Attachment 10 AFRC Policy Documents.pdf

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Armstrong Flight Research Center AFOP-1800.1-002, Revision C Edwards, California 93523 Expires July 1, 2029

Compliance is mandatory.

SUBJECT:

Health Unit Operating Procedures

RESPONSIBLE OFFICE:

Medical and Health Unit

Health Unit Operating Procedures AFOP-1800.1-002, Revision C Expires July 1, 2029

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AFOP-1800.1-002, HEALTH UNIT OPERATING PROCEDURES

Concurrence Signature

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CONTENTS

1.0 SCOPE, APPLICABILITY, & WAIVER

1.1. Scope

1.2. Applicability

1.3. Waiver

2.0 OBJECTIVES & METRICS

3.0 ROLES, RESPONSIBILITIES, & TASKS

3.1. Center Chief Medical Officer (CMO)

3.2. Medical Director

3.3. Chief Nurse

3.4. Clinician Nurse Practitioner/Physician Assistant

3.5. Registered Nurse Staff Nurse

3.6. Technical Document Specialist (TDS)

4.0 PROCEDURES

4.1. Physical Examination Procedures

4.2. Abnormal Vital Signs

4.3. Electrocardiograms (EKG)

4.4. Audiograms

4.5. Tuberculosis (TB) Skin Testing Procedures

4.6. Blood Specimen Collection (Venipuncture)

4.7. Urine Specimen Collection

4.8. Abnormal Laboratory Values

4.9. Fitness Center Operations

4.10. Medical Information Management

4.11. Confidentiality of Health and Medical Information

4.12. Copies of Medical Records

4.13. Disposition of Health and Medical Records

4.14. Medication Management

4.15. Health Unit Infection Control

4.16. Medical Waste

4.17. Bloodborne Pathogens

4.18. Respiratory Infection Control

4.19. Aerosol-Generating Procedures

4.20. Clinic Emergency Response Procedures

4.20.1. Assembly Points

4.20.2. Earthquake

4.20.3. Non-Earthquake (Fire, Chemical Spill, Smoke & Fumes, etc.)

4.20.4. Workplace Hazards

4.20.5. Medical Transportation

4.21. Quality Assurance and Performance Improvement

4.22. Performance Improvement

4.23. Calibration of Medical Equipment

4.24. Daily Calibration

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5.0 MANAGEMENT RECORDS & RECORDS RETENTION

6.0 RELEVANT DOCUMENTS

6.1. Authority Documents

6.2. Referenced Documents

6.3. Forms

APPENDIX A, Definitions

APPENDIX B, Acronyms

APPENDIX C, Requirement Verification Matrix

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1.0 SCOPE, APPLICABILITY, & WAIVER

1.1. Scope

This procedure applies to National Aeronautics and Space Administration (NASA) Armstrong Flight Research Center (AFRC, hereinafter referred to as Center) in Edwards, California, Health Unit general operations.

1.2. Applicability

This procedure applies to all staff members who work in the Health Unit, including clinician (physicians, physician assistants (PA), and nurse practitioners (NP)), as well as registered nurses (RNs) and administrative staff.

1.3. Waiver

Specific requirements within this procedure may be considered for waiver only with proper written justification at the discretion of the Chief Medical Officer (CMO). If granted, waivers will be time-limited, and a written copy of the waiver will be kept in the employee’s official medical record within the Electronic Health Record System (EHRS). The employee and employee’s supervisor will receive a copy of the waiver via encrypted e-mail.

2.0 OBJECTIVES & METRICS

Objective: Ensure the safety and accountability of medications and supplies.

Target: Zero discrepancies on medications and supplies.

Metric: Number of discrepancies per month.

Metric data collection and formulation: Notification of the CMO by e-mail from the Chief Nurse.

Where reported: Occupational Health Monthly Management Meeting (OHM3) with the Health Unit staff.

How often reported: Monthly.

Objective: Prevent bloodborne pathogen exposure incidents.

Target: Zero incidents.

Metric: Number of incidents per month.

Metric data collection and formulation: NASA Mishap Information System (NMIS) entry.

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Where reported: OHM3 with the Health Unit staff.

How often reported: Monthly.

3.0 ROLES, RESPONSIBILITIES, & TASKS

3.1. Center Chief Medical Officer (CMO)

The Center CMO is the Center’s technical authority in all issues regarding medical aeronautics and the main interface between the Center and the Office of the Chief Health Medical Officer (OCHMO).

The CMO will:

A. Ensure the Health Unit staff meet all pertinent Federal, State, and

NASA requirements.

B. Maintain a current Medical Board of California Physician or Surgeon license to practice medicine and keep a current American Heart Association (AHA) certification as well as an Advanced Cardiovascular Life Support (ACLS) certification to support any complex medical emergencies.

C. Perform NASA First-, Second-, and Third-Class aviation medical certifications, thus ensuring to maintain designation as a Federal Aviation Administration (FAA) Senior Aviation Medical Examiner

(AME).

