UPDATE to August February 2016 2014 Revisions Revisions Dear HCPro Customer: Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement is designed to keep your product up to date. Your next supplement will be in January 2017. If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 or e-mail customerservice@hcpro.com. At HCPro, customer comments and suggestions are very important to us let us know how we can serve you better. Please insert these new and revised pages as indicated, and keep these filing instructions at the front of your book. FILING INSTRUCTIONS Remove Insert Reason for Change Title page Title page updated vii/viii vii/viii Master List of Program Items for Customization updated xiii/xiv xiii/xiv OSHA Program Manual Contents updated Tab 2 Contents Tab 2 Contents updated 2-7 through 2-16 2-7 through 2-17 Tab 2: OSHA Program Administration updated Form 4-B, Form 5 Form 4-B, Form 5 Tab 11: Master Record Forms updated VISIT www.hcmarketplace.com for the latest compliance and training information. Rev. 8/16 OPMFMF Supplement to OSHA Program Manual for Medical Facilities
OSHA PROGRAM MANUAL for Medical Facilities About the Author Marge McFarlane, PhD, MT (ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, is an independent safety consultant with more than 38 years of healthcare experience. She has provided education, emergency management and safety plan review, life safety, and infection prevention facility surveys for healthcare and businesses in Wisconsin and across the nation since 2005. She is the author of The Compliance Guide to the OSHA GHS Standard for Hazardous Chemical Labeling, 2014 and the OSHA Training Handbook for Healthcare Facilities, Second Edition, 2014. 16E HCPro, a division of BLR 75 Sylvan Street, Suite A-101 Danvers, MA 01923 Tel: 800/650-6787 Fax: 800/639-8511 www.hcmarketplace.com 2005 2016 HCPro, a division of BLR. All rights reserved, including right of reproduction. The author(s) and their agent(s) have made every reasonable effort in the preparation of this publication to ensure the accuracy of the information. However, the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their agents, and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally, or consequentially by the information in this publication. This publication cannot and does not provide specific information for a user s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek the assistance of legal counsel regarding their particular situation.
OSHA Program Manual for Medical Facilities is published by HCPro, a division of BLR. Copyright 2016 HCPro, a division of BLR. All rights reserved. Printed in the United States of America. 5 4 3 2 1 ISBN: 978-1-60146-743-0 No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, a division of BLR, or the Copyright Clearance Center (978-750-8400). Please notify us immediately if you have received an unauthorized copy. HCPro, a division of BLR, provides information resources for the healthcare industry. HCPro, a division of BLR, is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Marge McFarlane, PhD, MT (ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, Author Sheila Dunn, DA, MT (ASCP), Contributing Editor John Palmer, Managing Editor Mike Mirabello, Fulfillment Specialist Susan Robinson, Content Management Specialist Matt Sharpe, Senior Manager of Production Elizabeth Petersen, Vice President Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for quantity discounts. For more information, contact: HCPro, a division of BLR 75 Sylvan Street, Suite A-101 Danvers, MA 01923 Telephone: 800-650-6787 or 781-639-1872 Fax: 800-639-8511 E-mail: customerservice@hcpro.com Visit HCPro online at: www.hcpro.com and www.hcmarketplace.com 8/16
Master List of Program Items for Customization Throughout this OSHA Program Manual, blanks are included for you to fill in information specific to your facility.! The following pages contain blanks for you to customize. Enter your initials and the date you made the entry in the far right columns. This way when you do your annual review you can quickly tell if you need to update old information. Page Item Information Needed Initials Date 2-2 Key Contacts for the OSHA Safety Program Safety officer name, employer name, phone numbers, safety manual location 2-10 Workplace Hazards Record other hazards found in facility 2-17 Annual Review Safety officers review of plan 3-2 Emergency Phone List Local contact phone numbers 3-18 Systems Failure Contact names and numbers 3-19 3-20 Evacuation Procedures 3-21 Evacuation Route Evacuation route 3-23 Emergency Preparedness Supplies How alarms and announcements will be made, employee duties in emergency, assembly location Items that will be kept on hand for emergencies 3-26 Civil Disturbance Assembly location 3-28 Severe Weather Safest location in building (Note: 3 blanks) 3-29 3-35 3-39 Workplace Violence Details of your Violence Prevention Plan (Note: 5 blanks and 7 lists that require checkmarks) 3-43 Crash Kit/Cart Components Items included in facility s crash kit/cart 3-43 3-47 3-50 3-53 Drug-Free Workplace Program Holiday Decorations 5-10 Exposure Prone Procedures Details of your Drug-Free Workplace Program (Note: if no options selected on 3-43, other customizations not necessary) A review of the combustible decorations allowed at your facility (Note: this assessment is not required) Procedures performed in facility that could expose employees 5-11 BBP Determination List Employees who have definite risk of exposure (class I) 5-13 BBP Determination List Employees who have possible risk of exposure (class II) 5-14 Restricted Access Areas Restricted areas not listed in items 1 3 vii
