Many dental offices are scrambling to achieve OSHA compliance with the recent announcement of random audits as part of TOSHA’s Local Emphasis Program. Numerous dental offices across the state of Tennessee have been randomly audited. There has been much confusion and quite a bit of stress resulting.
This article explores common violations we commonly see in dental offices in Tennessee. We hope you will find this information helpful in closing the gaps in your compliance program.
Work Exposure Control Plan
TOSHA requires dental offices to establish a written Exposure Control Plan designed to minimize or eliminate exposure to bloodborne pathogens (1). This is usually part of your OSHA Manual. The Exposure Control Plan is reviewed and updated at least annually. We commonly find that offices may have purchased a manual years ago and it is either a blank template or the information is outdated. It is citable if the plan is not current. There are important components of your Work Exposure Control Plan. Your plan should include:
- Determination of employee exposure
- Implementation of universal precautions, engineering controls, and work practice controls
- Personal protective equipment
- Post-exposure evaluation and follow up
- Procedure for evaluating circumstances surrounding an exposure incident
- Communication of hazards
Indicate who is responsible to maintain the program. We suggest choosing someone who is detail-oriented, communicates well, and is willing to ensure that the tasks are completed. Allocate the time necessary to assure completion. Additionally, the Employer must ensure that the Exposure Control Plan is accessible to the employees. 2 Our company suggests saving an electronic version stored in the practice management program. Employees have easy access to the program and are usually quite proficient in navigating it. Simply name an account “OSHA” or “Compliance” and store the electronic documents there. If you are using a paper copy, make certain everyone knows how to access it otherwise you will be cited.
Employee Medical Records
TOSHA requires a medical record for an employee with occupational exposure. The record must include a copy of the employee’s hepatitis B vaccination status, including the dates of all the hepatitis B vaccinations or any medical records relative to the employee’s ability to receive the vaccination(3). Also included are post-exposure management reports, work-related injuries, immunizations, etc.
We commonly find that records are missing entirely or if documentation is available, it is stored incorrectly in the OSHA Manual. Store the records securely. If you prefer electronic versions, create a password-protected file. Records remain on file 30-years past the final employment date.
There are lots of questions relevant to the hepatitis B vaccine. TOSHA requires the hepatitis B vaccine is made available at no cost within 10 working days of the initial assignment for employees at risk for occupational exposure to blood or other potentially infectious materials(4). According to OSHA, ‘documentation of vaccination status serves as a useful tool in assisting healthcare professionals who must administer post-exposure counseling and treatment to employees following an exposure incident.
Documentation showing administration of the complete 3-dose series is necessary to prevent unnecessary repeated vaccination. The Centers for Disease Control and Prevention (CDC) considers a reliable vaccination history to be a written, dated record of each dose of a complete series.
Employers must make every effort to obtain a reliable record of employees’ vaccination status. These efforts may include contacting the previous employer or facility where the vaccination was administered to obtain these records. As it is a requirement that all employers maintain these records for the duration of employment plus 30 years, a previous employer who administered hepatitis B vaccinations would have copies of those record (5). If a copy of the vaccination record cannot be obtained, then OSHA recommends that documentation verifying the employer's attempt to obtain the record be maintained. When these records cannot be obtained from the previous employer, the current employer must obtain from the employee a written statement about vaccination status, including the dates or, where this is not possible, the approximate dates of the vaccinations (6).
Training for employees with occupational exposure is required annually. Education and training should be provided during orientation to the setting regardless of the employee’s past experience, when new tasks or procedures are introduced and at a minimum annually. Training records are maintained according to state and federal requirements (7). TOSHA requires training records on file for 3-years and must include topics covered.
