Handling a TB Outbreak in Your Organization

When dealing with people’s lives, home health and hospice agencies need to make sure they’re not accidentally inflicting more harm than good. One of the most abundant areas of regulation in healthcare and especially home health is HR management. The HR chapter of many accreditation organizations is almost as thick as the patient care chapter. TB screening is usually a sentence in that very thick chapter and seems to be an easy regulation to follow. It’s not. Because of the nature of home health agencies, the TB screening regulation is complicated and difficult to enforce. Here’s why:

Most healthcare accrediting organizations require that TB screening is completed upon hire. In most cases home health field staff are employed by or contracted with several organizations. In fact, the turnaround rate for home health agencies and their field staff is so high that a field nurse, therapist, social worker or aide who works full time in home health can work in 15 to 20 companies within one year. In this case, the regulation can get a little blurry.

Another example of grey area is re-testing. Rumor has it that a self-questionnaire is enough for a certain time period while others claim that a chest x-ray is required. Most field staff are hesitant to undergo that much radiation. What about pregnant and breast feeding staff members? Do the same rules apply?

It’s important that HR managers at home health, hospice and private duty agencies understand the rules and the exceptions to those rules to maintain compliant charts that can pass a survey without deficiencies.

Here are key points each home health, hospice and private duty agency needs to consider when establishing their Tuberculosis screening program, according to “Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005” by the Department of Health and Human Services and the CDC (Centers for Disease Control and Prevention).

Determine if your organization is a low-risk, medium risk or high risk environment for exposure to M. tuberculosis

Home Health, Hospice and Private Duty companies need to perform risk assessment annually. If you are unsure of the risk level to assign, assign the higher risk level. The high risk status is usually assigned on a temporary basis to identify and correct an infection control situation. Outpatient, outreach and home-based healthcare settings are considered low risk if they had less than three TB patients in the previous year. Otherwise, the company should operate as medium risk.


Low Risk Agencies


Your company does not expect to encounter patients with TB disease

Exposure Potential

Exposure is unlikely


  1. All healthcare workers should receive TB screening upon hire to test for infection with M. tuberculosis.

  2. Healthcare workers with a negative result do not require additional TB screening unless exposure occurs.

  3. Healthcare workers with a positive result need to receive one Chest X-Ray to exclude TB disease. Repeat radiographs are not needed unless symptoms or signs of TB disease develop or unless recommended by a clinician.

Medium Risk Agencies


Healthcare workers may be exposed to persons with TB disease

Exposure Potential

Exposure is possible but transmission can be prevented


  1. All healthcare workers should receive TB screening upon hire to test for infection with M. tuberculosis.

  2. Healthcare workers with a negative result require annual TB screening in the form of symptom testing and testing for infection.

  3. Healthcare workers with a positive result need to receive one Chest X-Ray to exclude TB disease. Instead of participating in serial testing, healthcare workers should receive a symptom screen annually.

High Risk Agencies


This is usually used as a temporary status when transmission has been determined in the past year

Exposure Potential

Exposure and transmission have occurred in the past year and is likely to happen again


Testing for infections with M. tuberculosis need to be performed every 8-10 weeks until lapses in infection control have been corrected, and no additional evidence of ongoing transmission is apparent. 

If person to person TB transmission is suspected an investigation must be conducted to prevent further spread of the disease.

Once the situation has been contained, the company needs to operate under medium risk guidelines for at least one year. The following qualify as evidence of a TB transmission:

  1. Multiple individuals (healthcare workers and/or patients) who previously tested negative for TB are not testing positive.

  2. Healthcare workers with confirmed TB disease.

  3. Increased rates of TB positive tests.

  4. Unrecognized TB disease in patients or workers.

  5. Recognition of an identical strain of M. tuberculosis in workers and/or patients by DNA fingerprinting.


Which members of my home health agency need to be tested? Anyone who comes in contact with your home health patients needs to be tested and screened for Tuberculosis.

What if the staff member is not licensed and simply provides clerical or miscellaneous services like supply deliveries or community outreach? If the staff member comes into contact with patients, at any point in time, even if they don’t provide licensed home health services to your patients directly, they still need to be part of your agency’s TB surveillance program.

Our company is a private caregiver company and provides volunteers to keep our clients company, do their shopping and other personal errands. Do we need to monitor them for Tuberculosis? Personnel, regardless of employment category or terms, even volunteers, need to fulfill all health screening requirements that other licensed personnel are subject to.

We work with staffing companies that supplement staff to different home health and hospice agencies. Do we need to require that each staff member is screened for TB when they accept cases for our agency for the first time? No. Re-testing is not required to individuals who have undergone a baseline testing with a negative result for infection and do not currently display symptoms of TB. The agency must follow their own guidelines on how often regular TB screening will occur.