Page Item Information Needed Initials Date 5-16 Handwashing Locations Locations handwashing takes place 5-20 Sharps Recapping Instances when recapping is allowed 5-21 Safety Sharps Instances when safety sharps are not used 5-23 Laundry How biohazardous laundry is cleaned, or if only disposables are used 5-25 PPE Locations PPE provided in facility and its locations 5-30 When to Wear PPE If tasks not already listed are performed in facility, add to table 5-33 Hepatitis Vaccinations The provider and location for HBV vaccine 5-43 BBP Post -exposure Testing Who does medical evaluation and lab testing in case of an employee exposure 6-5 TB Risk Assessment Previous year data on TB from health department and facility 6-7 Early TB Identification Procedures to ID active TB patients and where they are referred for treatment 6-9 Managing TB Patients Where suspected TB patients will wait and where they will be transferred to 6-10 N-95 Masks Medical Air Purifying Respirators (PAPRs) Will the facility provide N-95 masks or not Will the facility provide PAPRs or not 6-15 TST Record Each employee s TST details 6-18 Employee TB Infections Where employees with positive TST or symptoms of TB will be referred 6-19 TB Exposure Log Only fill in if employee is exposed to TB 6-21 Pre-pandemic Planning Individual to be response coordinator, local key agencies, and contact information 6-22 Pre-pandemic Planning (con t) 6-24 Influenza Staff Shortage Communication plan, name of PR, and educational coordinators Number of staff needed and who will cover 6-25 Influenza Reporting Frequency of reporting, who will review reports 7-20 Chemical Exposure Facility name and phone for exposure medical follow-up 8-3 Housekeeping Your cleaning methods and frequency Schedule 8-21 Eyewash Stations Location and types of eyewashes 8-22 Biohazardous Waste Company name and phone number of who picks up your biohazardous waste 10-8, 10-9 New Employee Orientation 10-18 Annual Employee Training Record Copy master from Tab 11, or CD-ROM, and use for new hires Copy master from Tab 11, or CD-ROM, and use to document annual retraining viii
OSHA PROGRAM MANUAL Contents Front Pocket OSHA Poster 3165: IT S THE LAW! Laminated Eyewash Station Sign 4 Sample Biohazard Self-Adhesive Labels CD-ROM (MS Word for Windows 2000) with Master Record Forms (Tab 11) from this Manual for Customization. Introduction Page Important Information About the Use of This Program... i How to Customize This Program... iii Master List of Program Items for Customization... vii What Is Included in This Program... ix TAB 1: What Is OSHA? A Quick Look at OSHA... 1-1 States with OSHA-Approved Plans... 1-1 OSHA Consultative Services Division... 1-2 OSHA s Jurisdiction... 1-2 OSHA s General Duty Clause... 1-2 Employee or Employer... 1-4 Employer Responsibilities Under OSHA... 1-5 Overview of OSHA Standards... 1-5 OSHA Inspections... 1-6 Employee Complaints... 1-6 If an On-site OSHA Inspection Occurs... 1-7 During the Inspection... 1-8 What OSHA Inspectors May Ask Employees... 1-8 The Typical OSHA Inspection... 1-9 The Closing Conference... 1-10 OSHA Sanctions... 1-11 Whistleblower Protection... 1-13 Students and Volunteers... 1-15 xiii
Contents TAB 2: OSHA Program Administration Injury & Illness Prevention Plan Flowchart... Reverse Side of TOC Injury & Illness Prevention Plan... 2-1 Management Leadership and Employee Involvement... 2-1 Key Contacts for the OSHA Safety Program... 2-2 Location of the OSHA Manual Program... 2-2 Duties of the OSHA Safety Officer... 2-2 Accident/Incident Investigation & Reporting Procedure... 2-4 Definition of an Accident/Incident or Near-Miss Event... 2-4 When to Investigate an Accident/Incident... 2-4 How to Document an Accident/Incident... 2-5 Recording Accidents or Injuries for OSHA... 2-5 Correcting Unsafe or At-Risk Conditions... 2-5 Recordkeeping Requirements... 2-6 Equipment & Facility Records... 2-6 Bloodborne Pathogens Records... 2-6 Hazard Communication Records... 2-6 TB Records... 2-6 Training Records... 2-7 Employee Medical Records... 2-7 Evaluating Exposure Incidents... 2-8 OSHA Focus on Healthcare... 2-8 Workplace Hazard Analysis... 2-9 Practical Ideas for Involving Employees... 2-10 Organizing OSHA Compliance Duties... 2-11 Weekly Facility Review Checklist... 2-12 Monthly Facility Review Checklist... 2-13 Annual Facility Review Checklist... 2-14 Annual OSHA Safety Program (Includes Exposure Control Plan, Hazard Communication Program, and Respiratory Protection Plan) Review... 2-17 TAB 3: General Facility Safety Keeping Employees Safe... 3-1 Important Phone Numbers & Contacts...3-1 Emergency Phone List... 3-2 Fire Safety... 3-3 Automatic Sprinkler Systems... 3-3 Fire Alarms... 3-3 Fire Procedures: Immediate Actions... 3-3 Building Evacuation... 3-4 Fire Extinguishers... 3-4 Purchase the Right Extinguisher... 3-5 xiv
TAB 2: OSHA PROGRAM ADMINISTRATION Contents Page Injury & Illness Prevention Plan Flowchart... Reverse Side of TOC Injury & Illness Prevention Plan... 2-1 Management Leadership and Employee Involvement... 2-1 Key Contacts for the OSHA Safety Program... 2-2 Location of the OSHA Manual Program... 2-2 Duties of the OSHA Safety Officer... 2-2 Accident/Incident Investigation & Reporting Procedure... 2-4 Definition of an Accident/Incident or Near-Miss Event... 2-4 When to Investigate an Accident/Incident... 2-4 How to Document an Accident/Incident... 2-5 Recording Accidents or Injuries for OSHA... 2-5 Correcting Unsafe or At-Risk Conditions... 2-5 Recordkeeping Requirements... 2-6 Equipment & Facility Records... 2-6 Bloodborne Pathogens Records... 2-6 Hazard Communication Records... 2-6 TB Records... 2-6 Training Records... 2-7 Employee Medical Records... 2-7 Evaluating Exposure Incidents... 2-8 OSHA Focus on Healthcare... 2-8 Workplace Hazard Analysis... 2-9 Practical Ideas for Involving Employees... 2-10 Organizing OSHA Compliance Duties... 2-11 Weekly Facility Review Checklist... 2-12 Monthly Facility Review Checklist... 2-13 Annual Facility Review Checklist... 2-14 Annual OSHA Safety Program (Includes Exposure Control Plan, Hazard Communication Program, and Respiratory Protection Plan) Review... 2-17
