Alan A. Ayers, MBA, MAcc is Chief Executive Officer of Velocity Urgent Care and is Practice Management Editor of The Journal of Urgent Care Medicine.
Urgent message: Though the topic of OSHA doesn’t often come up in the context of urgent care facilities themselves, operators are nevertheless required to have a thorough understanding of its standards and guidelines towards ensuring their facilities are in compliance, and that the health and safety of employees, patients, and vendors are protected.
In the course of normal everyday operations, the following can (and does) occur in otherwise well-run urgent care centers:
- The storage of staff-concocted “toilet-bluing” solutions for drug screens in old, unlabeled bleach bottles
- The preservation of expensive vaccine inventory in the employee breakroom refrigerator while awaiting the repair of the broken vaccine refrigerator
- The temporary placing of broken lab equipment or worn office furniture to be shipped out or disposed of near the emergency exit route—if even for a few moments
What do these activities have in common? On the surface, they’re time and effort, cost-saving workarounds—but they’re also potential Occupational Safety and Health Administration (OSHA) violations. Even so, it probably isn’t the case that the urgent care staff had any intention of flagrantly disregarding the health and safety of their coworkers and patients. For many in urgent care, in fact, OSHA regulations tend to be somewhat vague given that a small medical facility with 8-12 employees holds few risks for harm or injury.
Compare that to, say, a warehouse whose operations require many hazardous chemicals, large and complex machinery, labor from heights that pose a falling risk, the hoisting of objects that can fall on employees, and complicated fire escape routes. In those types of workplaces, employers’ and employees’ understanding and familiarity with OSHA regulations would be more thorough and in-depth out of pure necessity, as potential dangers lurk literally everywhere and violations can result in citations, fines, serious injury, or even death.
Given that most urgent care centers are basically “doctor’s offices” and relatively safe, however, most staff are aware of just bits and pieces of the regulations, and not the full picture of OSHA as it pertains to a medical facility. Regardless, urgent care centers still contain a number of potential hazards where lax compliance can pose a similar risk of injury, citations, and fines. With that in mind, this article will take a closer look at the OSHA standards and guidelines that are relevant to a medical office environment such as urgent care, along with prescribed courses of action for promoting and strengthening OSHA compliance at your urgent care center.
What is OSHA?
The Occupational Safety and Health Administration (OSHA) was created by the United States Department of Labor in 1970 to promote and ensure safe and healthful workplaces by developing standards and guidelines for reducing workplace hazards. OSHA provides training, education, outreach, and consultation, along with enforcement of its standards and guidelines. OSHA’s stated mission is “to save lives, prevent injuries, and protect the health of America’s workers.” OSHA rules apply to every workplace in the United States with one or more employees. Twenty-eight states have their own OSHA programs, including California, whose OSHA regulations are stricter than those prescribed by the federal program.
The primary enforcement provision is the OSHA General Duty Clause, listed in Section 5(a)(1) of the Occupational Safety and Health Act, which requires that every employer furnish to each of its employees a workplace that is free from recognized hazards that are causing, or likely to cause, death or serious physical harm. The general duty clause also acts as a blanket provision for workplace circumstances that pose a potential risk or hazard where there is no specific standard in place. If an employee is therefore harmed and/or injured due to noncompliance with OSHA regulations, the employer is liable.
In short, the responsibility falls squarely on the employer to identify all risks, create policies for working safely, and train employees on those policies. Under OSHA standards and guidelines, an employer escapes responsibility for harm or injury only if the employer:
- Did not create the hazard
- Does not bear responsibility or have the ability to have the hazard corrected or removed
- Notified employees of the hazard and how to avoid the dangers associated with it
- Took appropriate alternative means to avoid the hazard and/or removed employees from the job setting to avoid the hazard
More often than not, though, the general duty clause will indicate that the employer and not the employee is at fault for a given violation. Naturally, employers are motivated to comply with OSHA standards considering the threat of inspections, citations, hefty financial penalties, and even OSHA-created press releases designed to “name and shame” some offenders.
