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JULIE L. JONES
SECRETARY
PROCEDURE NUMBER: 401.018
PROCEDURE TITLE:
REFUSAL OF TUBERCULOSIS TESTING AND
TUBERCULOSIS-RELATED CARE
RESPONSIBLE AUTHORITY: OFFICE OF HEALTH SERVICES
EFFECTIVE DATE:
FEBRUARY 4, 2015
INITIAL ISSUE DATE:
DECEMBER 11, 2002
SUPERSEDES:
NONE
RELEVANT DC FORMS:
DC4-520C, DC4-701, DC4-711, DC4-711A, DC4-773, AND
DC4-786
________________________________________________________________________________
ACA/CAC STANDARDS: 4-4355
STATE/FEDERAL STATUTES: CHAPTER 392, AND SECTION 944.35, F.S.
FLORIDA ADMINISTRATIVE CODE: RULES 33-401.105, 33-601.301, AND 33-602.210,
F.A.C.
Procedure 401.018
PURPOSE: To provide guidelines for the management of inmates who refuse the Tuberculosis
Symptom Questionnaire/Mantoux Tuberculin Skin Test and tuberculosis-related care.
These standards and responsibilities apply to both Department staff and Comprehensive Health
Care Contractor (CHCC) staff.
DEFINITIONS:
(1) Airborne Infection Isolation Room (AIIR) refers to an isolation room which has negative
pressure from the hallway to the room and the air is vented outside or through high-efficiency
particulate air (HEPA) filtration prior to joining the common ventilation air.
(2) Clinical Contract Monitor-Public Health refers to the central office employee who manages
the statewide infection control program.
(3) Comprehensive Health Care Contractor (CHCC) refers to contracted staff that has been
designated by the Department to provide medical, dental, and mental health services at
designated institutions within a particular region.
(4) Infection Control Nurse refers to an individual nurse designated by the Chief Health
Officer/Institutional Medical Director to oversee the inmate tuberculosis screening and control
program at a correctional institution.
(5) Latent Tuberculosis Infection (LTBI) refers to an infection with Mycobacterium
tuberculosis, but the bacterium has not caused active disease. A positive Tuberculin Skin Test
(TST) indicates latent tuberculosis infection.
(6) Screening refers to interviewing the inmates using the “Tuberculosis Symptom Questionnaire
for Inmates,” DC4-520C, to identify previous positive test results, signs, and symptoms of
tuberculosis, and then administration of the Mantoux Tuberculin Skin Test (TST) if
appropriate.
(7) Tuberculosis Disease refers to an infectious airborne disease caused by the bacterium
Mycobacterium tuberculosis. Tuberculosis can affect any organ causing damage to the body,
but commonly attacks the lungs.
(8) Tuberculin Skin Test (TST) refers to the method of tuberculosis test that is used by the
Department to test inmates.
(9) Tuberculosis-related Care refers to the Tuberculin Skin Test (TST), laboratory tests, x-rays,
and other examinations or procedures used to make a diagnosis of latent tuberculosis infection
or tuberculosis disease and any treatment ordered to prevent progression of the infection to
disease and the spread of the disease to others.
________________________________________________________________________________
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Procedure 401.018
SPECIFIC PROCEDURES:
(1) It is necessary to provide a safe living environment for inmates and a safe working
environment for Department employees. The Centers for Disease Control has identified
persons living or working in correctional institutions as being at a higher risk for exposure to
tuberculosis. Because of this, it is imperative that appropriate health care be promptly provided
to those persons who are infected with tuberculosis bacteria. All documentation related to
latent tuberculosis infection and active cases will be documented in the “remarks” field of the
Offender Based Information System (OBIS) on the appropriate health screen (i.e., liver
function tests, chest x-ray results, sputum results, magnetic resonance imaging, computerized
axial tomography scans, biopsy results, vital signs, weight, height, medications, and other data
pertinent to the inmate).
(2) INMATES TO BE TESTED:
(a) All inmates in the Department will be appropriately screened and tested for tuberculosis
upon reception and yearly after initial testing, as provided in “Identification and
Management of Latent Tuberculosis Infection (LTBI) and Tuberculosis Disease,” Health
Services Bulletin (HSB) 15.03.18.
(b) Testing will not be done if documentation of a prior positive test is available.
