The guidelines for health care facilities focus primarily on hospitals, with special sections on ambulatory care settings, emergency departments, autopsy rooms, and laboratories. They also include brief discussions of emergency medical services, hospices, long-term-care facilities, correctional facilities, dental settings, home health care settings, and medical offices. The guidelines define health care workers to cover paid and unpaid workers including contract employees, students, and volunteers.

In 1996, a CDC advisory group published recommendations for the prevention of tuberculosis in correctional facilities (CDC, 1996b). These recommendations are organized around the core activities of screening, containment, and assessment rather than around the hierarchy of controls listed above. Although the recommendations reflect differences between the purposes of correctional facilities and those of health care facilities, many elements are similar to the 1994 guidelines. For example, the discussion of tuberculin skin testing and follow-up for employees is consistent with the 1994 guidelines, except that no category of prison worker is singled out for retesting more often than once a year. Prisons that have medical units are advised to follow the 1994 CDC guidelines in those units. Facility personnel are also advised to be familiar with guidelines published by American Thoracic Society (ATS) and the National Commission on Correctional Health Care (NCCHC, 1992, 1996).

CDC’s 1992 recommendations for those who work with homeless people only briefly discuss protections for homeless shelter workers (CDC, 1992a). These protections include (1) tuberculin skin testing of shelter staff upon hiring and every 6 to 12 months thereafter, (2) evaluation of those with positive tests results, and (3) provision of treatment for those with latent tuberculosis infection, as appropriate.

In contrast to government regulations, the CDC guidelines on tuberculosis are advisory, which allows more leeway for institutional interpretation and judgment. The guidelines are not enforced by a government agency responsible for monitoring compliance and proposing penalties for noncompliance. Other federal and state agencies as well as accrediting organizations may, however, require tuberculosis control measures based on or similar to those recommended by CDC.3 In some circumstances, health care

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To receive Medicare payments, hospitals, nursing homes, and some other health care providers must meet requirements set by the Health Care Financing Administration (HCFA). Many hospitals qualify for Medicare payment through accreditation by the Joint Commission on the Accreditation of Healthcare Facilities (JCAHCO), which may specify additional criteria for certification. Both HCFA and JCAHCO require infection control programs in hospitals and nursing homes. For nursing homes, the HCFA guidelines used by state inspectors specifically require that facilities demonstrate procedures for early detection and management of residents with signs and symptoms of infectious tuberculosis, screening of residents and workers for tuberculosis infection and disease, and evaluation of workers exposed to tuberculosis in the workplace (AHCA, 2000).



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