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Long-term care (LTC) facility generic respiratory protection program

LONG-TERM CARE (LTC) FACILITY GENERIC RESPIRATORY PROTECTION PROGRAM

1. BACKGROUND AND PURPOSE

The COVID-19 Pandemic created a need for workers at

LTC facilities to use respirators to protect themselves

from people (patients and residents) who are exhibiting

symptoms of the disease. Almost all of these LTC

facilities have previously used face masks in the normal

course of their business but most have never actually

required the use of respiratory protection as defined

by OSHA in their standards. This all changed in early

March of 2020 when it became clear that LTC workers

needed to protect themselves from potential exposure

to the airborne COVID-19 virus from infected residents

and patients.

OSHA requires employers to develop a site-specific

Respiratory Protection Program (RPP) if employees are

required to use respirators in performing their job. The

current Pandemic has put LTC facilities in a position to

require their employees to wear respirators when they

are in close proximity to people who are potentially

ill with the COVID-19 disease. This Generic RPP

has been designed as a guideline for LTC Facilities to

develop their own site specific RPP and can be used as

a template to assist in meeting this OSHA requirement.

Even though we have attempted to meet the OSHA

RPP requirements for LTC facilities we recognize that

each LTC facility is unique in many ways. Therefore we

cannot guarantee that this Generic RPP plan covers all

the various activities and operations of all LTC facilities.

This RPP guideline is focused on LTC facilities to create a

procedure for the use and care of respiratory protective

equipment at LTC Facilities providing skilled nursing and

sub-acute rehabilitative services.

This program addresses the respiratory protection

requirements for the staff of the LTC facility with a focus

on current issues during the COVID-19 Pandemic. The

objective is to ensure that the practices are in compliance

with Occupational, Safety and Health Administration

(OSHA) guidelines and requirements and applicable

CDC guidelines.


2. SCOPE

3. INTERIM POLICIES FOR COVID-19

This program applies to all LTC Facility employees who

are required to wear a face mask or respirator while

performing a job task; and for those employees who

voluntarily use a face mask or respiratory protection.

We have limited our respirator use to only Filtering

Facepiece Respirators (FFRs). If the LTC Facility also

intends to use other respirators, such as air-purifying

elastomeric respirators or Power Air-Purifying

Respirators (PAPRs), then this must be added to the

site-specific RPP and is not covered in this Generic Plan.

The COVID-19 Pandemic created the need to make

many modifications to the use of face masks and

respirators. Many of these modifications clearly did not

meet the requirements and regulations under the OSHA

respirator standard. Many of these modifications were

permitted by OSHA recognizing that the Pandemic

created a crisis that necessitated lifting certain rules and

requirements so some level of respiratory protection

could be offered to employees of LTC facilities. These

policy changes are available on the OSHA.gov website

at:

www.osha.gov/SLTC/covid-19/news_updates.html

As the Pandemic subsides it is anticipated that many of

the interim respiratory protection policy changes made

by OSHA will be reversed and the full requirements of

the OSHA respirator standard will be enforced. When

this occurs this plan will need to be reviewed and

updated to meet the then current OSHA requirements.


4. DEFINITIONS

4.1 Air Purifying Respirator (APR)

A respirator which is designed to remove air

contaminants (i.e. dust, fumes, mists, gases, vapors,

or aerosols) from the ambient air as the air enters

the respirator.

4.2 Approved Respirator

A respirator which has been tested, found to meet

established performance criteria, and listed as

being approved by NIOSH (National Institute of

Occupational Safety and Health).

4.3 Face-Mask

A covering over the nose and mouth of various

substances such as cloth, fortified paper, and other

filtration material. It is not expected that the Face-

Mask will pass a Qualitative Fit-test.

4.4 Filtering Facepiece Respirator (FFR)

A negative pressure particulate respirator with a

filter as an integral part of the face piece or with the

entire face piece composed of the filtering medium.

Typically the filtering medium is at minimum classified

as an N-95 or greater. It is expected that the FFR will

pass a Qualitative Fit-test.

4.5 OSHA and the OSHA respirator standard

The Occupational Safety and Health Administration

provides regulations on the use of respirators

(29CFR1910.134)

www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134

Some states (22) have their own State-OSHA respirator

requirements that will meet or exceed Federal OSHA.