OSHA AS IT PERTAINS TO URGENT CARE
OSHA has a multitude of standards and guidelines to cover specific industries. For example, OSHA standards that are pertinent to an industrial setting might include (but are not limited to) Hearing Conservation, Respiratory Protection, and Crane/Hoisting Inspection. Medical office OSHA standards focus on protecting employees from being exposed to communicable diseases, hazardous chemicals, ionizing radiation, and general hazards such as obstructed emergency exit routes and electrical hazards. To that end, OSHA guidelines relevant to urgent care include:
- Bloodborne Pathogens
- Ionizing Radiation
- Hazard Communication
- Emergency Exit Routes
- Electrical Hazards
- Fire Prevention
- Personal Protective Equipment
- Record Keeping
- OSHA Inspections
- Reporting To OSHA
According to OSHA: The bloodborne pathogen standard is designed to protect employees where there is a risk of exposure to blood or other potential infectious materials (OPIM). It’s also OSHA’s most frequently requested medical guideline for the prevention of the spread of communicable diseases.
Relevance to Urgent Care: The most important standard to the urgent care setting. Exposure to bloodborne pathogens—usually from needlestick or sharps injury—is the greatest safety risk in urgent care. In fact, of the most frequently cited OSHA violations in medical offices year after year, the majority are related to the bloodborne pathogen standard.
How Violations Occur: The following are among the most common OSHA citations in medical offices pertaining to the bloodborne pathogen policy (BBP):
- Failure to implement and maintain a BBP standard
- Poor housekeeping under the BBP standard
- Failure to train under the BBP standard
- Failure to engineer out hazards/ensure hand washing under the BBP Standard
- Failure to make the hepatitis B vaccination available under the BBP Standard
- Failure to keep BBP training records and a sharps injury log
- Failure to use personal protective equipment under the BBP standard
Exposure can result from needlesticks, cuts from contaminated sharps such as scalpels and lancets, or glass from broken vials. Exposure can also occur from OPIM such as bodily fluids infected with HIV or Hepatitis A/B/C that comes in contact with the eyes, nose, or mouth.
Steps Towards Compliance: Employers with even one employee who has occupational exposure to blood or bodily fluids must have an effective written Bloodborne Pathogen Exposure Control Plan in place designed to prevent or minimize occupational exposure to blood and other potentially hazardous materials.
OSHA has created a model template, Model Plans and Programs for the OSHA Bloodborne Pathogens and Hazard Communications Standards, for employers to use in creating their own Exposure Control Plan that meets or exceeds OSHA’s requirement for the Bloodborne Pathogens Standard. The employer-created Exposure Control Plan must meet certain criteria:
- It must be written specifically and tailored for each facility.
- It must be reviewed and updated annually to reflect any relevant changes such as new employees at risk for exposure being trained on the standards.
- It must include workplace changes, modified job duties, or new technology introduced to reduce exposure to blood or body fluids.
- It must be readily available and accessible for all employees to view.
Urgent care operators must regularly educate their workers on the uses of the Exposure Control Plan and where it’s kept, so that it’s accessible when needed.
(Please note that information on accessing resources described in this article appears on page XX.)
An effective Exposure Control Plan would include the following:
- An evaluation/determination of employee exposure. The employer must identify jobs and tasks where exposure to blood and other potentially infectious material can occur
- Implementation of universal precautions such as those that ensure personal protective equipment is in place and is always being used
- Evaluation of safer medical devices and safer work practices. For example, consideration of using non-needle sharps or needle devices with safety features (ie, a sliding sheath that shields the attached needle after use, needles that retract into a syringe after use, and IV delivery systems with a catheter port and needle housed in protective covering)
- An offering of hepatitis B vaccination to all employees at risk of exposure at no cost, with a requirement of informed consent if the vaccination is declined
- Creation of a program for postexposure evaluation and follow-up
- Communication of bloodborne or bodily fluid hazards to employees, including the use of signs and labels
- A procedure for the management of medical waste
- The maintaining of a sharps injury log for practices with 10 or more employees. The log must protect employee confidentiality
- Provided training to employees on bloodborne pathogen hazards and precautions
Elements of the Bloodborne Pathogens training would include:
- Provided copy of OSHA’s Bloodborne Pathogens Standard
- Assessment of various modes of transmission (assessment of BBP exposure risks in the urgent care)
- Exposure Control Plan full review
- Training on how to recognize and respond to bloodborne and OPIM workplace hazards
- Training on risk reduction—such as engineering/work practice controls and the use of personal protective equipment
- Training conducted annually and records of each training retained for 3 years. The employer must pay for the training
Takeaway: Along with practicing universal precaution, the assumption must always be “treat everything as if it’s infected.” Chemicals are not the major exposure risk in a doctor’s office—it’s exposure to biohazards. There should be no food, drink, or make-up application in areas with potentially infectious agents. A vigilant approach to the bloodborne pathogen exposure control policy will reduce the greatest safety risk in urgent care.
