BY SANDRA HOBAN, MANAGING EDITOR Still recognizing the nursing home industry as one of the most hazardous in the United States, the Occupational Safety and Health Administration (OSHA) has developed a National Emphasis Program (NEP) for the industry. Is your organization a candidate for inspection? You could be if your facility is an SIC Code 8051'Skilled Nursing Facilities, 8052'Intermediate Care Facilities, or 8059'Nursing and Personal Care Facilities, Not Elsewhere Classified; if there is a safety-related complaint lodged against the facility; or if there are 14 or more injuries or illnesses per year that result in lost workdays or restricted activity for every 100 full-time employees (LWDII rate). On a secondary level, the NEP gives facilities with 8 or more injuries and illnesses a reasonable chance of inspection. The likelihood of inspections, for nursing homes, is relatively strong: According to Bureau of Labor statistics calculated for calendar year 2000, while the national LWDII rate for private industry was 3.0, the LWDII for nursing and personal care facilities was 7.9. Although many administrators today still fear the knock on the door, OSHA says that its intention-first and foremost-is to provide a safe working environment for employees, which, in turn, benefits the facility and its residents. Indeed, included in its NEP is an outreach effort designed to help facilities meet current safety standards before any inspectors come knocking.
If (or when) they do, though, what should you expect? All About OSHA (OSHA 2056, revised 2000) is available online at www.osha.gov/Publications/osha2056.pdf and offers the following guidance. The OSHA Inspection Before any inspection begins, you should insist on seeing the compliance officer's photo credentials, which are issued by the U.S. Department of Labor. Credentials also bear a serial number that can be verified by calling the nearest OSHA office. Prior to the facility walkaround, the OSHA compliance officer will explain why the facility is being inspected. The compliance officer will also explain the purpose of the visit, the inspection procedures and scope, the employee representation and/or interviews anticipated, and what the closing conference will entail.
As guided by the NEP, OSHA inspectors have narrowed the scope of their walkarounds to focus on four major areas of concern in the nursing home environment: (1) ergonomics; (2) exposure to blood and other potentially infectious materials; (3) exposure to tuberculosis (TB); and (4) slips, trips, and falls. Be advised that the NEP allows compliance officers to expand the range of scrutiny if observations, records, interviews, or a pattern of violations indicate that a facility might have other critical issues that need to be corrected.
The following is a general description of the infractions that OSHA inspectors will be looking for in the four focus areas.
Ergonomics. Prior to the walkaround, the compliance officer will review a facility's injury incident and severity rate records to determine if there was any increase or decrease over a three-year period, which indicates whether the facility's ergonomics program management and implementation exist and have been effective. Issues of importance include, but are not limited to, whether:
- 'the facility has a system for hazard identification and analysis,
'employees contribute to the development of lift and transfer procedures,
'there is a system in place to monitor compliance, and
'policies and procedures have had a positive or negative effect on the prevalence of injuries.
It is very important to present documentation that only those employees who have been trained to use the on-premises lifts and other transfer devices (gait belts, slings, slip sheets, etc.) are performing lifts and that, if an injury does occur, they recognize the importance of reporting the incident immediately.
Exposure to blood and other potentially infectious materials. When evaluating this hazard, a compliance officer will look at the facility's Exposure Control Plan (ECP) to determine how exposure to blood and other infectious ma-terials is to be handled. After reviewing the ECP, the compliance officer will seek to verify whether work practice controls and physical safeguards indicated by the facility's ECP are in place and being used correctly on the nursing floors.
For example, in situations that involve sharps such as insulin injections, the OSHA inspector will determine whether the employer has selected and is, in fact, using needleless systems and/or sharps products engineered to prevent a needle-stick injury. In addition, if the facility does not stock safer devices-such as retractable needles, safety needles on prefilled syringes, or single-use blood tube holders-the compliance officer will ask why. In addition to sharps protection, the facility must show that it has proper work procedures in place- especially relating to proper waste disposal-and that its employees consistently use protective gear.
