From: Staffing
On June 10, 2021, the Occupational Health and Safety Administration (OSHA) announced its COVID-19 Healthcare Emergency Temporary Standard (ETS). The ETS was developed to protect health care and health care support service workers from occupational exposure to COVID-19 in settings where people with COVID-19 are reasonably expected to be present. The ETS is effective June 21, 2021.
Covered employers include hospitals, nursing homes and assisted living facilities; emergency responders; home health care workers and employees in ambulatory care settings where suspected or confirmed coronavirus patients are treated.
The ETS requires covered health care employers to develop and implement a COVID-19 plan to identify and control COVID-19 hazards in the workplace and encourage vaccinations and respirator use when needed. This Compliance Bulletin reviews the requirements of the OSHA COVID-19 ETS for health care.
Health care employers should familiarize themselves with OSHA’s new COVID-19 ETS. Employers subject to the ETS requirements must implement all policies, measures and procedures necessary for compliance with the new standard. Employers are encouraged to visit OSHA’s COVID-19 Healthcare ETS website for compliance guidance and resources.
Employers should continue to monitor OSHA communications for updates on workplace safety and health issues.
Employers Subject to the ETS
The ETS applies to all settings where employees provide health care services or health care support services, except for:
- The provision of first aid by an employee who is not a licensed health care provider;
- The dispensing of prescriptions by pharmacists in retail settings;
- Non-hospital ambulatory care settings where all non-employees are screened prior to entry and people with suspected or confirmed COVID-19 are not permitted to enter those settings;
- Well-defined hospital ambulatory care settings where all employees are fully vaccinated and all non-employees are screened prior to entry and people with suspected or confirmed COVID-19 are not permitted to enter those settings;
- Home health care settings where all employees are fully vaccinated and all non-employees are screened prior to entry and people with suspected or confirmed COVID-19 are not present;
- Health care support services not performed in a health care setting (off-site laundry, off-site medical billing, for example); and
- Telehealth services performed outside of a setting where direct patient care occurs.
OSHA does not intend to preclude employers of employees who are unable to be vaccinated from the scope of the well-defined hospital ambulatory care and home health care settings. Under various anti-discrimination laws, workers who cannot be vaccinated because of medical conditions, such as allergies to vaccine ingredients, or certain religious beliefs may ask for a reasonable accommodation from their employer. Accordingly, where an employer reasonably accommodates an employee who is unable to be vaccinated in a manner that does not expose the employee to COVID-19 hazards (for example telework or working in isolation), that employer may be within the exemption of the well-defined hospital ambulatory care and home health care settings.
Where a health care setting is embedded within a non-health care setting (such as a medical clinic in a manufacturing facility or a walk-in clinic in a retail setting), the health care section of the ETS applies only to the embedded healthcare setting and not to the remainder of the physical location. Where emergency responders or other licensed health care providers enter a non-health care setting to provide health care services, this section applies only to the provision of the health care services by that employee (emergency responders or other licensed health care providers).
However, personal protective equipment (PPE), physical distancing and physical barriers do not apply to employees who are fully vaccinated in well-defined areas where there is no reasonable expectation that any person with suspected or confirmed COVID-19 will be present.
Finally, the implementation of ETS requirements, with the exception of any employee self-monitoring conducted before the start of each work day and shift, must be at no cost to employees. State or local government mandates or guidance still apply even if those requirements go beyond the requirements of the ETS, but they must not be inconsistent with the ETS.
COVID-19 Plan
Employers must develop and implement a COVID-19 plan for each workplace. Employers with more than 10 employees are required to have a written COVID-19 plan. Employers with multiple workplaces that are substantially similar may develop their COVID-19 plans by workplace type, rather than by individual workplace, so long as all required site-specific information is included in the plan.
