OSHA has physician offices in sight: Bloodborne regs most frequent citation

Philly office cites 16 physicians in local program

Whether fairly or not, physician offices and other ambulatory settings often are characterized as "flying under the radar" in discussions regarding infection control requirements and regulatory oversight. There appears to be even some misconception that physician offices are not subject to regulation by state and federal Occupational Safety and Health Administration (OSHA) plans.

On the contrary, physician offices are subject to requirements under OSHA's Bloodborne Pathogen Standard (29 CFR 1910.1030), the Hazard Communications Standard (29 CFR 1910.1200) and several other OSHA regulations. Some of the confusion about OSHA compliance may stem from the fact that physician offices currently are exempt from maintaining an official log of reportable injuries and illnesses (OSHA Form 300) under the federal record-keeping rule.

"We don't require physician offices to report on the OSHA 300 form," a spokeswoman in the national OSHA office in Washington, DC, told Infection Control for Physician Practices. "Hospitals have to write down every needlestick and keep a sharps injury log. That is not required for smaller facilities. In the record-keeping standard, there is an exemption for small facilities to cut down on the paperwork burden. Physician offices fall into that exemption."

The only other OSHA exemption is if the physician has no employees and is "a sole proprietor," she notes. "If a physician is by himself or herself and does not have any employees whatsoever — not even a person who answers the phone — those are the only individuals that would be exempt."

However, numerous other provisions of the bloodborne pathogen standard do apply to physician offices, including requirements for:

  • a written exposure control plan, to be updated annually;
  • use of universal (standard) precautions;
  • consideration, implementation, and use of safer, engineered needles and sharps;
  • use of engineering and work practice controls and appropriate personal protective equipment (gloves, face and eye protection, gowns);
  • hepatitis B vaccine provided to exposed employees at no cost;
  • medical follow-up in the event of an "exposure incident"
  • use of labels or color-coding for items such as sharps disposal boxes and containers for regulated waste, contaminated laundry, and certain specimens;
  • employee training;
  • proper containment of all regulated waste in physician offices.

Local program targets docs in PA

OSHA regional offices also can target physician practices through "local emphasis programs" like the one being conducted in federal OSHA Region 3, which includes Pennsylvania.

"We have a local emphasis program that started in October [2006] and runs for a year," says Kate Dugan, spokeswoman in the OSHA Region 3 office in Philadelphia. "It runs until Sept. 30, 2007, in Philadelphia, Wilkes-Barre, Allentown, Erie, and Pittsburgh. There is a formal program that is set up that establishes a local emphasis program for compliance with the bloodborne pathogen standard."

Though the program is ongoing and only limited data are available, Dugan reported that inspections of 50 physician offices in the Philadelphia area have resulted in 16 citations and an average fine of $463. As OSHA fines go, that is certainly on the modest side, but it also reflects that the program is more educational than punitive. "It is an education process," she notes. "[Other physicians] may say, 'They didn't come to [inspect] me, but I'd better review and make sure I am doing everything right.'"

Such local emphasis programs are proceeded by notification of the program via a letter to physician offices that alerts them to the effort and, reminds them of basic requirements and refers them to OSHA's web site for educational and compliance resources.

"Once the outreach and education phase is over, then they will actually select employers and go in and do inspections," Dugan explains. "That is the enforcement; and if there are any violations of the standard, we will issue citations. There were 40 violations in those 16 employers. The most frequently cited were [violations regarding] the exposure control plan, work practice controls, and communication of hazards to employees. "

Physicians in such cases can challenge the citations, but most typically pay the fine and correct the situation in their office, she adds. "They have 15 working days after they receive the citation to either request an informal meeting with us, to formally contest [the citation] — which means the next step would be court — or to fix the hazard, pay the penalty, and comply in the future," she says. "In most cases, that is what happens here."

Fines climb for repeat offenders

While the physicians drew relatively small fines there is always the risk of a public relations problem should such an OSHA citation make its way into the local press. Moreover, the citation sets the stage for much larger penalties later should an OSHA inspector return. "There is a sliding scale," Dugan says. "If the employer should have known that the hazard existed, [fines] could go up to $7,000. If there is willful violation — the employer knew of the hazard and ignored it — that could go up to $70,000. They can climb. In situations like this — where an office receives a penalty for $463 — in the OSHA world that certainly is [minimal]. We issue millions of dollars in penalties. However, the other side of that is any violation is considered a hazard; anytime a worker is put in a situation where there is a hazard, we are going to take that seriously."

Individual OSHA regions and state plans may undertake such local emphasis projects, but there currently are no plans by national OSHA to target physician offices in a large-scale inspection program, the spokeswoman in the national OSHA office in Washington, DC, said. However, a complaint by an office employee could always spark an OSHA inspection.

"For physician offices [enforcement], it is basically the same as any other type of facility," the OSHA spokeswoman says. "Last year, our total number of inspections done in doctor's offices was about 85. In addition, nine clinics were inspected for a total of 94 [ambulatory settings]. About half of those were complaints, received from either an employee or someone else on behalf of an employee. We can take complaints from spouses. When we find a violated standard, we cite it. The No. 1 citation we see for these types of facilities is the bloodborne pathogens standard — the same standard we would cite for hospitals."

The most frequently cited provision under the bloodborne pathogen standard for physician offices in the national OSHA data was for the exposure control plan.

"We see deficiencies most often in the written plan that every facility has to have within these small [offices]," the OSHA spokeswoman says. "It is the same kind of [record] kept by hospitals. It may show different details, but it has to show who is in charge of the program, who is doing the training, what types of precautions are in place like the types of engineering controls that have been selected. They seem to have a large number of issues with that, and after that employee training. What we find a lot is that annual training is not conducted. Usually, facilities will have done their initial training, but each year we require an annual training."

Another frequently cited provision of the bloodborne pathogen standard is the requirement for engineering controls such as regular review and implementation of needle safety devices to prevent employee injuries and blood exposures. "Needlesticks are an issue for the small facilities just as it is for the larger ones," she says.

OSHA enforcement in physician offices is not limited to the bloodborne pathogen standard. Another frequently cited OSHA requirement in office and ambulatory settings is the hazard communication standard. "The second most frequently cited is our haz-com standard because health care facilities including the smaller facilities do use chemicals and need to train their employees on what safety precautions, personal protective equipment to use and the hazards of using the various chemicals," the OSHA spokeswoman says.

The basic requirements of the hazard communications standard for medical offices include:

  • a written hazard communication program;
  • a list of hazardous chemicals (such as alcohol, disinfectants, anesthetic agents, sterility, mercury) used or stored in the office;
  • a copy of the Material Safety Data Sheet (MSDS) for each chemical (obtained from the manufacturer) used or stored in the office;
  • employee training.

[Editor's note: For more information see "Medical & Dental Offices: A Guide to Compliance with OSHA Standards" (OSHA 3187-09R) at www.osha.gov.]