OSHA Inspection: SOUTHERN NEVADA HEALTH DISTRICT

Issued

Dec 23, 2014

Abate by

Dec 26, 2014

Penalty

Initial $1,800 · Current $1,800

General-duty citation text

Nevada Revised Statute 618.375(1): Duties of employers. Every employer shall fur
nish employment and a place of employment which are free from recognized hazards
that are causing or are likely to cause death or serious physical harm to his o
r her employees: 1) Prior to this inspection, Southern Nevada Health District's
(SNHD) most recent Tuberculosis (TB) Risk Assessment did not include pertinent s
tatistical data or the accurate criterion necessary to be compliant with Center
for Disease Control and Prevention (CDC) guidelines. SNHD's most recent Tubercul
osis Infection Control Plan was not developed specifically for the facility, and
instructed employees to erroneously follow Washington State laws. The plan did
not include a written protocol for outbreak investigations, nor did it include t
he implementation of certain Administrative and Environmental controls required
of TB clinics per CDC guidelines. A compliant
Exposure Control Plan and Risk Assessment is necessary so the quality of the SNH
D's tuberculosis infection control can be properly evaluated, needed improvement
s can be identified and corrective actions can be made. 2) Southern Nevada Healt
h District did not follow its own TB Infection Control Plan and Risk Assessment
which state that TB Control Plan and Risk Assessment are to be reviewed and upda
ted annually. Prior to this inspection, the Tuberculosis Infection Control Plan
had not been evaluated since 2010. Based on numerous inaccuracies within the Fac
ility Risk Assessment, it is evident that the document does not reflect current
procedures, nor has the document been reviewed or updated since at least 2010. P
er the CDC, annual evaluations are needed to identify and correct possible probl
ems in TB infection control. A feasible and accepted abatement method for reduci
ng these hazards is to follow
Southern Nevada Health District's own 2010 Tuberculosis Infection Control Plan a
nd Facility Risk Assessment which require the TB Control Plan and Risk Assessmen
t to be reviewed and updated annually. The Risk Assessment should be completed f
ollowing the requirements of the TB Risk Assessment section. In addition, follow
ing the guidelines set forth by 2005 "Guidelines for the Transmission of Mycobac
terium tuberculosis in Health Care Facilities" and "Controlling Tuberculosis in
the United States: Recommendations from the American Thoracic Society, CDC, and
the Infectious Diseases Society of America" and developing a compliant TB Exposu
re Control Plan (ECP) would reduce the hazards of maintaining a non-compliant EC
P. THIS HAZARD WAS ABATED ON OCTOBER 1, 2014 BY DEVELOPING AND IMPLEMENTING AN A
CCURATE AND COMPLIANT TUBERCULOSIS EXPOSURE CONTROL PLAN.
References: 1) Nevada Administrative Code 441A.200: Infectious Diseases. List of
adopted recommendations, guidelines and publications; review of revision or ame
ndment ofadopted recommendation, guideline or publication: The following recomme
ndations, guidelines and publications are adopted by reference: (g) The recommen
dations for the counseling of and effective treatment for a person having active
tuberculosis or tuberculosis infection as set forth in: (1) "Controlling Tuberc
ulosis in the United States: Recommendations from the American Thoracic Society,
CDC, and the Infectious Diseases Society of America," Morbidity and Mortality W
eekly Report [54(RR12):1-81, November 4, 2005], published by the United States D
epartment of Health and Human Services and available at no cost on the Internet
at http://www.cdc.gov/mmwr/; (h) The recommendations of the Centers for Disease
Control and Prevention for preventing the transmission of tuberculosis in facili
ties providing health care set forth in
"Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Hea
lth-Care Settings, 2005," Morbidity and Mortality Weekly Report[54(RR17):1-141,
December 30, 2005]. 2) "Guidelines for Preventing the Transmission of Mycobacter
ium tuberculosis in Health Care Facilities," 2005. Centers for Disease Control a
nd Prevention (CDC), MMWR December 30, 2005/Vol. 54/No. RR-17. TB SCREENING RISK
CLASSIFICATIONS "The three TB screening risk classifications are low risk, medi
um risk, and potential ongoing transmission." MANAGING PATIENTS WHO HAVE SUSPECT
ED OR CONFIRMED TB DISEASE: CONSIDERATIONS FOR SPECIAL CIRCUMSTANCES AND SETTING
S "The recommendations for preventing transmission of M. tuberculosis are applic
able to all health-care settings, including those that have been described
(Appendix A)." APPENDIX A: TB CLINICS: Physically separate immunosuppressed pati
ents from those with suspected or confirmed infectious TB. Schedule appointments
to avoid exposing HIV-infected or other severely immunocompromised persons to M
. tuberculosis. Keep patients in the booth or AII room until coughing subsides.
Do not allow another patient to enter the booth or AII room until sufficient tim
e has elapsed for adequate removal of M. tuberculosis contaminated air. EVALUATI
ON OF TB INFECTION-CONTROL PROCEDURES AND IDENTIFICATION OF PROBLEMS "Annual eva
luations of the TB infection-control plan are needed to ensure the proper implem
entation of the plan and to recognize and correct lapses in infection control. D
ata from the case reviews and observations in the annual risk assessment should
be used to determine the need to modify 1) protocols for identifying and initiat
ing prompt airborne precautions for patients with suspectedor
confirmed infectious TB disease, 2) protocols for patient management, 3) laborat
ory procedures, or 4) TB training and education programs for HCWs." 3) "Controll
ing Tuberculosis in the United States: Recommendations from the American Thoraci
c Society, CDC, and the Infectious Diseases Society of America," MMWR November 4
