Skilled nursing facilities, assisted living communities, and ID/DD centers are required by OSHA’s Respiratory Protection Standard (29 CFR 1910.134) to establish and maintain a respiratory protection program when employees are exposed to airborne hazards, including infectious agents like COVID-19. Compliance is mandatory to avoid fines and penalties. 

AHCA/NCAL, in collaboration with MCA Consulting, LLC, offers a comprehensive Respiratory Protection Plan training and toolkit. This all-in-one resource contains everything needed for full compliance with OSHA’s federal Respiratory Protection Standard, including a customizable template plan, essential forms, training videos, and detailed reference guides.

Resources include:

• Access to OSHA-mandated 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

AHCA/NCAL offers a deeply discounted 3-year subscription for this complete all-in-one resource package valued at $4,000+ if purchased through consulting firms.

3-Year Subscription Rates:

AHCA/NCAL Members: $499

Non-members: $699

How the Subscription Works:

One individual will use their ahcancalED login credentials to subscribe. That individual may then share their ahcancalED login credentials with colleagues to access the subscription for unlimited use of all the resources for three years.  

Bulk purchases available.  Please contact educate@ahca.org 

ATTENTION ALABAMA: 

Is your facility located in Alabama? In collaboration between the Alabama Regional Center for Infection Prevention and Control (ARC IPC), Alabama Long-Term Care Strike Team (LTC Strike Team), and the Alabama Nursing Home Association (ANHA), skilled nursing facilities, assisted living facilities, and specialty care assisted living facilities in the state of Alabama are eligible to receive a discount code for free access to the AHCA/NCAL Respiratory Protection Program (limited to one access code per licensed facility). To verify eligibility and obtain a discount code, please contact arcipc@uab.edu.

Specific to this Template Respiratory Plan:

Why am I required to have a Respiratory Protection Program?

OSHA’s Respiratory Protection Standard 29 CFR 1910.134 states that: “in any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program.” While air contaminants can and should be reduced as feasible through engineering controls (i.e. ventilation) and work practice controls (i.e. distancing), the residual risk of exposure can still be high enough to require the use of Personal Protective Equipment (PPE). NIOSH N95 respirators are the last line of defense when it comes to protecting employees from airborne exposure. Thus, proper procedures, training and use are all critical to protection. Additionally, many infectious diseases require the use of airborne precaution protocols. Therefore, employees who encounter patients on airborne isolation precautions are required to wear respiratory protection which is the initial criteria given by OSHA for a respiratory protection program.

How do I customize this Template Plan for my facility?

All Respiratory Programs should include worksite specific procedures. This template plan meets the baseline requirements for a Respiratory Protection Program, as required by OSHA. Organization specific policies and procedures may be included in the “additional notes” sections of the plan. However, any additional procedures added to the template should be carefully followed. 

Can I use respirators other than conventional N95s?

There are many types of respirators as well as many levels of filtration. Airborne precautions require an “N95 filtration or greater”. Higher grade filters include but aren’t limited to N99s, N100s, P100s and P99s. N95s are a balance between protection and comfort. They are easiest to breathe through and are typically more readily available in supply chains.

Respirator styles such as elastomeric Full Face and Half Mask Respirators are reusable, but with the use of these types of respirators, comes more stringent maintenance, inspection, cleaning, and storage protocols that are not addressed in this template program. This program is primarily designed for the use of particulate filtering facepiece respirators (N95s) that are used to protect against airborne infectious diseases.

Why does this plan address only infectious diseases? Can I address other hazards?

This plan is tailored to meet the needs of long-term care environments. These environments typically do not deal with hazardous chemical exposures, harmful dusts, or low oxygen levels. Any of these hazards should either be eliminated from the worksite entirely or controlled in a manner to minimize exposure below permissible exposure limits (PELs). See 1910.134(d)(3)(i)(B) (Maximum Use Concentration) and 1910.1000 – (Air contaminants). For more information, see https://www.osha.gov/laws-regs/regulations/standardnumber/1910.

What’s the difference between qualitative and quantitative fit testing methods? Can I use quantitative methods to fit test employees?

Qualitative Fit Testing:

• Method: Relies on the respirator user’s sensory response (taste) to a test agent.
• Process: The user dons a respirator and is exposed to a test substance (e.g., Bitrex (bitter taste), saccharin (sweet taste)).
• Outcome: If the wearer detects the substance, the fit is inadequate; if not detected, the fit is adequate.

This method is typically used for both half-mask respirators and disposable respirators such as N95s.

Quantitative Fit Testing:

• Method: Utilizes instrumentation to numerically measure the fit of a respirator.
• Process: Typically involves a particle counting device or a machine that measures leakage around the mask.
• Outcome: Provides a numerical measurement of the fit factor, which indicates the level of protection provided by the respirator.

