Long-Term Care Infection Prevention

The Long-Term Care Perspective

By Cindy Fronning, RN, GERO-BC, IP-BC, AS-BC, RAC-CT, CDONA, FACDONA

Editor's note: This column originally appeared in the June 2021 issue of Healthcare Hygiene magazine.

Recently I had a facility ask what the Occupational Health and Safety Administration (OSHA) had to do with nursing homes. She had been asked for a bloodborne pathogen (BBP) plan and didn’t have one. She was of the opinion that she didn’t need one since her facility was a nursing home and not a hospital or industry-driven organization.

First, some history. OSHA was established under the Occupational Safety and Health Act of 1970. It was created to ensure safe and healthful working conditions for workers by setting and enforcing standards and by providing training, outreach, education and assistance.

The Occupational Exposure to Blood Borne Pathogens Standard, § 1910.1030(d)(3) (56 FR 64175) published in 1991, protects workers who can reasonably be anticipated to contact blood or other potentially infectious material (OPIM) as a result of performing their job duties. This applies to any employer with this potential -- hospitals, post-acute facilities, freestanding labs, etc.

The Centers for Disease Control and Prevention (CDC) estimates that 5.6 million workers in the healthcare industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and others. All occupational exposure to blood or other potentially infectious materials (OPIM) places workers at risk for infection from bloodborne pathogens.

Other potentially infectious materials include other body fluids such as semen, vaginal secretions, cerebrospinal fluid and saliva to name a few.

In the years following the BBP standard’s publication, the CDC found that nearly 600,000 percutaneous injuries were sustained by healthcare workers annually involving contaminated sharps. Due to the concern over these exposures and the technological developments which can improve employee protection, the Needlestick Safety and Prevention Act was passed in 2000 which directed OSHA to revise the BBP Standard, requiring employers to identify and make use of effective and safer medical devices. This revision was effective April of 2001.

So, what does this mean for long-term care facilities? The BBP standard must be followed. The BBP plan must have these components:

A written exposure plan to eliminate or minimize exposures that identifies which job classifications are at risk, together with a list of task/procedures that might result in an exposure.
The plan must be updated annually to reflect the following:
• Changes in tasks /procedures
• Positions
• Technological changes that might eliminate or reduce exposure
• Use of safer medical devices
• Document solicited input from frontline workers in identifying, evaluating and selecting effective engineering and work practice controls.
• Implementation of standard precautions.

Identify and use engineering controls such as sharps disposal containers, self-sheathing needles and sharps with engineered sharps injury protection and needleless systems.

Identify and ensure the use of work practice controls. These are practices that reduce the possibility of exposure by changing the way a task is performed.

Provide personal protective equipment (PPE), such as gloves, gowns, eye protection, and masks and the necessary fit testing if using N95 respirators.

Make available hepatitis B vaccinations to all workers with occupational exposure.

Make available post-exposure evaluation and follow-up to any occupationally exposed worker who experiences an exposure incident.

Use labels and signs to communicate hazards.

Provide information and training to workers

Maintain worker medical and training records including sharps injury log

Although the BBP standard is the main OSHA regulation that long term care facilities must follow, the premise of OSHA is one that we as employers must keep in mind at all times; to provide a safe and healthful working environment for our workers, and it carries a very high priority. Whether it is workplace violence, emergency preparedness or BBP we must be aware and always seeking ways to improve and provide the best working place we can for our employees.

COVID -19 placed a huge burden on the post-acute arena to not only keep our residents and clients safe and infection free but also our employees. Many of us lost employees to this pandemic infection. Those employees may have contracted the infection in the community or possibly at work. With that in mind we have reporting responsibilities not only to the Centers for Medicare & Medicaid Services (CMS), CDC, NSHN but also to OSHA.

OSHA was and is very much involved as evidenced by the three Interim Enforcement Response plan memorandums issued April 13, 2020, May 19, 2020 and March 3, 2021 involving annual fit testing of respiratory protection; six enforcement discretion memorandums dating from March 14, 2020 to Oct. 2, 2020 regarding respiratory protection; and three other memorandums addressing recording and reporting occupational injuries and illnesses and various standards that require annual or recurring audits, reviews, training or assessments.