Tab 2: Program Administration Tab 3: General Facility Safety Tab 3: Fire Tab 3: Emergency Tab 10: Employee Training Tab 4: Ergonomics INJURY AND ILLNESS PREVENTION PLAN FOR MEDICAL PRACTICES Safety Plans Tab 5: Bloodborne Pathogens Exposure Control Plan Tab 2: Accident Investigation Tab 2: Recordkeeping Tab 7: Hazardous Chemicals Safety Infection Control Tab 6: Respiratory Pathogens Tab 8: Waste Disposal Tab 8: Instrument & Surface Disinfection
OSHA Program Manual for Medical Facilities Training Records New Employee OSHA Orientation checklist.. Annual Employee Training Record.. OSHA Annual Retraining (sample essay test). OSHA Annual Retraining (sample multiple choice test).. OSHA Annual Retraining (sample T/F test). When new staff is added Annually Annually Annually Annually Employee Medical Records The OSHA Safety Officer or designee assembles confidential a medical record for each employee who could experience occupational exposure to blood or other potentially infectious material. These employees are listed on Exposure Determination List #1 and #2 (Form 8 and 9 located behind Tab 5). Employee s medical records consist of: The employee s name and social security number. Hepatitis B vaccination records, including the date of vaccination (with titer if vaccinated after 2000) and any medical records relative to the employee s ability to receive vaccination or declination form signed by the employee when they were hired. When applicable, post exposure records containing a copy of exam results, medical testing, follow-up procedures after the exposure including the Incident Report/ Sharps Injury Log, (Form 14 located behind Tab 11). When applicable, a copy of the healthcare professional s written evaluation report for any exposure incident (due within 15 days of the completion of the evaluation). When applicable, a copy of information sent to the evaluating physician for the exposure incident. Maintain medical records for exposed employees in strict confidence. Release of these records, whether within or outside of the workplace, may be made available only with the employee s written consent, except for those records required by law. Keep these records for the length of employment plus 30 years. Employers must inform employees (or anyone with written consent from the employee), upon request and within 15 working days, of the existence, location and availability of their training records or confidential medical and exposure records. Employers also must provide these records to employees upon request. Copies of hepatitis B vaccination records and medical records for employees who have worked for less than 1 year need not be retained if they are given to the employee upon termination of employment. If an employer plans to stop doing business and there is no successor employer to receive and maintain these records, the employer must notify employees of their right of access to their records at least 3 months before the employer ceases to do business. 2-7
OSHA Program Manual for Medical Facilities Evaluating Exposure Incidents The OSHA Safety Officer reviews the circumstances surrounding all exposure incidents by examining the Incident Report/Sharps Injury Log to determine: Engineering controls in use at the time. Work practices in use at the time. A description of the device/implement in use at the time. Protective equipment in use at the time of the incident. Based on this information, the OSHA Safety Officer determines if revisions to this OSHA Program Manual are needed and records appropriate changes. OSHA Focus on Healthcare In June 2015, OSHA released new guidance for inspections of healthcare facilities. While this enforcement targets inpatient settings, a complaint from an employee or patient might result in an inspection in an outpatient setting. All inspections, whether general surveys or complaint/incident surveys will cover the focus hazards. The goal is to significantly reduce over exposures to these hazards through a combination of enforcement, compliance assistance and outreach. The U.S. Department of Labor s Bureau of Labor Statistics (BLS) and OSHA s inspection history with the Nursing Home National Emphasis Program, CPL 03-00- 016 ending in April 2015, have shown that inpatient healthcare settings consistently have exposures to the safety and health hazards, notably: Musculoskeletal disorders (MSDs) relating to patient handling, Workplace violence (WPV) (Private sector 4 % of injuries, healthcare 13% of injuries) Bloodborne pathogens (BBP), the most frequently cited standard in healthcare Tuberculosis (TB), and Slips, trips and falls (STFs). Other hazards if noted can be cited, including: Multidrug resistant organisms (MDRO) e.g., methicillin-resistant Staphylococcus aureus (MRSA) Exposures to hazardous chemicals, such as sanitizers, disinfectants, anesthetic gases and hazardous drugs. New educational web resources can be found at www.osha.gov and include guidance products, fact sheets and self-assessments and industry-recognized best practices. 1. For ergonomics and MSDs: www.osha.gov/dsg/hospitals, www.osha.gov/stlc/ nursinghome/index and Safe Patient Handling: Preventing MusculoSkeletal Disorders in Nursing Homes, 2014 (www.osha.gov/publications/osha3708.pdf). 2-8