This is the link of states with OSHA programs:

www.osha.gov/stateplans

4.6 NIOSH and NIOSH certification of respirators

The National Institute of Safety and Health is a federal

governmental agency under the Center for Disease

Control (CDC) and is the primary US Agency to test

and approve (certify) respirators. Only NIOSH certified

respirators were permitted to be used under the OSHA

respirator standard. This requirement has been lifted

during the COVID-19 Pandemic due to the lack of supply

of available NIOSH certified respirators. See link for

alternatives:

Enforcement Guidance for Use of Respiratory Protection Equipment Certified under Standards of Other Countries During the Coronavirus Disease 2019 (COVID-19) Pandemic. (April 3, 2020).

4.7 N-95 FFR

This refers to the ability of a filtering material to remove

particles of all sizes which will include the very small size

of the COVID-19 virus. The 95 refers to the requirement

that the material filters out 95% of particles at a size

of 0.3 microns (which is the size considered to be the

most difficult to filter). To determine if an N-95 FFR

is protective, it should also be certified by NIOSH and

successfully pass a qualitative fit-test. Other country

certifications (i.e. KN-95 by China) may not meet the

NIOSH criteria and may not successfully pass a fit-test.

If they cannot be successfully fit-tested then these FFRs

will be considered a face mask only.


5. RESPONSIBILITIES

5.1 Respiratory Protection Program (RPP) Administrator

■ Responsible for administrating and overseeing

the Respiratory Protection Program (RPP) and

conducting the required evaluations of program

effectiveness required by 29 CFR 1910.134.

■ Reviews and revises the RPP as required by work

area, job tasks or regulation change and ensure

compliance with current federal, state and

local regulations.

■ Performs hazard assessments and exposure

assessments to determine the respiratory

protection requirement.

■ Issues approved respiratory protective equipment

to employees that have been cleared medically for

respirator use.

■ Periodically audits work areas and respiratory

storage areas to insure proper use and maintenance

of respiratory protective equipment.

■ Schedules annual fit testing and training for

all employees that use respiratory protective

equipment.

5.2 Supervisors

■ Notifies RPP Administrator of any operative changes

or new operations so that a hazard assessment

and/or exposure assessment can be performed to

determine the need for respiratory protection.

■ Receives training in the elements of the RPP.

■ Ensures that all staff have been medically cleared, fit

tested, trained, and have received a respirator from

the RPP Administrator prior to being assigned a task

requiring respirator use.

5.3 Staff

■ Receive training in the elements of the RPP.

■ Must be medically cleared and fit tested prior to

using respiratory protection.

■ Receive training in the use and limitations of

respiratory protection.

■ Uses proper respiratory protection when required.

■ Maintains respiratory protective equipment by

cleaning and storing properly.

4.8 Qualitative Fit Test

A pass/fail fit test to assess the adequacy of a respirator

fit that relies on the individual’s response to the test

agent. This is the typical fit-test required for a FFR.

4.9 Quantitative Fit Test

An assessment of the adequacy of a respirator fit by

numerically measuring the amount of leakage into

the respirator.

4.10 Respirator

Any device worn by an individual and intended to provide

the wearer with respiratory protection against inhalation

of airborne contaminants or oxygen-deficient air.


6.1 Risk Designations

LTC Facility has identified the following current

operations where respiratory protection is required

during the COVID- 19 Pandemic (the LTC Facility has

to identify what specific job classification or titles that

would fit into these three risk areas). The designations

below are:

6.2 Filtering Face Pieces

For protection of staff from the COVID-19 virus and

other potential infectious diseases identified by the

LTC Facility pursuant to CDC Guidelines and alerts,

the required respiratory protection for all user groups

will consist of a filtering face piece respirator such as a

N95 or equivalent.

6.3 Post COVID-19

Once the Pandemic is over and there are no infectious

diseases of concern identified by the CDC rising to

the level of COVID-19, then the LTC Facility can

downgrade it’s High Risk classifications to Medium

so Respirators are no longer mandated for those

job functions.

