Originally published in the August 2014 issue of Veterinary Practice News
Part 1: 10 Steps To OSHA Compliance
Ashley, the hospital manager of an emergency and referral practice in Pennsylvania, was picking up her morning coffee at the local gas station. When she hopped back in her car, she had three phone and five text messages.
Secondary containers should be labeled correctly.
What could be so urgent? Couldn’t it wait five more minutes?
She called her practice. The technician was frantic. Five people had just shown up to conduct an OSHA inspection.
Ashley immediately suspected that this was no coincidence. She had recently put an under-performing employee on probation, and after a week, the worker quit. This must have been the former employee’s idea of revenge, she thought.
Ashley kept her cool and took the five visitors, sent by the Occupational Safety and Health Administration, the state Department of Environmental Protection and the state Department of State on a hospital tour.
The OSHA inspector went through her checklist and made notes:
- No goggles in the entire building. Serious violation. Penalty: $1,600.
- No eyewash station. Serious violation.
- No written hazard communication plan; no material safety data sheets, known as MSDS; no employee training on hazardous chemicals; no list of hazardous chemicals present in the workplace. Serious violations. Penalty: $1,600.
- Inappropriate or absent labels on secondary containers. Serious violations.
- No fire extinguisher training. Minor violation. No penalty.
- No emergency exit plan. Minor violation. No penalty.
The OSHA inspector asked for all employees’ names, phone numbers, email addresses and home addresses. The manager complied but drew the line at giving home addresses. “I just didn’t want my co-workers to have a visit from an OSHA inspector at home.”
The Department of Environmental Protection inspector looked for appropriate leaded personal protection equipment in the radiology room. Gowns, gloves and thyroid shields were available, and staff actually wore them while taking radiographs.
The inspector also looked at about 40 radiographs to make sure that no human body parts were in the radiographs. Fortunately, this was the case. But there was no evidence of X-ray safety training.
The inspector from Pennsylvania’s Department of State checked licenses for controlled drugs. Were controlled substances properly stored? Was the drug log up to date and well kept?
Three medical records were pulled randomly. Did they contain SOAP notes and vital signs? Were drugs correctly recorded? Were any drugs, anywhere in the hospital, expired? The hospital was compliant on all fronts.
In the end, the hospital was compliant with some requirements and lacking on others. Cost of this little adventure, the so-called “original penalty”: $8,000.
After some negotiation, both in person and over the phone, the “proposed penalty” was reduced to $3,200. The fact that Ashley had shown “good faith” and there had been no prior OSHA visit helped her cause. Then OSHA offered a 25 percent reduction of the fine if the agreement were signed within 15 working days. Reduced penalty: $2,400.
An eyewash station is an OSHA requirement.
Various deadlines were offered. For example, our colleagues had 15 days to have all secondary bottles labeled and 60 days to initiate employee training and set up an emergency exit plan.
Ashley reported her two big surprises from the visit:
- A cold sterilization tray is strictly controlled. Only certain antiseptics are allowed, and they can be trusted only for so many hours. Instruments placed in the antiseptic need to be kept in it for the duration specified by the manufacturer. If an instrument is added, or if one is used and replaced, the tray is considered unsterile.
- Autoclaves should be spore-tested weekly, according to the state. You may want to check if this applies in your state.
“When you receive the initial citation, you have the option of calling within 15 working days for an informal phone conference,” Ashley explains. “The goals include discussing the fines, coming up with solutions and asking questions. This phone call is extremely important and helpful, even if you don’t contest any infraction.
“If you can demonstrate compliance before the deadline, the inspector may reduce your fine. In fact, our fine was further reduced to $2,080.
“Once the final agreement is signed, you have 30 days to pay the fine.”
Ashley promised the inspector that she would comply within the deadlines.
It was a stressful experience, Ashley admits. But all in all, the inspection went well “and it was constructive,” she says.
Here's The Background Behind the Surprise OSHA Inspection
The employee the manager believes had called OSHA was a part-timer; she worked one day a week. She was considered disruptive, with so-so technical skills. Interestingly, she was caught allowing a client in the treatment room to hold his pet to draw blood and place an IV catheter—a violation of hospital policy.
Cold sterile trays are more strictly regulated than you might think.
In addition, she would pick and choose what she wanted to do. After several warnings, she was put on probation for one month. Less than one week into her probation, she evidently called to file a complaint with OSHA.
The OSHA inspector called colleagues from the Pennsylvania Department of Environmental Protection and the Department of State to the rescue. And that is how five inspectors showed up one morning, unannounced, on the hospital doorstep.
Kelly Serfas, a certified veterinary technician in Bethlehem, Pa., contributed to this article.