Attachment 5 - 01 00 00.D - Appendix D1 SOP 138-06HV OCCUPATIONAL SAFETY AND HEALTH PROGRAM.pdf

OCCUPATIONAL SAFETY AND HEALTH PROGRAM

SOP 138-06HV

VA Hudson Valley Health Care System Wappingers Falls, NY 12590 Montrose, NY 10548

Signatory Authority:

Chief, Engineering

Responsible Owner:

Safety Manager

Service Line(s):

Engineering Service

Effective Date:

August 29, 2022

Recertification Date:

August 31, 2027

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on Occupational and Safety and Health Program for VA Hudson Valley Health Care System. This SOP must be followed by all employees and volunteers who work for the VA Hudson Valley Health Care System.

b. This SOP and Appendixes sets forth mandatory procedures and processes to ensure compliance with VA/VHA National Comprehensive Safety and Health Directive 7701 May 5, 2017. The VA Hudson Valley HCS has established mechanisms to ensure a safe environment for patients, employees and visitors through the establishment and maintenance of an effective Safety & Occupational Health Program which includes Safety, Security, Hazardous Materials and Waste, Emergency Preparedness, Life Safety, Medical Equipment, GEMS (Green Environmental Management Systems).

Infection Control, and Utility Systems. All employees will comply safety and health rules and regulations, safe work practices and for using personal protective equipment when required. Reporting, in a timely manner, unsafety or unhealthful conditions to their supervisor or other appropriate official.

2. PROCEDURES

a. The Safety Officer

(1) The Safety Officer is granted the authority to immediately intervene or stop work, operation, project, or acts that, in his/her opinion, may result in injury, impairment, sickness, or immediately endangers the life of patients, employee, or visitors, or threatens damage to equipment or buildings. Inform employees that they have access to their employee exposure and medical records, that the records are made available, upon written request, to the employee or their representative, from Occupational Health during a reasonable time period, that the initial records are provided at no cost to the employee or their representative, and that subsequent copies of the same records may incur a reasonable copying charge.

August 29, 2022 SOP 138-06HV

b. Service-Level Emergency Response Plans

(1) Will be prepared by Service Chiefs/Care Line Managers and submitted to the Safety Officer for approval, and then forwarded to the Emergency Preparedness Coordinator. These plans will state how the Care Lines/Services will respond in a disaster situation. Service cascade lists will be attached to these plans.

(2) Service-Level Safety Plans will be prepared by Service Chiefs/Care Line Managers and submitted to the Chairman, EOC Committee, through the Safety Manager and the Chief, Engineering Service for approval. These will state that the hospital-wide policy will be followed and will include procedures (if any) that are specific to the Services. Each Care Line/Service will create a Care Line/Service Safety Sub- Committee (a sub-committee of the hospital wide EOC Committee). Smaller Services will include safety as a standing agenda in their regular meetings. The committee will meet at least ten times a year and the minutes will be submitted to the Safety Office.

Review of all job-related accidents will be included as a standing agenda item. The committee will attempt to resolve safety problems at the Service level but may refer problems to the hospital wide committee.

c. Reporting and Correcting Safety Hazards:

(1) Any employee discovering a safety hazard will immediately report the hazard to his/her supervisor or directly to the Safety Office, ext. 207233 (SAFE) or safety office staff. Anonymous reports may also be made by dialing “20 SAFE” (7233) from either campus. Reprisal will not be taken against any employee reporting a safety hazard.

(2) The supervisor will report the hazard to the Safety Office, ext. 207233 (SAFE) or safety office staff.

(3) The hazard will be entered into the safety log with the date and name of the person calling, unless specified to be anonymous. Action taken will depend on the type of hazard. This is normally accomplished by the supervisor at the hazard location but may also be initiated by the Safety Specialist or Industrial Hygienist.

(4) Other hazards will require further investigation by the Safety Office. The action taken to correct the hazard will be entered into the safety log and the person reporting the hazard will be notified of the action taken.

(5) If an employee is not satisfied with the facility’s response, they may contact:

(a) First, the VISN office.

(b) Second, the VHA Director of Safety, Health, Environmental and Emergency Management (10NS) if not satisfied with the VISN response.

(c) Third, the VA Director of the Office of Occupational Safety and Health (00S1) if not satisfied with the (10NS2) response.

(d) Fourth, to the Occupational Safety and Health Administration (OSHA).

(6) This SOP is distributed to all employees by the posting on the Hudson Valley Website and copies can be obtained by contacting the Safety Office.

3. ASSIGNMENT OF RESPONSIBILITES

a. The Medical Center Director is responsible for ensuring the implementation of this SOP and for providing a place of employment free from recognized hazards.

b. The Assistant Director is assigned as the Chairperson of the Accident Review Board to review employee and investigate accidents in the workplace.

c. The Chief of Engineering Service is responsible for acting as the facility Safety Officer and Chairperson of the Environment of Care Committee for the implementation of the Occupational Safety and Health Program.

(1) The design and implementation of a utilities systems program that assures the operational reliability, assessment of special risks involved, and response to failure of any utility system that supports the patient care environment.

(2) The design and implementation of a medical equipment management program that assesses and controls the clinical and physical risks of fixed and portable equipment used for the diagnosis, treatment, monitoring, and care of the patients, and other fixed and portable electrically- powered equipment according to policy.

