5. Attachment B MVH-LSC-GN-1 Policy - Respiratory Protection Program.pdf
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- Attached to
- RFP for Respiratory Protection Program MVH
- Solicitation number
- RFP 512 260000002433 1
- Issued by
- Michigan
About this file
This is a Life Safety Code policy document from Michigan Veteran Homes (MVH) establishing guidelines for a Respiratory Protection Program compliant with OSHA's Respiratory Protection Standard (29 CFR 1910.134). The policy outlines the framework for providing respiratory protection to staff when workplace hazards cannot be controlled through engineering or administrative measures. The Infection Preventionist serves as the Program Administrator responsible for running the program, evaluating its effectiveness, and controlling workplace respiratory hazards. Key operational requirements include selection and fit-testing of employees, mandatory user seal checks before each use, and proper storage and maintenance of respirators according to manufacturer specifications. The policy distinguishes between disposable respirators, which cannot be disinfected and must be discarded if soiled or damaged, and respirators with replaceable filters, which should be cleaned before use by different individuals.
The policy addresses contingency measures for crisis capacity situations, permitting limited reuse and extended use of respirators in accordance with CDC guidance when shortages occur. Decisions to implement extended use or limited reuse shall be made by the Program Administrator in consultation with state and local public health departments on a case-by-case basis, considering respiratory pathogen characteristics, disease prevalence, infection attack rates, illness severity, and local conditions such as available supply levels and current usage rates. The document references the CMS State Operations Manual, OSHA publications, and CDC guidance on PPE optimization strategies. The policy was approved by Steven Rolston, Chief Operating Officer, and Anne Zerbe, Executive Director, with an effective date to be determined and annual review schedule through 2028.
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Text version
LIFE SAFETY CODE
General: Respiratory Protection Program
POLICY
The purpose of this policy is to implement a respiratory protection program as required by the Occupational Safety and Health Administration’s (OSHA) Respiratory Protection Standard (29 CFR 1910.134). The program ensures that proper respiratory protection is provided when necessary to protect staff from respiratory hazards.
GUIDELINES
1. OSHA requires that each employer must provide respirators to protect workers from workplace hazards during work to prevent inhalation of hazardous materials that cannot be controlled by other measures (i.e., engineering, or administrative controls).
2. MVHs have a respiratory protection program, which is compliant with the OSHA respiratory protection standard and provides respirators suitable for their intended purpose.
3. The Program Administrator is the home’s Infection Preventionist who has the responsibility to run the program, evaluate its effectiveness, recognize, evaluate, and control the hazards in the workplace.
4. Selection of appropriate respirators will be made by the Program Administrator based on the identification and evaluation of the workplace respiratory hazards.
5. Employees are selected by the Program Administrator for fit testing of respirators. Employees will complete a medical questionnaire to determine the employees’ ability to use a respirator prior to fit testing. The Program Administrator will review the questionnaire and recommend/approve fit testing.
6. Employees who are selected to use the respirator must pass an appropriate fit test. Note: OSHA shall exercise enforcement discretion concerning the fit testing requirement as directed in enforcement memorandums. Refer to the United States Department of Labor, as applicable.
7. Every time an employee puts on a respirator, he or she must conduct a user seal check.
8. Respirators provided will be clean, sanitary, and in good working order to ensure the equipment protects as designed.
9. Respirators will be cleaned according to manufacturer recommendations to maintain sanitary condition.
a. Disposable respirators cannot be disinfected (see below for contingency and emergency use) and are assigned to only one person, they are to be discarded if soiled, physically damaged or reach the end of their service life.
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MICHIGAN VETERAN HOMES
A Place of Honor & Compassion
ATTACHMENT B
b. Respirators with replaceable filters, should be cleaned before being worn by different individuals when issued to more than one employee, after use for emergency use and after fit testing/training.
10. Respirators will be stored in a manner that protects them from contamination and prevents facepiece or valve deformation.
11. Contingent or crisis capacity situations may require the facility to implement limited reuse of respirators. During times of crisis, it may be needed to practice limited re-use on top of extended use. Refer to the CDC for guidance.
12. The decision to implement extended use or limited reuse of respirators should be made by the
Program Administrator in consultation with input from the state/local public health departments. The decision to implement these practices should be made on a case by case basis taking into account respiratory pathogen characteristics (e.g., routes of transmission, prevalence of disease in the region, infection attack rate, and severity of illness) and local conditions (e.g., number of disposable N95 respirators available, current respirator usage rate, success of other respirator conservation strategies, etc.). The facility may wish to implement extended use and/or limited reuse before respirator shortages are observed, so that adequate supplies are available during times of peak demand. For non-emergency (routine) situations, current CDC recommendations specific to that pathogen should also be consulted.
REFERENCES
Centers for Medicare & Medicaid Services, Department of Health and Human Services. State Operations Manual (SOM): Appendix PP Guidance to Surveyors for Long Term Care Facilities. (November 2017 Revision) F880. http://www.osha.gov/Publications/OSHA3767.pdf May 2015.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/strategies-optimize-ppe-shortages.html July 16, 2020
APPROVED BY _______________________________________ DATE ___________________
Steven Rolston, Michigan Veteran Homes, COO
APPROVED BY _______________________________________ DATE ___________________
Anne Zerbe, Michigan Veteran Homes, Executive Director
SEC POLICY PAGE
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MICHIGAN VETERAN HOMES
A Place of Honor & Compassion http://www.osha.gov/Publications/OSHA3767.pdf https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/strategies-optimize-ppe-shortages.html
POLICY EFFECTIVE DATE ______________________________
ANNUAL POLICY REVIEW:
YEAR 2020 2021 2022 2023 2024 2025 2026 2027 2028
Initials Review Date Initials Review Date
SEC POLICY PAGE
LSC-GN 1 3 of 3
MICHIGAN VETERAN HOMES
A Place of Honor & Compassion
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