Employers must designate one or more workplace COVID-19 safety coordinators to implement and monitor the COVID-19 plan developed under the ETS. The COVID-19 safety coordinator must be knowledgeable in control principles and practices as they apply to the workplace and employee job operations. The identity of the safety coordinator must be documented in any written COVID-19 plan. The safety coordinator must have the authority to ensure compliance with all aspects of the COVID-19 plan.
Employers must conduct a workplace-specific hazard assessment to identify potential workplace hazards related to COVID-19. In order for an employer to be exempt from providing controls in a well-defined area with fully vaccinated employees, the COVID-19 plan must include policies and procedures to determine an employee’s vaccination status.
Employers must seek input and involvement of non-managerial employees and their representatives in the hazard assessment and during the development and implementation of their COVID-19 plan. Employers must monitor each workplace to ensure the ongoing effectiveness of their COVID-19 plans and update them as needed. COVID-19 plans must address the hazards identified by the assessment and include policies and procedures to:
- Minimize the risk of COVID-19 transmission for each employee. Although the employer’s plan must account for the potential COVID-19 exposures to each employee, the plan can do so generally and does not need to address each employee individually.
- Effectively communicate and coordinate with other employers. When employees of different employers share the same physical location, each employer must effectively communicate its COVID-19 plan to all other employers. They must also coordinate to ensure that each of their employees is protected and adjust their COVID-19 plans to address any particular COVID-19 hazards presented by the other employees. This requirement does not apply to delivery people, messengers or other employees who only enter a workplace briefly to drop off or pick up items.
An employer with one or more employees working in a physical location controlled by another employer must notify the controlling employer when those employees are exposed to conditions at the location that do not meet the requirements of this section.
- Protect employees who in the course of their employment enter into private residences or other physical locations controlled by a person not covered by the Occupational Safety and Health Act (OSH Act). This must include procedures for employee withdrawal from that location if those protections are inadequate.
Employers must develop and implement policies and procedures to adhere to the U.S. Centers for Disease Control and Prevention’s (CDC) Guidelines for Isolation Precautions.
Patient Screening and Management
In settings where direct patient care is provided, employers must:
- Limit and monitor the points of entry to the setting. This provision does not apply where emergency responders or other licensed health care providers enter a non-health care setting to provide health care services.
- Screen and triage all clients, patients, residents, delivery people and other visitors and other non-employees entering the setting.
- Implement other applicable patient management strategies in accordance with the CDC’s COVID-19 Infection Prevention and Control Recommendations.
Employers are encouraged to use telehealth services where available and appropriate in order to limit the number of people entering the workplace.
PPE Requirements
Employers are required to provide, and ensure that employees wear, facemasks (surgical, medical procedure, dental or isolation masks that are approved by the Food and Drug Administration and wear them over their mouth and nose when indoors or occupying a vehicle with other people for work purposes.
Employees must change their facemasks at least once per day—or more frequently, as necessary, whenever they are soiled or damaged. Employers must provide a sufficient number of facemasks so employees can change facemasks as required.
Exceptions
Exceptions to the facemask requirements include:
- When an employee is alone in a room.
- While employees are eating and drinking at the workplace, provided each employee is at least six feet away from other persons or separated from other people by a physical barrier.
- When employees are wearing respiratory protection in accordance with OSHA’s respiratory protection program (29 CFR 1910.134) or the ETS.
- When it is important to see a person’s mouth (communicating with hearing impaired individuals) and the conditions do not permit a facemask that is constructed of clear plastic. In those situations, employers must ensure that employees wear an alternative means to protection, such as a face shield, if the conditions permit it.
- When employees cannot wear facemasks due to a medical necessity, medical condition or disability as defined in the Americans with Disabilities Act (ADA) or due to religious belief. OSHA has indicated that exceptions must be provided for a narrow subset of persons with a disability if they cannot wear a facemask or cannot safely wear a facemask because of a disability under the ADA. The remaining subset of people who cannot wear a mask may be exempted on a case-by-case basis as required by the ADA. In all such situations, employers must ensure that any such employee wears a face shield for the protection of the employee, if their condition or disability permits it. Accommodations may also need to be made for religious beliefs consistent with Title VII of the Civil Rights Act.
