Summary of Plan of Action submitted by Providence Memorial Hospital after babies exposed to worker with active tuberculosis

September 30, 2014- SUMMARY OF PLAN OF CORRECTION SUBMITTED BY PROVIDENCE MEMORIAL HOSPITAL TO THE TEXAS DEPARTMENT OF STATE HEALTH SERVICES AND THE CENTERS FOR MEDICARE AND MEDICAID SERVICES

SUMMARY OF DEFICIENCIES
On August 22, 2014, Providence Memorial Hospital self-reported to the El Paso Department of Public Health (El Paso DPH or DPH) a potential diagnosis of active tuberculosis in one of its healthcare workers and possible exposure of patients.

Following the report and an unidentified complaint, officials from the Texas Department of State Health Services (DSHS) performed an on-site review of Providence Memorial Hospital’s infection control program on September 9, 2014.

Following the review, the state identified two areas requiring corrective action:

The hospital’s infection control process did not effectively protect patients when a healthcare worker with symptoms of active tuberculosis was permitted to return to work following an annual health screening.
The hospital’s governing board did not exercise proper oversight over the hospital’s infection control program.

These areas resulted in two statements of deficiency for violations at the federal and state level. The hospital submitted a plan of correction to DSHS and the Centers for Medicare and Medicaid Services (CMS) to address these deficiencies.

The plan of correction was accepted on September 30, 2014. The hospital expects to be re-surveyed by the state in early October and looks forward to demonstrating that its action plans are effective.

SUMMARY OF HOSPITAL ACTIONS
Since August 22, 2014, the Chief Executive Officer, the Chief Nursing Officer, the Infection Prevention and Control Director, and the Director of Clinical Quality Improvement at Providence Memorial Hospital have been implementing a plan of correction in which the hospital:

Tested all healthcare workers who worked with this employee, and all results received to date have been negative for active tuberculosis.
Provided the El Paso DPH, on an ongoing basis, the names of patients who may have had close contact with the healthcare worker. To date, that list totals approximately 850 patients. The hospital stands ready to provide information on additional patients should the DPH decide to expand the population of patients selected for notification and testing.
Collaborated with the El Paso DPH to send notification letters to patients, offered free TB skin testing and chest x-rays to those who may have been exposed, and held press conferences with the DPH to inform the public and communicate the availability of free testing.
Audited all employee health records for compliance with annual tuberculosis testing requirements.
Revised its preexisting policies on tuberculosis exposure and infection control, employee work restrictions, screening of new employees and others who work in patient care areas to clarify the circumstances in which employees must be removed from patient care areas and requiring reporting certain contagious diseases to state and local health authorities.
Provided written counseling and additional training to personnel involved in the incident. Continued monitoring and auditing hospital operations to ensure compliance with hospital processes.

Providence Memorial Hospital will continue to work closely with the El Paso DPH and DSHS as they work to identify, contact and test individuals who may have been exposed to the healthcare worker. The Plan of Correction is posted along with other information about the hospital’s response at
http://www.sphn.com/en-us/aboutus/ourquality/tbinfo/pages/default.aspx.