OSHA Program Manual for Medical Facilities 2. NIOSH defines workplace violence (WPV) as violent acts to include physical assaults and threats of physical assaults. Facilities should complete/implement the Preventing Workplace Violence for Healthcare and Social Service Workers, www. osha.gov/publications/osha3148.pdf. The CPL 02-00-150 published 4/22/11 is the first guidance for OSHA inspectors. Work place violence assessments for medical clinics includes all types but the enhanced OSHA enforcement will focus on Type II incidents patient violence against staff, whether violence is intentional or not. 3. BBP 29 CFR 1910.1030: CLP 02-02- 069 Enforcement Procedures for BBP. 4. TB General Duty Clause, CDC Guidelines, CPL 02-02-078 Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis. 5. Slips/Trips/Falls 29 CFR 1910.23 Fall Protection in General Industry; OSHA directive 01-01- 2013. 6. MDROs CDC 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 7. Hazard Communication 29 CFR 1910.1200; CPL 02-02- 079 Inspection Procedures for the Hazard Communication Standard (HCS 2012). Workplace Hazard Analysis Hazards in each workplace must be identified so that they can be mitigated before incidents occur. A workplace hazard analysis identifies where interventions are needed, e.g., eye protection, lifting programs, etc. Management has assessed risks associated with the general facility as well as all tasks performed at this site and determined that the standards below apply. Individual safety and health programs for each of these standards are located behind the designated Tabs in this Manual. These standards are: General Facility Safety (Tab 3): Fire, Electrical, Emergency Evacuation Program, Workplace Violence, Slips, Trips and Fall Prevention Ergonomics (Tab 4): While there is no longer an OSHA standard, Ergonomic concerns can be cited by OSHA under the General Duty Clause Bloodborne Pathogens Exposure Control Plan (Tab 5) identifies: - Employees who could be exposed to bloodborne pathogens Tasks performed that could expose an employee to bloodborne pathogens, and which PPE is required when performing these tasks - Areas in the facility where access is restricted - Areas where PPE and handwashing facilities are located TB/Infection Prevention and Control Plan (Tab 6) contains a facility TB risk assessment, steps to take to identify potential TB patients, and procedures for avoiding TB transmission (while TB is no longer a federal OSHA standard, some State OSHA plans have infectious disease standards). Tab 6 also includes a plan for pandemic influenza and other infectious diseases and a discussion on multi-drug resistant organisms Hazard Communication (Tab 7) describes how to handle and store hazardous 2-9
OSHA Program Manual for Medical Facilities substances, which are listed on the Hazardous Substances List (Form 19) Other Hazards in This Facility: (Check applicable procedures) Decontamination and high-level disinfectants (Tab 8) Cytotoxic drug mixing or administration (Tab 9) Gas cylinder use (Tab 9) Electro surgery (Lasers) (Tab 9) Liquid nitrogen handling (Tab 9) Surgical safety (Tab 9) Lab safety (Tab 9) Cryogenic Liquids (i.e., nitrogen and CO2) (Tab 9) Vaccine Handling and Storage (Tab 9) Waste Anesthetic Gases (Tab 9) Employees who perform tasks that put them at risk for exposure to bloodborne pathogens or hazardous chemicals have been trained, understand and follow the policies and procedures in this OSHA Program Manual. Workplace hazards are reviewed and can be assessed through the following mechanisms: Weekly Facility Review Checklist (Form 4A) Monthly Facility Review Checklists (Form 4B). Annual Facility Review Checklists (Form 5). Incident Report/Sharps Injury Log (Form 14). Safety Report for employee concerns (Form 1). Observation of near-misses and at-risk behaviors. Workplace hazards are reviewed: Whenever new substances, processes or procedures are introduced. When previously unidentified hazards are recognized. When incident occur or workplace conditions warrant a review. Once a potential hazard is identified, the OSHA Safety Officer records the changes to the procedures contained in the appropriate Tab of this Manual. Practical Ideas for Involving Employees An employee complaint is the number one reason for an OSHA inspector to show up at a healthcare facility s door. Whether it s the disgruntled employee who sees his complaint as a way to retaliate against a supervisor or a person who has consistently received a deaf ear from management about a perceived hazard, OSHA will come. OSHA inspectors, once in the facility, rarely, if ever, leave without reviewing other required OSHA records. You can nip potential complaints to OSHA in the bud. Here are some practical suggestions for doing this the best part is, they don t cost a penny. Try some or all of them to reduce your real or perceived liability: 2-10
OSHA Program Manual for Medical Facilities During staff meetings, encourage employees to bring up any concerns about their safety on the job. Listen to their responses and encourage discussion. When an employee states a concern, show interest and ask for more details. Regardless of whether that concern is high on your priority list or not, address it and resolve either to fix the problem or allay the employee s fears. Bring this OSHA Program Manual for to staff meetings to reinforce the fact that your practice has a tangible program that contains policies to ensure staff safety. Take 5 minutes at these same meetings to do a safety-related demonstration, such as showing how to remove exam gloves without splashing your colleagues, how to clean up a biohazardous spill, how to locate and read an MSDS (SDS), etc. These short exercises reinforce the commitment to safety. One approach is to have different employees demonstrate a safety topic to their peers each month. Practice evacuation drills for fire, violent behavior, and other emergencies that could potentially occur. After the drill, critique the staff s performance and amend the emergency plan, if necessary. Ensure that staff are trained on the changes. Finally, the ultimate goal of an OSHA Safety Officer should be zero non-compliance and minimal exposure incidents. Make sure that employees know exactly what safety measures to take. Employees should know that using appropriate work practices and wearing appropriate protective gear is not optional. Employees should expect consistent enforcement of safety policies and know what happens if there is non-compliance. Disciplinary actions should be fair and consistent: Follow an unheeded verbal warning with a written warning. If no corrective action follows, take further disciplinary action and/or termination. Organizing OSHA Compliance Duties To help organize a busy OSHA Safety Officer s efforts to get a facility in compliance and keep it there, HCPro offers four useful tools: 1. A Weekly Facility Review Checklist (highly recommended). 