Physicals, TB Tests, Flu Shots for California Primary Care Clinics

 

An ongoing question for Medical Directors, Nurse Managers and Executive Directors of California Primary Care Clinics is what are the requirements for Physicals, TB Tests, and Flu Shots. The following points and links are for Title 22 Primary Care Clinics.

Physicals

1. California Health and Safety Code 1226.1 requires all Primary Care Clinics “provide” at our expense a physical with 6 months before or 15 days after employment.
2. Records of Physicals, TB Tests and vaccinations are to be kept on file and are protected by HIPAA.

 

TB Testing

1. Title 22 Section 75051 remains repealed since 2015. There is no longer a requirement to test for TB annually. Read it Here
2. Federal Guidelines on healthcare worker TB exposure is managed by The CDC in their Division of Tuberculosis Prevention and Elimination. They have a 7 page assessment worksheet. Read it Here
3. Assuming your risk assessment is “low”, the CDC says test at employment. Read their posting on testing Healthcare Workers here
   • This sheet says employees shall be screened for TB to set a “baseline” at the time of employment.
   • This page does not seem to define the timeframe of “At Employment.” So CHSC 1226.1 probably fits well.
   • The provision to accept a TB test within a year from another facility is no longer available. That was repealed with Title 22 Section 75051. The CDC and OSHA seem very concerned that each employer take a the burden and concern for TB Testing. Expecting an employee to seek and produce a copy of the TB Test from another facility appears to cross a line of transferring the burden to the employee.
   • Employees are to be educated annually in TB exposure resources are listed at the bottom of the CDC page
   • It also says “Annual TB testing of health care personnel is not recommended unless there is a known exposure or ongoing transmission.”
4. This CDC page refers to State TB departments. If you follow the link and go to California healthcare workers there is an “adult risk assessment form.”
   • At the top of this California Adult risk assessment form, it states, “Do not repeat testing unless there are new risk factors since the last test” This means the CDC Risk Assessment indicates higher risk, or a new exposure incident happens within your employees.
5. CCR Title 8 Section 5199 is all the CAL OSHA policy on Airborne Transmissible Disease (ATD). There is A LOT of information in here on employee safety compliance. Primary Care Clinic Directors should read through and make sure you are in compliance. The following are related to TB Specifically:
   • Section a(1)(B) and b defines “healthcare worker” and occupational exposure to include staff and volunteers.
   • Section a(4) the provisions in 5199 are the burden of the employer to provide
   • Section h(3) appears to mandate testing, but it does not necessarily for us.
     1. The annual testing requirement is for “Latent” cases meaning, they test positive on your baseline, and have been cleared by a doctor at employment for being free of TB. The State Says, these employees should be tested, and screened for symptoms of TB annually.
     2. There is an exception in h(3)(D) for “Production Laboratories” (that’s us) where “M. tuberculosis containing materials are not reasonably anticipated to be present.”
   • Section h(6) Only partially applies. We are not screening our clients for TB. So in testing our employees, if we learn that a new employee has a TB infection, we have TB Screening to do for all if they have already joined the workforce! Additionally, if we are notified that there has been a TB Exposure (would come as a notification from the County or the CDC) we have Employee Wide Screening to do.
6. Section h(9) Physician opinion on the a positive TB Test shall be received within 15 days of the completion of medical evaluations or 30 days after the time of employment
7. All that being said, the CDC, CDPH, The Board of Directors, The Executive Director or the Medical Director may choose to test more often utilizing their own judgment in place of the risk assessment. Clinic leadership should be very careful before making policy to exceed standard practice. ALARA principles apply here. How much medical information do we really need from our employees to get our mission accomplished? Are we placing undue burden on employees?
8. Additionally, since the heavy requirements for annual testing have been lifted, there is a shortage of ppd tests. If we had to implement annual testing, we would likely have to draw blood and have a lab tests done for TB antibodies. This was covered in a NIFLA medical tip on September 2019.

 

Vaccinations

1. California Title 8 Section 5199 c(6)(D) and h(10) requires the employer “Make Available” seasonal flu vaccines to employees with occupational exposure during the time period designated by the CDC. Employees may decline the flu, but must sign a statement of declination.
2. California Title 8 Section 5199 h(5) requires the employer “Make Available” all vaccines listed on Appendix E. This is where we are required to provide MMR, Tetanus, Varicella vaccines to those with occupational exposure, that probably does not mean ALL your employees in fact it might be none of them! Employees may decline the vaccination, but must sign a statement of declination.
3. Federal OSHA requires employers with employees that have occupational exposure to Blood an OPIM to be offered Hep B Vaccination. https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact05.pdf These are likely the medical employees. Your employees may decline the vaccination, but must sign a statement of declination.
4. Check your County’s Health Department requirements for vaccinating employees. For example, San Diego County requires Community Clinic – Primary Care Clinics (NOT Free Clinics) who have employees who decline the flu vaccine to wear a mask when within 5 feet of a client. If you don’t know which kind of Primary Care Clinic you are, check your license.