(3) Ensures that construction/renovation projects are conducted in a manner that protects patients, employees, visitors, and facility property.

(4) Ensures that construction/renovation projects are conducted in a manner that protects patients, employees, visitors, and facility property.

(5) Ensures that the program is continually improving, including implementation of interim measures as needed.

d. The Safety Manager is responsible for:

(1) The development, implementation, and monitoring of the medical center’s Safety Management Program and Hazardous Materials Program including and annual review of the effectiveness of the program. Ensuring that new and existing employees receive the required training necessary to perform their job functions and that it is documented for all training required by OSHA, EPA, VA and any other pertinent agency. Training includes but is not limited to fire safety, hazard communication, emergency response plan, waste disposal, the structure of the hospital safety program, GEMS, Utilities, Infection Control, service specific safety procedures, accident reporting and violence in the workplace/security.

(2) Implementation and maintenance of an ongoing, facility-wide system to collect and evaluate information about hazards, safety practices and safety management issues for use by the Safety Committee. This includes documenting survey of all areas to identify environmental hazards and unsafe practices and taking appropriate action when hazardous conditions are found.

(3) Recording and investigating complaints of unsafe working conditions on the Safety Log and taking appropriate action when hazardous conditions related to fire safety, accident prevention, and other safety issues exist.

(4) Coordinating with Occupational. Health in determining what medical surveillance is required. Management of the OSHA 300 Log and Summary, Life Safety Code Inspections of Community Care Homes, Contract Nursing Homed, Adult Day Care, Grant Per Diem and Medical Foster Homes, and reporting to OSHA, EPA, and the VISN when required.

e. Occupational Health is responsible for coordinating and conducting pre-employment physicals, medical surveillance.

f. Education Service is responsible for providing basic safety training (E-Safety) as part of orientation for all employees, which will include Fire Safety, Hazard Communication, Accident Reporting, and the Structure of the Hospital Safety Program, Emergency Preparedness, GEMS, Utility Systems, Infection Control, Medical Equipment, Security/Violence in the Workplace and MRI Safety.

g. The Fire Dept Chiefs are responsible for Fire Prevention and NFPA Life Safety Management is implemented and managed by the Fire Chief to include an annual review of the effectiveness of the program as well as reporting fires resulting in injuries or property damage in excess of $10,000 to the Network Director and entering reports of fires into the CEOSH fire reporting database, in accordance w Radiation safety is managed by a Radiation Safety Committee chaired by the hospital Radiation Safety Officer.

h. All Managers and Supervisors are responsible for maintaining their areas of authority free of recognized hazards and for taking appropriate action to eliminate such hazards and developing and implementing Care Line/Service’s level Emergency Response Plans and service level safety plans with VHA Directive 2009-039, Fire Incident Reporting. Supervisors will conduct routine daily inspections of their work areas for unsafe or unhealthful working conditions and for takin appropriate action to eliminate such conditions ensuring employee compliance with all Safety & health rules and regulations or if employee fails or refuses to comply, take appropriate action. Train employees under their supervision in safe and environmental work procedures. Training new employees in the hazards of each work operation before assignment of that employee to that work operation. Investigate, follow-up, and document all job-related accidents.

4. DEFINITIONS

None.

5. REFERENCES

Executive order 12196 Occupational Safety and Health Programs for Federal Employees.

6. REVIEW

This SOP must be reviewed at minimum at recertification and including when there are changes to the governing document, and any regulatory requirement for more frequent review.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of August 2027. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

John Cliffe Chief, Engineering Service

DATE APPROVED:

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Web Home - Hudson Valley HCS (sharepoint.com) https://dvagov.sharepoint.com/sites/VHAHVHDCS/default.aspx

June 22, 2022 SOP 138-06HV

APPENDIX A-H

A-1

Appendix A – Hazardous Communication Appendix B – Formaldehyde Exposure Control Program Appendix C – Control of Hazardous Chemicals Gasses and Vapors Appendix D – Sterile Packaged Transport Appendix E – Accident Investigation Appendix F – Lockout/ Tagout Program Appendix G – Compressed Gas Cylinder Appendix H – Lead Hazard Control Program

APPENDIX A.doc APPENDIX B.doc APPENDIX C.doc APPENDIX D.docx APPENDIX E.docx

APPENDIX F.doc APPENDIX G.doc APPENDIX H.doc

SOP: 138-06HV

APPENDIX A

HAZARD COMMUNICATION

1. PURPOSE: To delineate procedures for the safe handling of hazardous materials substances through proper labeling, provision of Material Safety Data Sheets (MSDS) and employee training throughout the VA Hudson Valley HCS.

2. POLICY: The VA Hudson Valley HCS has established mechanisms to provide its employees with the information and training on the hazardous materials present in the workplace so that a high level of safety can be maintained for all patients, visitors and employees, especially in areas where hazardous materials are used and stored.

3. RESPONSIBILITIES:

a. The Director is responsible for ensuring that this policy is implemented

b. The Chief, Engineering Service is responsible for the implementation of this policy and that that effective hazard communication procedures are practiced.

c. Industrial Hygienist, as the designated Hazardous Material Coordinator is responsible for coordinating the provision of information on the hazards of chemicals used in the workplace to the employee by means of a comprehensive Hazard Communication Program. This will be accomplished by the following:

1) Provide Hazard Communications training to employees and/or "train the trainer" training to Service chiefs and supervisors on the Hazard Communication Program at the request of the Service chief and Care Line managers.