1. The documentation will include the date(s) of tuberculosis testing, results in
millimeter (mm) induration, and the signature of a licensed health care provider.
2. If documentation of a prior tuberculosis test for an inmate is available, the inmate will
be screened for symptoms on the “Tuberculosis Symptom Questionnaire for Inmates,”
DC4-520C. Further medical care will be provided in accordance with HSB 15.03.18.
(c) Intervals for tuberculosis testing after reception will be in accordance with HSB 15.03.18.
(3) INMATES WHO REFUSE TUBERCULOSIS SCREENING/SKIN TESTING:
(a) When documenting the inmate’s refusal for tuberculosis screening/testing, health services
staff will refer to Rule 33-401.105, F.A.C.
(b) Any inmate who refuses to be screened/tested for tuberculosis will be provided the
following education and opportunities to accept the screening/testing:
1. Health services staff will provide a verbal explanation of the importance of the testing.
2. Health services staff will allow an opportunity for the inmate to decide to change the
refusal status and will document the following in the inmate’s medical record and on
the “Inmate Health Education,” DC4-773:
a. the type of education provided;
b. the reason it was provided; and
c. the inmate’s response.
3. If the inmate continues to refuse tuberculosis screening/testing, care of the inmate will
be based on whether s/he is symptomatic or asymptomatic.
4. If the inmate is asymptomatic, the nurse will document on the “Chronological Record
of Health Care,” DC4-701, that the inmate was provided tuberculosis education
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Procedure 401.018
5.
(“Inmate Health Education,” DC4-773), that the inmate has denied any current
tuberculosis symptoms and appears to be asymptomatic and that the inmate has been
instructed on the need to return to the medical department if s/he develops any of the
symptoms discussed. The inmate will then be scheduled for her/his next annual
tuberculosis screening for the following year.
If the inmate is symptomatic, the inmate will be placed in an Airborne Infection
Isolation Room (AIIR) at the institution.
a. Prior to the inmate being placed in the AIIR, the Chief Health
Officer/Institutional Medical Director or her/his designee will explain to the
inmate that the placement is necessary to protect other inmates and staff from
possible exposure to an infectious disease.
b. The Chief Health Officer/Institutional Medical Director will document the
explanation to the inmate and the reasons for the placement in the inmate’s
medical record.
c. The Chief Health Officer/Institutional Medical Director or her/his designee will
notify the Warden, Regional Medical Director (will notify Regional Infection
Control Nurse), and Regional Director that the inmate has been placed in the
AIIR for having symptoms of tuberculosis and refusal to have a screening/TST.
d. A chest x-ray (CXR) and sputum collection will be done as outlined in HSB
15.03.18 to determine a diagnosis of active tuberculosis.
e. The inmate who is placed in an AIIR will wear a surgical mask at all times when
out of the cell.
f. While awaiting the results of the CXR and sputum cultures, a health services staff
member will observe the inmate each shift for tuberculosis related symptoms and
will ask the inmate if s/he will agree to the screening/testing. The encounter will
be documented in the inmate’s medical record.
g. If the inmate agrees to the screening/testing, the health care staff member will
complete an “Authorization for Health Care Services/Statement of Consent,”
DC4-711, prior to the screening/testing. The inmate will sign the DC4-711
consenting to the screening/TST.
h. If the CXR and/or sputum results are positive for active tuberculosis disease, the
health care staff member will refer to HSB 15.03.18.
i. If the CXR and sputum is negative for active tuberculosis disease, the inmate may
be released from the AIIR. Further work up and treatment for her/his presenting
symptoms will be determined by the clinician.
j. The inmate will again be offered a TST. If the inmate again refuses, the nurse
will document on the DC4-701 that the inmate was provided tuberculosis
education (DC4-773) and that the inmate has been instructed on the need to return
to the medical department if s/he develops any new symptoms and for next annual
tuberculosis screening.
(4) REFUSAL OF TB-RELATED CARE:
(a) If treatment is determined by the clinician to be necessary to protect the health of other
persons, treatment may be administered under the supervision of the clinician or designee
with authorized use of force pursuant to section 944.35(1)(a)6a, F.S.
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Procedure 401.018
(b) Following a positive response to a TST, it is necessary for health services staff to obtain
chest x-ray films, draw blood for laboratory studies, and perform a physical exam to make
a complete evaluation regarding the active or inactive status of tuberculosis infection. In
addition, it may be necessary to obtain sputum specimens.