According to OSHA: Ionizing radiation contains enough energy to ionize atoms that can destabilize molecules within cells which results in tissue damage. As radiation sources are used in many occupational settings, excess and uncontrolled radiation levels pose a significant hazard to the health of workers.
Relevance to Urgent Care: Many urgent care centers have on-site x-ray machines therefore staff are at risk for excess exposure to ionizing radiation.
Steps Towards Compliance: The OSHA guidelines for ionizing radiation apply to facilities that have an x-ray machine. It includes three basic requirements:
- A survey of the specific types of radiation in use.
- All x-ray machinery and all doors to rooms with x-ray equipment must be labeled with signs.
- All areas containing radiation or x-ray equipment should have restricted access and should limit radiation exposure to employees. Personal radiation monitors should be provided to all employees who operate the equipment and to all employees whose work involves exposure to radiation.
Takeaway: X-ray machinery and equipment have their own additional set of safety standards and guidelines, covered outside of OSHA, for safe operation of radiology equipment. Ensure that your urgent care staff is knowledgeable about those standards and in compliance to protect employee health.
According to OSHA: OSHA guidelines require medical offices to provide employees with information regarding any hazards that are present. The hazard communication standard is also known as the “employee right-to-know” standard, as employees must always have access to hazard information.
Relevance to Urgent Care: The primary hazards that exist in urgent care include:
- Bloodborne pathogen exposure and OPIM, including medical wastes
- Hazardous chemicals used or stored in the medical office
- Ionizing radiation
- Electrical hazards
- Obstructed emergency exit routes
How Violations Occur: The area with the second most frequent violations of OSHA standards in medical offices, after the bloodborne pathogen standard, is the hazard communications standard. The most typical of these citations is a failure to train employees on the hazard communication standard.
Steps Towards Compliance: All medical offices are required to have a written plan for hazard communications, as well as documentation of compliance training for hazard communication to employees. When hazards are identified, the onus falls on the urgent care operator to evaluate the hazard to determine if its covered under an existing plan, or otherwise write a new policy and train all employees on it.
For hazardous materials and substances, OSHA requires a Safety Data Sheet (SDS) listing the hazards and precautions required for handling and storage. Because the makeup of every batch of chemicals differs, manufacturers provide a new SDS for every batch, which employers must keep on file for 30 years when dealing with chemicals that may pose health issues with long-term exposure. The general rule of thumb for chemicals is “If they sell it at Walmart, then an SDS is not required.” The cleaning products and other substances kept in an urgent care center are typically in small quantities and the packaging itself comes with manufacturer labelling with pictograms. Therefore, it’s important to never put cleaning agents and other chemicals in anything other than its original container.
Management of Medical Waste
According to OSHA: All medical waste must be:
- Contained in a special red bag or sealed plastic bin that indicates it’s a biohazard
- Stored in a segregated area (or closet) with the door clearly labelled with the “Biohazard” sign
- Removed by an authorized contractor
Takeaway: While hazard communication in urgent care is not as big an issue as bloodborne pathogen exposure, a lax approach holds significant risk to employee health and safety and should be treated as such.
According to OSHA: OSHA has comprehensive standards regarding electrical hazards, covering a multitude of workplace settings and environments.
Relevance to Urgent Care: A medical office is full of electrical equipment; therefore, it’s important that all equipment is used safely and properly and undergoes regular maintenance and inspection to protect employees from injury.
How Violations Occur: Frayed electrical cords can result in shocks or electrocutions. Fraying can result from rubbing against door or window edges, by staples and fastenings, being rolled over by wheels, or simple wear and tear—which can result in insulation breaks, short-circuits and exposed wires. Damaged connectors and receptacles and unsafe work practices involving electrical can result in injury. Injuries from tripping over exposed cords can also occur.
Steps Towards Compliance: It is important to perform regular inspections and maintenance of all electrical equipment. Electrical standards to protect employees from injury include:
- Staff training in the proper usage of all equipment. Equipment should only be used by an employee for the purpose of performing their job.
- Equipment must be tagged with the inspection date, the due date of the next inspection and the inspector’s initials.
- In the event of failure or malfunction, immediately mark the equipment as, “OUT OF SERVICE.”