NOTE

The FAA examinations will be supported by both the CMO and the Health Unit Director.

D. Perform five peer-reviews per quarter of the contracted Health Unit Director and one peer review per quarter of any other physician contracted to support the Health Unit.

Some of the Health Unit Director’s peer-reviews up to three per quarter, may be performed by another physician within the contract, thus, the CMO is to complement this requirement.

E. Serves as final authority on any waiver or deviations from the Center medical requirements and standards.

3.2. Medical Director

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Ensures the Center Health Unit is appropriately managed and all medical staff are properly and safely implementing the Health Unit Medical Director’s Standing Orders and Protocols. They serve as the technical/medical authority for the Health Unit medical staff.

The Health Unit Medical Director shall:

A. Maintain a current Medical Board of California Physician or Surgeon license to practice medicine.

B. Maintain current ACLS certification.

C. Develop and maintain Standing Orders and Protocols for the Health

Unit staff to include the PA, NP, and RNs that specifically addresses all occupational examinations performed at the Center. These Standing Orders/Protocols will follow NASA Procedural Requirements (NPR) 1800.1, NASA Occupational Health Program Procedures, and OCHMO-Standard (STD)-1880.1, NASA Aviation Medical Standards.

This document will be a living document with expected revisions based on any new OCHMO policy or CMO Center policy. In addition, any added requirement not stated in the NPR will be discussed with the CMO for approval to include in the Health Unit Standing Orders and Procedures. A copy of these orders will be provided to each clinician/provider at the Health Unit. The Health Unit Director will ensure understanding and compliance to the orders.

D. Ensure annual competency assessment of all licensed medical providers (LMPs) supporting the Health Unit.

E. Perform PA and NP oversight and ensure that at least one LMP maintains current status as a Certified and Registered Federal Motor Carrier Safety Administration (FMSCA) Medical Examiner.

F. Review, evaluate, and document the assessment of the NP’s /PA’s certifications/experience, as well as provide the appropriate scope of practice for these practitioners.

G. Perform medical flight clearances for Qualified Non-Crewmembers (QNC), FAA, and NASA First-, Second-, and Third-Class aviation medical certifications and duties which require the Medical Director to maintain a current FAA designation as a Senior AME.

H. Respond to emergency calls (when onsite) for people at the Center who have acute cardiovascular events, and, therefore, the Medical Director will keep a current AHA certification as an ACLS Provider.

I. Perform three peer-reviews per quarter of the CMO and/or other physician’s charts supporting the Health Unit.

J. Perform a minimum of three peer-reviews per quarter of the NP and/or

PA.

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K. Ensure thorough medical examinations and evaluations of all employees in the Hearing Conservation Program (HCP) with Standard Threshold Shifts (STS). Provide medical assessment and final determination of exposure origin to the Center’s Industrial Hygienist investigation report that will be included as part of the NMIS report.

3.3. Chief Nurse

Responsible for the daily Health Unit readiness for support of the Center workforce. This position ensures the Health Unit has the needed staff and oversees the day-to-day operations of the Health Unit.

The Chief Nurse shall:

A. Maintain a State of California professional RN license and California

Occupational Hearing Conservation (CAOHC) certification.

B. Ensure Health Unit Staff have the required state and Federal licenses and certification to perform all required examinations and tests, such as administering pulmonary function spirometry testing (National Institute of Occupational Safety and Health (NIOSH) training);

audiometry testing; AHA ACLS provider; CAOHC (all Health Unit RNs will maintain CAOHC certification to perform audiograms), etc.

C. Ensure annual competency assessments of all full-time RNs and NP/PAs supporting the Health Unit is performed.

D. Ensure a full-time licensed medical provider supporting the Health Unit functions as the Health Unit Inventory Control Officer.

E. Ensure a full-time licensed medical provider supporting the Health Unit functions as the Center Automated External Defibrillator (AED) Coordinator. The coordinator will develop a strategy for implementation ensuring NPR 1800.1 requirements are followed. The Chief Nurse will ensure a Health Unit staff maintains certification as an AED and First Aid Instructor, so to provide regular AED first aid training to employees who require such training as part of their jobs. This training will also introduce the “Stop the Bleed” cursory awareness training.

F. Ensure appropriate Health Unit equipment is calibrated and undergoes routine preventive maintenance.

G. Coordinates the Health Unit’s portion of the OCHMO annual Health Unit self-audits requirements, as well as the OCHMO tri-annual Health Unit and Fitness Center NASA Occupational Health Program Audit preparations, coordination, and participation.

H. Determine Health Unit response to any 911 emergency medical calls and assess if Center security will need to call upon Edwards Air Force

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Base (EAFB, hereinafter referred to as Air Force Test Center (AFTC)) Emergency Medical Technicians and Ambulance services.

