Tuberculosis (TB)

1. Tuberculosis, MRSA, Hazard Communication, PPE with Respirators, and Emergency Action/Pandemic Planning

2. Tuberculosis (TB) 1. Determine whether the establishment has had a suspected or confirmed TB case among residents within the previous 6 months prior to the date of the opening conference: if not, do not proceed with this section of the inspection. If a case has been documented or suspected, proceed with the inspection according to the guidance document, CPL 02-00-106, referenced above. 2. Determine whether the establishment has procedures in place to promptly isolate and manage the care of a resident with suspected or confirmed TB, including an isolation room and other abatement procedures. 3. Determine whether the establishment offers tuberculin skin tests for employees responsible for resident care, specifically those described in CPL 02-00-106, referenced above.

3. Tuberculosis (TB) 4. CPL 02-00-106, for enforcement procedures including citation guidance for: Citation Guidance. The CSHO should refer to a. Respiratory Protection (Note: All respiratory protection citations must be cited under 29 CFR 1910.134 - Respiratory Protection). b. Accident prevention signs and tags, 29 CFR 1910.145. c. Access to employee exposure and medical records, 29 CFR 1910.1020. d. Recordkeeping, 29 CFR Part 1904. Evaluation of Exposure to Tuberculosis Among Employees at Long-term Care Facility-HHE Program Report No. 2012-0137-3178

4. MRSA and MDRO • Nursing and residential care facilities are among the settings at increased risk of potential transmission of MRSA and other MDROs. • Recommendations for standard precautions and contact precautions to reduce or eliminate exposure to MRSA and other MDROs are outlined in CDC guidelines, including the Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007.

5. Hazard Communication • Site Specific Written Program • Chemical Inventory • MSDSs/SDSs • Labeling • Non-routine Tasks • Contractors • Training

6. Hazard Communication

7. Personal Protective Equipment in the Nursing Home Common Observations

8. Personal Protective Equipment Assessment

9. Content of the Assessment • Documented as “written certification” • Location evaluated • Completed by… • Date • 1910.132(d)(2) • The employer shall verify that the required workplace hazard assessment has been performed through a written certification that identifies the workplace evaluated; the person certifying that the evaluation has been performed; the date(s) of the hazard assessment; and, which identifies the document as a certification of hazard assessment.

10. Common Omissions • Faceshield and safety glasses in laundry and/or dietary • Gloves and apron in laundry • Respirators…

11. Respiratory Protection Is a filtering face piece a respirator? How about a one-strap mask? How about a two-strap mask? What about a surgical mask? Why would you wear a respirator?

12. Respiratory Protection • Mask vs. respirator 1 2 3 • Dust mask (not NIOSH approved) • Surgical mask (not a respirator and not PPE) • NIOSH approved filtering face piece respirator

13. What is a Respirator? Respirators are devices that protect workers from inhaling harmful airborne substances. Some respirators also ensure that workers do not breathe air that contains dangerously low levels of oxygen (O2). (OSHA’s Small Entity Compliance Guide, 9/30/98)

14. When Do We Need Respirators? • Engineering or administrative controls are not always possible: • Confinement of infectious agent may be difficult or impossible • Improved ventilation may not be practical or feasible • Employees may be exposed to a widevariety of air contaminants • infectious agents • chemical agents • Environmental controls may not befeasible If respirators are REQUIRED, a Respirator program is also REQUIRED

15. Limitations of Respirators • All respirators have limitations: • improper fit • improper donning • damage • contamination

16. Respiratory Concerns REMEMBER: Surgical masks are not considered respirators and are not approved to protect from infectious disease or chemicals. SARS Smallpox Measles Varicella (Chicken Pox) Tuberculosis (TB) Chemical agents The minimal acceptable level of respirator protection for TB is the N95 respirator

17. What’s Happening Down in Maintenance? • Painting • Welding • Adhesives • If maintenance is using more than a disposable N95 for any tasks…. • A comprehensive respiratory protection program is required.

18. Emergency Preparedness

19. Hindsight Is 20/20 http://oig.hhs.gov/oei/reports/oei-06-06-00020.pdf Office of Inspector General:Nursing Home Emergency Preparedness & Response During Recent Hurricanes (2006 Report) Whether evacuating or shelter-in-place, there are potentially problems with both: Transportation contracts not honored Lengthy travel times Complicated medication needs Inadequately prepared host facilities Inadequate staffing Insufficient food/water

20. Example Plan Overview Organizational Structure Assumptions Business Continuity Employee Health Management of Ill/Injured Staff Management of Ill/Injured Residents Attendance and Leave policies Payroll Administration Training Employee Services Workplace Practices Recovery

21. Plans should address… Evacuation or Shelter-in-Place Method of alert Assembly areas Facility access and infrastructure Supply/Deliveries/Services

22. Plans should address… Communication planning Mental health planning Vulnerable populations Residents Staff

23. Plans should address… Pandemic/Disease Access and use of antivirals and vaccines Disease surveillance Clinical evaluation & diagnosis Isolation & quarantine

24. Top 10 Errors in Workplace Planning Lack of Upper-Management support No employee buy-in Poor or no planning Limited training/practice No designated leader Communication failure Exclusion of OSHA regulations Contingency plan for facility equipment No roles and responsibilities Non-occupational exposure risk