6. REQUIREMENTS

Low Risk

Medium Risk

High Risk

staff with direct resident contact

(within 6 feet for >10 minutes):

■ Medical staff (physicians, nurses, nursing aides)

■ Occupational and physical therapists

staff with minimal direct contact

(< 6 feet for short periods of time <10 minutes)

■ Housekeeping, custodial, and maintenance staff

■ Food service staff

staff with incidental or no direct contact

(< 6 feet for short periods of time <5 minutes)

■ Administrative personnel

■ Kitchen Staff


7.1 Application

This procedure outlines the selection, use, and

maintenance of respiratory protective equipment at

LTC Facility as required by 29 CFR 1910.134 (OSHA’s

Respiratory Protection Standard) and LTC Facility’s

internal policy. All employees who use respiratory

protective equipment, or manage those who use

respiratory protective equipment, shall be trained in

the content of this procedure.

7.2 Engineering and Administrative Controls

LTC Facility utilizes engineering and administrative

controls when feasible. Engineering controls include

physical barriers between residents/patients and

staff. Administrative controls include staff rotation

to minimize contact as much as possible. If these

controls are not feasible, or not effective, appropriate

respiratory protective equipment is used. Respiratory

protection will meet the requirements as outlined in

29 CFR 1910.134.

7.3 Respirator Selection

Respirators certified by the National Institute for

Occupational Safety and Health (NIOSH) must be

selected and used in compliance with the conditions of

its certification. In accordance with the April 3, 2020

guidance provided by OSHA, respirators manufactured

in other countries that are certified by that other

country’s standards may be used if they successfully

pass a qualitative fit-test.

Respirators must be selected on the basis of the

respiratory hazard(s) in the work area and user factors

that affect respirator performance and reliability.

7.4 Respirator Fit Testing

Each employee required to wear a respirator shall be

fit tested using accepted fit test methods as described

in 29 CFR 1910.134, Appendix A. The fit testing

requirements include:

■ Qualitative or Quantitative fit testing must be

performed prior to initial use of respirators.

■ 29 CFR 1910.134 states fit testing must be

performed at least annually thereafter. A March

3, 2020 memorandum released by OSHA states

that field offices will use discretion regarding

the annual fit testing requirements as long as the

employer has made a good-faith effort to comply

with the requirements of the Respiratory Protection

Standard.

■ Quantitative fit testing must be performed for

respirators with a Fit Factor greater than 100

(e.g. full-face air purifying respirator). Generally

Quantitative fit testing is not conducted on

N-95 FFR. A qualified person must administer fit

testing. The person performing the fit testing will

provide required documentation of the fit test

protocol(s) used and results.

■ Fit tests shall be performed using the same make,

model and size of respirator to be worn. The March

3, 2020 memorandum released by OSHA states that

field offices will use discretion when an employer has

switched to a similar make/model due to shortages of

respiratory protection.

■ A user seal test following Appendix B-1, 1910.134

(Attachment A) must be performed immediately

after donning and adjusting the respirator, each time

a respirator is used.

7. PROCEDURE


7.5 Respirator Training

Employees required to wear respirators must be

trained before wearing a respirator. Training must

be comprehensive and understandable. It must be

performed prior to requiring the employee to use a

respirator and annually thereafter.

The following, as a minimum, shall be included in

the training:

■ Why the respirator is necessary

■ How improper fit, usage, or maintenance can

compromise the respirator.

■ The limitations and capabilities of the respirator.

■ How to use the respirator effectively in

emergency situations.

■ How to inspect, don, doff, and seal check

the respirator.

■ Procedures for maintenance and storage of

the respirator.

■ Recognizing medical signs and symptoms that

may limit the respirator use.

7.6 Respirator Maintenance and Care

■ Respirators shall be properly maintained and be

in working order.

■ Respirators that are not functioning properly

shall be removed from use by turning in to the

RPP Administrator.

■ Respirators must be stored to protect them from

damage, contamination, dust, sunlight, extreme

temperatures, excessive moisture, damaging

chemicals, and to prevent deformation of the

face piece.

7.7 Respirator Inspection

■ Respirators must be inspected as follows and must

include a check of respirator function, tightness of

connections, and the condition of the various parts

of the respirator, including a check of the elastomeric

parts for pliability.