OSHA has been surveying post-acute care facilities through the pandemic:
- 310 OSHA surveys have taken place in 23 states as of Jan. 14, 2021
- 912 tags have been issued resulting in more than $4 million in fines
- New York had 64 surveys with 172 tags and New Jersey had 101 surveys with 324 tags

The tags issued were similar among the 310 surveys (some facilities had multiple surveys done); they included PPE and reporting.
 1910.134(e) Medical evaluation: specifies the minimum requirements for medical evaluation that employers must implement to determine the employee's ability to use a respirator
 1910.134(e)(1) General: employer shall provide a medical evaluation to determine the employee's ability to use a respirator, before the employee is fit tested or required to use the respirator in the workplace.
 1910.134(f)(1) Fit Testing: Fit testing is required prior to initial use, whenever a different respirator facepiece is used, and at least annually thereafter.
 1910.134(g)(1)(i)(A) The employer shall not permit respirators with tight-fitting facepieces to be worn by employees who have facial hair that comes between the sealing surface of the facepiece and the face or that interferes with valve function;
 1904.29(a) Basic requirement. OSHA 300, 300-A, and 301 forms, or equivalent forms, for recordable injuries and illnesses must be used. The OSHA 300 form is called the Log of Work-Related Injuries and Illnesses, the 300-A is the Summary of Work-Related Injuries and Illnesses, and the OSHA 301 form is called the Injury and Illness Incident Report. (https://www.osha.gov/recordkeeping/forms)
 1904.39(a)(1) Within eight (8) hours after the death of any employee as a result of a work-related incident, you must report the fatality to the Occupational Safety and Health Administration (OSHA), U.S. Department of Labor.
 1904.39(a)(2) Within twenty-four (24) hours after the in-patient hospitalization of one or more employees or an employee's amputation or an employee's loss of an eye, as a result of a work-related incident, you must report the in-patient hospitalization, amputation, or loss of an eye to OSHA.
 1904.39(a)(3) You must report the fatality, inpatient hospitalization, amputation, or loss of an eye

In reviewing complaints to OSHA regarding essential industries (healthcare, retail trade, grocery stores, construction, general warehousing, restaurants/eating establishments and auto repair) healthcare had 45 percent of the complaints issued.

The take-away from all this data are some questions that we need to ask ourselves regarding our facility and OSHA responsibilities:
- Do we have a complete BBP plan that is reviewed annually?
- Are we providing the training on the BBP plan and do we make it available to our employees?
- Are providing the appropriate PPE and providing fit testing when employees use N95 respirators?
- Are we gathering input from our employees and using that data to edit and improve our plan?
- Are we documenting and retaining that documentation for the time period indicated?
- Are we using the OSHA forms 300, 300A, and 301 and posting 300A from Feb. 1 to April 30 each year?
- How satisfied are our employees with the efforts we are expending to keep them safe?

Are we ready for a visit from OSHA? Can we afford to be unprepared for the sake of our residents/clients and staff? If you haven’t given OSHA much attention in the past, it might be time to sit down and do a thorough review of the facility BBP plan, supplies/equipment and reporting process.

Cindy Fronning, RN, GERO-BC, IP-BC, AS-BC, RAC-CT, CDONA, FACDONA is a master trainer and director of education for the National Association of Directors of Nursing Administration in Long-Term Care (NADONA).

References:
1. https://www.osha.gov/aboutosha
2. https://www.osha.gov/bloodborne-pathogens/hazards

Resources:
https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.151AppA
https://www.osha.gov/sites/default/files/publications/bbfact01.pdf
https://www.osha.gov/needlesticks/needlefact.html
https://www.osha.gov/recordkeeping/forms
https://www.osha.gov/recordkeeping
https://www.osha.gov/coronavirus/standards#temp_enforcement_guidance

Standard Precautions Versus Universal Precautions to Control BBPs


https://www.osha.gov/enforcement/covid-19-data/inspections-covid-related-citations
https://www.osha.gov/enforcement/covid-19-data#complaints_essential