2) Ensure review and compliance with TJC’s Standards that require all hazardous material to be handled in a safe manner.

3) Maintain copies of Service’s inventory of hazardous chemicals used at the VA Hudson Valley HCS.

4) Maintain a file for Material Safety Data Sheets provided by Services and Care Lines.

5) Be available to conduct familiarization meetings with outside contractors who perform work at the facility. These meetings will be to:

(a) Inform contractors of chemicals likely to be encountered by their employees, labeling system used by the facility, and methods that their employees may use to protect themselves from any on-site chemical hazards; and

(b) Obtain information from the contractor on the hazardous material that they will be using, including information on the labeling system and copies of all MSDSs, and any precautions they will use to prevent patient, visitor and employee exposure to any of these chemicals.

6) Provide follow-up investigation and reporting for all hazardous material exposures/incidents with recommendations/corrective actions taken to prevent re-occurrences.

7) To respond to Service chiefs, Care Line managers or supervisors request for assistance or information concerning hazardous materials and the Hazard Communication Program.

8) To inspect Services and Care Line areas for implementation and compliance with the VA Hudson Valley Healthcare System’s Hazardous Material Management Program.

d. Service Chiefs, Care Line Managers and Supervisors are responsible for:

1) Ensuring compliance with the Hazard Communication Program and the Medical Surveillance Program within their areas of responsibility.

2) Providing the employee, information on the hazardous material that they work with through container labeling and SDSs, and training in the elements as listed in this policy.

3) Developing and implementing Care Line/Service's Hazardous Management Program include the following:

(a) Preparing and maintaining a current inventory of all hazardous materials used by the Service.

(b) Providing a copy of the inventory to the Safety Office at least on an semi-annual basis and updated whenever there is a significant change in the inventory (addition/deletion of products or major changes in amounts ordered).

(c) Maintain copies of SDSs for all hazardous materials used in the Service. Copies of SDSs for any highly hazardous materials or materials stored in large amounts should also be provided to the Safety Office for use in emergency situations.

(d) Investigation of accidents in their areas involving hazardous material exposure.

(e) Reporting instances or circumstances where it is felt that the Hazardous Material Program requires modification to allow compliance or to achieve a safe condition.

(f) To ensure that SDSs are ordered for all hazardous materials. When credit cards are used, the SDS is to be requested at the time of ordering. When a VA Form 90-2237 is used, the words "Hazardous: SDS Required" are to be included in bold letters in the description block for the purchase requests.

(g) To obtain, maintain and review applicable MSDS and to ensure proper labeling on containers.

(h) To provide results of any industrial hygiene monitoring done in the employee's work area to the employee and the employee’s supervisor.

(i) Ensure that employees are aware of the location of this Hazard Communication Plan.

(j) Employees will also be made aware of the location of the chemical listing and copies of the MSDSs for all hazardous chemicals that are used in their work area.

e. Network Acquisition and Logistics (NAL) is responsible for:

Ensuring that the hazardous material requirements in the Federal Acquisition Regulation (FAR) 49 CFR 52.223-3 and FSS Clause Manual I-FSS-22 are contained in the acquisition document if the words "Hazardous: SDS Required" are in the purchase request. See Paragraph 4.b. for Hazardous Materials Inventory (MHI) Procedures.

f. Contracting Officers Technical Representatives (COTR’s) are responsible for:

1) Ensure that all contractors provide SDS’s for products used at the facility to the Industrial Hygienist.

2) Ensure that all contractors participate in familiarization training with the facility Industrial Hygienist prior to the start of any work/projects.

g. Chief, Education Service is responsible for maintaining records of employee training, including Orientation and Hazardous Material Management/Hazard Communications Training.

h. Occupational Health is responsible for:

1) The establishment and performance of the Medical Surveillance Program

2) Coordinating with the Industrial Hygienist in identifying job categories with exposures that trigger requirements.

3) Establishing a Medical and Biological Monitoring Program for employees who are exposed to hazardous chemicals or hazardous conditions.

i. Employees are responsible for been familiar with and to follow the guidelines of the Hazardous Material Management and Medical Surveillance Programs by the following:

1) To report any unsafe condition or use of hazardous materials to the supervisor.

2) Promptly reporting accidents and spills that result in chemical exposure to patients, visitors or employees.

3) To report to the Occupational Health physician when instructed to do so by their supervisor.

4) Employees have the right to be informed about the potential hazards associated with materials to which they may be exposed. In addition, they will be informed of the results of any industrial hygiene monitoring done in their work area.

5) All employees who may be exposed to hazardous material will receive training in hazard recognition and in safe use of hazardous chemicals. Training will follow the guidelines of the Federal Hazard Communication Standard, 29 CFR

1910.1200. Employees, who desire information regarding materials that they may be exposed to, or who have suggestions for safer use of hazardous materials, may direct questions and comments to the Safety Office.

6) Any employee who transfers chemicals from the manufacturer’s container to a secondary container is responsible for labeling the secondary container with the following information:

(a) Chemical or product name;

(b) Health hazards associated with the chemical or product; and

(c) Physical hazards associated with the chemical or product.

