​​Efforts to keep residents, staff, and others safe were heightened during the pandemic, and respiratory protection was a top priority. The Occupational Safety and Health Administration (OSHA) is increasing the focus on its Respiratory Protection Standard (29 CFR 1910.134) to make sure these efforts continue. As facilities are wrestling with regulatory changes, staffing shortages, and other challenges, this may seem like one more concern to deal with; but there is help and guidance to enable everyone to breathe easier.

Stringent Standards: What Do They Mean?

The OSHA Respiratory Protection Standard requires nursing facilities, assisted living communities, and ID/DD centers, among other health care organizations, to establish and maintain a respiratory protection program when respirators are required to protect against airborne hazards, including infectious agents such as COVID-19.

This mandate includes performing medical evaluations, conducting fit testing, providing appropriate respirators, and ensuring proper training for all at-risk employees. Failure to comply can result in substantial fines, penalties, increased liability, and severe health risks to employees.

OSHA identifies several required elements for a respiratory protection program within its standard. These include:

• Identification/assignment of a “suitably trained” program administrator to oversee the program. This could be an infection preventionist or nurse, for example.
• A written respiratory protection program (RPP) with details of specific procedures and elements for required respirator use and other information.
• A risk assessment to identify workers who are at risk of exposure to airborne hazards. These individuals could include clinical or nonclinical staff who come in close contact with residents who have confirmed or suspected COVID-19 or other airborne illnesses during services such as bathing, dressing, toileting, and direct care.
• Procedures to select appropriate types of respirators based on the facility’s hazards and other workplace factors.
• Assurance that any worker using a tight-fitting respirator is fit tested before initial use. This ensures that the size, make, and model provides a proper facial seal to protect the wearer.
• Procedures for conducting medical evaluations of workers who are required to use respirators to assess their ability to wear a respirator safely before they need one.
• Procedures/schedules for respiratory maintenance and storage.
• Training for workers who are required to wear respirators. These should be customized for the education level of each person and ensure that they understand all instructions.

A facility’s respiratory protection plan applies to all employees who are required to wear a respirator and those that voluntarily wear one. Each employee must be medically cleared to wear a respirator, and a health care professional must review a medical questionnaire form that may include information such as limitations or conditions of use. 

A fit test is needed to determine that the respirator a person will use on the job fits their facial features and maintains a tight seal. Every person must be re-fit tested annually, as well as if the facility changes respirator models or a person experiences a change in facial structure (such as weight loss or gain). Workers should never use a different model of respirator other than the one they are fit tested to use; and they should notify their supervisor if their respirator no longer fits for some reason or the respirator they are fit tested on isn’t available. 

The written plan can be flexible, enabling facilities to respond to possible changing guidance during an emergency, shortages in supplies, reallocation of personnel, and other circumstances that may cause certain aspects of the plan to be impossible to follow or require additional precautions.

New Focus for Old Standards

As penalties for noncompliance with these standards can be significant, facilities are feeling pressure to get processes in place. However, Michael Arther, owner of MCA Consulting, LLC , noted that this actually isn’t a new standard. What’s new is the focus on nursing homes and assisted living facilities. The baseline is: Have you done a hazard assessment? If you identify a hazard, an airborne hazard in this case, it requires you to implement protections that meet the OSHA standard.

In long term care facilities, said Arther, the closest thing to an identifiable hazard pre-COVID was tuberculosis (TB); and the standard only applied if a facility housed “known active” TB patients. They would need a method of transferring those individuals out to a secondary provider, such as a hospital, with respiratory protection efforts such as negative pressure environments.

When COVID hit, the need for more formal respiratory protection processes became clear. This contributed to OSHA’s expansion of their standards to encompass long term care. The agency noted, “Long term care facilities are different than other health care settings because they assist residents and clients with tasks of daily living in addition to providing skilled nursing care.” The agency further observed, “While this guidance focuses on protecting workers from occupational exposure to SARS-CoV-2 (the virus that causes COVID-19 disease) by the use of respirators, primary reliance on engineering and administrative controls for controlling exposure is consistent with good industrial hygiene practice and with OSHA’s traditional adherence to a ‘hierarchy of controls.’ Under this hierarchy, engineering and administrative controls are preferred to personal protective equipment (PPE). Therefore, employers should always reassess their engineering controls (e.g., ventilation) and administrative controls (e.g., hand hygiene, physical distancing, cleaning/disinfection of surfaces) to identify any changes they can make to avoid over-reliance on respirators and other PPE.” 

