Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities and State Correctional Centers

PURPOSE: This rule establishes tuberculosis testing requirements for residents and workers in long-term care facilities and state correctional centers. (1) General Requirements. Long-term care facilities and state correctional centers shall screen their residents and staff for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit (5 TU) test. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained for all residents, employees, and volunteers. (A) In interpreting this rule, long-term care facilities shall include employees, volunteers, and residents of residential care facilities I, residential care facilities II, intermediate care facilities and skilled nursing facilities as defined in section 198.006, RSMo. (B) In interpreting this rule, state correctional centers shall include all employees and volunteers of the Missouri Department of Corrections and the residents of all correctional institutions operated by the Missouri Department of Corrections. (C) Whenever tuberculosis is suspected or confirmed, or tuberculosis infection is diagnosed among residents, employees or volunteers, the Department of Health or local health authority shall be notified as required in 19 CSR 20-20.020(2). (2) Long-Term Care Residents. Within one (1) month prior to or one (1) week after admission, all residents new to long-term care are required to have the initial test of a Mantoux PPD two (2)-step tuberculin test. If the initial test is negative, zero to nine millimeters (0–9 mm), the second test, which can be given after admission, should be given one to three (1–3) weeks later. Documentation of chest X ray evidence ruling out tuberculosis disease within one (1) month prior to admission, along with an evaluation to rule out signs and symptoms compatible with infectious tuberculosis, may be accepted by the facility on an interim basis until the Mantoux PPD two (2)-step test is completed. (A) All skin test results are to be documented in millimeters (mm) of induration. (B) Bacillus of Calmette and Guerin (BCG) vaccination shall not prevent residents from receiving a tuberculin test. (C) A reaction of ten millimeters (10 mm) or more shall be considered as infected with Mycobacterium tuberculosis for an individual with a history of BCG vaccination. (D) Evidence of tuberculosis infection is considered to be a reaction of five millimeters (5 mm) or more for all contacts to infectious tuberculosis or for an individual who is immunosuppressed or has abnormal chest X-ray findings consistent with old healed tuberculosis disease, and ten millimeters (10 mm) or more for all others. (E) Residents with a negative, zero to nine millimeters (0–9 mm), Mantoux PPD two (2)-step test need not be routinely retested unless exposed to infectious tuberculosis or they develop signs and symptoms which are compatible with tuberculosis disease. (F) Residents with a documented history of tuberculosis infection or an adequate course of preventive treatment shall not be required to be retested. Residents with a documented history of tuberculosis disease and adequate chemotherapy shall not be required to be retested. In the absence of documentation, a repeat test shall be required. (G) All skin test results of five millimeters (5 mm) or more for contacts to infectious tuberculosis or for an individual who is immunocompromised, or ten millimeters (10 mm) or more for all others, shall require a chest X ray within one (1) week, or a review of the results of a chest X ray taken within the month prior to admission along with an evaluation to rule out signs and symptoms compatible with tuberculosis disease to rule out active pulmonary disease. (H) Individuals with a positive finding presenting evidence of a recent, within one (1) month of the date of admission, chest X ray need not be given a new X ray. However, the results of the X ray must be reviewed in the light of the additional information of the identification of tuberculosis infection as indicated by the Mantoux PPD skin test. (I) An individual who is skin-test positive with a normal chest X ray should be considered for preventive medication. Those who complete a recommended course of preventive treatment and those for whom preventive treatment is not medically indicated need have no further testing for tuberculosis unless signs and symptoms which are compatible with tuberculosis disease are present. (J) All residents of long-term care facilities who are exposed to a case of infectious tuberculosis or who develop signs and symptoms which are compatible with tuberculosis disease shall be medically evaluated. All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. (3) Long-Term Care Employees and Volunteers. All new longterm care facility employees and volunteers who work ten (10) or more hours per week are required to obtain a Mantoux PPD two (2)-step tuberculin test within one (1) month prior to starting employment in the facility. If the initial test is zero to nine millimeters (0–9 mm), the second test should be given as soon as possible within three (3) weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two (2) years. It is the responsibility of each facility to maintain a documentation of each employee’s and volunteer’s tuberculin status. (A) All skin test results are to be documented in millimeters (mm) of induration. (B) BCG vaccination shall not prevent employees and volunteers from receiving a tuberculin test. (C) For an individual with a history of BCG vaccination, a reaction of ten millimeters (10 mm) or more shall be considered as infected with Mycobacterium tuberculosis. (D) Evidence of tuberculosis infection is considered to be a reaction of five millimeters (5 mm) or more for all contacts to infectious tuberculosis or for an individual who is immunosuppressed or has abnormal chest X ray findings consistent with old healed tuberculosis disease, and ten millimeters (10 mm) or more for all others. (E) Employees and volunteers with an initial zero to nine millimeters (0–9 mm) Mantoux PPD two (2)-step test shall be one (1)-step tuberculin tested annually and the results recorded in a permanent record. (F) Employees and volunteers with a documented history of a positive Mantoux PPD test shall not be required to be retested. In the absence of documentation, a repeat test shall be required. (G) All positive findings shall require a chest X ray to rule out active pulmonary disease. (H) Individuals with a positive finding need not have repeat annual chest X rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. (I) An individual who is skin-test positive with a normal chest X ray should be considered for preventive medication. Those who complete a recommended course of preventive medication need have no further testing for tuberculosis unless signs and symptoms which are compatible with tuberculosis disease are present. (J) All employees and volunteers of long-term care facilities who are exposed to a case of infectious tuberculosis or who develop signs and symptoms which are compatible with tuberculosis disease shall be medically evaluated. All employees or volunteers of these facilities shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. (4) State Correctional Centers Residents. All residents of state correctional centers are required to obtain a Mantoux PPD two (2)-step tuberculin test upon admission to rule out tuberculosis. If the initial test is negative, zero to nine millimeters (0–9 mm), the second test should be given within ninety (90) days of entrance into the state correctional system. (A) All skin test results are to be documented in millimeters (mm) of induration. (B) BCG vaccination shall not prevent residents from receiving a tuberculin test. (C) For an individual with a history of BCG vaccination, a reaction of ten millimeters (10 mm) or more shall be considered as infected with Mycobacterium tuberculosis. (D) A positive test is defined as having a reaction of five millimeters (5 mm) or more for all contacts to infectious tuberculosis or for an individual who is immunosuppressed or has abnormal chest X ray findings consistent with old healed tuberculosis disease, and ten millimeters (10 mm) or more for all others. (E) Individuals with an initial negative zero to nine millimeters (0–9 mm) Mantoux PPD two (2)-step test shall be one (1)-step tuberculin tested annually and the results recorded in a permanent record. (F) Individuals with a documented history of a positive Mantoux PPD test shall not be required to be retested. In the absence of documentation, a repeat test shall be required. (G) All positive findings shall require a chest X ray to rule out active pulmonary disease. (H) Individuals with a positive finding need not have repeat annual chest X rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. (I) An individual who is skin-test positive with a normal chest X ray should be considered for preventive medication. Those who complete a recommended course of preventive medication need have no further testing for tuberculosis unless signs and symptoms which are compatible with tuberculosis disease are present. (J) All residents of state correctional centers who are exposed to a case of infectious tuberculosis or who develop signs and symptoms which are compatible with tuberculosis disease shall be medically evaluated. All residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. (5) Missouri Department of Corrections New Employees and Volunteers. All new employees and volunteers who work ten (10) or more hours per week for the Missouri Department of Corrections are required to obtain a Mantoux PPD two (2)-step tuberculin test within three (3) weeks of starting employment. If the initial test is negative, zero to nine millimeters (0–9 mm), the second test should be given one to three (1–3) weeks after the initial test. It is the responsibility of each state correctional center to maintain documentation of each employee’s or volunteer’s tuberculin status. (A) All skin test results are to be documented in millimeters (mm) of induration. (B) BCG vaccination shall not prevent new employees and volunteers from receiving a tuberculin test. (C) For an individual with a history of BCG vaccination, a significant reaction of ten millimeters (10 mm) or more shall be considered as infected with Mycobacterium tuberculosis. (D) A positive test is defined as having a reaction of five millimeters (5 mm) or more for all contacts to infectious tuberculosis or for an individual who is immunosuppressed or has abnormal chest X ray findings consistent with old healed tuberculosis disease, and ten millimeters (10 mm) or more for all others. (E) Employees and volunteers with a negative zero to nine millimeters (0–9 mm) Mantoux PPD two (2)-step test shall be one (1)-step tuberculin tested annually and the results recorded in a permanent record. (F) Employees and volunteers with a documented history of a positive Mantoux PPD test shall not be required to be retested. In the absence of documentation, a repeat test shall be required. (G) All positive findings shall require a chest X ray to rule out active pulmonary disease. (H) Individuals with a positive finding need not have repeat annual chest X rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. (I) An individual who is skin-test positive with a normal chest X ray should be considered for preventive medication. Those who complete a recommended course of preventive medication need have no further testing for tuberculosis unless signs and symptoms which are compatible with tuberculosis disease are present. (J) All employees and volunteers of state correctional centers who are exposed to a case of infectious tuberculosis or who develop signs and symptoms which are compatible with tuberculosis disease shall be medically evaluated. All employees and volunteers shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. AUTHORITY: section 199.350, RSMo 1994.* Original rule filed April 17, 1995, effective Nov. 30, 1995. Emergency amendment filed June 14, 2000, effective June 24, 2000, expired Feb. 22, 2001. Amended: Filed June 14, 2000, effective Nov. 30, 2000. *Original authority: 199.350, RSMo 1992.