1. Any inmate with a positive TST who refuses the follow-up diagnostic studies:
a. will be educated per section (3)(b) of this procedure;
b. may be placed in an AIIR as directed by the Chief Health Officer/Institutional
Medical Director or her/his designee; and
c. will sign the “Refusal for Health Care Services,” DC4-711A.
2. Per HSB 15.03.18, the inmate will be placed in the health services area in an AIIR if
s/he is suspected of having infectious tuberculosis disease and could be contagious.
(c) Following a complete evaluation and determination of the status of tuberculosis (active
disease or latent tuberculosis infection), the Chief Health Officer/Institutional Medical
Director will prescribe appropriate medication per HSB 15.03.18. Any inmate who refuses
treatment for latent tuberculosis infection or for active disease will be provided care in the
following manner:
1. For latent tuberculosis infection, the inmate will be housed in her/his assigned housing
location and will be scheduled an appointment once a month, effective for the number
of months from the date the medication was ordered (i.e., 4, 6, 9, etc.), to be
monitored by health services staff for the development of tuberculosis related
symptoms. The inmate will resume the scheduled screening by questionnaire as any
previous positive TST is screened (i.e., annually).
a. If the inmate is symptomatic, s/he will be referred to the clinician to determine if
symptoms of tuberculosis disease have developed.
b. If an inmate refuses a scheduled appointment to be monitored by health services,
s/he will be disciplined in accordance with Rule 33-601.301, F.A.C.
2. For suspected or confirmed active tuberculosis disease, the inmate will be housed in
an AIIR and will remain there until s/he receives appropriate treatment and the criteria
for release from an AIIR are met in accordance with CDC guidelines, HSB 15.03.18,
and Chapter 12, “Tuberculosis Exposure Control,” in the Environmental Health and
Safety Manual.
(5) REPORTING:
(a) On a monthly basis (by the tenth [10th] day of the month), the Institutional Infection
Control Nurse will report all cases of screening/testing on the “Inmate TST Testing
Report,” DC4-786, and submit the DC4-786 to the CHCC Regional Infection Control
Nurse who will then submit to the central office Clinical Contract Monitor-Public Health
or designee.
(b) A monthly report of inmates who are in an AIIR or are being seen in sick-call or
tuberculosis clinic for refusal of tuberculosis-related care will be included on the DC4-786
in the comments section by the Institutional Infection Control Nurse and/or CHCC
Regional Infection Control Nurse.
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Procedure 401.018
(c) A monthly-report that includes the total of all inmates who have refused testing or
tuberculosis-related care for all institutions will be submitted, via email or memo, to the
Assistant Secretary of Health Services by the central office Clinical Contract MonitorPublic Health or designee.
(d) The Institutional Infection Control Nurse will contact the CHCC Regional Infection
Control Nurse for assistance in reporting. The CHCC Regional Infection Control Nurse
can call the central office Clinical Contract Monitor-Public Health or designee for
assistance.
(e) All suspected or diagnosed cases of tuberculosis will be reported by the Institutional
Infection Control Nurse to the CHCC Regional Infection Control Nurse by telephone upon
identification.
1. The CHCC Regional Infection Control Nurse will call the Department of Health,
Bureau of Communicable Diseases and TB Control Section, TB Program Registered
Nurse Consultant to coordinate the Department of Health assistance in contact
investigation, and complete and send the “TB Case Reporting Requirements” form.
2. The Institutional Infection Control Nurse will conduct a contact investigation
completing section “II” of the Department of Health, “TB Contact Reporting
Requirements” form and send the form to the CHCC Regional Infection Control
Nurse, who will complete section “I,” and send to the Department of Health, Bureau
of Communicable Diseases and TB Control Section, TB Program Registered Nurse
Consultant.
(f) For privately run facilities contracted by the Department of Management Services, the
Institutional Infection Control Nurse or designee shall report directly to the Clinical
Contract Monitor-Public Health or designee.
(6) REFERENCE: Morbidity and Mortality Weekly Report (MMWR), July 7, 2006, Vol.55/RR9: Prevention and Control of Tuberculosis in Correctional and Detention Facilities:
Recommendations from CDC.
_/S/_________________________
Secretary
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