OSHA Updates TB-Related Inspection Procedures for Health Care Settings

Focus is on Healthcare: Fourth OSHA Document in Three Months Aimed at Healthcare

The Occupational Safety and Health Administration has updated inspection procedures related to worker exposures to tuberculosis in health care settings effective June 30, 2015.  This follows the June 25 memorandum entitled “Inspection Guidance for Inpatient Healthcare Settings” and the April 2 announcement that the National Emphasis Program (NEP) on Nursing and Residential Care Facilities will continue indefinitely. Also in April OSHA issued revised guidelines for preventing workplace violence against workers in the healthcare and social service fields.

According to the agency, the new Compliance Directive incorporates guidance from the Centers for Disease Control and Prevention report, “Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005.”  The revised directive does not create any additional enforcement burdens for employers; it simply updates the agency’s inspection procedures with the most currently available public health guidance and covers additional workplaces regarded as health care settings, such as sites where emergency medical services are provided and laboratories handling clinical specimens.  The new Compliance Directive, CPL 02-02-078, also introduces a newer screening method for analyzing blood; classifies health care settings by risk; and reduces the frequency of TB screenings for workers in some settings.  The new Directive can be downloaded at: https://www.osha.gov/OshDoc/Directive_pdf/CPL_02-02-078.pdf

According to the CDC, nearly one-third of the world’s population is infected with TB, which kills almost 1.5 million people per year.  In 2013, 9,582 TB cases were reported in the United States, and approximately 383 of those cases were among healthcare workers. Multi-drug-resistant (MDR) and extremely drug-resistant (XDR) TB continue to pose serious threats to workers in healthcare settings.

Significant Changes:  This Instruction explicitly covers additional workplaces regarded as healthcare settings, e.g., settings in which emergency medical services are provided, and laboratories handling clinical specimens that may contain M. tuberculosis. This Instruction uses the term “tuberculin skin test” (TST) instead of “purified protein derivative test” (PPD).  This Instruction also introduces a newer screening method: the blood analysis for M. tuberculosis (BAMT).  The new Compliance Directive uses the following risk classifications for healthcare settings: low, medium, and potential ongoing transmission and in some scenarios, this Instruction calls for less frequent TB screening for workers.

Inspection Scheduling and Scope:  In workplaces containing healthcare settings, OSHA Area Offices shall conduct inspections related to occupational exposure to TB in the following circumstances:

1. In response to any valid employee complaint regarding TB exposure or in response to any valid referral regarding TB exposure from a government agency or safety and health professional.

NOTE:  Complaints received from state and local government employees who are outside federal jurisdiction in federal enforcement states must be referred to the appropriate agency by the Area Office.

2. In response to TB-related employee fatalities or catastrophes.
3. As part of all health inspections in facilities where the incidence of TB infection among patients/clients in the relevant facility or healthcare setting is greater than the incidence of TB among individuals in the most local general population for which the health department has information.

Healthcare settings that may be inspected in accordance with this Instruction include:

1. Inpatient settings such as patient rooms, emergency departments, intensive care units, surgical suites, laboratories, laboratory procedure areas, bronchoscopy suites, sputum induction or inhalation/respiratory therapy rooms, autopsy suites, and embalming rooms.
2. Outpatient settings such as TB treatment facilities, medical offices, ambulatory-care settings, dialysis units, and dental-care settings.
3. Nontraditional facility-based settings may include emergency medical service (EMS) facilities, medical settings in correctional facilities (e.g., prisons, jails, and detention centers), long-term care settings (e.g., hospices and skilled nursing facilities), drug treatment centers, and homeless shelters.
4. Home Healthcare TB inspections of employers with employees who work in home healthcare settings will be limited to employer Exposure Control Program evaluations and off-site employee interviews.

Inspection Details

• Exposure Control Plan: All inspections related to occupational exposure to TB will include a review of the written Exposure Control Plan for employee TB protection. Such plans may include a TB infection control program, a respiratory protection plan, and a medical screening program.

• Employee interviews and site observations are also an integral part of the evaluation process.