I. Ensure that the emergency Medical Connex is appropriately stocked to support any major Center emergency.

J. Ensure that all full-time RNs supporting the Health Unit undergo peer-review of one to three charts every quarter.

3.4. Clinician Nurse Practitioner/Physician Assistant

The Center will have an Occupational Health Unit NP and /or PA. These individuals provide technical oversight to the nurse staff and assisting the physician with medical examinations.

The NP/PA shall (be):

A. Maintain a State of California professional RN license or PA license, meeting all the requirements for the California Board of Registered Nursing Holding Out Regulations for Nurse Practitioners, or the Board of Physician Assistant of California.

B. Maintain certification by the CAOHC for administering audiograms and maintain current AHA certification as an ACLS Provider.

C. Make critical judgments in conducting health assessments, making differential diagnoses, and prescribing pharmacological and non-pharmacological treatments in the direct management of acute and chronic illnesses and injuries, within the scope of Federal and state regulations, as well as NASA’s procedural guidelines, and Center Health Unit guidelines.

D. Implement care through independent action, health counseling, and collaboration with other members of the Occupational Health team, including nurses, physicians, and the Center Medical Director.

E. Provide a range of services, from job-certification physical examinations to medical surveillance exams, to assessment and treatment of acute occupational illnesses and injuries with the primary focus being to promote optimum workplace safety and health, prevent illness and injury, as well as evaluate and treat occupational illnesses and injuries.

F. Gather and analyze required metric data under the Occupational Safety and Health Administration (OSHA) HCP.

G. Provide relevant information regarding the current state or trend of-any emerging epidemic, endemic, or pandemic. This information will be shared with the Chief Nurse and other Occupational Health Staff during the monthly OHM3 metrics meeting.

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• In addition, these positions may require some administrative duties.

H. Ensure assessment and treatment of Center personnel who present to the Health Unit for urgent or emergent conditions, such as unstable angina, acute myocardial infarction, pulmonary embolus, or cerebrovascular accident (stroke) and for expeditiously responding in the Health Unit Medical Emergency Response Vehicle (MERV) with the supporting RN(s) to 911 Emergency Medical calls. Two LMPs will attend all 911 emergency medical calls. If no physician is present, the Center NP or PA then directs and assists with medical response at the scene to stabilize treated individuals to the extent possible in accordance with (IAW) standard Basic Life Support (BLS) protocols, and when needed, start ACLS and Center written protocols and to determine if Emergency Medical Services (EMS) Ambulance response is needed for transport to an off-site Emergency Department.

I. Recognize all instances where the clinical situation is beyond the scope of training and/or practice of the Center NP or PA, and, in these situations, the Center NP and/or PA is responsible for consulting the contracted physician for further assessment and disposition. In an emergency, and if the contracted physician is not available, the Clinician may contact the Center CMO for direction.

J. Follow the approved standard operating procedures set by the Health Unit Director. If there is a medical emergency or the need for immediate deviation from the standing operating procedures, the NP/PA will follow the CMO or onsite contracted physician guidance for providing the services.

3.5. Registered Nurse/ Staff Nurse

A Center Health Unit Staff Nurse is accountable for maintaining a State of California professional RN license, certification by the CAOHC, and current AHA certification as a BLS and ACLS Provider.

The Health Unit Staff Nurse shall:

A. Obtain and record employee medical information and health histories, performing physical exams and diagnostic tests, counseling employees regarding healthy lifestyles and other aspects of medical education, administering medications, performing wound care, interpreting medical information, determining necessary actions where appropriate, and consulting with nurse supervisors and physicians to determine medical plans.

B. Provide the Chief Nurse with the medication and supplies list and ensuring the Health Unit has all the supplies needed for treatments.

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3.6. Technical Document Specialist (TDS)

The Center Health Unit Technical Document Specialist (TDS) supports the clinical director, CMO, and Chief Nurse with various administrative, medical office, and record keeping functions ensuring the clinic runs efficiently.

The individual should use good interpersonal skills in person, by phone, and with email, and for understanding how to follow written and oral instructions.

The TDS also exhibits the ability to read, speak, and understand English fluently, for employing basic office skills, including typing at least 40 words per minute, filing, and phone management, and for appropriately using job-related computer skills.

4.0 PROCEDURES

4.1. Physical Examination Procedures

Employees, whether civil servants or contractors, are often required to have a physical examination performed in order to perform their job function. In some cases, such as fitness center clearances or executive physicals, these examinations are optional. In any case, specific requirements for each type of examination are found in NPR 1800.1, Occupational Health Program Procedures.

Implementing these requirements through the Health Unit entails the following:

A. Examination is requested, usually by phone call, by either the employee, or a representative for the employee (e.g., supervisor, scheduler, etc.), to the Health Unit TDS.

B. The TDS will send AFRC 10858, Medical Clearance Request, to the individual electronically for the employee and their supervisor to complete.

