Every finding on record at Pioneer Memorial Hospice

Based on policy review, personnel file review and interview, it was determined the hospice failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases with regard to tuberculosis (TB) screening and annual monitoring for 7 of 8 employees and volunteers (Employees #2, #3, #4, #5, #6 and #7). --- Findings: Review of the agency policy "Tuberculosis (TB) Screening and Testing Healthcare Workers," last revised 01/2022, stipulated "1. All new HCW[s] will receive the following from a hospital RN trained to complete these assessments: a. A Risk Assessment b. A TB Symptom Screen. 2. If the HCW has a negative screen, they will advance to TST or IGRA testing ... The completed document will be retained within the HCW['s] employee medical file." Review of documentation in the personnel file of Employee #2 lacked documentation of TB screening. As of 8/14/2024, the record failed to include documentation of annual TB monitoring. Review of documentation in the personnel file of Employee #3 revealed documentation of TB screening dated 2022. As of 8/14/2024, the record failed to include documentation of annual TB monitoring subsequent to 2022. Review of documentation in the personnel file of Employee #4 revealed documentation of TB screening dated 2019. As of 8/14/2024, the record failed to include documentation of annual TB monitoring subsequent to 2019. Similar findings were discovered in the personnel files of Employees #5 - #8. During an interview on 8/14/2024, beginning at 4:00 PM, the Director was made aware of the above findings. The Director confirmed "There is no annual questionnaire for TB. We haven't been doing them."