- When the employer can demonstrate that the use of a facemask presents a hazard of serious injury or death to an employee. In these situations, employers must ensure that each employee wears an alternative means of protection (for example, a face shield), if the conditions permit it. Any employee not wearing a face mask must remain at least six feet away from all other people unless the employer can demonstrate physical distancing is not feasible. Employees must resume wearing a facemask when not engaged in the activity where the facemask presents a hazard.
Employers may determine that the use of face shields, without facemasks, in certain settings is not appropriate due to other infection control concerns. Where a face shield is required, employers must ensure that face shields are cleaned at least daily and are not damaged. When employees bring their own face shields, employers may allow them to use them and employers are not required to reimburse the employees for those face shields.
PPE During COVID-19 Exposure
When employees are exposed to a person with suspected or confirmed COVID-19, or for aerosol-generating procedures performed on a person with suspected or confirmed COVID-19, employers must provide:
- A respirator to each employee and ensure that it is provided and used in accordance with the respiratory protection program; and
- Gloves, an isolation gown or protective clothing and eye protection to each employee and ensure that the PPE meets the ETS requirements.
When there is a limited supply of filtering facepiece respirators, employers may follow CDC’s Strategies for Optimizing the Supply of N95 Respirators.
Employers may provide respirators to their employees instead of a facemask as required by the ETS. In such circumstances, employer must also comply with the ETS mini respiratory protection program (§ 1910.504). In addition, employers must provide protective clothing and equipment (respirators, gloves, gowns, goggles, face shields) to each employee in accordance with the standard and transmission-based precautions in health settings in accordance with the CDC’s Guidelines for Isolation Precautions.
Aerosol-generating Procedures for Suspected or Confirmed COVID-19
When an aerosol-generating procedure is performed on a person with suspected or confirmed COVID-19, employers must:
- Limit the number of employees present during the procedure to only those essential for patient care and procedure support.
- Ensure that the procedure is performed in an existing airborne infection isolation room (AIIR), if available.
- After the procedure is completed, clean and disinfect the surfaces and equipment in the room or area where the procedure was performed.
Physical Distancing and Barriers
Employers must ensure that each employee is separated from other people by at least six feet when indoors unless they can demonstrate that such physical distancing is not feasible for a specific activity. This requirement does not apply to momentary exposure while people are in movement (passing in hallways or aisles).
When establishing six feet of physical distancing is not possible, employers must ensure that their employees are as far apart as possible from all other employees. OSHA suggests that physical distancing can be achieved through any or all of the following measures:
- Telehealth;
- Telework or other remote work arrangements;
- Reducing the number of people, including non-employees, in an area at one time;
- Visual cues such as signs and floor markings to indicate where employees and others should be located, or to indicate their direction and path of travel;
- Staggered arrivals, departures, and work and break times; and
- Adjusted work processes or procedures to allow great distance between employees.
At each fixed work location outside of direct patient care areas (entryway/lobby, check-in desk, triage, hospital pharmacy windows, bill payment) where each employee is not separated from all other people by at least six feet, employers must install cleanable or disposable solid barriers. An exception is possible for employers that can demonstrate that installing barriers is not feasible. Barriers must be sized and located to block face-to-face pathways between individuals, based on where each person would normally stand or sit. The barrier may have a pass-through space at the bottom for objects and merchandise. Physical barriers are not required in direct patient care areas or resident rooms.
Cleaning and Disinfection
In patient care areas, resident rooms and for medical devices and equipment, employers must follow standard practices for cleaning and disinfecting surfaces and equipment in accordance with the CDC’s COVID-19 Infection Prevention and Control Recommendations and the Guidelines for Environmental Infection Control.