This method can be used for both half-face and full-face respirators. There are probe devices that can be inserted into particulate filtering facepieces as well that allow for this method to be used. 

Which employees must meet the requirements of the Respiratory Protection Plan (be trained, medically cleared, and fit tested)?

Any employee who is required by their employer to wear a respirator as part of their work duties falls within the scope of the OSHA’s respiratory protection requirements and this respiratory protection plan. All employers are required to assess the workplace for respiratory hazards and provide appropriate respirators for employees when necessary.

Some employees may prefer to wear a respirator even when it is not required. Disposable N95 Respirators can be worn under the Voluntary Use policy. Employees who do not have to wear a respirator as part of their job duties, may still choose to wear a respirator.

Employees are not required to be medically cleared and fit tested WHEN:

1. They choose to voluntarily wear a disposable N95 respirator,
2. And are outside the known hazardous areas where respiratory protection is required. 

What type of circumstances would require program updates and retraining?

The Respiratory Protection Plan should be updated as needed. A few scenarios where this would come into play includes:

• Any change in procedures
• A change in Program Administration
• A new identified hazard in the workplace
• Respirator use issues that are observed in routine audits
• A change in the type of respirators used at a workplace (Introduction of Half Mask or Full-Face Respirators)
• Deficiencies from program audits that show room for improvement
• Regulatory changes

Regular review and updating of the RPP ensure that it remains effective in protecting employees from respiratory hazards and compliant with OSHA regulations.

Respiratory Protection Program:

Do all elements of a respiratory protection program need to be in writing?

Yes, all worksite-specific procedures and elements for required respirator use must be documented in writing. Not all worksites are equal. Some requirements in the OSHA Respiratory Protection Standard may not be applicable to every organization (i.e. an organization that used only disposable respirator models would not have to have procedures for changing out respirator filters).

How often should the written respiratory protection program be updated?

The program should be updated whenever there are changes in the workplace or in respirator use, such as new respirator choices, changes in fit testing, or changes in work operations.

Program Administrator:

How will the Compliance Safety and Health Officer (CSHO) determine if a person is qualified and trained to be a respirator program administrator?

The CSHO will review the written program and interview the program administrator to assess their familiarity with the respirator standard and the use of respirators in the workplace.

Does the standard provide a list of approved training courses for program administrators?

No, OSHA only requires the program administrator to have sufficient training to manage the complexity of the respirator program at the worksite.

Who is qualified to be a Program Administrator?

There is not a discipline qualification requirement for Program Administrator.  Infection Preventionist is always a good option, but not required. The responsible person must be able to maintain the components of the program and be able to communicate with OSHA on the program. 

Respirators:

What is meant by the conditions of a respirator’s certification?

Respirators are certified by NIOSH as an assembly. Conditions of certification include the limitations of use specified by NIOSH. Parts from other manufacturers or models cannot be substituted.

How many respirator models and sizes are sufficient?

The standard is performance-based; there must be enough models and sizes to ensure all users can achieve an acceptable fit.

Medical Evaluation:

Can a fit test for a respirator be performed before the initial medical evaluation has been completed?

No, the initial medical evaluation must be conducted before fit testing to identify individuals whose health may be harmed by even the limited use of a respirator during fit testing.

Does the medical questionnaire have to be administered by a PLHCP (Physician or other Licensed Healthcare Professional)?

No, the standard does not specify the qualifications of the individual who administers the medical questionnaire, but the employee must be able to discuss the results with the PLHCP.

Are physicians the only medical professionals allowed to perform medical evaluations for respirator use?

No, various healthcare professionals can perform medical evaluations depending on the scope of practice permitted by the state’s licensing, registration, or certification agencies.

Who is an “other Licensed healthcare professional” for purposes of reviewing medical questionnaires?

Under the Respiratory Protection Standard (29 CFR 1910.134), an "other licensed healthcare professional" (OLHCP) is defined as a person whose legally permitted scope of practice (i.e., license, registration, or certification) allows them to independently provide or be delegated the responsibility to review and approve someone for fit testing. Review of the questionnaire does not necessarily require a medical evaluation; therefore, an MD is not always necessary.

An OLHCP can be, but not limited to:

• Physicians
• Registered Nurses (RNs)
• Physician Assistants (PAs)
• Nurse Practitioners (NPs)

Can an employee decline to be medically evaluated for the use of a respirator?

No, an employee cannot refuse the medical evaluation and still use a respirator. The employer must provide a medical evaluation before the employee uses a respirator in the workplace.

What are the recordkeeping requirements for the Medical Questionnaire?

