|Survey Date: 12/12/2007|
Regulation Title: PERSONNEL RECORDS: HEALTH
Regulation Description: The governing body, through the chief executive officer of the ESRD facility, is responsible for maintaining and implementing written personnel policies and procedures that ensure that complete personnel records are maintained on all personnel including health status reports.
Based on employee health file review, facility policy and procedure manual review and staff interview, it was determined that the governing body, through the chief executive officer of the ESRD facility, failed to ensure that employee health files were complete for three (#2, #3 and #5) of six employee health files reviewed, and that the employees were free from communicable disease, specifically tuberculosis. The findings were:
The facility's policy and procedure was reviewed on 12/11/07. The policy and procedure #4-06-05, entitled; "Tuberculosis Monitoring and Follow-up" stated, in pertinent part: "Follow up TB (tuberculosis) screening using TST (Tuberculin skin testing) will occur on an annual basis..."
The health file for employee #2 was reviewed on 12/11/07. Employee #2, a registered nurse (RN), was hired in 2002. The most recent TST was performed on 7/20/06.
The health file for employee #3 was reviewed on 12/11/07. Employee #3, a RN, was hired in 2002. The most recent TST was performed on 7/20/06.
The health file for employee #5 was reviewed on 12/11/07. Employee #5, a social worker, was hired in 2003. The most recent TST was performed on 7/20/06.
The senior director of clinical services was interviewed on 12/11/07 at approximately 10:30 a.m. The senior director stated the TST should be done on an annual basis as per facility policy.
Facility Plan of Correction:
The TB testing for Teammates # 2, 3 and 5 have been completed. The Facility Administrator (FA) will ensure that all teammates are monitored for TB according to DaVita policy 4-06-05. An audit of 100% of teammate files will be audited quarterly to ensure compliance. Teammates will be counseled as needed. Results of the teammate file audits will be reviewed in scheduled CQI meetings. A corrective action plan will be developed as needed. The Facility Administrator is responsible for compliance.
Completion date: Jan 3, 2008