C. Once the Medical Clearance Request (MCR) has been received by the TDS, questionnaire(s) will be emailed from the EHRS, as well as any other forms that need to be completed, IAW examination requirements found in NPR 1800.1.

D. Once the employee has completed the prerequisite questionnaires/documents, the TDS will schedule the examination(s) accordingly.

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E. Some examinations are conducted in two visits (i.e., two different days) and some are conducted all in one visit. Two-visit examinations are required if blood work is drawn; in those cases, the test results will need to be discussed by the NP/PA and thus a second visit is required.

Information on which exams are one-part versus two-parts is found in NPR 1800.1, NASA Occupational Health Program Procedures.

F. The Health Unit RN will accomplish the required parts of the examination, depending on which examination is requested (and based on the requirements of NPR 1800.1).

G. After the RN has completed requirements, the chart will be given to the clinician (e.g., either NP, PA, or physician), who will review the EHRS chart, then conduct a medical examination.

H. After examination, the clinician will complete AFRC 10858, Medical Clearance Request, indicating the clearances for which the individual meets standards, as well as the expiration date(s) of the clearance.

Any restrictions, as appropriate, will also be noted. The clinician will then sign, date, and stamp the form with their name stamp.

I. The individual will be made aware of the clearances for which the individual meets standards, and with some clearances will be asked to acknowledge such by signing the MCR form. The Health Unit staff will make a copy and give it to the individual.

J. If clearances are denied, a Follow-up Advice letter will be created that lists what information is required in order to further evaluate whether a clearance can be completed. This letter is also used for abnormal findings which require following from the individual’s Primary Care Physician.

K. After the clinician has finished with the employee’s chart, the TDS will scan the paperwork into Cority® EHRS. Paper records are being phased out and will no longer be used after June 2024.

4.2. Abnormal Vital Signs

A. The RN will provide immediate attention to all employees presenting with abnormal vital signs. Upon determination of significantly abnormal vital signs, the RN will immediately contact one of the available clinicians. For the purposes of this procedure, abnormal vital signs are defined as the following, alone or in combination:

1) Pulse: Resting pulse less than 50/minute or more than 100/minute, or of an irregular rhythm.

2) Blood Pressure (BP): Greater than 140 or less than 90 systolic;

greater than 90 or less than 50 diastolic. Employees whose systolic BP is 210 mm Hg or greater or diastolic BP is 120 mm Hg or greater, and/or those with symptoms, will be referred immediately

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to the clinician. Symptoms include any of the following, alone or in combination: visual changes, numbness and/or tingling in the extremities, headache, diaphoresis, dizziness, or slurred speech.

3) Respiration: Respiratory rate greater than 20 breaths per minute;

as well as difficulty breathing, noisy breathing, or breathing with retractions.

4) Temperature: Oral temperature greater than 103 degrees Fahrenheit.

4.3. Electrocardiograms (EKG)

A. Current EKG (also known as ECG) equipment will perform a standard 12-lead tracing and provide an automated interpretation. These automated interpretations may present both false negative and false positive readings. Therefore, the EKG interpretation (e.g., “Normal”, “Otherwise Normal”, and “Borderline”) will be used as a guide, in conjunction with the employee’s history, signs, and symptoms, and other factors, in evaluating cardiac status. For EKGs where the lower limb lead is placed on the torso, “Limb lead on torso” will be written on the EKG printout.

B. The Health Unit clinician will be consulted regarding any EKG read as “Abnormal” on the automated interpretation, to determine if the abnormality requires immediate attention. The employee will be informed about the clinical significance of any abnormality. Counseling and referral recommendations will be clearly documented in the medical record.

C. If the EKG indicates a life-threatening situation, the principles of BLS and/or ACLS will take precedence over the accomplishment of an EKG. These principles include the application of a defibrillator, administration of oxygen, and starting an intravenous (IV) line.

4.4. Audiograms

A. Audiograms are performed on many physical examinations, including those for participants in the HCP (see Armstrong Flight Research Center Standard (AFST)-1800.1-003, Hearing Conservation).

B. The manufacturer’s instructions for operating the audiometer will be maintained near the hearing booth.

C. The RN will observe an individual’s tympanic membranes prior to testing; if the tympanic membrane is not visible, e.g., excessive cerumen, the audiogram will be delayed until the cerumen can be cleared.

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D. Required training IAW the HCP requirements listed in AFST-1800.1- 003 (and corresponding NASA procedural requirements), will be accomplished at the time of physical examination. This training will be accomplished by the clinician or certified CAOHC nurse.

E. Appropriate documentation of the individual’s training and testing will be accomplished in the EHRS.

4.5. Tuberculosis (TB) Skin Testing Procedures

NPR 1800.1 requires a baseline, initial TB test with annual screening for all active Security, Health Care and Food Handling personnel.

