Attachment 1 - OSHA Regional Improvements to the Administration of VPP
- Nationwide consistency in OSHA’s administration of VPP.
- To ensure fair and consistent nationwide operation and implementation of VPP, follow the VPP Policies and Procedures Manual, CSP 03-01-003, April 18, 2009 and the VPP Federal Register Notice, 74 927, January 9, 2009. Current modifications to these procedures are being reviewed.
- Communication with applicant/participant concerning VPP approval. VPP Policies and Procedures Manual: Chapter 6, Onsite Evaluations
Implement new policy: Effective immediately, the VPP policy of the onsite evaluation team sharing with applicant/participant representatives the team’s approval recommendation is rescinded. The team will not discuss its recommendation unless it first obtains approval from the Regional Administrator. The team will not provide applicant/participant with a copy of its draft report unless it first obtains approval from the Regional Administrator.
- The Regional VPP Manager must ensure that the Regional Administrator is briefed on any 90-day items and their completion before the Regional Administrator makes participation decision/recommendation.
- The team will continue to verbally share with site personnel information on hazards found and their elimination or control, safety and health management system strengths and deficiencies, and suggested worker safety and health improvements.
Review and make needed improvements in Area Office and Regional Office actions and documentation following a fatality, catastrophe, serious injury, or other significant event at a VPP site. VPP Policies and Procedures Manual: Chapter 2, Responsibilities; Chapter 8, Enforcement Activity at VPP Worksites
- Ensure that copies of internal written communications; notes documenting oral communications, both internal and between OSHA and the participant; and pertinent information relating to the event, its causes, and OSHA actions taken are placed in the participant file, including a summary of enforcement actions with final disposition or contested status. IMIS information from related enforcement actions should also be placed in the participant file, e.g., citations and penalties issues.
- Ensure that all required reports are properly prepared and submitted in a timely manner. (See, for example, Chapter 8, Sections V.C.; VI.A; VII; and VIII.)
- Determine appropriate action vis-à-vis VPP participation and, when warranted, submit a Regional Administrator recommendation of termination to the Assistant Secretary. If a decision ultimately is made by the Assistant Secretary to terminate the VPP participant, ensure that the required procedure for termination is adhered to and documented in the participant file. Document decision and rationale and maintain in the Regional Office VPP participant file and the Area Office enforcement file and submit documentation to National Office. (Chapter 7, Section VIII.)
- Ensure DCSP-OPR is immediately informed when the Region learns of a fatality/significant event. Keep DCSP-OPR informed via email of significant contacts and actions following the fatality/significant event. Updates to include: conference call with participant, enforcement results (citations, penalties), VPP onsite review and date, request for withdrawal and final disposition. Direct the email to the Director DCSP with a cc to the Director OPR and the OPR Regional Liaison.
The instruction in the VPP Policies and Procedures Manual, Chapter 6, Section VII.A.3. was modified by the January 2009 Federal Register Notice at Section VIII.B.3., which reads:
Whenever a 3-year rate (either the TCIR or the DART rate) of a Star Program participant exceeds the 3 most recent years’ national averages published by BLS, at the discretion of the Regional Administrator or other appropriate OSHA official, the participant may be required to develop an agreed upon 2-year rate reduction plan.
- If appropriate, OSHA may make an assistance visit to help the participant develop the plan.
- The plan may be developed in conjunction with needed corrections to deficiencies within the safety and health management system that have resulted in OSHA placing the participant on 1-year conditional status. (See VII.C.1.b.)
- OSHA may lift a participant’s conditional status before completion of the rate reduction plan.
- If, after 2 years, a participant’s rates have not returned to acceptable levels, the participant will be asked to withdraw from VPP. Failure to withdraw will result in termination.
Take action as follows when a VPP participant’s 3-year rates exceed VPP requirements:
- During reapprovals and upon receiving annual submissions, the Region must conduct an analysis to determine whether a Star participant’s excessive 3-year rates warrant a 2-year rate reduction plan and, when the excessive rates are accompanied by safety and health management system deficiencies, imposition of 1-year conditional status. Any communications or work notes relating to this analysis should be made part of the participant file. Should a decision be made not to take action, the rationale must be documented in the participant file.
