shall provide written evidence of an additional TST or BAMT eight to ten (8 to 10) weeks after that exposure to M. tuberculosis ended. (CDC: Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, December 30, 2005).

e. Baseline positive with or without documentation of treatment for latent TB infection (LTBI) (See Section 101.BB) or TB disease shall have a symptoms screen prior to employment and annually thereafter.

f. Upon hire, staff/direct care volunteers/private sitters with a newly positive test result for M. tuberculosis infection (i.e., TST or BAMT) or signs or symptoms of tuberculosis, e.g., 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). Repeat radiographs are not needed unless symptoms or signs of TB disease develop or unless recommended by a physician. These staff members/direct care volunteers/private sitters will be evaluated for the need for treatment of TB disease or latent TB infection (LTBI) and will be encouraged to follow the recommendations made by a physician with TB expertise (i.e., the Department's TB Control program).

3. Medium Risk:
a. Baseline two-step TST or a single BAMT: All staff/direct care volunteers/private sitters (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/direct care volunteer/private sitter 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 prior to resident contact.

b. Periodic testing (with TST or BAMT): Annually, of all staff/direct care volunteers who have risk of TB exposure and who have previous documented negative results. Instead of participating in periodic testing, staff/direct care volunteers with documented TB infection (positive TST or BAMT) shall receive a symptom screen annually. This screen shall be accomplished by educating the staff/direct care volunteers who have documented TB infection about symptoms of TB disease (including the staff's and/or direct care volunteers' responses concerning symptoms of TB disease), documenting the questioning of the staff/direct care volunteers about the presence of symptoms of TB disease, and instructing the staff/direct care volunteers 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. Periodic testing (with TST or BAMT): Annually, of all private sitters who have risk of TB exposure and who have previous documented negative results. Instead of participating in periodic testing, private sitters with documented TB infection (positive TST or BAMT) shall provide the facility with written evidence of a symptom screen annually. Documentation of education about symptoms of TB disease (including responses concerning symptoms of TB disease) and written evidence of the questioning about the presence of symptoms of TB disease, and the report of any such symptoms shall be provided immediately to the facility administrator.

d. Post-exposure TST or a BAMT for staff/direct care volunteers upon unprotected exposure to M. tuberculosis: Perform a contact investigation (See Section 101.M) when unprotected exposure is identified. Administer one (1) TST or a BAMT as soon as possible to all staff/direct care volunteers/private sitters who have had unprotected exposure to an infectious TB case/suspect. If the TST or the BAMT result is negative, administer another TST or BAMT eight to ten (8 to 10) weeks after that exposure to M. tuberculosis ended.

e. Post exposure TST or a BAMT for private sitters upon unprotected exposure to M tuberculosis: Written evidence of a contact investigation when unprotected exposure is identified shall be provided to the facility administrator. The private sitter shall provide documentation of a completed single TST or a BAMT prior to resident contact. If the TST or BAMT result is negative, the private sitter shall provide written evidence of an additional TST or BAMT eight to ten (8 to 10) weeks after that exposure to M. tuberculosis ended.

4. Baseline Positive or Newly Positive Test Result:
a. Baseline positive with or without documentation of treatment for latent TB infection (LTBI) or TB disease shall have a symptoms screen prior to employment and annually thereafter.

b. Upon hire, staff/direct care volunteers/private sitters with a newly positive test result for M.tuberculosis infection (i.e., TST or BAMT) or signs or symptoms of tuberculosis, e.g., 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). Repeat chest radiographs are not required unless symptoms or signs of TB disease develop or unless recommended by a physician. These staff members/direct care volunteers/private sitters will be evaluated for the need for treatment of TB disease or latent TB infection (LTBI) and will be encouraged to follow the recommendations made by a physician with TB expertise (i.e., the Department's TB Control program).

c. Staff/direct care volunteers/private sitters 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 written approval by the Department's TB Control program. Repeat chest radiographs are not required unless symptoms or signs of TB disease develop or unless recommended by a physician.

E. Resident Tuberculosis Screening (I)

1. Tuberculosis Status. Prior to admission, the tuberculosis status of a resident shall be determined in the following manner in accordance with the applicable risk classification:
a. For Low Risk and Medium Risk:
1. Admission/Baseline two-step TST or a single BAMT: All residents within thirty (30) days prior to admission shall have completed the first step of the two step tuberculin skin test followed seven to twenty one (7 to 21) days later by a second test unless there is a documented TST or a BAMT result during the previous twelve (12) months. If a newly-admitted resident 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 within one (1) month prior to admission to the facility to serve as the baseline. As an exception, a resident may be admitted with at least the first step of the TB screening process completed prior to admission and the second step within fourteen (14) days of admission.

2. Periodic TST or BAMT is not required.

3. Post-exposure TST or a BAMT for residents 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 residents who have had exposure to an infectious TB case/suspect. If the TST or the BAMT result is negative, administer another TST or a BAMT eight to ten (8 to 10) weeks after that exposure to M. tuberculosis ended.

b. Baseline Positive or Newly Positive Test Result:
1. Residents with a baseline positive or newly positive test result for M. tuberculosis infection (i.e., TST or BAMT) or documentation of treatment for latent TB infection (LTBI) or TB disease or signs or symptoms of tuberculosis, e.g., 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). 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. If diagnosed with latent TB infection (LTBI) the resident shall be encouraged to follow the recommendations made by a physician with TB expertise (i.e., the Department's TB Control program). For those residents diagnosed with TB disease, the facility shall assure that the affected residents follow the recommendations made by a physician with TB expertise (i.e., the Department's TB Control program).

2. Residents who are known or suspected to have TB disease shall be transferred from the facility if the facility does not have an Airborne Infection Isolation room (See Section 101.E), required to undergo evaluation by a physician, and permitted to return to the facility only with written approval by the Department's TB Control program.

F. Individuals who have been declared in writing to be in an emergency crisis stabilization status may be admitted to the facility without the initial step of the two-step tuberculin skin test and/or while awaiting the result of a BAMT. These individuals shall be placed in an area separate from the general population. This admission to the facility may be made provided:

1. There is documentation at the facility of the declaration by Adult Protective Services of the South Carolina Department of Social Services or the South Carolina Department of Mental Health that the admission is, in fact, an emergency (NOTE: Only these agencies may declare these crisis stabilization admissions to be an emergency);

2. There is written evidence of a chest x-ray within one (1) month prior to admission and a written assessment by a physician or other authorized healthcare provider that there is no active TB and a negative assessment for signs and/or symptoms of tuberculosis; and,

3. The resident will receive the initial step of the two-step tuberculin test within twenty-four (24) hours of admission to the facility. The second step of the two-step tuberculin skin test must be administered within the next seven to fourteen (7 to 14) days.

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