7) New employees will receive adequate information and training concerning the identity, hazards and safe handling of hazardous materials used in their workplace in accordance with 29 CFR 1910.1200(h).

4. PROCEDURES:

a. Definitions

1) Hazardous Chemical or Hazardous Material: Any chemical, product or substance which has a health hazard and/or a physical hazard associated with it.

2) Health Hazard: A chemical or chemical product for which there is statistically significant evidence, based on at least one study conducted in accordance with established scientific principles that acute or chronic health effects may occur in exposed employees. The term health hazard includes chemicals which are carcinogens, toxic or highly toxic, reproductive toxins, irritants, corrosives, sensitizers, hepatotoxins, nephrotoxins, neurotoxins, agents having an effect on the hematopoietic system, and agents which damage the lungs, skin, eyes, or mucous membranes.

3) Physical Hazard: A chemical or chemical product for which there is scientific valid evidence that it is a combustible liquid, a compressed gas, explosive, flammable, an organic peroxide, an oxidizer, pyrophoric, unstable (reactive) or water reactive.

b. Hazard Determination

Service Chiefs, Care Line Managers, and supervisors will review all available information, including, but not limited to, labeling and MSDSs, for any health or physical hazards associated with the chemicals that are used by their Service, and determine which chemicals fit the definition of a hazardous material. If the Service chief, product line manager or supervisor cannot make a determination for any chemicals, they will contact the Industrial Hygienist for assistance/additional information.

c. Hazardous Materials Inventory (HMI)

1) Service Chiefs and Care Line Managers will conduct an initial HMI within their respective areas. A current Master Inventory will be maintained in each area and kept updated as each new chemical or product or substance is received or deleted. The inventory will be subdivided to indicate the chemicals used in each section or work unit within a Service or product line, and a copy placed in that work unit to be available to all employees on all shifts.

2) The inventory for hazardous materials will be recorded on the "Hazardous Materials Inventory Sheet" (Attachment A) or on the computer in a file that contains all of the requested information for each material. Each Service/Care line must assure an SDS’s is available for each of the chemicals list on the inventory (as noted on the Hazardous Materials Inventory Sheet). If the information is recorded on the computer, a print out of the information must be available to all employees on all shifts.

3) A semi- annual inventory summary must be submitted to the Industrial Hygienist in Engineering. All materials used during the year must be included even though their use may have been sporadic or discontinued at the time of an inventory.

4) The inventory must be complete and accurate for the entire year by continuously updating it as changes occur.

d. Safety Data Sheets (SDSs)

1) Service Chiefs and Care Line Managers will obtain the most current copy of the specific MSDS for each chemical or hazardous material meeting the VA definition of hazardous material required to be listed in the Service's HMI.

2) MSDSs are available upon request from the vendor. It is sometimes necessary to contact either the distributor or manufacturer, but usually the salesperson, customer Service department or the product managers are the appropriate contacts to request an MSDS. Most MSDS’s are also available on the Manufacturer’s or Distributor’s webpage.

3) Service chiefs and Care Line managers will request a copy of the most current SDS from the vendor when orders for hazardous materials are placed with Fiscal and they will maintain the SDS’s within their areas. Any problems with obtaining a MSDS from a supplier or manufacturer will be reported to the Industrial Hygienist for follow-up prior to reconciliation of the order

4) Fiscal Service will ensure that a MSDS is obtained for all hazardous materials ordered by VA Form 90-2237 with the words "Hazardous: SDS Required" in the description block. No new hazardous materials will be delivered without the appropriate SDS attached. No payment to the vendor will be made by Fiscal without the appropriate MSDS being received.

5) All SDSs obtained by Services and Care Lines (directly or from Fiscal) will be placed into the Hazardous Material Binder for the area where the material is being used. For Service’s and Care Line’s with multiple locations, a Hazardous Material Binder with SDSs for all locations will also be kept in the Service’s or Care Line’s main office or other central location.

6) The COTR or Project Engineer will also ensure that SDSs for all hazardous materials used by contractors are obtained before the project is started. Copies of the SDSs for the project will be provided to the area(s) affected by the project and the Industrial Hygienist.

7) Service Chiefs and Care Line Managers will provide SDSs for any highly hazardous material or materials that are stored in large amounts to the Industrial Hygienist. The Industrial Hygienist will maintain these SDSs in a central file at the Safety Office.

8) The Safety Department with provide a listing of the site hazardous material inventory to the VHA Center of Engineering and Occupational Safety and Health SDS/3e Chemical Inventory Service to assure the site inventory is available on line via the intranet.

e. Labeling

1) Labels and other forms of warning information that accompany all hazardous chemical containers will not be removed or defaced. Labels that are damaged or fall off are to be replaced by the user.

2) Where hazardous chemicals are transferred to a secondary container, the subsequent container must be labeled, tagged, or marked with the following information:

(a) Identification of the hazardous chemical contained therein, as it appears on the sSDS.

(b) Appropriate health hazard warnings, such as Poison, Carcinogen, Corrosive to skin, eyes and mucous membrane, Irritant, Sensitizer, etc.

