OSHA requirements are set by statute, standards and regulations. Our interpretation letters explain these requirements and how they apply to particular circumstances, but they cannot create additional employer obligations. This letter constitutes OSHA's interpretation of the requirements discussed. Note that our enforcement guidance may be affected by changes to OSHA rules. Also, from time to time we update our guidance in response to new information. To keep apprised of such developments, you can consult OSHA's website at https://www.osha.gov.

March 2, 2022

MEMORANDUM FOR:
REGIONAL ADMINISTRATORS
STATE PLAN DESIGNEES
THROUGH:
AMANDA EDENS
Deputy Assistant Secretary
FROM:
KIMBERLY A. STILLE, Director
Directorate of Enforcement Programs
SUBJECT:
COVID-19 Focused Inspection Initiative in Healthcare

Background: This memorandum provides instructions and guidance to Federal OSHA Area Offices for a highly focused, short-term inspection initiative directed at hospitals and skilled nursing care facilities that treat or handle COVID-19 patients. OSHA’s goal is to mitigate the spread of COVID-19 and future variants of the SARS-CoV-2 virus and ensure the health and safety of healthcare workers at heightened risk for contracting the virus. Through this initiative, OSHA will assess employer compliance efforts, including the readiness of hospitals and skilled nursing care employers to address any ongoing or future COVID-19 surges. This Initiative supplements OSHA’s targeted enforcement under the COVID-19 National Emphasis Program (NEP), See DIR 2021-03 (CPL 03), Revised National Emphasis Program – Coronavirus Disease 2019 (COVID-19), July 7, 2021 (or successor directive), by focusing on follow-up and monitoring inspections of hospitals and skilled nursing care facilities that OSHA had previously inspected or investigated.

Overview: The intent of this initiative is to magnify OSHA’s presence in high-hazard healthcare facilities over a three-month period (March 9, 2022 to June 9, 2022), to encourage employers in these industry sectors to take the necessary steps to protect their workers against the hazards of COVID-19. These focused, partial-scope inspections shall be conducted following the procedures below, at establishments within the four North American Industry Classification System (NAICS) codes listed in Attachment 1: two NAICS codes representing Hospital sectors and two NAICS codes representing Nursing and Residential Care sectors. Inspections opened under this initiative shall comprise 15% of all inspections per Region for the designated three-month period. However, this goal may be adjusted or terminated based on COVID-19 case rates, establishment density, or similar criteria present in a particular Region, or based on new information or developments regarding COVID-19.

Criteria for Conducting Focused Healthcare Inspections: Facilities in the NAICS codes listed in Attachment 1 may be selected for inspections under this initiative if they meet one of the following criteria:

  1. Follow-up inspection of any prior inspection where a COVID-19-related citation or hazard alert letter (HAL) was issued;
  2. Follow-up or monitoring inspections for randomly selected closed COVID-19 unprogrammed activity (UPA), to include COVID-19 complaints and Rapid Response Investigations (RRIs); or
  3. Monitoring inspections for randomly selected, remote-only COVID-19 inspections where COVID-19-related citations were previously issued.

Note: Programmed inspections of healthcare establishments selected from the targeting list under the COVID-19 NEP within the designated three-month period of this memorandum, are not covered under this initiative and should not be limited in scope to procedures set forth here. The COVID-19 NEP includes additional NAICS codes for healthcare establishments not listed in Attachment 1 of this memorandum. Therefore, establishments in those additional NAICS codes are not included in this focused inspection initiative. For follow-up inspections of other healthcare establishments not covered by this memorandum and for any COVID-19 inspection after the designated three-month period, continue to follow the instructions in the COVID-19 NEP. See DIR 2021-03 (CPL 03), Revised National Emphasis Program – Coronavirus Disease 2019 (COVID-19), July 7, 2021 (or successor directive).

Focused Healthcare Inspection Procedures:

Site Selection: Area Offices should generate a list of previously inspected establishments where COVID-19 citations or HALs were issued, including remote-only inspections where COVID-19-related citations were issued. They should also create a list of establishments with closed COVID-19 UPA, including COVID-19 complaints and RRIs. The establishments on these lists shall be limited to the NAICS codes listed in Attachment 1, the criteria for focused healthcare inspections listed above, and generated using the OSHA Information System (OIS) beginning with March 1, 2020. Area Offices will use either list or a combination of the lists to meet their inspection goals.

Note: Sites covered by this initiative are to receive an onsite OSHA inspection unless the facility does not treat or handle known COVID-19 patients. If it is determined through records review and employer and employee interviews that a facility does not treat or handle COVID-19 patients, the inspection should be closed as “records only.” Facilities that transfer patients or residents exhibiting symptoms of COVID-19 offsite, should receive an inspection. Compliance safety and health officers (CSHOs) should assess the employers’ procedures for protecting employees while making this determination during initial care of the patient or resident.