In all other areas, employers must:
- Clean high-touch surfaces and equipment at least once a day, following manufacturers’ instructions for application of cleaners; and
- Clean and disinfect, in accordance with CDC’s Cleaning and Disinfecting Guidance, any areas, materials and equipment under the employer’s control when the employer is aware that an employee who is COVID-19 positive has been in the workplace within the last 24 hours.
Employers must provide alcohol-based hand rub that is at least 60 percent alcohol, or provide readily accessible hand washing facilities.
Ventilation
Employers that own or control buildings or structures with existing heating, ventilation and air conditioning (HVAC) systems must ensure that:
- The HVAC system is used in accordance with the HVAC manufacturer’s instructions and the design specifications of the HVAC system;
- The amount of outside air circulated through its HVAC system and the number of air changes per hour are maximized to the extent appropriate;
- All air filters are rated minimum efficiency reporting value (MERV) 13 or higher, if compatible with the HVAC system. If MERV-13 or higher filters are not compatible with the HVAC system, employers must use filters with the highest compatible filtering efficiency for the HVAC system;
- All air filters are maintained and replaced as necessary to ensure the proper function and performance of the HVAC system; and
- All intake ports that provide outside air to the HVAC system are cleaned, maintained, and cleared of any debris that may affect the function and performance of the HVAC system.
Employers that have an existing airborne infection isolation room (AIIR) must maintain and operate it in accordance with its design and construction criteria. The ETS does not require installation of new HVAC systems and AIIRs. Employers should, however, consider other measures to improve ventilation in accordance the CDC’s Ventilation Guidance. This can include maximizing ventilation in buildings without HVAC systems or in vehicles.
Health Screening and Medical Management
Employers must screen each employee before each work day and each shift. Screening may be conducted by asking employees to self-monitor before reporting to work or may be conducted in-person by employers. Employers that require COVID-19 tests for screening purposes must provide these tests at no cost to the employees.
Screening
Employers must require each employee to promptly notify them when the employee:
- Is COVID-19 positive (confirmed positive test for, or has been diagnosed by a licensed health care provider with, COVID-19);
- Has been told by a licensed health care provider that they are suspected to have COVID-19;
- Is experiencing recent loss of taste or smell with no other explanation; or
- Is experiencing both a fever equal to or greater than 100.4 degrees Fahrenheit and a new unexplained cough associated with shortness of breath.
Employer Notification of COVID-19 Exposure
Employers that receive notification that a person who has been in their workplace is COVID-19 positive must complete the following requirements within 24 hours. The requirement applies regardless of whether the infected individual is an employee or a client, patient, resident, vendor, contractor, customer, delivery person, visitor or other non-employee.
- Notify each employee who has been in close contact with a COVID-19 positive individual. This requirement applies to employees who were not wearing a respirator or any other required PPE and have been in close contact with that person in the workplace. The notification must state that the employee was in close contact with someone with COVID-19, along with the date(s) that contact occurred.
- Notify all other employees who were not wearing a respirator or any other required PPE and worked in a well-defined portion of a workplace in which the positive COVID-19 person was present during the potential transmission period. The potential transmission period runs from two days before the person felt sick (or, for asymptomatic people, two days prior to test specimen collection) until the time the person is isolated. The notification must specify the dates the person with COVID-19 was in the workplace during the potential transmission period.
- Notify other employers whose employees were not wearing respirators or any other required PPE and were in close contact with the COVID-19-positive person, or worked in a well-defined portion of a workplace (for example, a particular floor) in which that person was present, during the potential transmission period (as described above). The notification must specify the dates the person with COVID-19 was in the workplace during the potential transmission period and the locations where the person with COVID-19 was in the workplace.
Notifications must not include any employee names, contact information (phone number, email address) or occupation. The notification provisions are not triggered by the presence of a patient with confirmed COVID-19 in a workplace where services are normally provided to suspected or confirmed COVID-19 patients (emergency rooms, urgent care facilities, COVID-19 testing sites, COVID-19 wards in hospitals).