• Upon entry, the OSHA Compliance Safety Health Officer (CSHO) should request the presence of the infection control director and the occupational health professional responsible for the control of occupational health hazard(s). Other individuals who may asked to join the inspection include the training director, the facility engineer, and the director of nursing.

• The CSHO must determine whether the facility has had a suspected or confirmed TB case among patients/clients or employees within the six months prior to the opening conference. This determination can be based upon:

• Interviews and a review of available infection control data.

• Validation from the appropriate local or state health department that the facility has reported a TB cases during the previous year.

• A review of the facility’s OSHA 300 log entries for confirmed cases of work-related TB.

If the CSHO determines there are no suspected or confirmed TB cases among patients/clients or employees in the facility within the previous six months, he or she should suspend the TB portion of the inspection.

• If the facility has had a suspected or confirmed TB case within the previous six months, then the CSHO will proceed with the TB portion of the inspection. The CSHO is to verify implementation of the employer’s plans for TB protection through employee interviews and direct observations. The walkthrough inspection may include patient rooms, the emergency and radiology departments, intensive care units, surgical suites, laboratories, laboratory procedure areas, bronchoscopy suites, sputum induction or inhalation/respiratory therapy rooms, autopsy suites, and embalming rooms. Compliance will be determined through review of the facility plans for employee TB protection, employee interviews, and an inspection of appropriate areas of the facility.

• CSHOs may perform smoke-tube testing of ventilation systems in isolation rooms to verify negative pressure and should adhere to the procedures described in Appendix B of the new CPL. Smoke testing should not be conducted in any occupied rooms unless it can be determined that there is no potential respiratory impact on the patient.

Violations:  If an employer does not comply with the requirements of applicable OSHA standards, the Area Director should consider appropriate citations or notices. Although citations are to be classified on a case-by-case basis, the violations will often be classified as serious because occupational exposure to TB hazards can result in a substantial probability of death or serious physical harm.

• General Duty Clause (Section 5(a)(1)): OSHA’s standards do not completely address the hazards associated with occupational exposure to TB, so employers may be found to have obligations under the General Duty Clause.  Section 5(a)(1) of the OSH Act provides, “Each employer . . . shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.”
• Respiratory Protection (29 CFR 1910.134): The CDC recommends that employees wear, at a minimum, a NIOSH approved N95 filtering facepiece respirator (non-powered, air-purifying half facepiece) when respiratory protection is needed due to TB hazards.
• Personal Protective Equipment (29 CFR 1910.132):  A citation can be issued based on an employer’s failure to provide or ensure the use of PPE – including respirators, gloves, gowns and eye protection.
• Specifications for Accident Prevention Signs and Tags (29 CFR 1910.145): A citation can be written based on an employer’s failure to post a biological hazard tag outside rooms where there is potential for TB exposure or an employer’s failure to utilize hazard warning tags with a proper signal word (i.e., “Danger,” “Caution,” “Biological Hazard,” or “BIOHAZARD”) or the biological hazard symbol.
• Access to Employee Exposure and Medical Records (29 CFR 1910.1020): CSHOs can issue a citation if employees have not been notified (on an annual basis) that they have the right to access their medical and exposure records.   Records of TB skin test results and medical evaluations and treatment are employee medical records.
• Recording and Reporting Occupational Injuries and Illnesses (29 CFR Part 1904): Under 29 CFR 1904.11(a), covered employers must record TB cases when an employee has been occupationally exposed to anyone with a known case of active TB and the employee subsequently develops TB infection evidenced by a positive skin test or diagnosed by a physician or other licensed health care professional. The case must be recorded by checking the “respiratory condition” column on the OSHA 300 Log.

Bottom Line:  The focus on healthcare compliance continues.  This Compliance Directive and the Inspection Guidance for Inpatient Healthcare Settings which was released on June 25, represents the third time in two months that OSHA has warned those in the healthcare industry of its intent to increase enforcement. In April, OSHA issued revised guidelines for preventing workplace violence against workers in the healthcare and social service fields. The agency states that it is responding to “some of the highest rates of injury and illness” for these workplaces when compared with industries tracked nationwide.

Be advised, be ready and BE IN COMPLIANCE!

Article brought to you by: Stephen A. Burt, BS, MFA