A. The initial baseline test used at the Health Unit is the Mantoux purified protein derivative (PPD) tuberculin skin. The RN will ask the individual if they have ever had a significant reaction previously to the Mantoux (PPD) skin test. If the individual has had an allergic reaction to a previous PPD skin test and is required by the position to test negative for TB, the RN will instruct the individual to obtain a blood test for TB sensitivity. If TB blood test results are positive; the individual would need to provide the Health Unit RN with negative TB results from a chest x-ray.

B. The annual TB screening requirement will be satisfied an electronic questionnaire send to the individual by the Health Unit via the EHRS record system.

• Center Health Unit is unable to draw blood or do chest x-rays for TB test at this time, thus, this test will need to be conducted by an outside licensed laboratory. The results of the test shall be provided to the Health Unit RN for uploading into the individual’s EHRS medical records. Employees who have received the Bacillus Calmette Guerin (BCG) vaccine will still be tested with a PPD tuberculin skin test (i.e., BCG is not a contraindication to testing).

C. The RN will administer the PPD in the standard fashion. The employee’s reaction to the Mantoux test will be read 48 hours after the injection; if the employee returns to the Health Unit outside of the maximum 48-hour time frame, the entire process will be restarted.

D. The area of induration (palpable swelling) around the site of injection will be measured perpendicular to the long axis of the forearm;

erythema (redness) will not be measured. All reactions will be recorded in millimeters of induration and will be recorded in the EHRS.

4.6. Blood Specimen Collection (Venipuncture)

A. The RN will confirm that the individual has been fasting for 12 hours and has never had a syncopal (fainting) episode during venipuncture. If there is a history of syncope or near-syncope, the individual will be

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placed in a recumbent position before initiating the blood draw. Such a history will be annotated in the individual’s medical record, if not already done so.

B. Once the blood has been collected, the RN will spin the balanced tubes in the laboratory centrifuge for 15 minutes.

C. The RN will ensure that all specimens are placed in the appropriate vendor’s laboratory bag, with the laboratory slip identification facing outward, and will ensure specimens are delivered to the clinical lab vendor’s pick-up station before close-of-business that same day.

4.7. Urine Specimen Collection

A. The RN (i.e., the collector) will direct the employee to the restroom adjacent to the laboratory area and instruct them on the proper way to obtain a specimen in the sterile urine collection cup.

B. The collector will transfer urine to sterile screw cap container making sure top is securely fastened.

C. If a simple urine dipstick analysis is required, the collector will perform it according to the instructions for the reagent strips for urinalysis found in each box.

D. The collector will dispose of excess urine in toilet adjacent to the laboratory area and dispose of the urine cup accordingly.

4.8. Abnormal Laboratory Values

A. When the laboratory results (i.e., urine dip) are received, the RN will highlight abnormal laboratory values and will bring them to the attention of the clinician; significantly abnormal results will be brought to the clinician’s attention immediately. Lab results through the EHRS are assigned to the clinician. Abnormal urine dipstick results are to be addressed while the examinee is in the clinic.

B. The clinician communicates the abnormal results to the examinee. This may be by phone, encrypted email, through face-to-face consultation (e.g., during the second part of the physical examination), by letter, or by some other means as determined by the clinician. If such communication is not immediately forthcoming, the clinician will ensure that a reasonable attempt to make such communication has been made. In the event of a failure to communicate with the examinee, the clinician will specifically document the types of attempts made, noting the dates, times, and the methods of communication attempted.

C. The clinician will document the communication with the employee in the employee’s EHRS, noting the specific result(s) of concern. Any recommendations for follow-up with the employee’s private medical

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doctor will be noted. The employee will be offered a copy of the laboratory results.

4.9. Fitness Center Operations

Medical Clearance: All Fitness Center participants will be cleared through a Center Health Unit Clinician. A clearance simply signed by an individual’s private physician is NOT acceptable. A Fitness Center medical clearance does NOT guarantee that an individual will not get injured or experience medical problems (e.g., myocardial infarction (MI)), while exercising.

The procedure for obtaining a medical clearance is as follows:

A. Employees will complete a Fitness Center Clearance Evaluation

Questionnaire (for initial clearance) and a PAR-Q+ (annually) and return it electronically to the TDS. The TDS will schedule the participant for a nurse appointment where the nurse will obtain medications, allergies, and a set of vital signs (including height and weight).

B. A Health Unit clinician will review the applicant’s questionnaire(s), medications, allergies, and vital signs. Based on the responses to the Fitness Center Clearance Questionnaire(s) and health evaluation, the clinician will determine whether to clear the applicant. If cleared, an AFRC 10858, Medical Clearance Request, will be completed. If not cleared, the applicant will be given information regarding the additional evaluation that will be required.

C. Unless otherwise noted, medical clearance is good for 1 year beyond the date of questionnaire, as listed on AFRC 10858. The Health Unit approving clinician can require a medical clearance on a more frequent basis, depending on the specific case. Any restrictions, as warranted, will be listed.