2. A Monthly Facility Review Checklist (highly recommended). 3. An Annual Facility Review Checklist (highly recommended to assist in the annual assessment of the facility safety program). 4. An Annual OSHA Program Manual Review Form (mandatory and includes the Exposure Control Plan, the Hazard Communications Plan and the Respiratory Protection Plan). These forms are located on the following pages, as well as behind Tab 11: Master Record Forms. These forms document and organize compliance duties. If it is determined that revisions need to be made, the OSHA Safety Officer ensures implementation of the recommendations and makes changes to the OSHA Program Manual. For this purpose, use the Annual OSHA Program Manual Review Form located on page 2-14 and behind Tab 11: Master Record Forms (Form 3). 2-11
OSHA Program Manual for Medical Facilities WEEKLY FACILITY REVIEW CHECKLIST Mark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered No to any question, explain on the reverse of this form. Facility Are all secondary containers, such as spray bottles and chemical bottles, properly labeled and readable? Are all sharps containers filled below the fill line (or 2/3 full) and positioned firmly so that they cannot be casually knocked over? Are biohazard waste bags/storage bins in the proper locations (in every area where blood or OPIM is encountered) and functioning properly? Is the biohazard storage area clean and orderly? Is the autoclave working properly? Are weekly biological indicator test records complete? (Reference Form 2.) Are scavenging systems for waste anesthetic gas (hoses, bags, masks, and connections) inspected for cracks and leaks? Is the eyewash station functioning properly? (Run water for several minutes and disinfect eyepieces; see Tab 8 for details.) Are exit signs visible and illuminated where required? Administration Have hepatitis B vaccinations been made available to unvaccinated new hires with occupational exposure to bloodborne pathogens after training and within 10 working days of initial assignment? Have tuberculin skin tests (TST) been made available to new hires before exposures to patients with TB or within 10 working days of initial assignment? Is the exam/treatment room set-up and clean-up procedure consistently followed? (Reference Form 7.) Date: OSHA Safety Officer: 2-12
OSHA Program Manual for Medical Facilities MONTHLY FACILITY REVIEW CHECKLIST Mark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered No to any question, explain on the reverse of this form. Facility Are compressed gas cylinders securely fastened in an upright condition? Are empty or unused gas cylinders capped and properly labeled? Are exit doors free of blockage, clearly marked and unlocked? Are fire extinguishers fully charged, accessible, and in their designated places? Are all floors and carpets dry and free of tripping hazards? Are stored items not stacked higher than 5 feet (unless a stepstool is available), stable, and located more than 3 feet from any heat source? Are PPE (gowns, face shields, gloves, shoe covers, etc.) and respirators (N95s or medical PAPRs) in the proper location, available in the correct sizes and amounts, and functioning properly? Are hand sanitizers available, in date and in the proper locations? Are all chemicals labeled legibly so contents and hazards are clearly identified? Are chemical and biohazard spill kits available and within their expiration date? Are all first aid kit/crash cart components within their expiration dates? Administration Have all new employees completed a New Employee OSHA Orientation checklist? (Reference Form 26.) Is the SDS binder and the Master Hazardous Substances List up to date, reflecting any new chemicals brought into use this month? (Reference Form 19, SDS Binder.) Do the Exposure Determination Lists #1 and #2 reflect new employees with occupational exposure? Have employees who left the facility been removed? Have employees whose job duties changed been added/deleted? (Reference Form 8, 9.) Has a new clinical procedure been implemented which requires face, body, or hand protection? If so, has the PPE table (Tab 5) been updated? Date: OSHA Safety Officer: 2-13