, 2005/Vol. 54/No. RR-12:1-81. Roles and Responsibilities of Jurisdictional Publ
ic Health Agencies "Planning and policy development. The blueprint for TB contro
l for a given area is a responsibility of the jurisdictional public health agenc
y. Policies and plans should be based on a thorough understanding of local epide
miologic data and on the capabilities and capacities of clinical and support ser
vices for clients, the fiscal resources available for TB control, and ongoing in
dicators of program performance. Open collaboration is essential among public he
alth officials and
community stakeholders, experts in medical and nonmedical TB management, laborat
ory directors, and professional organizations, all of whom provide practical per
spectives to the content of state and local TB-control policy. Policies and proc
edures should reflect national and local standards of care and should offer guid
ance in the management of TB disease and LTBI. A written TB control plan that is
updated regularly should be distributed widely to all interested and involved p
arties. The plan should assign specific roles and responsibilities; define essen
tial pathways of communication between providers, laboratories, and the public h
ealth system; and assign sufficient resources, both human and financial, to ensu
re its implementation, including a responsible case manager for each suspected a
nd verified case of TB. The plan should include the provision of expert consulta
tion and oversight for TB-related matters to clinicians,
institutions, and communities. It should provide special guidance to local labor
atories that process TB-related samples, assist local authorities in conducting
contact or outbreak investigations and DOT, and provide culturally appropriate i
nformation to the community. Systems to minimize or eliminate financial and cult
ural barriers to TB control should be integral to the plan, and persons with TB
and persons at high risk with TB infection should receive culturally appropriate
education about TB and clinical services, including treatment, with no consider
ation for their ability to pay. Finally, the plan should be consistent with curr
ent legal statutes related to TB control. Relevant laws and regulations should b
e reviewed periodically and updated as necessary to ensure consistency with curr
ently recommended clinical and public health practice (e.g., mandatory reporting
laws, institutional infection-control procedures, hospital and correctional sys
tem discharge planning, and involuntary confinement laws) (218).
Timely and accurate reporting of suspected and confirmed TB cases is essential f
or public health planning and assessment at all levels. Analyses of these data s
hould be performed at least annually to determine morbidity, demographic charact
eristics, and trends so that opportunities for targeted screening for diseaseor
infection can be identified. Regular reviews of clinical data (e.g., collaborati
ve formal case presentations and cohort analyses of treatment outcomes; complete
ness, timeliness and effectiveness of contact investigations; and treatment of L
TBI) may be used as indicators of program performance. TB-control programs shoul
d serve as sources of information and expert consultation to the health-care com
munity regarding airborne infection and appropriate infection-control practice.
A TB program's presence raises overall provider awareness of TB and facilitates
timely diagnosis, reporting, and treatment. Collaboration with local health-care
facilities to design and assist in periodic staff education and screening is of
ten a health department function. Expertise in airborne infections by TB-control
personnel may be shared with
biologic terrorism programs to assist in the design and implementation of local
protocols." OUTBREAK INVESTIGATIONS "When an outbreak is identified, short-term
investigation activities should follow the same principles as those for the epid
emiologic part of the contact investigation (i.e., defining the infectious perio
d, settings, risk groups, mode of transmission, contact identification, and foll
ow-up). However, long-term activities require continued active surveillance, M.
tuberculosis genotyping, additional contact investigations and related follow-up
for additional cases, and continuing education of providers, staff, and patient
s. Consequently, a plan for long-term support should exist from the outset of th
e investigation. A written protocol should be developed. At a minimum, the proto
col should outline the outbreak response plan, including indications for initiat
ing the
plan, notification procedures, composition of the response team, sources of staf
fing, plan for follow-up and treatment of contacts, indications for requesting C
DC assistance, and a process for evaluation of the outbreak response. The outbre
ak response plan should also include information on how to work strategically wi
th the media during the public health emergency. CDC offers training packages to
assist public HCWs in media communications, including emergency and crisis comm
unication. This training emphasizes prevent planning, event response activities,
and post-event follow-up." 4) Southern Nevada Health District 2010 Tuberculosis
Infection Control Plan Page 6 ADMINISTRATIVE CONTROLS "In TB infection control
programs for settings in which patients with suspected or confirmed TB disease a
re expected to be encountered, develop a written TB
infection control plan that outlines a protocol for the prompt recognition and i
nitiation of airborne precautions for persons with suspected or confirmed TB dis
ease, and update it annually." 5) Southern Nevada Health District Facility Risk
Assessment Page 24 PROGRAM EVALUATION "This TB ECP will be reviewed at least yea
rly. The review will include a reassessment of the clinic's risk level..."