D. Routine Staffing and Qualifications

1) For safety reasons and because it can be accessed 24/7, the

Fitness Center will be monitored through the video monitor system located in the Security Office.

2) A Health Unit Staff will provide orientation to newcomers—and recurring instruction as needed—to individuals using the equipment in the facility. However, this person is not qualified or permitted to conduct personal fitness training or instruction.

3) The Health Unit staff, including the TDS, will be certified in (Cardiopulmonary Resuscitation (CPR)/AED) and will maintain a current certificate to such effect from either the American Red Cross or the AHA.

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E. Unanticipated Closure: If the Fitness Center will be closed for a period of time, an announcement indicating the closure will be facilitated by Health Unit personnel via a public email or equivalent.

F. Maintenance: See Armstrong Flight Research Center Operational Procedure (AFOP)-1800.1-004, Fitness Center Operations.

4.10. Medical Information Management

Chart Components: Per NASA paper reduction guidelines, paper medical charts are currently being phased out. Prior to June 2024, all medical records will be transitioned to the EHRS. No new paper medical records will be created, and remaining paper records will be scanned and stored in the EHRS. Once scanned into the EHRS, paper records will be disposed of as per NASA requirements.

4.11. Confidentiality of Health and Medical Information

A. All medical confidential information will be handled IAW 5 Code of Federal Regulations (CFR) Part 293 (Personnel Records), 5 CFR Part 297 (Privacy Provisions for Personnel Records), 5 USC 552a (b) (Conditions of Disclosure), Office of Personnel Management (OPM)/ Government (GOVT)-10 (Employee Medical File System (EMFS) Records, including authorized “Routine Uses” for those records, Health Insurance Portability and Accountability Act of 1996 (HIPAA, Public Law 104-191), and the Privacy Act of 1974 and subsequent amendments, as well as the guidance provided by OSHA.

B. Medical confidentiality is the responsibility of each clinic staff member, and no unauthorized person will have access to the health record. All state and federal regulations that apply to privileged information and confidentiality of records will be followed to ensure the confidentiality of the health record. Authorization for disclosure of information will be accomplished IAW the provisions of section 5, in conjunction with the applicable state and federal laws (as noted in the previous section).

Until all paper medical records are uploaded to the EHRS, they will be kept under lock and key during non-duty hours. The security of the EHRS is managed centrally through OCHMO/Headquarters (HQ).

4.12. Copies of Medical Records

A. The CMO (or clinician designee) properly releases health and medical information. Any inadvertent or improper release of confidential medical information will be brought to the attention of the CMO by an e-mail outlining the relevant facts and circumstances of the release.

B. Copy Requests Directly from Employees: Employees are entitled to any and all of the medical information in their medical chart, though the

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medical record itself remains the property of NASA. Employees will be given a copy of their own medical chart, or any part thereof, upon request at no financial charge.

C. Copies of medical records will be provided within 15 days from date of receipt of written request within the Health Unit, provided appropriate consent by the individual for release of such information has been provided.

D. Any OUTSIDE request for medical information WILL be accompanied by an authorization from the individual employee. If an employee authorization does not accompany the request, the request and a release form will be returned to the requestor with an explanation. The relevant, requested part(s) of the medical record will be provided from the EHRS. The original medical record release form will be retained and filed in the employee's record. No payment will be accepted for requests; any payment received by the Health Unit will be returned with the medical record.

E. Any requests from an attorney or legal agency for copies of medical records will be forwarded to the Center Office of the Chief Counsel.

Further direction on how to handle the request will be provided by the Legal Office.

4.13. Disposition of Health and Medical Records

For medical records digitally stored entirely in the EHRS, medical records disposition is managed at Agency level and OCHMO/HQ. The Health Unit is not involved in the archiving process.

Prior to June 30, 2024, for civil servants, the CA Human Capital Office will inform the Health Unit staff regarding retiring or separating civil servants. If possible, the TDS will scan the medical chart into the EHRS which will then serve as the archive. If this cannot be accomplished, the TDS will transfer the medical chart contents to the “Employee Medical Folder” (Standard Form (SF)-66D). The technical documents specialist will then label the SF-66D with individual’s name, identification number, and date of birth, and then send it in an appropriately labeled envelope to:

National Archives and Records Administration (Annex) 1411 Boulder Boulevard Valmeyer, IL 62295

4.14. Medication Management

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Narcotic and controlled meds are no longer maintained in the clinic.

A. Providing, Tracking and Disposal

1) For the purposes of this procedure, administering a medication is defined as giving a single dose to an individual employee.

Dispensing (and/or “furnishing”) a medication means transferring the medication from a stock supply to a smaller container, i.e., multiple doses to be taken over a period of time, for an individual employee. RNs may administer over-the-counter medications, but will not dispense them. IAW applicable policies of the California Nurse Practice Code, NPs may furnish medications. For the purposes of this procedure, “furnishing” includes the act of providing prophylactic travel medications for deploying aircrew, e.g., malaria chemoprophylaxis, for travel.