OSHA Program Manual for Medical Facilities ANNUAL FACILITY REVIEW CHECKLIST Mark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered No to any question, explain in the space provided below or on the reverse of this form. General Facility Safety The OSHA poster, It s the Law (or state equivalent poster) is visible to all employees. Exit doors are free of blockage, clearly marked, and unlocked. Exit signs are properly lit and backup lights/batteries are functioning. If your facility has 10 or more employees, a written evacuation plan/route is posted. Medical equipment cords have grounded 3-pronged plugs. Extension cords are being used properly (not as permanent wiring). Electrical cords are managed to prevent tripping hazards (not placed under rugs or across doorways). Electrical cords are in good condition (no frays, defects, etc.). The fire alarm is in proper working order. An appropriate number of fire extinguishers are present/accessible. The fire extinguishers have been inspected and tagged within the last 12 months and are fully charged. Panic buttons, or public address systems, are in working order. The worksite is maintained in a clean and sanitary condition. Restricted areas (lab, decontamination room, etc.) are designated with signage. Break Room The break area is free of contamination from blood and other potentially infectious materials (OPIM). Employees discard PPE before entering the break area (before leaving exam rooms). The break area is free from hazardous chemicals. Check-in/Reception An up-to-date emergency contact list is posted or present. (Reference Form 7-A.) The reception area is free of contamination from blood and OPIMs. Employees discard PPE before entering the reception area (before leaving exam rooms). The reception area is free from hazardous chemicals. Administration Area All employees have undergone OSHA annual retraining on bloodborne pathogens, hazard communication, and TB in the last 12 months and this training is documented. (Reference Form 27.) All new employees received initial OSHA training (if not previously trained) or completed a New Employee Orientation Checklist (if previously trained) and this training is documented. (Reference Form 26.) 2-14
OSHA Program Manual for Medical Facilities (Annual Facility Review Checklist, page 2 of 3) Employees are trained on the proper precautions, and how to properly don and use, the PPE necessary for their job duties. (Reference Forms 26, 27) All employees participated in at least one fire drill this year. (Reference Forms 5-A, 5-B) Employees have been trained on how to respond in the event of a fire (R.A.C.E. or A.R.A.C.E.). (Reference Forms 26, 27) Employees have been properly trained on how to use a fire extinguisher (P.A.S.S.)? (Reference Forms 26, 27) All OSHA training records from the last three (3) years are available? (Reference Forms 26, 27) Exposure Determination Lists #1 and #2 document all employees with risk for exposure. (Reference Forms 8, 9) The facility has documented all needlesticks and other sharps injuries which occurred this year using the Incident/Sharps Injury Log? (Reference Form 14 ) All employee accidents, near-misses, injuries and complaints (check Safety Report and Incident/Sharps Injury Logs) were examined for trends. The need to change engineering controls, policies or procedures was evaluated. (Reference Forms 1, 14) In areas where trends were noted above or safer sharps have not yet been implemented frontline employees have evaluated new safety devices for possible future implementation. Evaluations have been documented, and evaluation forms are retained. (Reference Forms 10, 11, 12, 13) Hepatitis B vaccination records (or declination forms) are available for all employees. (Reference Forms 15, 16) Employee post-exposure medical records (for all employees who sustained a needlestick or other BBP or chemical exposure) are complete and located in a confidential area. Records are available from the last 30 years. (Reference Forms 14, 17, 18, 18-A) Engineering controls are functioning effectively (protective shields have not been removed or broken, and all parts are functioning as intended). The Hazardous Substances List contains all hazardous chemicals in the facility (check for new chemicals recently brought into use). (Reference Form 19) SDS binder(s) are in the proper location (accessible to employees). SDS are present for all hazardous chemicals in the facility, including fire extinguishing chemicals. (Reference SDS binder) TB skin test (TST) records are on file for all employees. (Reference Forms 22, 23) The annual TB risk assessment has been performed. (Reference Form 21) The contents (type and number of items) of the first aid kit have been reviewed and are considered adequate for emergencies anticipated in the facility. Storage Area Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in a flammable cabinet etc.) and are disposed of properly. Chemicals are labeled legibly with contents and hazards clearly identified. Labels match the identity on the corresponding SDS. (Reference Form 19, SDS binder) Appropriate PPE (gloves, respirators, goggles/face-shields, aprons) is available/ accessible for handling hazardous chemicals. (Reference SDS binder) All items are stored at least 18 inches from the ceiling. 2-15
OSHA Program Manual for Medical Facilities (Annual Facility Review Checklist, page 3 of 3) Exam Rooms/Clinical Areas All eyewash stations are in proper working order. Universal Precautions/Standard Precautions are used when handling all blood and Other Potentially Infectious Materials (OPIMs). Handwashing facilities (sinks with soap or alcohol gels) are available in all areas where biohazards and patients are encountered. The biohazard symbol/label is used to indicate the potential presence of BBPs for all blood & OPIMs. Contaminated items and regulated waste are placed into approved biohazard bags and containers displaying the biohazard symbol. Biohazard waste bags/storage bins are located in every area where blood or OPIM are encountered and functioning properly (i.e. they seal). PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is available in the correct sizes and amounts, and functions properly. Sharps containers are in the proper locations and positioned firmly so that they cannot be knocked over. Sharps containers are replaced as soon as they reach the fill line and not filled past 2/3 full. The most effective engineering controls are available and functioning correctly? (i.e. safety needles, sharps containers, fume hoods, splash shields) Employees decontaminate and clean work surfaces as soon