Bethesda West meets OSHA.

It is a moment that many nursing homes dread: strangers showing up at your reception desk, identifying themselves as compliance officers for the Occupational Safety and Health Administration (OSHA), asking to inspect your facility's safety and health plans and programs, and able to impose "citations" possibly costing thousands of dollars. There is no warning beforehand. There is almost certainly no recourse to spending significant time and money in making, and documenting, the needed corrections. Since March 1 some 18 facilities have gone through this experience as part of OSHA's seven-state Nursing Home Initiative. One of the first such facilities was Bethesda West, a 210-bed not- for-profit nursing center located near St. Louis, MO - and it did not get through unscathed. Recently Nursing Homes Magazine asked administrator Al Poelker and assistant administrator Susan McClure to describe their encounter with OSHA, what they learned from it, and how other facilities might benefit from their education."

Poelker: "The inspection actually occurred on a Good Friday, when I was out of the office, so I'll let Susan begin by telling what happened that morning."

McClure: "Two inspectors arrived at the reception desk around 9 a.m., informed me they were from OSHA and asked permission to do an inspection. I asked them to have a seat in the lobby while I made some phone calls. I was aware that I could require them to present a search warrant to conduct an inspection. I contacted Mr. Poelker and was advised to let the inspection proceed. The inspectors were directed to our conference room, where they set up base.

"The inspectors made a list of documentation they wanted to see and explained that afterwards they would 'walk-through' the facility. They asked to see our OSHA 200 logs for the past 13 months, then proceeded to request copies of the supplementary records (OSHA 101) for all incidents involving aggressive behavior by residents. Next they inquired about our workplace violence plan. I explained that we did not have a written plan, but we conducted training for staff on handling resident aggression and had workplace practices to communicate pertinent information to appropriate staff. Since there is no OSHA standard for workplace violence prevention, they could not officially cite us for lacking a written plan, but they did strongly advise us to put one together.

"The inspectors reviewed our Safety Committee minutes and our Hazard Communication Manual. They also asked to see our written plans for Energy Control (maintenance/servicing of machines/equipment) and Exposure Control (bloodborne pathogens). Although we did have policies and procedures for bloodborne pathogens, we did not have them in the plan format they were looking for. Nor did we have a written plan for Energy Control.

"After the documentation review, the inspectors requested a walk- through of the building. I allowed them to request the areas they wanted to inspect. They chose the nursing division, the laundry and the boiler room/mechanical/maintenance areas.

"Our In-service Education Director accompanied me and the inspectors on the tour. The inspectors conducted informal interviews with our directors of housekeeping/laundry and maintenance, as well as a nursing employee and a housekeeping employee. They asked questions regarding our policies and procedures for Exposure Control and Energy Control, specifically looking at the use of sharps containers, personal protective equipment, storage and disposal of contaminated wastes and laundry procedures. They photographed the laundry carts, sharps containers, waste storage areas and the maintenance area. Other areas of interest included specifics on our vaccination procedures for hepatitis B and how we handled potential exposure to HIV.

"The inspectors complimented us on our use of lifts and our resident transfer procedures. We are fortunate to have several lifts for bed-to-chair transfers and for bed-to-bath transfers.

"At approximately 3 p.m. they concluded their inspection and left the facility. They returned about one week later to inspect our food service department.

"We did receive three citations. We were instructed to develop written plans for Exposure Control and Energy Control and to provide machine guarding for two large mixers in the food service department."

Poelker: "The only citation that involved a fine - $1,300 - was the citation that involved lack of a written Energy Control plan. We chose to sign an informal settlement document agreeing to correct the violations in the citations and, in return, the fine was reduced to $650.

"Over the next several weeks we developed a sophisticated Exposure Control plan, pulled together an Energy Control plan and purchased machine guarding for the mixers. We then physically delivered the documentation to the local OSHA office."

McClure: "Those plans represented a lot of work. The most time-consuming aspect involved an equipment inventory for the Energy Control plan. This entailed listing every piece of equipment in the building and writing a general or a specific procedure for shutdown and restart of the equipment."

Poelker: "As you can imagine with a 210-bed, 5-story facility, we have thousands of pieces of equipment - kitchen equipment, many individual fan coil units and much, much more. This took a great deal of time by maintenance, housekeeping and other staff who had their normal hectic routine to complete."

McClure: "If I were to make any suggestions for other nursing facilities, it would be to make sure they have written programs for Exposure Control, Energy Control and Hazard Communication based on the OSHA standards. Also, some type of review of employee incidents/injuries on a routine basis (such as our Safety Committee conducts) was perceived as proactive. Our mistake might have been thinking OSHA's focus would involve the nursing department and back injuries. We were not prepared for the intensive scrutiny in the area of energy control."

Poelker: "All in all, I would say that the inspection forced us to accelerate the process of current policy development and to fine-tune policies that were already in place. There was a tremendous amount of work that had to be accomplished in a short period of time. So, while it wasn't the worst of experiences, it wasn't the best, either."