(c) Appropriate physical hazard warnings, such as Flammable, Water Reactive, Compressed Gas, Oxidizer, Corrosive

Acid, etc.

f. Training

1) Each employee who works with or is potentially exposed to hazardous chemicals will receive initial training prior to the initial assignment (Orientation), upon reassignment to a new work area, or whenever a new hazard is introduced into the work area. Refresher training will be conducted annually. Service chiefs/Care Line managers/supervisors are responsible for the training of their employees. If requested by a Service chief or Care

Line manager, the Industrial Hygienist will assist with the training and/or development of Service or Care Line specific training Programs.

2) Hazard Communication Training will include:

a. The requirements of OSHA Standard 29 CFR 1910.1200.

b. The elements of the VA Hudson Valley Hazard Communication Program.

c. Hazardous chemical properties, including visual appearance, odor, and technical equipment that can be used to detect the presence or release of hazardous chemicals.

d. Physical and health hazards associated with potential exposure to chemicals used in the workplace.

e. Procedures and equipment to be used to protect against hazards, such as personal protective equipment, work practices, use of engineering controls and emergency procedures.

f. Hazardous chemical spill and leak procedures for cleanup purposes.

g. The location of the Service’s SDS’s and inventory list.

h. Non-routine tasks performed by the Service and specific work practices to be used, chemicals hazards resulting from the work, and personal protective equipment required. Retraining of affected employees on these elements will be conducted immediately prior to performance of non-routine tasks by the employees' supervisor.

g. Outside Contractors

1) Outside contractors will be informed of the following elements:

(a) Chemicals to which their employees may be exposed and how to obtain SDSs for those chemicals.

(b) Methods that may be used to protect employees from hazardous exposure to those chemicals.

(c) An explanation of the facility's chemical container labeling system.

2) If a contractor must bring hazardous chemicals onto the facility, a SDS for each chemical must be provided to the VA staff in the area(s) where they will be using the chemicals and the Industrial Hygienist prior to starting work.

5. REFERENCES:

TJC Comprehensive Accreditation Manual 29 CFR 1960.134d - Federal Employee Occupational Safety and Health Program.

29 CFR 1910.1200 - OSHA Hazard Communication Standard.

VHA Directive 2003 -030 Management of Hazardous Chemicals.

Master agreement between the Department of Veterans Affairs and the American Federation of Government Employees VA Directive 0059, VA Chemicals Management and Pollution Prevention

ATTACHMENT A: HAZARDOUS MATERIALS INVENTORY SHEET

SERVICE: DATE OF INVENTORY:

No. Chemical

Product Trade Name & Waste

Manufacturer Contact Phone Number

City ST Average Quantity in Stock

Maximum Quantity On Hand

Location:

Building/ Room

MSDS

on File?

SOP 138-06HV

APPENDIX B

FORMALDEHYDE EXPOSURE CONTROL PROGRAM

1. PURPOSE: The purpose of this policy is to prescribe policies and procedures for use of formaldehyde at the health care system in order to control and reduce exposures.

2. Plan : It is the plan of the health care system to maintain exposures to formaldehyde below regulatory limits by adhering to the Occupational Safety and Health Administration (OSHA) requirements found in 29 CFR 1910.1048.

3. RESPONSIBILITIES:

a. The Director is responsible for implementing a comprehensive program detailing training, medical monitoring, environmental monitoring, and control measures.

b. The Safety Manger is responsible for overall coordination, implementation and monitoring of the program to control formaldehyde exposure.

c. The Industrial Hygienist is responsible for providing training, upon request from Services/Care Lines, to conduct exposure monitoring, and program evaluation.

d. Occupational Health is responsible for conducting medical surveillance as required under 29 CFR 1910.1048(l) and for maintaining medical and exposure (routine monitoring and emergency) records.

e. Service Chiefs/Care Line Mangers in areas where formaldehyde is used or stored are responsible for ensuring that employees are trained, follow proper precautions, and abide by the requirements of this program.

f. Employees who work with formaldehyde are responsible for following the practices outlined in this program and attend all training sessions.

a. Monitoring and Occupational Exposure Limits

1) OSHA’s Permissible Exposure Limit (PEL) is 0.75 parts of formaldehyde per million parts of air as an eight-hour time weighted average (TWA).

2) The “Action Level” is 0.5 parts per million (ppm), calculated as an eight-hour TWA concentration.

3) The “Short Term Exposure Limit” (STEL), or 15-minute concentration during procedures most likely to cause the highest exposure, is 2 ppm.

4) Representative samples for each job classification will be taken to document exposure for all employees who may be exposed to formaldehyde at or above the action level or STEL.

SP 42HV

VA Hudson Valley Health Care System

5) Initial monitoring will be undertaken each time there is a change in process, equipment, personnel, or control measures which may affect exposure to formaldehyde.

6) Annual periodic monitoring will be conducted in all areas of potential formaldehyde exposure.

If the Action Level, PEL or STEL is exceeded, quarterly monitoring will be conducted until exposures are reduced.

7) Affected employees will be notified of the monitoring results within 15 days of receipt. A copy of these results will be included in each employee’s medical file.

8) Affected employees and/or their designated representatives shall be afforded the opportunity to observe any monitoring of employee exposure to formaldehyde.

b. Control of Exposure to Formaldehyde

1) Regulated areas will be established in all areas where OSHA limits for formaldehyde are exceeded. Regulated areas will be identified by signs stating “DANGER –

FORMALDEHYDE – IRRITANT AND POTENTIAL CANCER HAZARD – AUTHORIZED

PERSONNEL ONLY”, located at all entrances.

