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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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

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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

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