2) Medications to be administered will be in their original container provided by the manufacturer or pharmacist and will have the original label. That is, no medications may be repackaged and/or relabeled by the RN. Any such medication will include specific written directions for use.

3) The RN will also give the individual the appropriate information sheet for the particular medication, and will advise the employee about:

a) Name of the drug and what it is for;

b) Dose and frequency;

c) Precautions to follow while taking the drug, and contraindications for using the drug;

d) What to do if a dose is missed;

e) What potentially serious side effects the employee should report to the Health Unit; and

f) The mild to transitory side effects that need not be reported to the Health Unit unless they persist.

B. Tracking

All medications dispensed or administered from the Health Unit will be annotated on a Medication Log worksheet listing the name of the medication, the date of administration or dispensing, the amount, the dose, the lot number, and the expiration date of the medication. This worksheet will be used to track medication manufacturer recalls, if they occur, so as to notify recipients of the medication recall and the reason why. The medication log will be reconciled with the medication inventory on a monthly basis. Any discrepancies will be brought to the

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attention of the CMO by an email outlining the facts and circumstances of the discrepancy. A discrepancy is also reported during the monthly OHM3 metric meeting.

C. Disposal

1) Medications that are expired will be kept in a separate locked cabinet until they are disposed. They will be disposed of as biohazardous waste (see section 4.17).

Epinephrine and nitroglycerine will be kept and handled separately from other medications.

2) Medications that are less than 50% of original unit of issue will be placed in expired medication receptacle on site and disposed following the requirements set in NPR 1800.1.

Expired epinephrine and nitroglycerine will be initially placed in an expired medication receptacle. Sharps receptacles are considered non-hazardous pharmaceutical waste under the EPA Resource.

D. Pending final disposal, used needles and syringes will be temporarily stored in closed, one-way, puncture-resistant receptacles, i.e., “sharps” containers.

4.15. Health Unit Infection Control

A. Health Unit staff members will employ universal precaution measures (aka “universal precautions”), whenever there is a potential for exposure to bloodborne pathogens, respiratory pathogens, or other potentially infectious material. Specifically, universal precautions will be used when working with the following substances:

1) Blood and unknown body fluids;

2) Semen and vaginal secretions;

3) Feces;

4) Urine;

5) Vomitus;

6) Sputum.

B. “Universal precautions” means that the staff member will:

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1) Use appropriate barrier precautions such as gloves, masks, and gowns when exposure to blood and other body fluids is likely;

2) Wear gloves when handling all blood and body fluid specimens or performing venipuncture;

3) Change gloves after each employee contact, and wash hands immediately after removing gloves; and

4) Immediately and thoroughly wash hands and other skin surfaces if contaminated with blood or other body fluids.

C. The Health Unit Medical Director will designate an Infection Control Officer (ICO). The ICO will have an Infection Control meeting. Notes from the meeting will include agenda/topics discussed and a list of attendees.

4.16. Medical Waste

Medical waste in California consists of the following types of waste:

A. Biohazardous waste

• Biohazardous waste is not expected to be produced. For those very rare instances, the waste will be contained in a biohazard red bag, stored securely with other medical waste, and shipped for disposal within 30-days of being generated.

B. Sharp waste

1) Sharp waste such as needles, disposable syringes, lancets, scalpel blades, and vacutainers will be placed in a closable, puncture resistant “sharps” container. “Sharps” containers will be of a tamper-resistant design and will be either:

a. Locked to a mounting device that is securely fastened to the building structure; or

b. Located in a room or area that is locked or under continuous visual surveillance of Health Unit personnel.

2) When a sharps container is 3/4 full, it will be removed and replaced.

Containers will be properly closed before removal and handled in a manner that will prevent spillage during handling, storage, or moving. Used containers will be stored in a secured location. Used containers will not be reused, opened, emptied, or cleaned by hand or handled in a way that will risk occupational exposure or needle-stick injury.

3) All sharp waste will be disposed of within 30-days after being placed in storage. A receipt or other documentation of the waste

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provided to the disposal facility will be maintained in the office of the Site Supervisor for a period of no less than 3 years.

C. Pathology waste

• Pathology waste will not be produced.

D. Pharmaceutical waste

• Pharmaceutical waste will be placed in a container and labeled with a “Non-Hazardous Waste” label and described as pharmaceutical waste. Waste will be disposed at the same time as all other medical waste. Expired inhalers are considered hazardous waste and will be given to Environmental Office for disposal.

E. Trace chemotherapy waste

• Trace chemotherapy waste will not be produced.

F. Trauma scene waste

• Trauma scene waste may occur onsite due to an unexpected incident. When such events occur, the Health Unit will contact Kern County Health Department for a registered trauma scene waste management practitioner to direct the Center as to the proper handling and disposal of such waste.