2) Engineering and work practice controls are the primary means of controlling exposure.

Whenever possible, formaldehyde will be used only under a direct exhaust system, such as in fume hoods.

3) Personal protective equipment for exposure to formaldehyde will be provided at no cost to employees. Chemical protective clothing such as goggles, face shields, and gloves must be used when handling liquids 1% or more formaldehyde, as appropriate for the operation. The supervisor, with assistance from the Industrial Hygienist, will determine required protective clothing for specific operations. The following will apply:

(a) Clothing contaminated with formaldehyde is to be cleaned before reuse or discarded.

(b) Respiratory protection will be utilized for activities exceeding the action level until engineering of work practices controls are implemented to control the hazard. The Industrial Hygienist will select the type of respiratory protection required based on monitoring results. Employees who require respiratory protection must be medically evaluated, trained and fitted in accordance with the Respiratory Protection Program.

4) All areas that store or use formaldehyde solutions of 1% or greater will be provided with quick drench showers. Areas that store or use formaldehyde solutions of 0.1% or greater will be provided with eyewash stations.

5) All areas containing formaldehyde will be surveyed for leaks on a regular basis by the employee who uses the container.

c. Medical Surveillance

1) All employees who are or have been exposed to formaldehyde at concentrations above the applicable exposure limits shall participate in the medical surveillance program.

2) Medical Surveillance is required for all employees who develop signs and symptoms of overexposure to formaldehyde, and for all employees who must respond to emergency involving formaldehyde.

3) Medical surveillance will be performed by Occupational Health in accordance with 29 CFR 1910.1048(l).

4) Medical removal procedures required by OSHA standard will be implemented by Safety/Industrial Hygienists and Human Resource Management.

5) All employees in the medical surveillance program for formaldehyde will be given a physical examination at the time of initial identification and annually thereafter with an emphasis on the skin and respiratory system and will receive counseling concerning conditions that may be aggravated by exposure to formaldehyde.

6) Occupational Health staff performing medical surveillance for formaldehyde will be provided with the OSHA standard, a description of the employee’s duties, representative exposure levels, personal protective equipment used by the employee and information from previous medical examinations.

7) Occupational Health staff performing medical surveillance for formaldehyde exposure will provide a written opinion on the results of the medical surveillance that will be placed into the employee’s medical records. A copy of the written opinion will be provided to the employee within 15 days of receipt.

8) In cases where the Occupational Health staff determines that an employee’s exposure requires additional evaluation due to existing medical conditions or limitations, the Industrial Hygienist will also be provided with a copy of any written opinion.

d. Employee Information and Training

1) All employees working with formaldehyde will be trained in the formaldehyde program at the time of their initial assignment and whenever a new hazard from formaldehyde is introduced to the work area.

2) This training will be provided annually for employees who have been exposed to formaldehyde above any occupational exposure limits.

3) Safety Data Sheets (formerly MSDSs) or the specific formaldehyde containing substance, if greater than 0.1% formaldehyde, shall be available in all workplaces where the substance is utilized.

4) All containers for substances that are capable of releasing formaldehyde at levels of 0.1 ppm to 0.5 ppm, shall have a label that identifies the substance, that the substance contains formaldehyde, the name and address of the responsible party, state the physical and health hazards, and a statement that the hazard information is readily available from the employer and from SDSs.

5) All containers for substances that are capable of releasing 0.5 ppm or more formaldehyde shall have a label with the above information, and state that it is a respiratory sensitizer and contains the actual words “Potential Cancer Hazard”.

6) The formaldehyde training program will include:

(a) The OSHA regulation, the contents of this written program, and the contents of the Safety Data Sheet (SDS).

(b) The purpose and description of the medical surveillance program.

(c) Description of operations where formaldehyde is present and safe work practices.

(d) The proper use of personal protective equipment.

(e) Spill and emergency procedures.

(f) An explanation of engineering and work practices controls.

e. Record Keeping

1) Exposure measurements are maintained in the Safety Office and a copy placed in each employee’s medical record.

2) Medical surveillance information is maintained in the employee’s medical record maintained by Occupational Health.

3) Exposure and medical records will be kept for the duration of employment plus 30 years.

f. Spill, Leak and Disposal Procedures

1) Only attempt the cleanup of a formaldehyde spill if you are familiar with the health and physical hazards of the material. Use appropriate personal protective equipment.

2) For small spills (50 milliliters or less), clean up the spilled material with absorbent material and place into an airtight container for disposal. Contact Industrial Hygienist at Ext. 2321 or 5265 to arrange proper disposal of cleaned up material.

3) For leaking containers of a liter or less, place leaking container into secondary containment (a wide mouth jar, tray or tub, depending on size of leaking container), cover top and place into a well-ventilated are, preferably under a fume hood. Contact Industrial Hygienist to arrange pickup of container.

4) For larger spills or leaking containers, evacuate area. Notify supervisor and others in the area of the spill. Deny access to the area to all but emergency personnel. Contact the Fire Department using Ext. 2222 at Montrose and Ext. 5212 at Castle Point. Do not touch spilled materials and shut off ignition sources if you can do so without personal risk.

5) Formaldehyde odors may be neutralized with sodium sulfite solution or commercially available products.