Sufficient and Appropriate Personal Protective Equipment (PPE)
Sufficient and appropriate PPE must be available (e.g., examination gloves, surgical face masks, appropriate level procedural masks, protective eyewear/face shields, protective clothing, utility gloves, sterile surgeon’s gloves for surgical procedures). PPE must be readily accessible. Please note that PPE will be considered appropriate only if it does not permit blood or OPIM to pass through to or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use for the duration of time which the PPE will be used. The
Employer must evaluate the task and the type of exposure anticipated and based on that determination select the “appropriate” personal protective equipment (8). For example, cloth jackets must be fluid resistant and laundered by the employer. Disposable jackets may be a good alternative if cloth jackets cannot be properly maintained. Provide details in your policies where PPE is located and how it is maintained. Ensure that utility gloves are used to handle loose, contaminated instruments and when mixing chemicals. Wear eyewear protection and keep in mind that prescription glasses are not considered safety goggles. Select a mask according to the procedure. For example, a level 3 mask has a minimum filtration of 98% and is appropriate for procedures that generate splash and splatter. Masks are single use. Do not attempt to wear it with more than one patient. TOSHA will cite for this issue.
Sharps containers must be easily accessible to personnel or located as close as feasible to the immediate area where sharps are used (9). If the sharps containers are not located near the hazard such as the treatment rooms and sterilization center, you will be cited. According to the National Institute for Occupational Safety and Health (NIOSH), the ideal standing installation height for a fixed sharps container is 53 to 56 inches. This location will comfortably accommodate 95% of all adult female workers. The seated position location is 38 – 42 inches above the floor on which the chair rests. Therefore, sharps containers are NOT hidden in a cabinet or on the floor.
Safer Medical Device Evaluation & Log
Often missing in practice’s safety program is the evaluation of safer medical devices and the implementation log. TOSHA will ask for these documents. Examples of safer devices include safer syringes, blade remove systems, needle recapping systems, disposable blades, needleless IVS, etc.
According to TOSHA, instruments may not be transported on an open tray or carried by hand to the sterilization center. This involves work practice controls and engineer controls. The Bloodborne Pathogens Standard reads, “Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed. These containers shall be puncture resistant; labeled or color-coded in accordance with this standard; leakproof on the sides and bottom (10).” Be sure to affix a biohazard label to the container.
Infection Control Plan
Written infection prevention policies and procedures specific to the dental setting should be available, current, and based on evidence-based guidelines. Policies and procedures should be appropriate for the services provided by the dental practice and extend beyond OSHA’s bloodborne pathogens training. TOSHA will evaluate your infection control policies as it relates to employee safety.
Hazard Communication Plan
According to TOSHA, employers must prepare and implement a written hazard communication program and must ensure that all containers are labeled. Employees are provided access to Safety Data Sheets (SDS). An effective training is conducted for all potentially exposed employees. Don’t be surprised if a TOSHA inspector asks an employee to identify the hazards of the high-level disinfectant and the appropriate PPE. Training records will also be audited (11).
Employers are required to compile the SDS and ensure the sheets are readily accessible during working hours. Whether you maintain a paper copy or an electronic version, employees must know how to find the SDS. We recommend verifying your SDSs against an order history to make certain nothing is missing. Also, if you maintain a software solution, add a shortcut icon on every workstation.
TOSHA also requires you prepare a workplace chemical list using the SDS. The list should detail whether the product is hazardous or nonhazardous.
Affix a chemical identification label on all secondary containers and provide a legend for the corresponding pictograms. You may download a free legend a https://dentalcompliancetn.com/ (scroll down). Also, contact the TDA for your space saver
payroll posters that contain the OSHA posters.
In summary, prepare now and achieve peace of mind that if you are audited, you will pass with
flying colors. If you have any questions, please email firstname.lastname@example.org.
1 OSHA, 29 CFR 1910.1030(c)(1)
2 OSHA, 29 CFR 1910.1020(e)
3 OSHA, 29 CFR 1910.1030(h)(1)(ii)(B)
4 CDC’s Basic Expectations, p. 23 and OSHA 29 CFR 1910.1030(f)(2)(i)
5 OSHA, 29 CFR 1910.1030(h)(1)(iv)
6 https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=25648 on March 3, 2018
7 OSHA, 29 CFR 1910.1030(g)(2)(ii)(B) and CDC’s Basic Expectations, p. 6.
8 OSHA, 29 CFR 1910.1030(d)(3)(i)
9 OSHA 29 CFR 1910.1030(d)(4)(iii)(A)(2)(I), CDC’s Basic Expectations, p. 12
10 OSHA 29 CFR 1910.1030(3)(2)(viii)(A) – (C).
11 OSHA 29 CFR 1910.1200