4.17. Bloodborne Pathogens

The Health Unit staff will follow the requirements in the Center’s operating procedures for Bloodborne Pathogens, AFOP-1800.1-003.

4.18. Respiratory Infection Control

To prevent infection, the Health Unit staff use a hierarchy of controls to prevent potential exposure of the healthcare personnel and individual employees to infectious agents. This hierarchy of controls is as follows:

A. ELIMINATION of potential exposures: Health Unit staff will minimize visit time for employees with mild influenza-like illness who do not have risk factors for complications. They will postpone elective visits by employees with suspected or confirmed influenza until they are no longer infectious. More specifically, Health Unit staff will self-assess for symptoms of febrile respiratory illness; staff members who have a fever (i.e., T oral > 101.5 degrees Fahrenheit) and respiratory symptoms (e.g., coughing, sneezing, runny nose, congestion, shortness-of-breath, and/or wheezing) will not report to work.

Moreover, they will be excluded from work for at least 24 hours after they no longer have a fever without the use of fever-reducing

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medications, and respiratory symptoms have abated. For COVID, work restrictions will be as per current Center For Disease Control (CDC) guidelines. However, anyone with the following emergency warning signs will seek urgent medical attention:

1) Difficulty breathing or severe shortness of breath;

2) Pain or pressure in the chest or abdomen;

3) Sudden dizziness;

4) Pronounced confusion;

5) Severe or persistent vomiting; and/or

6) Return of flu-like symptoms after initial improvement (with fever and worsening cough).

B. ENGINEERING CONTROLS: When directed by the CMO, Health Unit staff will install partitions in triage areas and other areas accessible to the public to reduce potential exposures by shielding staff and other employees.

C. ADMINISTRATIVE CONTROLS: In general, Center employees are strongly advised to stay home and seek medical care from their Primary Care Provider if they have signs of an infectious illness. Health Unit staff will promote and (when able) provide vaccination to individuals against known infectious agents. They will enforce exclusion of ill healthcare personnel from work. They will implement respiratory hygiene/cough etiquette strategies by having symptomatic employees cover their nose and mouth with tissues when coughing or sneezing, or have employees put on facemasks, if tolerated. Also, the staff will set up a triage station and separate the area for employees who visit the Health Unit with influenza-like illnesses, and will assign a specific staff member in order to minimize the number of healthcare personnel exposed to those with suspected or confirmed influenza.

D. PERSONAL PROTECTIVE EQUIPMENT (PPE): All staff members will perform appropriate hand hygiene frequently, including before and after all employee contact, and before putting on and removal of PPE.

Either soap and water, or alcohol-based hand sanitizers, will be used.

Employees and Health Unit staff should be educated so that the number and amount of surfaces contacted are limited. Health Unit staff that are in close contact with employees with suspected or confirmed infections will use a respirator that is at least as protective as a fit-tested disposable N95 respirator. Employees with respiratory symptoms will be promptly asked to wear a face mask and encouraged

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to practice respiratory hygiene and cough etiquette when coughing or sneezing.

4.19. Aerosol-Generating Procedures

Some procedures performed on employees are more likely to generate higher concentrations of respiratory aerosols than coughing, sneezing, talking, or breathing. CPR has a very high exposure risk for aerosolized particles. In these instances, Health Unit personnel will adhere to standard precautions with respiratory protection equivalent to a fitted N95 (or higher) respirator for any employee who is suspected of presenting an increased infection risk to Health Unit staff. The Health Unit staff will use a clean mouth barrier, mouth to mask resuscitator, or ambu-bag when performing CPR.

4.20. Clinic Emergency Response Procedures

4.20.1. Assembly Points

The Health Unit staff will proceed to the emergency evacuation assembly point, unless the assembly point is unsafe. During a major disaster, personnel that cannot reasonably check into their own assigned assembly point, should check in to the nearest assembly point, and report their presence to the zone coordinator for that assembly point. No Health Unit staff member is authorized to remain behind to operate or shut down critical operations. The Health Unit staff will remain at the assembly point until the Health Unit is declared safe for reentry.

4.20.2. Earthquake

A. In the event of an earthquake, staff members will take immediate precautions to protect themselves and any employees who may be in the Health Unit. This is conventionally known as “duck and cover.” When the immediate shaking has subsided, Health Unit staff will gather emergency response equipment and put it into the MERV. They will then evacuate the Health Unit by driving the MERV to the parking lot across the street. One Health Unit staff member will report to the designated assembly point to give the zone coordinator the status of the Health Unit. They will also give the apparent facility status of Bldg. 4822 (Health Unit) and Bldg. 4877 (Fitness Center). Staff will await Facilities Engineering and Logistics Management Branch personnel to give permission for Bldg.

4822 and Bldg. 4877 to be re-occupied, if and when it is safe to do so. Otherwise, Facilities Engineering and Logistics

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