7.8 Filtering Face Piece Respirator Use and Reuse

Donning (Putting the respirator onto the face)

■ Wash hands and use hand sanitizer

■ Put gloves on clean and dry hands

■ Don filtering face piece respirator (N95 or

equivalent). Avoid touching the inside of the

respirator. If inadvertent contact is made with the

inside of the respirator, perform hand hygiene as

described above.

■ Use a pair of clean (non-sterile) gloves when donning

a used filtering face piece respirator and performing a

user seal check. Discard gloves after the filtering face

piece respirator is donned and any adjustments are

made to ensure the respirator is sitting comfortably

on your face with a good seal.

■ Don fresh pair of gloves

Doffing (Removing the respirator from the face)

■ Remove gloves and place in garbage bag

■ Clean hands with soap and water. If soap and water is

not available, disinfectant wipes or hand sanitizer may

be used.

■ Don fresh pair of gloves on dry hands

■ Remove gloves and place in garbage bag

■ Don fresh pair of gloves on dry hands

■ Remove N95 (or equivalent) and place in a clean

paper bag. Avoid touching the inside of the respirator.

■ Remove gloves and discard in garbage bag


Reuse

■ Wash hands and use hand sanitizer

■ Put gloves on clean and dry hands

■ Remove N95 (or equivalent) from paper bag;

discard bag

■ Follow protocol in Sections 6.3.1 (Donning) and

6.3.2 (Doffing)

■ N95s (or equivalent) may be reused if they meet the

following criteria:

■ No obvious contamination or heavy soiling

of respirator

■ Not deformed; has original shape

■ Straps still functional – holds respirator tight

to face

■ Not obviously damaged or has become hard to

breathe through

■ Stored correctly in a clean paper bag

■ Follow manufacturer’s guidance on # of times it can

be re-used, or CDC/NIOSH guidance of no more than

5 uses. For reuse guidance see:

www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html

Disinfecting N95 (or equivalent)

■ Do not use alcohol or any type of cleaner on the

filtering face piece respirator.

■ If available, use UV-C light according to instructions

that come with the light to kill pathogens on the

surface. (Note – there is no guarantee pathogens that

are not touched by UV-C light will be killed, but the

“bioburden” should be substantially reduced).

■ Ensure employees understand the hazards of UV-

light to their own skin and eyes, and use appropriate

controls/PPE

■ If available, use any other disinfection method

appropriate, such as ozone chamber treatment

Storage

■ N95 (or equivalent) is to be stored in a clean paper

bag in a clean and dry area

■ Employee’s name and number of uses are to be

written on the paper bag

7.9 Respirator Repair

■ Respirators that fail an inspection or are otherwise

found to be defective are removed from service

and discarded.

7.10 Medical Surveillance

■ Employees assigned to tasks requiring the use of

respirators shall be medically evaluated to determine

if they are physically able to wear respirators without

posing a physical hazard. These determinations

must be made prior to any use, including fit testing,

and must be completed by a physician or licensed

health care professional (PLHCP). These medical

evaluations shall be reviewed periodically as

deemed appropriate by the physician or RP

Administrator or if there are medical reasons

to evaluate the employee.

■ The following information must be provided to the

physician or licensed health care professional

before a medical determination can be made:

■ Type and weight of respirator that is to be used

■ Duration and frequency of respirator use

■ Expected physical work effort

■ Additional protective clothing and equipment to

be worn;

■ Temperature and humidity extremes that may

be encountered

■ Written copy of this respiratory protection

program.


■ A written recommendation must be obtained from the

PLHCP. The recommendation will provide information

on any limitations on respirator use. Additional medical

evaluations must be provided if any of the following

occurs:

■ An employee reports medical signs or symptoms that

are related to ability to use a respirator.

■ A PLHCP, supervisor, or the Respirator Program

Administrator determines that an employee needs

to be reevaluated.

■ Information from the respiratory protection program,

including observations made during fit testing and

program evaluation, indicates a need for employee

reevaluation.

■ A change occurs in workplace conditions that may

result in a substantial increase in the physiological

burden placed on an employee.

■ The Medical Surveillance questionnaire can be found

in the OSHA regulation 29 CFR 1910.134 Appendix C.

7.11 Special Considerations in Respirator Use

Facial Hair

■ Respirators shall not be worn when conditions prevent

a good respirator face piece-to-face seal. Persons with

facial hair that interferes with the face piece-to-face

seal or the operation of the inhalation or exhalation

valves shall not be permitted to wear or be fitted with

a respirator until such conditions are corrected.