OSHA guidelines regarding the retention of completed Medical Questionnaires can be unclear, particularly when facility staff such as an RN or NP act as the facility’s Licensed Health Care Professional (PLHCP). It's important to note that OSHA’s confidentiality requirements specifically apply to the Medical Questionnaire itself, not the Clearance Form. The Clearance Form, which indicates an employee's medical clearance to use respiratory protection, should be kept in the employee’s training or other records according to your facility’s policies and procedures. This ensures proper documentation while maintaining the confidentiality of the Medical Questionnaire.

            What You Can Do with Completed Medical Questionnaires

• If your medical director serves as your PLHCP:
  • Request that they retain the completed Medical Questionnaires off-site.
• If you use an outside third-party provider as your PLHCP:
  • Ensure that the individual or organization is solely responsible for retaining the completed Medical Questionnaires off-site.
• On-site retention by a staff PLHCP:
  • A staff member serving as the facility’s PLHCP may retain the Medical Questionnaires on-site, provided they are the only individual with access to these records and are not serving as an employee’s supervisor.
• Third-party vendors:
  • Utilize a third-party vendor or medical professional to retain your Medical Questionnaires securely.

            What You Should Never Do with Completed Medical Questionnaires

• Sharing with Management, Supervisors, or Employees:
  • Never share completed Medical Questionnaires with management, supervisors, or employees, as these are considered private medical records.
• Inclusion in Personnel or Training Files:
  • Never keep completed Medical Questionnaires in an employee’s personnel or training file, or any other file that others can access.
• Access by Non-PLHCP Staff:
  • Do not share completed Medical Questionnaires with management, the employee’s supervisor, or any other staff who are not serving as the facility's PLHCP and medical reviewer. (Note: An employee’s supervisor should never serve as the PLHCP responsible for completing or receiving Medical Questionnaires and should not have access to the information contained in these questionnaires.)
• Leaving Documents Unsecured:
  • Never leave a completed Medical Questionnaire in a location where others might see it, such as on a desk, in an unlocked file cabinet, in a garbage can, or at the nurse’s station.

Does the employer have to medically reevaluate the employee’s ability to wear a respirator on an annual basis?

No, there is no annual or periodic requirement for medical reevaluation. The standard specifies four conditions that trigger medical reevaluation: when an employee reports signs or symptoms related to the ability to wear a respirator; when the PLHCP, administrator, or supervisor deems it necessary; when information from the respiratory protection program indicates a need for reevaluation; or when a change in workplace conditions substantially increases the physiological burden on the employee.

Do respirators and surgical masks provide the same type and level of protection for the user?

No, respirators and surgical masks serve different purposes and offer varied levels of protection. Surgical masks are primarily used for source control, safeguarding patients from healthcare workers' secretions and large droplet splashes. They are loose-fitting, disposable, and lack a tight seal to the face, thus not effectively filtering airborne particles. Consequently, they do not shield the wearer from inhaling airborne particles transmitted by coughs, sneezes, or certain medical procedures. In contrast, respirators provide a higher level of protection by forming a tight seal to the face and filtering out airborne particles, making them suitable for preventing exposure to airborne transmissible diseases.

Fit Testing:

How many respirators must be available for an employee to choose from when picking out their respirator?

There must be a sufficient variety of respirator models and sizes available so that the user can select one that fits properly and is acceptable for their use.

Can an employee wear a tight-fitting respirator with a beard or other facial hair?

No, employees with facial hair that interferes with the sealing surface of the respirator facepiece are prohibited from wearing tight-fitting respirators when they are required.

Does a “user seal check” qualify as a fit test?

No, a User Seal Check is a procedure performed by the employee each time they put on the respirator to ensure it is properly sealed to their face. It is not a substitute for a fit test, which evaluates the fit of a specific type, model, and size of respirator on an individual.

Is there a certification for a person to obtain before conducting a fit test?

No. The OSHA standard only requires the individual conducting a fit test to be competent in the process. 

Training:

Does the standard specify the format or method of training?

The standard is performance-oriented regarding training format. Employers may use any effective training method for their specific worksite as long as it covers the required topics. This could include audiovisual presentations, classroom discussions, informal talks during safety meetings, or a mix of these methods.

Program Evaluation:

How often should the respirator program be re-evaluated?

Employers must review and revise the written program elements specified in paragraph (c)(1) as necessary whenever workplace conditions affecting respirator use change. There is no requirement for an annual review, but rather a review and revisions are needed as workplace conditions change. The frequency of evaluation depends on factors such as program complexity, workplace hazards, types of respirators used, variability of processes, number of respirator users, and worker experience. Employers must ensure continuous, successful implementation of all written program elements through regular review of respirator use in the workplace.