It is worth noting that addressing respiratory protection in long term care has been a focus for the U.S. Department of Labor for several years. In 2021, the agency announced a new emergency temporary standard to protect more than 84 million workers from the spread of the coronavirus on the job. Under this standard, covered employers were required to “develop, implement, and enforce a mandatory COVID-19 vaccination policy, unless they adopt a policy requiring employees to choose to either be vaccinated or undergo regular COVID-19 testing and wear a face covering at work,” according to a press release from the agency at the time. “The federal government was really pushing for an infectious disease standard that would cover all potential exposures for all employers, but primarily health care providers,” said Arther.

Respirator Review

Arther stressed, “The primary purpose of a respirator is to protect your health from airborne hazards, which come in multiple forms.” These include solid particles like dust, droplets like mists, or even gases. Respirators are a type of PPE used to protect workers against breathing these airborne hazards. They are often used in conjunction with other types of PPE such as gloves, goggles, and procedure gowns. Practitioners and direct care staff are obvious candidates for the use of respirators and other PPE and a clear target of training for the OSHA standard. However, Arther observed that respiratory protection may be needed for other workers as well. For instance, maintenance staff may be exposed to airborne hazards when they are performing tasks such as replacing filters or making repairs in high-risk areas.

When a respirator is required to protect against COVID-19, employees should use a National Institute for Occupational Safety and Health (NIOSH)-approved filtering face piece respirator rated at N95 or greater. The respiratory protection program administrator should coordinate with infection preventionist and/or other team leaders regarding respirator selection, supplies, and usage. This individual also will monitor the inventory and availability of respirators. Of course, there may be instances where respirator supply is limited; when this happens, alternate precautions may be employed based on guidance such as emergency use authorization.

Help Is Here

“Preparation for compliance with the standard starts with the training and education piece,” said Arther. This is especially key in a world where turnover is high, and training can fall through the cracks for new employees. Everyone needs to know what the potential exposures are and the correct application of PPE. They need to know that if masks and other devices are used properly, they are protected. Arther, who frequently conducts training on respiratory protection, said that there is a sigh of relief among people once they understand the basics and the value of a respiratory protection plan. They realize that if there is another pandemic or other respiratory emergency, they will be able tobest protect their residents, colleagues, family, friends, and themselves.

There are many tools and materials for providers to help them start this journey and stay on track. Among the resources is a comprehensive Respiratory Protection Plan from AHCA/NCAL, in collaboration with MCA Consulting. This training program and tool kit provides everything needed to comply with the new OSHA standard, including a customizable template plan, essential forms, training videos, and detailed reference guides.

Resources include:

• Access to OSHA-compliant forms for program documentation.
• Step-by-step fit testing instructions to ensure proper respirator use.
• Customizable templates tailored to your facility's specific needs.
• Practical guides and tools for straightforward implementation.
• Video training for managerial staff and program administrators on respiratory protection requirements.
• Video training for employees, meeting all annual OSHA training requirements.

“This is beyond a template or a course. We built a system with all the tools providers need,” said Arther. “They don’t need to be experts on respiratory protection. We know what OSHA requires and what they will be looking for and enable them to have OSHA-compliant policies and procedures. This system is customizable for each organization.”

Looking on the Bright Side

While a more comprehensive awareness of this standard may require facilities to implement some new programs and policies, they will also reap benefits. “It’s important for staff to know that you have a respiratory protection program and that you are going to supply them with everything they need to protect themselves,” said Leslie Eber, MD, CMD, a Colorado-based multi-facility medical director.

The OSHA standard, she suggested, “codifies for facilities the steps they need to take to have an appropriate respiratory protection program.” She added, “This helps ensure you don’t get caught off guard with the next respiratory emergency.” As a result, everyone in a facility or community—from the business offices to the kitchen and housekeeping staff—will have the knowledge and confidence to protect residents, themselves, and others from airborne illnesses and other infections. They will know what it feels like when an N95 mask fits correctly.

Once this gets on everyone’s radar and facilities get a process in place, they can ensure yearly testing and keep their plans moving forward. Arther added, “It's going to reduce airborne infection and make it possible for facilities to take in more residents.”

He stressed, “This isn’t about keeping people in respirators day in and day out. You want to maintain it for the purpose of being able to react and respond quickly and agilely. This will keep you ahead of things, which is important for reacting to surges in respiratory virus activity in your community.”

Instead of panicking, facility leaders should take stock about what processes and policies they already have in place so they don’t try to reinvent the wheel. “Providers likely have most of the pieces, but the AHCA/NCAL resource gives them the checklists to identify any gaps or missing pieces and address them promptly and effectively,” said Arther. He added that having an effective respiratory protection program sends a positive message to current and prospective staff. It tells them, he suggested, that the facility prioritizes staff safety and will work to protect them from illness and infections.

Joanne Kaldy is a freelance writer and communications consultant based in New Orleans.