902 KAR 20:200. Tuberculosis testing in long-term care facilities.

 

      RELATES TO: KRS 215.520-215.600, 216B.010-216B.131, 216B.990

      STATUTORY AUTHORITY: KRS 216B.042, 216B.105

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 216B.042 and 216B.105 mandate that the Kentucky Cabinet for Human Resources regulate health facilities and health services. KRS 215.520 to 215.590 mandates that nursing homes report cases of tuberculosis. The purpose of this administrative regulation is to establish licensure requirements concerning uniform procedures for the identification and control of tuberculosis in nursing facilities, skilled nursing facilities, intermediate care facilities, nursing homes, and personal care homes. These procedures are necessary to minimize the transmission of tuberculosis infection among the staff and residents of such facilities.

 

      Section 1. Definitions. (1) "Induration" means a firm area in the skin which develops as a reaction to injection tuberculosis proteins when a person has tuberculosis infection. The diameter of the firm area is measured to the nearest millimeter to gauge the degree of reaction. A reaction of ten (10) millimeters or more of induration is considered highly indicative of tuberculosis infection.

      (2) "Skin test" means a tuberculin skin test utilizing the intradermal (Mantoux) technique using five (5) tuberculin units of purified protein derivative (PPD). The results of the test must be read forty-eight (48) to seventy-two (72) hours after injection and recorded in terms of millimeters of induration.

      (3) "Two (2) step skin testing" means a series of two (2) tuberculin skin tests administered seven (7) to fourteen (14) days apart.

 

      Section 2. Admission of Patients under Treatment for Pulmonary Tuberculosis Disease. No licensee shall admit a person under medical treatment for pulmonary tuberculosis disease unless there is documentation of three (3) consecutive sputum smears negative for acid-fast bacilli within the month prior to admission and the patient is considered noninfectious by a licensed physician.

 

      Section 3. Tuberculin Skin Testing of Residents. (1) For residents entering a facility, no skin testing is required if one of the following can be documented:

      (a) A previous documented skin test has shown ten (10) or more millimeters of induration; or

      (b) The resident is currently receiving or has completed six (6) months of prophylactic therapy or a course of multiple-drug chemotherapy for tuberculosis; or

      (c) The resident can document that he/she has had a tuberculin skin test within three (3) months prior to admission.

      (2) For all other residents, however, skin testing is required upon admission to the facility. For such residents whose initial skin test shows less than ten (10) millimeters of induration, two (2) step skin testing is required, unless they can document that they have had a tuberculosis skin test within one (1) year prior to their initial testing upon admission to the facility. The skin test status of all residents must be documented through recording of the date and millimeters of induration of the most recent skin test in the medical record. The front cover of the medical record shall be labeled in a conspicuous manner with the notation "PPD+" for all residents with a reaction of ten (10) or more millimeters of induration.

 

      Section 4. X-raying of Residents. All residents found on admission testing to have a skin test of ten (10) or more millimeters of induration shall receive a chest x-ray, unless a chest x-ray done within two (2) months prior to admission showed no evidence of tuberculosis disease or the resident can document the previous completion of a course of prophylactic treatment with isoniazid.

 

      Section 5. Monitoring of Residents with a Skin Test of Ten (10) or More Millimeters of Induration. Residents with a skin test of ten (10) or more millimeters of induration shall be monitored for development of pulmonary symptoms such as cough, sputum production or chest pain. If such symptoms develop and persist of three (3) weeks or longer, a chest x-ray shall be taken and three (3) sputum samples shall be submitted to the Division of Laboratory Services, Department for Health Services, Frankfort, Kentucky, for tuberculosis culture and smear.

 

      Section 6. Monitoring of Residents with a Skin Test of Less than Ten (10) Millimeters of Induration. Annual skin testing is required. In addition, if pulmonary symptoms develop and persist for three (3) weeks or more, the tuberculin skin test shall be repeated, three (3) sputum samples shall be submitted to the Division of Laboratory Services, Department for Health Services, Frankfort, Kentucky for tuberculosis culture and smear, and a chest x-ray shall be taken.

 

      Section 7. Tuberculin Skin Testing of Staff. The skin test status of all staff members shall be documented in the employee's personnel record. A skin test shall be initiated on all new staff members before or during the first week of employment and the results shall be documented in the employee's personnel record within the first month of employment. No skin testing is required at the time of initial employment if the employee documents a prior skin test of ten (10) or more millimeters of induration or if the employee is currently receiving or has completed six (6) months of prophylactic therapy or a course of multiple-drug chemotherapy for tuberculosis. Two (2) step skin testing is required for new employees over age forty-five (45) whose initial test shows less than ten (10) millimeters of induration, unless they can document that they have had a tuberculosis skin test within one (1) year prior to their current employment. All staff who have never had a skin test of ten (10) or more millimeters induration must be skin tested annually on or before the anniversary of their last skin test.

 

      Section 8. X-raying and Monitoring of Staff with a Skin Test of Ten (10) or more Millimeters of Induration. All staff who are found to have a skin test of ten (10) or more millimeters induration, on initial employment testing or annual testing, must receive a chest x-ray unless a chest x-ray within the previous two (2) months showed no evidence of tuberculosis or, the individual can document the previous completion of a course of prophylactic treatment with isoniazid. They shall be advised of the symptoms of the disease and instructed to report to their employer and seek medical attention promptly, if symptoms persist.

 

      Section 9. Responsibility for Screening and Monitoring Requirements. The administrator of each long-term care facility is responsible for ensuring that all skin-tests, chest x-rays and sputum sample submissions are done in accordance with Sections 1 through 8 of this administrative regulation. In those facilities not employing professional staff with the technical training to carry out the screening and monitoring requirements, the administrator shall arrange for professional assistance from either the local health department or private medical practitioners. Irrespective of who carries out the screening and monitoring requirements, all skin testing dates and results, all chest x-ray reports and all sputum sample culture and smear results shall be recorded as a permanent part of the medical record and be summarized on the individual's transfer form when an interfacility transfer occurs.

 

      Section 10. Reporting to Local Health Departments. The following shall be reported to the local health department having jurisdiction by the administrator of the long-term care facility immediately upon becoming known: chest x-rays which are suspicious for tuberculosis; sputum smears positive for acid-fast bacilli; sputum cultures positive for mycobacterium tuberculosis; residents or staff who converts from a skin test of less than ten (10) to a skin test of ten (10) or more millimeters of induration; and all residents and staff who have a skin test of ten (10) millimeters or more induration at the time of admission or employment, respectively.

 

      Section 11. Prophylaxis of Persons with Recent Infection but no Disease. Any resident or staff whose skin test status changes on annual testing from less than ten (10) to ten (10) or more millimeters of induration shall be considered to be recently infected with Mycobacterium tuberculosis. Such recently infected persons who have no signs or symptoms of tuberculosis disease on chest x-ray or medical history should be given preventive therapy with isoniazid for six (6) months unless medically contraindicated as determined by a licensed physician. Medications shall be administered to patients only upon the written order of a physician. If such individual is unable to take isoniazid therapy, the individual shall be advised of the clinical symptoms of the disease, and have an interval medical history and a chest x-ray taken and evaluated for tuberculosis infection every six (6) months during the two (2) years following conversion.

 

      Section 12. Any staff or resident who can document completion of preventive treatment with isoniazid shall be exempt from further screening requirements except in accordance with Section 5 of this administrative regulation. (11 Ky.R. 914; eff. 12-11-84; Am. 12 Ky.R. 65; eff. 8-13-85; 13 Ky.R. 1302; eff. 2-10-87; 18 Ky.R. 1443; eff. 1-10-92.)