Long-Term Care Facilities (LTCFs) have not heard much from the Occupational Safety and Health Administration (OSHA) in terms of specific industry guidance since the middle of May when the agency released a one-page document consisting of bulleted “tips” to reduce the risk of worker exposure to the coronavirus. That changed, however, on October 30, 2020, with the release of a seven-page guidance document that addresses respiratory protection in LTCFs, including nursing homes, assisted living facilities, inpatient hospice, convalescent homes, and group homes with nursing care.
The guidance document itself is fairly broad and contains links to several other OSHA documents and enforcement memoranda, as well as Centers for Disease Control and Prevention (CDC) pages, which are in need of review, update, and consolidation to keep them relevant at this stage of the pandemic.
Highlights from the OSHA guidance:
Hierarchy of Controls
Under OSHA’s hierarchy of controls, engineering controls, such as improving ventilation systems, and administrative controls, such as cohorting, hand hygiene, and other work practices, are preferred over the use of PPE and may prevent over-reliance on the use of respirators; however, the guidance also makes clear that respirators are required when close contact with someone who is known to have or suspected of having COVID-19 cannot be avoided. A written respiratory protection program (RPP) that is specific to the work-site is required in such instances.
Source Control Measures and Respirators
The guidance provides a very clear description of the differences among face coverings, face masks, FDA-cleared/authorized surgical masks, and respirators. It also provides insight into the circumstances in which each may be worn. For staff in close contact with a resident confirmed to have or suspected of having SARS-CoV-2 infection, a NIOSH-approved N95 (or higher level) respirator is required. A surgical N95 respirator must be worn if protection against exposure to splashes and sprays of infectious material from others is also needed.
OSHA used the guidance to highlight important aspects of RPPs. While an in-depth review of the respiratory protection standard is needed to develop and implement an RPP, the guidance provides a shorthand glimpse into some aspects of RPPs emphasized by OSHA.
A “suitably trained” program administrator to oversee all elements of the RPP is required. This can be the facility’s infection preventionist, a nurse administrator, such as the Director of Nursing, or an industrial hygiene consulting service.
Risk assessments are needed to identify those workers who are at risk of exposure and to what extent. The results can then be used to determine which workers must wear respirators in the workplace.
Medical evaluations for workers required to use respirators are necessary to rule out contraindications to their ability to safely wear a respirator in the workplace. Many LTCFs use their medical director to conduct such evaluations.
Because a respirator designed to be tight-fitting will not be effective absent a good seal on the face of the wearer, proper fit-testing is critical. Fit-testing is required prior to initial use of a respirator, whenever there is a change in the type, size, model, or make of the respirator, and annually thereafter.
Maintenance and Storage
It is crucial for LTCFs to establish maintenance and storage protocols to ensure that reusable respirators and disposable respirators used in accordance with CDC contingency and crisis strategies maintain their efficacy.
Workers risk ineffective performance from respirators if they are not properly trained in how to put them on and take them off, perform a user seal check, and otherwise use them in a safe manner.
The OSHA guidance also briefly addresses the agency’s use of time-limited enforcement discretion contained in several enforcement memoranda. In order to receive enforcement discretion, the employer must demonstrate and document good-faith efforts to comply with OSHA standards, and the employer must have “considered and taken all possible steps” to comply with measures in a particular control strategy. Thus, because the memoranda set a very high bar for the application of enforcement discretion, LTCFs will need to be proactive in drafting and implementing an RPP as soon as possible so they can avoid the need for enforcement discretion altogether.