- Only authorized personnel should attempt to service or repair malfunctioning medical equipment
Takeaway: While not a major urgent care hazard, electrical hazards can lead to fires and even fatalities. Electrical hazards should therefore always be treated with the utmost seriousness and addressed immediately by authorized personnel.
Emergency Exit Routes
According to OSHA: An exit route is a continuous and unobstructed path of exit travel from any point within a workplace to a place of safety. Exit routes have three parts:
- Exit access – part of the exit route that leads to an exit.
- Exit – part of the exit route that is separated from other areas to provide a protected travel path to the exit discharge.
- Exit discharge – part of the exit route that leads directly outside or to the street or area of refuge.
Relevance to Urgent Care: All medical offices are required to provide safe and accessible exits from the building in the event of an emergency. All exits are to be marked. Diagrams that show evacuation routes must be posted in highly visible areas.
How Violations Occur: More common examples of violations include objects obstructing or blocking any part of the emergency exit route for any length of time, or not displaying proper signage or highly visible exit route diagrams.
Steps Towards Compliance: OSHA has a fact sheet that provides the answers to common questions including:
- What is an exit route?
- How many exit routes should a workplace have?
- Are there specific construction and design requirements for exit routes?
- What additional requirements are there for exits?
For urgent care centers with 10 or fewer employees, you’re allowed to communicate your exit route plan orally. For 10 or more employees, however, the exit route plan must be written, available onsite, and accessible to all employees.
Takeaway: Even though employers are not required to have an emergency action plan (EAP) in conjunction with the exit route plans unless a particular OSHA standard requires it, OSHA still recommends strongly that all employers institute an EAP and train all employees on it.
According to OSHA: Fire prevention plans (FPP) go hand-in-hand with emergency exit route plans and emergency action plans (EAP).
Relevance to Urgent Care: Most municipalities will require fire prevention plans be created in any medical facility or place of business. The fire prevention plan must:
- Assure a sufficient number of fire extinguishers are available, placed near areas of fire risk, and inspected regularly as required by law.
- Identify fire hazards related to storage.
- Have a training plan for fire evacuation including procedures for calling 911.
- Outline each employee’s duty in evacuation including equipment that needs to be shut down.
How Violations Occur: Examples of violations of fire prevention standards include storage of cleaning supplies and paper goods like toilet paper and paper towels in the HVAC room where the furnace or water heater may have a pilot light; nonfunctional fire extinguishers; and unsafe accumulation of flammable and combustible materials.
Steps Towards Compliance: These are the minimum OSHA-recommended provisions for an FPP:
- Up-to-date list of all major fire hazards, instructions for the safe handling and storage of hazardous materials, potential ignition sources and their control, and the specific fire protection equipment required for each hazard.
- Action plans and procedures for controlling accumulations of combustible and flammable waste materials.
- Regular maintenance schedule of safeguards installed on heat-producing equipment for prevention of accidental combustion of materials.
- Name or job title of employees responsible for maintaining equipment to prevent or control accidental combustion or ignition of materials.
Takeaway: Similar to the aforementioned emergency exit plan, urgent care centers with 10 or fewer employees may communicate the fire prevention plan orally to their employees. Urgent care centers with at least 10 employees must provide a written plan that is kept onsite and accessible to employees for review. Although employers are only required to have an FPP when the applicable OSHA standard requires it, OSHA strongly recommends that all employers have an FPP. In addition, when you assign employees to a job, you must inform them of any fire hazards they may be exposed to. You must also review with each employee those parts of the fire prevention plan necessary for self-protection.
Personal Protective Equipment
According to OSHA: Personal Protective Equipment (PPE) is any equipment worn to minimize exposure to workplace hazards. PPE items include eye and foot protection, gloves, masks, earplugs, hard hats, and respirators.
Relevance to Urgent Care: In a medical office environment like urgent care it’s important to have a thorough accounting of all workplace hazards, as well as the PPE necessary to protect employees from those potential hazards. Scrubs and white lab coats are considered PPE given that they’re “protective” garments made of special fibers that are nonabsorbent against blood and other bodily fluids. Additional protective equipment could include:
- Face/eye shields (for working in the laboratory or for administering CPR)
- Face masks or other barrier devices
- For physicians and medical assistants, rubber gloves, gowns, face shields, eye protection, mouthpieces
- CPR masks and resuscitation devices
Note: Emergency equipment such as the first aid kit and eye wash should also be in place and functional in case an injury occurs.