as contaminated and at the end of every shift with an appropriate disinfectant? Cleaning/Decontamination Room PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is available in the correct sizes and amounts, and functions properly? Is appropriate PPE (rubber or vinyl gloves, respirators, goggles/face shields, aprons) available and accessible for handling hazardous chemicals in the workplace? Employees decontaminate and clean work surfaces as soon as contaminated and at the end of every shift with an appropriate disinfectant? Chemicals are labeled legibly with contents and hazards clearly identified. Labels match the identity on the corresponding SDS. (Reference Form 19, SDS binder) Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in an explosion-proof flammable cabinet etc.) and are disposed of properly. Soaking basins or reservoirs used for decontamination of instruments have tight fitting covers to reduce evaporation of hazardous vapors and are properly labeled for chemical and biohazards. Comments (explain any No answer): Date: OSHA Safety Officer*: * Note: Also document this annual OSHA Program Manual review on Form 3. 2-16
OSHA Program Manual for Medical Facilities ANNUAL OSHA SAFETY PROGRAM (INCLUDES EXPOSURE CONTROL PLAN, HAZARD COMMUNICATION PROGRAM AND RESPIRATORY PROTECTION PLAN) REVIEW Date Reviewed By Page # of Changes Summary of Revisions* *Include evaluations of sharps containers, safety needles and protective equipment 2-17
OSHA Program Manual for Medical Facilities MONTHLY FACILITY REVIEW CHECKLIST Mark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered No to any question, explain on the reverse of this form. Facility Are compressed gas cylinders securely fastened in an upright condition? Are empty or unused gas cylinders capped and properly labeled and segregated? Are exit doors free of blockage, clearly marked, and unlocked? Are fire extinguishers fully charged, accessible, inspected and in their designated places? Are all floors and carpets dry and free of tripping hazards? Are stored items not stacked higher than 5 feet (unless a stepstool is available), stable, and located more than 3 feet from any heat source? Are PPE (gowns, face shields, gloves, shoe covers, etc.) and respirators (N95s or medical PAPRs) in the proper location, available in the correct sizes and amounts, and functioning properly? Are hand sanitizers available, in date and in the proper locations? Are all chemicals labeled legibly so contents and hazards are clearly identified? Are chemical and biohazard spill kits available and within their expiration date? Are all first aid kit/crash cart components within their expiration dates? Do emergency backup lights/batteries have documented testing for 30 sec every month? Administration Have all new employees completed a New Employee OSHA Orientation checklist? (Reference Form 26.) Is the SDS binder and the Master Hazardous Substances List up to date, reflecting any new chemicals brought into use this month? (Reference Form 19, SDS Binder.) Do the Exposure Determination Lists #1 and #2 reflect new employees with occupational exposure? Have employees who left the facility been removed? Have employees whose job duties changed been added/deleted? (Reference Form 8, 9.) Has a new clinical procedure been implemented which requires face, body, or hand protection? If so, has the PPE table (Tab 5) been updated? Date: OSHA Safety Officer: Form 4-B
OSHA Program Manual for Medical Facilities ANNUAL FACILITY REVIEW CHECKLIST (1 of 3 Pages) Mark Yes (Y), No (N) or Not Applicable (NA) for the following OSHA requirements. Explain any No responses in the space provided at the end of this form. General Facility Safety Break Room The most current OSHA poster, It s the Law (or state equivalent poster) is visible to all employees. Exit doors are free of blockage, clearly marked and unlocked. Exit signs are properly lit and backup lights/batteries are functioning. (annual testing of backup lights/batteries is documented) If your facility has 10 or more employees, a written evacuation plan/route is posted. Medical equipment cords have grounded 3-pronged plugs. Extension cords are being used properly (not as permanent wiring). Electrical cords are managed to prevent tripping hazards (not placed under rugs or across doorways). Electrical cords are in good condition (no frays, defects, etc.). The fire alarm is in proper working order, if present. An appropriate number of fire extinguishers are present/accessible. The fire extinguishers have been inspected and tagged within the last 12 months and are fully charged. (record review shows the extinguishers were inspected during each of the last twelve months). Panic buttons, or public address systems, are in working order. The worksite is maintained in a clean and sanitary condition. Restricted areas (lab, decontamination room, biohazardous waste storage, etc.) are designated with signage. The break area is free of contamination from blood and other potentially infectious materials (OPIMs). Employees discard PPE before entering the break area (before leaving exam rooms). The break area is free from hazardous chemicals unless properly segregated. Check-in/Reception An up-to-date emergency contact list is posted or present. (Reference Form 7-A) The reception area is free of contamination from blood and OPIMs. Employees discard PPE before entering the reception area (before leaving exam rooms). The reception area is free from hazardous chemicals. Administration Area All employees have undergone OSHA annual retraining on bloodborne pathogens, hazard communication and TB in the last 12 months and this training is documented. (Reference Form 27) All new employees received initial OSHA training (if not previously trained) or completed a New Employee Orientation Checklist (if previously trained) and this training is documented. (Reference Form 26) Form 5
