Look to OSHA, JCAHO for employee safety guidance

Develop plan for high-risk environments

A home care employee’s workplace can be an apartment in an inner city riddled with drugs and gangs; it could be in the home of an abusive family member; or it could include a drug addict who sees the caregiver standing between him and his next fix.

Providing a safe working environment for home care workers is a unique challenge because their workplaces offer a variety of environments. In an uncontrolled environment such as the patient’s home, definitions of a threatening work environment as issued by the federal Occupational Safety and Health Administration (OSHA) can offer guidance.

In every situation, the home care agency has the responsibility, as an employer, to provide a safe work environment or see to it that caregivers are protected. This responsibility is not one simply decreed as a matter of moral imperative, but it is also a standard required by the Joint Commission on Accreditation of Healthcare Organizations under EC 1.2 in the Environmental Safety chapter of its standards book. The standard states: "The organization’s planning process addresses how the organization establishes and maintains security to protect both staff and patients from harm."

While the standard is not one that agencies often fail to meet, it deserves revisiting to ensure that the agency is appropriately addressing caregiver safety.

What the Joint Commission is looking for is simple: evidence that an agency has a plan in place to protect employees in dangerous environments, and that the plan is consistently implemented.

They will also be measuring performance based on interviews with patients, leaders, and staff; going out on home visits; touring offices and warehouses; observing delivery vehicles; and examining an agency’s policies and procedures.

Melville, NY-based Olsten Health Services considers not only Joint Commission standards, but also OSHA regulations in its companywide policy.

"At no time do we wish to to place employees at personal risk, even though the home care environment is difficult to control," says James Wycoff, spokesman for Olsten Health Services, a division of The Olsten Corporation.

Balancing patient needs with caregiver safety

In its employee and office procedure manuals, Olsten directs its workers to avoid or neutralize high-risk situations. For caregivers, though, this can be a difficult to do when a patient’s needs are at stake. In order to balance patient needs with caregiver safety, Olsten instructs its branch staff to take the following measures when possible:

• Provide a police escort to and from the patient’s home.

• Get a family member of the patient or a patient’s neighbor to escort the caregiver into the home.

• Have caregivers make a telephone call to the on-call employee when the caregiver arrives at the patient’s home.

• Negotiate safer visiting times with the physician and patient to avoid unsafe situations.

Olsten uses OSHA guidelines to determine situations that require actions, such as police or security escorts. The company considers these three OSHA-identified factors:


This includes the prevalence of handguns, the decreased availability of medical attention to the mentally ill, patients’ right to refuse medication, and sites that contain medication or money viewed as a target for robbery.

Administrative and work practices.

This includes shortage of staff, reduction in trained regular staff, working alone in a remote area, and poorly lit parking areas.

Perpetrator and victim.

This includes working in an environment where there are people with a history of violence, people seeking revenge, gang members, drug or alcohol abusers, social deviants, or people who feel threatened and desperate.

Ultimately, however, it is left for each branch agency to make case-by-case judgment calls, says Wycoff. For instance, there may be instances where the agency doesn’t have complete confidence in the security service providing escort services, so the home visit is cancelled and other care arrangements are made.

Because the Joint Commission knows each case is unique, it does not impose standards requiring implementation of specific security measures, says John Herringer, associate director of the Joint Commission’s department of standards.

Standards provide examples

"The examples are going to spell out some of the things they are going to want to consider," Herringer says. "We don’t give them any specifics; it’s not prescriptive at all."

But the Joint Commission does give home care agencies examples of what types of measures to use. For example, the Joint Commission suggests agencies provide cellular phones to staff when staff have to go into private homes.

Other examples include:

• All field personnel carry hand-held alarm or noise devices.

• Agencies provide protective sprays along with the proper training on how to use them.

• Agencies implement a buddy system.

• Field staff should prepare a daily work plan and keep office personnel apprised of their location throughout the day.

• Administration develops a response system in the event that an employee falls into a threatening situation.

• Agencies provide safety seminars, which can be conducted by local police, to raise awareness and help avoid situations that can lead to robbery, rape, and other assaults.

• Agencies should keep a log of all incidents of threats or aggressive behavior. The log should be used to improve safety procedures to avoid future problems.

Ultimately, procedures should employ simple common sense. Surveyors will look for instances where agency employees unknowingly leave themselves open to crime, Herringer says. For instance, a surveyor’s inspection of an agency’s delivery vehicles may show that delivery personnel are not hiding the contents of the vehicle, such as syringes, that might make the vehicle a target for theft.

"You have to explore all the issues related to employee safety," Herringer says. "The important thing is that you always educate your staff not to put themselves in a dangerous situation."