6) For unprotected exposure to skin, rinse area with running water. Follow first aid directions on SDS. If redness or irritation develops, immediately inform supervisor and report to Occupational Health/Urgent Care. Bring copy of SDS if readily available.

7) For exposure to the face and eyes, rinse area for a minimum of 15 minutes, and then immediately report to Occupational Health/Urgent Care. Inform the supervisor of the exposure and also bring a copy of the SDS.

8) Used, expired and/or excess formalin and other solutions of formaldehyde are to be collected as chemical waste. Contact the Industrial Hygienist for disposal instructions.

OSHA 29CFR1910.1048 Formaldehyde

Master Agreement between the Department of Veterans Affairs and the American Federation of Government Employees

APEENDIX C

CONTROL OF HAZARDOUS CHEMICALS GASES & VAPORS

1. PURPOSE: To establish procedures for the identification, safe storage, handling, use and disposal of chemicals that produce hazardous gases and vapors in the workplace.

2. REQUIREMENT: The VA Hudson Valley Health Care System has established a program to monitor and control hazardous gases and vapors produced by chemicals used at the facilities so that patients, visitors and employee exposures, and environmental releases comply with federal and state regulations.

a. Service Chiefs/Care Line Managers/Supervisors are responsible for:

1) Identifying hazardous chemicals that are used in their services and maintaining inventory lists with quantities stored.

2) Meeting all requirements of the Hazard Communication Standard and other federal and state regulations for use of hazardous material chemicals, including proper labeling, maintaining Safety Data Sheets (SDS), and providing required training.

3) Developing specific written procedures for the handling of highly toxic, carcinogenic, and reproductive hazardous gases and vapors present in their services.

4) Providing personal protective equipment when required to work with hazardous gases and vapors.

b. The Chief, Engineering Service is responsible for evaluation, installation, and maintenance of engineering control systems, such as local exhausts and fume hoods.

c. The Safety Office is responsible for:

1) Assisting Service Chiefs/Care Lines/Supervisors in identification, training, procedure development and personal protective equipment selection as required above.

2) Inspecting areas where hazardous chemicals are stored or used for compliance with federal, state or other applicable regulations. This includes performing personnel and environmental air monitoring by the Industrial Hygienist when required by such regulations.

3) Ensuring that the Fire Department responds to hazardous material incidents for the purpose of controlling and cleanup of releases. During such activities, the Fire Department will take into account the production of hazardous gases and vapors and take measures to reduce their generations and concentration.

d. Occupational Health is responsible for:

1) Providing medical surveillance for employees exposed to hazardous vapors as required by federal regulations

2) Maintaining all medical and exposure records for the duration of employment plus 30 years.

f. Employees are responsible for:

1) Following the requirements delineated in this policy, service specific procedures, and manufacturer’s recommendations when working with materials that produce hazardous gases and vapors.

2) Taking all reasonable actions to reduce the production of and exposure to hazardous gases and vapors, such as the use of installed engineering controls, following administrative controls, and use of provided personal protective equipment.

a. General

1) Service chiefs/care line managers/supervisors will evaluate, with the assistance of the Industrial Hygienist, the chemicals used in their service to determine which materials could produce hazardous (i.e. flammable, asphyxiant, corrosive, irritant, toxic, highly toxic, carcinogenic or reproductive hazard) gases and vapors. See Attachment A for listing of common chemicals presently used at this Health Care System that produce hazardous vapors.

2) The use of all materials identified as producing hazardous vapors will be evaluated by the using service to determine if the use of the materials could be substituted for other materials or processes that are less hazardous.

3) The Industrial Hygienist will evaluate employees’ exposure to hazardous materials, especially those that produce gases and vapors. When required by regulatory agencies, or if the Industrial Hygienist suspects that an exposure could result in adverse health effects, the Industrial Hygienist will conduct monitoring to quantify the actual airborne concentration. Actions will be taken to reduce exposures that exceed safe levels (OSHA Permissible Exposure Limits, OSHA Short Term Exposure Limits, ACGIH Threshold Limit Values and other recommended limits) through the use of engineering controls, development of written procedures, changes in work practices, and use of personal protective equipment.

4) Engineering Service will evaluate the use of hazardous materials that exceed safe levels for the installation engineering controls.

5) Written safety precautions will be developed by the service to reduce employee exposure when it is suspected that safe levels are being exceeded.

6) If it is not practical to install engineering controls, or while engineering controls are being installed, employees will be issued personal protective equipment (PPE) to reduce/eliminate exposures to hazardous gases and vapors. Issuing of respiratory protection to employees will be according to SOP 138-10HV.

7) The storage, handling, and use of all materials that produce hazardous gases and vapors will be in accordance with information provided on labeling and the Safety Data Sheet

(SDS).

8) All containers of materials that produce hazardous gases and vapors are to be kept tightly closed or covered when not in use.

9) Materials that produce hazardous gases and vapors will be separated from incompatible chemicals so that the material and/or its vapors will not react.

10) Disposal of materials that produce hazardous gases and vapors will be according to SOP 137-17HV. All containers of waste that produce hazardous gases and vapors will be kept tightly sealed. Intentional evaporation of hazardous waste as a method of disposal, especially those that produce hazardous vapors, is not permitted.

b. Flammable Gases and Vapors

1) Materials that produce flammable gases and vapors are not to be used or stored around open flames or other sources of ignition.

