OSHA's nursing home initiative: what to expect.

INTERVIEW WITH KEITH MOTLEY, COORDINATOR, OSHA NURSING HOME INITIATIVE

Nursing homes have the reputation of belonging to one of the most hazardous industries in the United States. No matter how justified this may or may not be, it has subjected nursing homes to a "hazard" of their own - an unannounced visit by inspectors from the Occupational Safety and Health Administration (OSHA). Many nursing homes find this to be a daunting prospect - not only due to potential citations, but to the time and expense involved in bringing their safety and health programs up to OSHA's muster. As with other industries, nursing homes throughout the country can be OSHA-inspected at any time based on specific complaints they generate. However, OSHA began focusing special attention this past March on facilities in seven states (Florida, Illinois, Massachusetts, New York, Ohio, Pennsylvania and Missouri) in its new Nursing Home Initiative. What are the implications of the Initiative and other inspections for nursing homes? Recently, Keith Motley, OSHA's coordinator for the Initiative, addressed questions on this theme posed by Nursing Homes Editor Richard L. Peck.

Peck: Would you explain how OSHA is selecting nursing homes for inspection under the Initiative?

Motley: We're doing it now on the basis of a list we purchased from Dun & Bradstreet, which gives the names, addresses, numbers of employees, and so forth, for a variety of industries. We broke out a subset of nursing homes in the seven states and randomized it.

Peck: So these nursing homes' "claim to fame" for OSHA inspection is that they happen to be on this list?

Motley: That's correct. We hope soon to move toward a more targeted approach, focusing on those facilities with the worst safety and health records - perhaps in a few months.

Peck: Is the Initiative confined solely to nursing homes, and not other facilities for the elderly?

Motley: Yes, this is applied strictly to nursing homes, as defined under the Industry Classification Codes 8051, 8052 and 8059.

Peck: How many nursing home inspections have been completed thus far (late August) under the Initiative?

Motley: Since we began to conduct planned inspections in March, we have completed 46 inspections, including 18 that were planned, 20 that resulted from complaints or referrals, and 8 follow-ups. Nationally, since the first of the year, we have completed 220 inspections of nursing homes.

Peck: What is the difference between a planned inspection and one that arises from a complaint?

Motley: With the planned inspections, we are mandating that the compliance officers take a close look at the facility's records and analyze them to make sure that various safety and health programs are in place; it is relatively comprehensive. The complaint inspections are triaged: the compliance officers look at the specific circumstances of the complaint and calculate the facility's lost workday incidence rate (based on illness and injury reports). If that rate is higher than the national average for the industry, then the officers conduct a planned type of inspection - that is, facility-wide or, if not, presenting a good reason why. If the rate is lower than the industry average, the officers do not expand the inspection beyond the complaint items.

Peck: What are some of the results of the Initiative thus far?

Motley: The most common citations to date have been in the areas of blood-borne pathogens and personal protective equipment. There have been no ergonomics citations as yet, but we have issued warning letters for ergonomics and for tuberculosis situations, as well. The letters are informal - they simply indicate that officers have found that a health or safety problem exists, though not to the extent there is sufficient evidence for a citation. It is a way of putting the facility on notice. This does not necessarily mean, however, that there will be a reinspection.

Peck: One of the interesting instruments OSHA uses in this approach is its Program Evaluation Profile (PEP), which gives each facility an overall score for its safety and health status and uses that to determine the scope of the inspection. Would you elaborate on the PEP?

Motley: The PEP is a pilot program that gives OSHA compliance officers a standardized format for evaluating nursing homes' safety and health programs. OSHA is considering using it on a national basis, and it has been used in some nursing homes. A facility is given a score from 1 to 5 (5 being best) on each of six elements, including management leadership and employee participation; workplace analysis; accident and record analysis; hazard prevention and control; emergency response; and safety and health training. These scores are then compiled for an overall score. A nursing facility scoring 3 or better (i.e. average or above) and having controlled the specific causes of its illness and injury rates will have, in essence, completed its inspection; nothing will be pursued beyond what already has been found. Those facilities scoring less than 3 can expect to receive a more comprehensive inspection.

Peck: What are OSHA's plans for the rest of this calendar year in terms of number of inspections or possible expansion of the Initiative into other states?

Motley: We have no specific number of inspections in mind; much will depend on the resources available and possibly on whether we can resume our targeted approach to those with the worst safety and health records. Also, there are no plans I know of at this time to expand the Initiative beyond the seven states. However, any efforts by OSHA to target high-hazard industries in other states will pick up nursing homes.

Peck: As you know, OSHA inspections have raised various specific concerns among nursing homes, and I wonder if you would comment on them - to begin with, the issue of residents' rights and videotaping of work procedures?

Motley: OSHA's policy is that the resident has the absolute right not to be videotaped or photographed. Our compliance officers have been instructed to obtain the resident's consent to be photographed, whether in writing or on tape. If the resident's cognitive capabilities are a potential problem for obtaining consent, the officers should instead approach residents who have normal capabilities. We don't seek families' proxy consents for impaired residents because of the time and difficulty this may involve. In sum, residents are not to be photographed without their personal consent.

Peck: What about the "engineering controls" - the lifts, hoists, slide boards, etc. - that OSHA appears to recommend? Some facilities take these recommendations to be prescriptive - devices that they "must have" to pass OSHA inspection.

Motley: All that OSHA is really prescribing are safety and health programs. The facility is asked to analyze its own illness and injury patterns and come up with its best solutions for the problems that are found. As long as there is evidence that they are doing so, and the illness and injury rates improve, this will be acceptable to OSHA.

It is true that we have published examples in which lifts were used, but these were examples - they didn't mean that all facilities had to do the same thing. Some nursing homes may, for example, choose to increase staffing to reduce the physical burdens on individuals. Some are not using lifts to any significant degree at all and are experiencing lower illness and injury rates; others have purchased lifts that didn't work for them because of staff resistance and/or lack of training.

In other words, OSHA thinks that the experts in resident handling, the facilities themselves, should review the universe of controls available - lifts, hoists, slide boards, flip sheets, increased staffing, special bathing facilities and the like - and devise practical solutions that will give their residents the care they need without high injury rates for staff.

Peck: What about situations in which facilities are cited for ergonomics-related violations even though there is no standard as yet for these?

Motley: The citations are brought under the General Duty Clause of the OSHA Act. Under this clause, we may review situations on a case-by-case basis and levy citations if there are high rates of serious injury and little evidence that facilities are addressing them. We also have the responsibility of recommending a means of "abatement," but these recommendations are not law.

Peck: Some facilities, confronted by a Federal "recommendation" in black and white, consider this to be "the law."

Motley: That's understandable, but again, we're only looking for something that works. The facility may propose its own solution, and so long as they show evidence of recognizing the problem and they're making a legitimate effort to solve it, they'll probably be OK with OSHA.

Peck: How might facilities waiting for the OSHA inspection "shoe to drop" prepare for this?

Motley: They should implement a comprehensive safety and health program addressing their particular illness and injury experiences. They should review their records, perform self-inspections, involve their employees in developing the needed programs and implement them.

Peck: All of which costs money, particularly in staff time, that many facilities these days may feel they don't have. What is your response to those facilities that raise budgetary concerns about OSHA compliance?

Motley: We believe that implementing these programs will pay for itself in the long run. Take, for example, workers compensation costs - a back injury can run into the thousands of dollars in compensation, lost time and possibly higher insurance premiums. If you have a high rate of such injuries, you're already paying out a lot of money. If you implement a program that reduces them, you've begun to put yourself in a moneymaking position.