To recognize that the physical environment plays a large role in preventing exposure to blood or other infectious materials, prominently display warning signs and labels. Make sure that all handwashing areas are clean and in good working order, that alcohol gels or other appropriate skin cleansers are placed where water is unavailable (in fact, recent Centers for Disease Control [CDC] guidelines favor alcohol preparations only if the person involved is not contaminated with blood), and that an EPA-approved disinfectant is used to clean all contaminated surfaces.
OSHA guidelines require that vaccination against hepatitis B be available to employees dealing with blood and other potentially hazardous materials within 10 working days from the first day of work in a high-risk assignment. OSHA will also want to know whether antibody testing will be available to anyone at risk for percutaneous injury.
Employees must know where and when to immediately report a potentially infective incident. The facility should be prepared to provide immediate medical attention in such incidents, including a rapid HIV test.
Exposure to TB. Of most immediate interest to an OSHA inspector is whether the facility has had a suspected or confirmed case of TB within the past six months. TB skin tests should be offered to resident-care employees. For OSHA compliance, the facility needs to have procedures in place to promptly isolate and manage a resident suspected of having the disease, including a designated isolation room to protect staff, visitors, and residents.
Slips, trips, and falls. This bane of the nursing home industry is probably one of the simpler inspection violations to correct. During an OSHA walkaround, dietary, halls, laundry, and areas of entry or exit will come under scrutiny. Inspectors will look for slippery, wet, or uneven floors; cluttered or obstructed areas; poorly maintained walkways; broken equipment (e.g., ladders, platforms, and scaffolds); inadequate lighting; and inadequate corridor space for moving residents during emergencies.
Facility policy should emphasize that employees must report and act immediately to clean up spills, placing the appropriate signage to mark the slippery area. It should also require the removal of clutter and emphasize the importance of proper employee footwear to minimize the opportunity for injury. Where appropriate, the inspector will evaluate the use of no-skid or other products used to enhance surface traction throughout the facility. OSHA Outreach Although an inspection can be daunting, OSHA is trying to soften the blow by initiating outreach programs to educate and inform nursing home operators of OSHA requirements and how to have a successful inspection.
Local OSHA offices have been encouraged to develop programs designed to support the goals of the NEP. They are encouraged to disseminate information helpful to nursing home operators by offering training sessions and/or news releases. Having an OSHA representative speak to professional organizations, safety councils, hospitals, etc., would help to get everyone on the same page to enhance employee safety.
In addition, OSHA funds free, confidential consultation services to assist employers in discovering potential hazards in the workplace, improving their safety and health management systems, and possibly qualifying for a one-year exemption from routine OSHA inspections. A directory of consultants by state is available online at www.osha.gov/html/consultation.html. Citations What if worse comes to worst, and your facility is found to be in violation? In general, an OSHA citation explains to the employer and staff which regulations and standards are in alleged violation and reports on hazardous working conditions identified. The citation also establishes a period for abatement and any proposed penalties. Some violations can be corrected immediately, in which case the inspector records the correction as the employer's sign of good faith for compliance.
Three types of penalties can be imposed by the OSHA Area Director:
1. Other-than-serious. This violation has a direct relationship to job health and safety but probably would not result in serious harm to an employee. A penalty of up to $7,000 can be levied for each violation, but can be reduced downward in relation to the size of the facility, history of violations, and the employer's good faith compliance measures.
2. Serious. This category involves a violation that could precipitate a substantial probability of death or serious injury, although the employer was aware (or should have been aware) of the risk. Again, the penalty is up to $7,000 with downward adjustment possible.
3. Willful. This violation indicates that an employer knowingly, with disregard for the law, was aware of the hazardous condition and made no effort to eliminate it. A willful violation carries a penalty of up to $70,000 for each violation. Downward adjustments depend on the size of the business and its history of violations. However, no good faith credit is considered. Other penalties are also possible (see Table). Conclusion Driven by logic, common sense, and a true regard for staff safety, OSHA guidelines present administration with a chance to show staff that they are held in high regard. What's more, a healthy, well-cared-for staff will more likely produce the ultimately desired outcome for any nursing home: residents functioning to the maximum of their capabilities. Viewed in this manner, OSHA compliance can be viewed as more an opportunity than an obstacle. NH
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