OSHA Program Manual for Medical Facilities (Annual Facility Review Checklist, page 2 of 3) Employees are trained on the proper precautions, and how to properly don, doff and use, the PPE necessary for their job duties. (Reference Forms 26, 27) All employees participated in at least one fire drill this year or signed Safety Committee/ Staff meeting minutes where they reviewed the fire drill discussion/results. Employees have been trained on how to respond in the event of a fire (R.A.C.E.). (Reference Forms 26, 27) Employees have been properly trained on how to use a fire extinguisher (P.A.S.S.)? (Reference Forms 26, 27) All OSHA training records from the last three (3) years are available? (Reference Forms 26, 27) Exposure Determination Lists #1 and #2 document all employees with risk for exposure. (Reference Forms 8, 9) The facility has documented all needlesticks and other sharps injuries which occurred this year using the Incident/Sharps Injury Log? (Reference Form 14 ) All employee accidents, near-misses, injuries and complaints (check Safety Report and Incident/Sharps Injury Logs) were examined for trends. The need to change engineering controls, policies or procedures was evaluated. (Reference Forms 1, 14) In areas where trends were noted above or safer sharps have not yet been implemented frontline employees have been included in the evaluation of new safety devices for possible future implementation. Evaluations have been documented, and evaluation forms are retained. (Reference Forms 10, 11, 12, 13) Hepatitis B vaccination records (or declination forms) are available for all employees. (Reference Forms 15, 16) Employee post-exposure medical records (for all employees who sustained a needlestick or other BBP or chemical exposure) are complete and located in a confidential area. Records are available from the last 30 years. (Reference Forms 14, 17, 18, 18-A) Engineering controls are functioning effectively (protective shields have not been removed or broken, and all parts are functioning as intended). The Hazardous Substances List contains all hazardous chemicals in the facility (check for new chemicals recently brought into use). (Reference Form 19) SDS binder(s) are in the proper location (accessible to employees). SDS are present for all hazardous chemicals in the facility, including fire extinguishing chemicals. (Reference SDS binder) TB skin test (TST) records are on file for all employees. (Reference Forms 22, 23) The annual TB risk assessment has been performed. (Reference Form 21) Storage Area The contents (type and number of items) of the first aid kit have been reviewed and are considered adequate for emergencies anticipated in the facility. Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in a flammable cabinet, incompatible chemicals are segregated, etc.) and are disposed of properly. Chemicals are labeled legibly with contents and hazards clearly identified. Labels match the identity on the corresponding SDS. (Reference Form 19, SDS binder) Appropriate PPE (gloves, respirators, goggles/face-shields, aprons) is available/ accessible for handling hazardous chemicals. (Reference SDS binder) All items are stored at least 18 inches from the ceiling in sprinklered areas. Form 5
OSHA Program Manual for Medical Facilities Exam Rooms/Clinical Areas (Annual Facility Review Checklist, page 3 of 3) All eyewash stations are in proper working order. Universal Precautions/Standard Precautions are used when handling all blood and Other Potentially Infectious Materials (OPIMs). Handwashing facilities (sinks with soap or alcohol gels) are available in all areas where biohazards and patients are encountered. The biohazard symbol/label is used to indicate the potential presence of BBPs for all blood & OPIMs. Contaminated items and regulated waste are placed into approved biohazard bags and containers displaying the biohazard symbol. Biohazard waste bags/storage bins are located in every area where blood or OPIM are encountered and functioning properly (i.e. they seal). PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is available in the correct sizes and amounts, and functions properly. Sharps containers are in the proper locations and positioned firmly so that they cannot be knocked over. Sharps containers are replaced as soon as they reach the fill line and not filled past 2/3 full. The most effective engineering controls are available and functioning correctly? (i.e. safety needles, sharps containers, fume hoods, splash shields) Employees decontaminate and clean work surfaces as soon as contaminated and at the end of every shift with an appropriate disinfectant? Cleaning/Decontamination Room PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is available in the correct sizes and amounts, and functions properly? Is appropriate PPE (rubber or vinyl gloves, respirators, goggles/face shields, aprons) available and accessible for handling hazardous chemicals in the workplace? Employees decontaminate and clean work surfaces as soon as contaminated and at the end of every shift with an appropriate disinfectant? Chemicals are labeled legibly with contents and hazards clearly identified. Labels match the identity on the corresponding SDS. (Reference Form 19, SDS binder) Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in an explosion-proof flammable cabinet etc.) and are disposed of properly. Soaking basins or reservoirs used for decontamination of instruments have tight fitting covers to reduce evaporation of hazardous vapors and are properly labeled for chemical and biohazards. Comments (explain any No answer): _ Date: OSHA Safety Officer*: * Note: Also document this annual OSHA Program Manual review on Form 3. Form 5