Employers must pay for all protective equipment except nonspecialty protective footwear (ie, employees must bring their own shoes). Scrubs could be considered “everyday” clothing vs garments used exclusively for safety; hence, urgent care isn’t required to pay for scrubs. Many urgent care centers, however, will provide a set of scrubs at the beginning of employment and annually, or otherwise offer a credit towards purchasing scrubs.
How Violations Occur: Wearing “street” clothing or garments that do not offer protection from workplace hazards would be considered a violation of the PPE standard, as would not having a sufficient supply of specific PPE prescribed for employees and/or the necessary job functions, and not wearing PPE when job function regulations require it.
Steps Towards Compliance: Per OSHA, responsibility falls on the employer to ensure that the following PPE procedures occur:
- Identify and provide appropriate PPE for employees
- Employee training in the use and care of PPE
- Procedure for maintaining and replacing worn or damaged PPE
- Periodic review of the effectiveness of the current PPE standard, with updates as necessary
- Process for informing management or a supervisor when PPE needs to be repaired or replaced
Takeaway: In a medical office like urgent care, the risk of wearing street clothes (including Halloween costumes) is that if they’re intermingled and washed in cold water with the family laundry, it can lead to the spread of Staph, Strep and other bacteria to family members. Additionally, alongside PPE policies and standards, urgent care centers should also enforce a dress code. The dress code would cover garments that are appropriate to the workplace and/or required (such as leather, closed shoes) and address hair, nails, beards, jewelry, and other “grooming” standards.
According to OSHA: OSHA regulates most workplaces and specifications for safety signs, accident prevention signs, and safety tags. Employers are required to warn employees (including temporary employees), vendors, contractors, and visitors about any workplace hazards they might be exposed to. This is best accomplished by using and following established safety sign and marking standards.
OSHA has three classifications of signs:
- Danger signs– These signs indicate immediate danger and that special precautions are necessary. OSHA specifies that red, black and white colors are to be used for danger signs
- Caution signs– These signs warn against potential hazards or caution against unsafe practices. OSHA specifies that caution signs must have a yellow background and black panel with yellow letters. All letters used against the yellow background must be black
- Safety instruction signs– Safety instruction signs are required where there is a need for general instructions and suggestions relative to safety measures. OSHA specifies that safety instruction signs must have a white background, green panel and white letters. Any letters used on the white background must be black
Relevance to Urgent Care: A medical office such as an urgent care center is home to any number of potential safety hazards of which people on the premises must be warned and that must be labelled with appropriate signage.
How Violations Occur: Not having proper signage in place in designated areas. Objects blocking or obstructing the visibility of signs.
Steps Towards Compliance: The following signs should be clearly displayed in appropriate areas in an urgent care center:
- Security Camera in Use
- No Firearms Allowed (specific verbiage may be required in states with concealed carry laws)
- For refrigerators used for vaccines and/or lab sample storage: No Food or Drink Allowed!
- For refrigerators used for employee food – Food Only (no medication or lab samples allowed)
- Authorized Personnel Only sign limiting access to the electrical/cleaning/telephony closets
- Oxygen in Use (or Oxygen Being Stored) signs, as oxygen is highly flammable
- X-ray in Use sign
- Signs warning of biohazards (ie, biohazard disposal closet, laboratory, sharps containers)
- In the lab and medical station: No Food or Drink Allowed
Takeaway: Other signage, such as labelling of exits and/or emergency evacuation routes, will be regulated by the local fire inspector and not covered by OSHA signage requirements. Fire extinguishers, first aid kit, and eye wash should also be clearly labelled with appropriate signage
Exhibit: OSHA Compliance Checklist for Urgent Care
Follows are a list of items that an urgent care center should be on the lookout, to assure employee safety and compliance with OSHA standards related to patient care.
Resources Regarding OSHA Compliance for Urgent Care Centers
- Occupational Safety and Health Administration. Model Plans and Programs for the OSHA Bloodborne Pathogens and Hazard Communications Standards. Available at: https://www.osha.gov/Publications/osha3186.pdf.
- 5 Osha Guidelines for Medical Offices. Available at: https://www.ceu360.com/2016/01/25/5-osha-guidelines-medical-offices/#radiation.
- Occupational Safety and Health Administration. OSHA Fact Sheet. Emergency Exit Routs. Available at: https://www.osha.gov/OshDoc/data_General_Facts/emergency-exit-routes-factsheet.pdf.