- As appropriate, the participant file should document any assistance visits, the development of an agreed upon 2-year rate reduction plan, imposition of 1-year conditional status, participant progress reports submitted to the Region, plan/status, and final disposition.
- At the completion of a 2-year period of rate reduction (or earlier if warranted), the Region must determine whether the Star participant has returned its rates to acceptable levels. If rates continue to be above the acceptable level for Star participation, the Region must ask the participant to withdraw from VPP. Failing withdrawal, the Region must institute and properly document termination procedures.
- At the completion of a 1-year conditional period, see #5, below.
- Notify DCSP-OPR via email when a participant is placed on a 2-year rate reduction plan or a 1-year conditional status and when such plan/status is completed to the satisfaction of the Region. Direct the email to the Director DCSP with a cc to the Director OPR and the OPR Regional Liaison.
Take action when the onsite evaluation team’s reapproval report recommends 1-year conditional status and specifies goals for needed improvements in the participant’s safety and health management system:
- See Chapter 6, Section VII.A.2. and Section VII.B. Ensure that the Region’s participant file contains documentation of a 90-day deferral period and the participant’s satisfactory completion of 90-day items and commitment to maintain a Star quality system; imposition of conditional status; and participant progress reports.
- At the end of a 1-year conditional period, an onsite review team must return to the site/Designated Geographical Area to determine whether the participant has maintained its safety and health management system at Star quality. After considering the team’s recommendation, the Regional Administrator must submit a recommendation to the Assistant Secretary. That recommendation must be to either
- Remove conditional status and return the participant to full Star status, or
- Terminate participation.
- Ensure that the Region’s participant file contains documentation of any actions and correspondence related to the participant’s conditional status.
- Notify DCSP-OPR via email when a participant is placed on a 1-year conditional status and when the status changes. Direct the email to the Director DCSP with a cc to the Director OPR and the OPR Regional Liaison.
- Review each annual self-evaluation for continued compliance with VPP requirements. Take appropriate action when VPP deficiencies are identified. Document deficiencies in the participant file. Notify DCSP of actions taken on appropriate forms.
- Whenever a VPP team conducts an onsite reapproval evaluation, the team must not only review injury and illness data and recalculate 3-year rates (Chapter 6, Section III.B.1.a.), but also must compare the rates verified onsite with the rates reported in the participant’s most recent annual self-evaluation.
- If the team finds any discrepancy between verified rates and the rates the participant has reported in its most recent annual self-evaluation, the team must inform the participant and recommend that the participant revise its records, including the self-evaluation.
- The Region must notify DCSP-OPR of appropriate changes to the annual VPP summary data. Corrections should be submitted via email to the Director OPR and the OPR VPP data coordinator.
Review the Medical Access Order requirements. (Chapter 6, Section II.B.5). Take action as follows:
- Establish a Regional MAO tracking system to help ensure all MAOs are requested and received prior to conducting VPP onsite evaluations.
- To ensure adequate time for the OSHA Directorate of Technical Support and Emergency Management, Office of Occupational Medicine to process an MAO request, submit the request form at least three weeks prior to the scheduled onsite evaluation.
- Maintain a copy of the MAO request in the applicant/participant file.
- Indicate on the updated VPP documentation whether the MAO was requested and also if the MAO was: 1) received prior to the onsite evaluation; 2) received during the onsite evaluation; or 3) not received in time for the onsite evaluation.
Implement ways to ensure greater Regional adherence to evaluation timeframes as follows:
- Submit monthly the VPP Activity Report Form (VPP Log) to provide status of VPP applications in the Region.
- Generate reports from the VPP Automated Data System (VADS) or the Region’s data system to track the timely conduct of onsite evaluations in the Region. Take appropriate action to schedule overdue onsite evaluations.
- Notify DCSP-OPR via email of decisions to postpone onsite evaluations, including rationale. The email should be addressed to the Director DCSP, the Director OPR, and the OPR Regional Liaison.
- Documentation regarding onsite evaluations scheduled outside normal timeframes must be placed in the participant file.
Update the Regional audit process:
- Regions must review their current audit procedures and documentation and update the audit criteria, in coordination with the Directorate of Evaluation and Analysis, to monitor the policies and procedures described in #1-8 above.
- When the revised VPP worksheets are final and approved, Regions must use them on all VPP onsite evaluations.