OSHA, CMS Step Up Hospital Inspections
COVID-19: Occupational or community-acquired?
The Occupational Safety and Health Administration (OSHA) has issued a National Emphasis Program (NEP) to ensure that employees in high-hazard industries, such as healthcare, are protected from contracting SARS-CoV-2.
This emphasis program augments OSHA’s efforts to respond to COVID-19-related “complaints, referrals, and severe incident reports, by adding a component to target specific high-hazard industries or activities where this hazard is prevalent.”1 OSHA also is providing whistleblower protections to ensure workers who report unsafe conditions are protected from retaliation.
“Particular attention for on-site inspections will be given to workplaces with a higher potential for COVID-19 exposures, such as hospitals, assisted living, [and] nursing homes, and other healthcare and emergency response providers treating patients with COVID-19, as well as workplaces with high numbers of COVID-19-related complaints or known COVID-19 cases,” OSHA states. “These include, but may not be limited to, correctional facilities, and workplaces in critical industries located in communities with increasing rates of COVID-19 transmission, and where workers are in close proximity.”
According to the general inspection procedures outlined in the document, OSHA visits may be programed or unprogrammed, meaning inspectors could show up unannounced, particularly in response to a complaint or fatality.
“The [OSHA inspector] shall review the establishment’s injury and illness logs (OSHA 300 and OSHA 300A) for calendar years 2020 and 2021 to date to identify work-related cases of COVID-19,” the NEP document states. “[We] may choose to verify the employer’s assertions regarding workplace conditions or possible existence of worker exposures to SARS-CoV-2 by interviewing employee(s) at the site.”
The agency’s action is a direct response to a Jan. 21, 2021, executive order by President Biden to protect workers from COVID-19. It also raises the question of whether OSHA will issue a temporary standard or pursue official rulemaking on infectious disease protections for workers.
In another development on this front, the Centers for Medicare & Medicaid services announced on March 13, 2021, it was ending a 30-day suspension of hospital surveys and resuming oversight.
“Non-Immediate Jeopardy (IJ) Hospital Complaints received during the survey suspension period beginning Jan. 20, 2021, must be investigated within 45 days of the date of this memo,” the CMS stated.2
Hospital Plans of Correction (POCs) will be required for deficiencies cited on surveys performed on or after Jan. 20, 2021. Onsite Revisits are authorized and should resume as appropriate, the CMS stated.
“Providers who may have difficulty allocating resources to develop and implement a POC because they are currently experiencing an outbreak of COVID-19 in their area should contact their state agency and/or CMS location to request an extension on submitting a POC,” the CMS said.
The CMS is allowing hospital “desk reviews” under certain conditions, but facilities must submit evidence that supports correction of noncompliance.
“This evidence may include dates of training, staff in attendance, and evidence that staff were evaluated for skill(s) competency when applicable,” the CMS stated. “It may also include monitoring for policy implementation and successful performance by staff.”
Despite these hospital regulatory actions during the pandemic, some researchers are finding that healthcare workers are more likely to be infected in the community than at work.
In a recently published report, researchers did a cross-sectional study of 24,749 healthcare personnel (HCP) in three U.S. states, finding that contact with a known COVID-19 case in the community was the strongest risk factor-associated infection.3
Also predictive of SARS-CoV-2 seropositivity was living in a ZIP code with higher prevalence of COVID-19. Remarkably, none of the assessed workplace factors were associated with seropositivity. But this was to some degree expected, as the a priori hypothesis was that community exposure — not healthcare exposure — would be linked to seropositivity.
Of significance, the Centers for Disease Control and Prevention (CDC) participated in the study, which was conducted at four sites in the CDC Prevention Epicenters Program: Emory Healthcare in Atlanta; Rush University in Chicago; and Johns Hopkins Medicine and the University of Maryland Medical System, both in Baltimore.
These academic institutions collaborate with each other and the CDC to perform cutting-edge infection prevention research, so they may have better compliance with PPE and other measures than, for example, small community and rural hospitals.
“I think what this study shows — at least in these academic centers — is that we probably had pretty good compliance with the things we know that matter — masks, eye coverings, and so on,” says co-author Anthony Harris, MD, a healthcare epidemiologist at the University of Maryland.
The implications of the study certainly could complicate a healthcare worker’s claim they acquired a COVID-19 infection occupationally. Harris concedes it is difficult to apply the findings to an individual case, although they suggest the broad trend of community acquisition.
“Healthcare workers are not bubbled in the hospital — it’s really difficult to tell,” he says.
“From a similar point of view, if a patient gets it four days [after admission], did they get it in the hospital? Did they come in with it? It’s hard to pinpoint,” Harris adds.
In any case, an OSHA inspector is likely to assume COVID-19 infections were occupational if other problems with PPE or policies are found in a surveyed hospital. For example, after being reported by a nursing union, Albany (NY) Medical Center Hospital is contesting citations and fines levied by OSHA for allegedly failing to protect nurses from COVID-19. The violations cited include failing to give nurses respirators to protect them from aerosolized COVID-19 and not ensuring that nurses could demonstrate how to check the seals of respirators that were in use. The violations are considered “serious” by OSHA, and fines total $40,959, according to the agency’s web page.4 The hospital disputes the violations and is contesting the citations and charges.
- Occupational Health and Safety Administration. Directive Number: DIR 2021-01 (CPL-03) Effective Date: March 12, 2021. National Emphasis Program – Coronavirus Disease 2019 (COVID-19). https://www.osha.gov/sites/default/files/enforcement/directives/DIR_2021-01_CPL-03.pdf
- Centers for Medicare & Medicaid Services. Resuming hospital survey activities following 30-day restrictions. March 26, 2021. https://www.cms.gov/files/document/qso-21-16-hospitals.pdf
- Jacob JT, Baker JM, Fridkin SK, et al. Risk factors associated with SARS-CoV-2 seropositivity among US health care personnel. JAMA Netw Open 2021;4:e211283.
- Occupational Health and Safety Administration. Inspection: 1503896.015 - Albany Medical Center Hospital. https://www.osha.gov/pls/imis/establishment.inspection_detail?id=1503896.015
The Occupational Safety and Health Administration has issued a National Emphasis Program to ensure that employees in high-hazard industries, such as healthcare, are protected from contracting SARS-CoV-2.
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