Assessment of COVID-19 Mitigation Strategies: All COVID-19 focused healthcare inspections should follow inspection procedures in the Field Operations Manual (FOM) (including the presence of employee representatives, e.g., union officials, during all aspects of the inspection), and coding instructions in the COVID-19 NEP, but shall be limited to the following assessments:

  • Determine whether previously cited COVID-19-related violations have been corrected or are still in the process of being corrected. For follow-up inspections of closed UPA and RRIs, determine whether COVID-19-related complaint or referral items have been corrected. Review violation worksheets or UPA complaint or referral items and any employer-provided abatement-certification.
  • Determine whether the employer has implemented a COVID-19 plan that includes preparedness, response, and control measures for the SARS-CoV-2 virus. If this plan is a part of another emergency preparedness plan, the review should not be expanded to the entire emergency preparedness plan (i.e., a limited review addressing issues only related to exposure to SARS-CoV-2 would be adequate).
  • Verify the existence and effectiveness of all control measures, including procedures for determining vaccination status by reviewing relevant records. Verification of vaccination protocols may be an indicator of a facility’s overall COVID-19 mitigation strategies. OSHA will refer any vaccination-related deficiencies to the Centers for Medicare and Medicaid Services (CMS).
  • Request and evaluate the establishment’s COVID-19 log and the Injury and Illness Logs (OSHA 300 Log, OSHA 300A Summary, and any applicable OSHA 301 Incident Reports) for calendar years 2020, 2021, and 2022, if available, to identify work-related cases of COVID-19.
  • Review the facility’s procedures for conducting hazard assessments and protocols for personal protective equipment (PPE) use.
  • Conduct a limited records review of the employer’s respiratory protection program. The records reviewed may be limited to the written respiratory protection program and fit tests, medical evaluations, and training records for the interviewed employees.
  • Perform a limited, focused walkaround of areas designated for COVID-19 patient treatment or handling (common areas, walkways, and vacant treatment areas where patients have been or will be treated), including performing employee interviews to determine compliance.

Walkaround: The walkaround portion of the inspection shall be less extensive than a usual inspection, limited in scope, and focused on the areas of potential non-compliance listed below. In accordance with the FOM, the scope of an inspection may be expanded where plain-view hazards are identified during the walkaround, or where information obtained from workers or worker representative(s) indicate deficiencies in compliance;

  • Determine compliance under the Respiratory Protection Standard (29 CFR 1910.134), especially in areas involving close-contact work with suspected or confirmed positive COVID-19 patients, to include fit testing, medical evaluations, training, and proper use of respirators. Conduct employee interviews.
  • Review documentation of any procedures or efforts made by the employer to obtain and provide appropriate and adequate supplies of PPE.
  • Determine whether the employer has implemented procedures for screening workers and/or any measures to facilitate physical distancing (e.g., barriers or administrative measures to encourage 6-foot distancing).
  • Determine whether the employer ensures the use of face coverings or facemasks by employees, and by visitors in accordance with current public health guidance from the Centers for Disease Control and Prevention (CDC) here https://www.cdc.gov/coronavirus/2019-ncov/index.html

Applicable OSHA Requirements: For COVID-19-related hazards, several OSHA standards may apply, depending on the evidence establishing exposures of workers to such hazards. CSHOs must evaluate the specific findings in each case in determining applicability of OSHA standards. The list of general industry standards applicable to infectious diseases, such as COVID-19, include the following:

  • 29 CFR Part § 1904, Recording and Reporting Occupational Injuries and Illness.
  • 29 CFR § 1910.132, General Requirements-Personal Protective Equipment.
  • 29 CFR § 1910.134, Respiratory Protection.
  • 29 CFR § 1910.1020, Access to Employee Exposure and Medical Records.
  • 29 CFR § 1910.502(q)(2)(ii) and (q)(3)(ii)-(iv), Healthcare ETS COVID-19 log and Availability of records.
  • 29 CFR § 1910.502(r), Healthcare ETS Reporting COVID-19 fatalities and hospitalizations to OSHA.
  • Section 5(a)(1), General Duty Clause of the OSH Act.

NOTE 1: For additional COVID-19 inspection and citation guidance see Updated Interim Enforcement Response Plan for Coronavirus Disease 2019 (COVID-19), July 7, 2021 (or successor).

NOTE 2: On December 27, 2021, OSHA announced its decision to withdraw the non-recordkeeping portions of the Healthcare ETS. OSHA will accept compliance with the terms of the Healthcare ETS as satisfying employers’ related obligations under the general duty clause, respiratory protection, and PPE standards. See DIR 2021-02 (CPL 02), Inspection Procedures for the COVID-19 Emergency Temporary Standard, June 28, 2021 (or successor directive).

Closing Inspections in Absence of Violations: Where violations of OSHA standards, regulations, or the general duty clause are not observed or documented, CSHOs should close the inspection and mark it as “in compliance.”

Outreach: The National Office will continue to conduct nationwide outreach on COVID-19 upon issuance of this memorandum, using public announcements and communications to media, stakeholders, and alliances. Each Area Office shall continue conducting its own outreach programs, including under this memorandum and all new guidance. Area Offices are also encouraged to promote the availability of On-Site Consultation services to small business employers. OSHA has continually conducted outreach at the National, Regional, and Area Office levels throughout the duration of the pandemic outbreak. Additional outreach efforts will be implemented to specifically direct assistance to employers and employees within the affected NAICS codes. OSHA resources may be of assistance in this outreach effort. A variety of online resources can be accessed through OSHA’s public webpage, including the OSHA COVID-19 Safety and Health Topics Page (www.osha.gov/coronavirus). Internal resources for COVID-19 are also available on the OSHA intranet. See also DIR 2021-03 (CPL 03), Revised National Emphasis Program – Coronavirus Disease 2019 (COVID-19), July 7, 2021.

This guidance is also being provided to the OSHA-approved State Plans for informational purposes and consideration. If you have any questions regarding this Memorandum, please contact the Office of Health Enforcement at (202) 693-2190.

cc:      DCSP
           DTSEM
           DSG

Attachment 1

Covered Healthcare NAICS

622110 General Medical and Surgical Hospitals

622210 Psychiatric and Substance Abuse Hospitals

623110 Nursing Care Facilities (Skilled Nursing Facilities)

623312 Assisted Living Facilities for the Elderly