2) Materials that produce flammable gases and vapors are to be stored in approved fire rated storage cabinets or rooms. A working quantity (amount that would normally be used within one day) can be kept out in the general work area, providing it is kept closed when not in use and is returned to an approved storage area at the end of the workday.

3) Maximum storage quantities for flammables in an area are not to exceed National Fire Prevention Association (NFPA) and OSHA limits. Contact the Fire Department for additional information.

4) Materials that produce flammable gases and vapors are to be used under direct exhaust when available. If a flammable must be used in the general work area, ensure that the area has sufficient general ventilation to keep the vapor concentration at a safe level (below 5% of the lower explosive limit). Contact the Fire Department or Industrial Hygienist for additional information and testing.

5) When flammables are transferred from a conductive (metal) container, the container must be properly grounded in order to prevent the buildup of static electricity.

c. Asphyxiants

1) Exposures to asphyxiants are not to exceed OSHA or recommended standards.

2) Dry ice, liquid nitrogen, and other cryogenic gases are to be stored and used in large, well-ventilated areas. Contact the Industrial Hygienist for evaluation of ventilation systems where these materials are used.

d. Corrosive, Irritant, and Toxic

1) Exposures to corrosive, irritant, and toxic gases and vapors are not to exceed OSHA or recommended standards.

2) Material that produces corrosive, irritant and toxic gases, and vapors should be used under direct exhaust when available. These materials can only be used in the general work area, providing exposures do not exceed OSHA or recommended standards.

e. Highly Toxic, Carcinogens, and Reproductive Hazards

1) All exposures to highly toxic, carcinogens, and reproductive hazardous gases and vapors are to be kept as low as reasonably achievable so as not to exceed OSHA or recommended standards.

2) Highly toxic, carcinogenic, and reproductive hazardous materials that produce gases and vapors must be used under direct exhaust systems.

3) All services using highly toxic, carcinogenic or reproductive hazardous materials will develop specific written procedures.

4) Cancer Hazard labels will be affixed to chemical containers and storage cabinets where carcinogens are stored.

5) Pregnant and breast-feeding personnel should not be assigned to work with highly toxic carcinogens or reproductive hazardous materials.

f. Specific Chemicals

1) Antineoplastic Drugs

(a) All cytotoxic agents should be prepared in a Class II, Biological Safety Cabinet, Type A or B by Pharmacy Service.

(b) Antineoplastic drug waste is disposed of in accordance with SOP137-17HV

2) Anesthetic Gases and Vapors

(a) Only non-flammable anesthetic agents are to be use at this health care facility.

(b) Scavenging systems are to be used whenever anesthetic gases or vapors are used.

3) Formaldehyde: See Formaldehyde Control Program, SP: 42HV

4) Mercury: See Mercury Control Policy, SOP 138-17HV.

5) Pesticides

(a) Pesticide Storage Areas are to be well ventilated, with a minimum of 6 outdoor air changes per hour.

(b) Employees are to be informed that pesticides will be applied in their work area prior to any application. SDSs for pesticides used by EMS and contractors are kept on file by EMS and are available upon request from EMS or the Industrial Hygienist.

29CFR1910.1000 Air Contaminants

29CFR1910.1048 Formaldehyde

29CFR1910.1200 Hazard Communication Standard

29CFR1910.1450 Occupational Exposure to Hazardous Materials in Laboratories

ACGIH Threshold Limit Values and Biological Indices

NIOSH/OSHA Occupational Health Guidelines for Chemical Hazards (Publication No.81-123)

Master Agreement between the Department of Veterans Affairs and the American Federation of Government Employees

Attachment A – Common Chemicals Used at VA Hudson Valley HCS that Produce Hazardous Gases/Vapors

Attachment A

Name Hazard Classifications OSHA PEL Other Standards

Acetic Acid Corrosive 10 ppm

Ammonia Corrosive 50 ppm

Enflurane Reproductive/Toxic NIOSH - 2 ppm (1 hr. C)

Ethanol Flammable 1000 ppm

Formaldehyde Cancer/Irritant 0.75 ppm OSHA STEL - 2 ppm

Freon (11,12 & 22) Toxic ACGIH - 1000ppm

Gasoline Flammable/Toxic ACGIH - 300ppm

Glutaraldehyde Irritant/Susp. Cancer ACGIH - 0.2 ppm (C)

Halothane Reproductive/Toxic NIOSH - 2ppm (1hr. C)

Hydrochloric Acid Corrosive OSHA - 5 ppm (C)

Isopropyl Alcohol Flammable/Toxic 400 ppm

Mercury Toxic - Heavy Metal OSHA - 1mg/10 cubic M

(ACC)

Methanol Flammable/Toxic 200 ppm

Methyl Methacrylate Flammable/Toxic 100 ppm

Nitrous Oxide Reproductive/Toxic NIOSH - 25 ppm

Peroxyacetic Acid Corrosive 10 ppm - as Acetic Acid

Xylene Flammable/Toxic 100 ppm

ACGIH – American Conference of Governmental Industrial Hygienists

NIOSH – National Institute of Occupational Safety and Health

OSHA – Occupational Safety and Health Administration ppm – parts per million

PEL – Permissible Exposure Limit

(C) – Ceiling Limit for 1 hour

(ACC) – Acceptable Ceiling Concentration

STEL – Short Term Exposure…