Eyeglasses & Corrective Lenses

■ Employees with eyeglass temple pieces which interfere

with the face piece-to-face seal of the respirator shall

not be permitted to wear or be fitted with a respirator

until such conditions are corrected.

■ If corrective lenses are required, contact lenses or

special lens holding devices which do not interfere

with the face piece-to-face seal may be utilized.

7.12 Recordkeeping

■ Records of employee exposure, monitoring, medical

surveillance, training, inspection and maintenance

will be maintained in accordance with the

requirements of 29 CFR 1910.134.

■ Fit Tests

Records of qualitative and/or quantitative fit tests

shall be maintained until the employee’s next fit test.

The records must include the name and identification

of employee, type of fit test performed, make, model,

style, and size of respirator tested, date of fit test, and

fit test results.

■ Medical Evaluations

Records of the employees’ medical evaluation

indicating that they are capable of wearing a tight-

fitting facepiece will be maintained for the length of

their employment plus 30 years.

7.13 Program Evaluation

The Respiratory Program Administrator shall, at

least annually, conduct periodic evaluations of the

Respiratory Protection Program. The Respiratory

Program Administrator should:

■ Consult with users to determine program acceptance

■ Conduct inspections of respirator use

■ Review required records.


7.14 Voluntary Use of Respiratory Protection

■ Respirators will be provided at no charge to

employees for voluntary use.

■ The Respiratory Program Administrator will provide

all employees who voluntarily choose to wear

respirators with a copy of Appendix D of OSHA’s

Respiratory Protection Standard (Attachment B).

Appendix D details the requirements for voluntary

use of respirators by employees. Employees choosing

to wear a half face piece APR must comply with the

procedures for Medical Evaluation, Respirator Use,

and Cleaning, Maintenance and Storage.

■ The Respiratory Program Administrator shall

authorize voluntary use of respiratory protective

equipment as requested by all workers on a case-

by-case basis, depending on specific workplace

conditions and the results of the medical evaluations.


ATTACHMENT A – 29 CFR 1910.134 Appendix B ATTACHMENT B – 29 CFR 1910.134 Appendix D

Appendix B-1 to § 1910.134: User Seal Check

Procedures (Mandatory)

The individual who uses a tight-fitting respirator is to

perform a user seal check to ensure that an adequate

seal is achieved each time the respirator is put on.

Either the positive and negative pressure checks listed

in this appendix, or the respirator manufacturer’s

recommended user seal check method shall be used.

User seal checks are not substitutes for qualitative or

quantitative fit tests.

I. Facepiece Positive and/or Negative Pressure Checks

A. Positive pressure check. Close off the exhalation

valve and exhale gently into the facepiece. The face fit is

considered satisfactory if a slight positive pressure can

be built up inside the facepiece without any evidence of

outward leakage of air at the seal. For most respirators

this method of leak testing requires the wearer to first

remove the exhalation valve cover before closing off the

exhalation valve and then carefully replacing it after the

test.

B. Negative pressure check. Close off the inlet opening

of the canister or cartridge(s) by covering with the

palm of the hand(s) or by replacing the filter seal(s),

inhale gently so that the facepiece collapses slightly,

and hold the breath for ten seconds. The design of the

inlet opening of some cartridges cannot be effectively

covered with the palm of the hand. The test can be

performed by covering the inlet opening of the cartridge

with a thin latex or nitrile glove. If the facepiece remains

in its slightly collapsed condition and no inward leakage

of air is detected, the tightness of the respirator is

considered satisfactory.

II. Manufacturer’s Recommended User Seal CheckProcedures

The respirator manufacturer’s recommended

procedures for performing a user seal check may be

used instead of the positive and/or negative pressure

check procedures provided that the employer

demonstrates that the manufacturer’s procedures are

equally effective.

Appendix D to Sec. 1910.134 (Mandatory)

Information for Employees Using Respirators

When Not Required Under the Standard

Respirators are an effective method of protection

against designated hazards when properly selected

and worn. Respirator use is encouraged, even when

exposures are below the exposure limit, to provide an

additional level of comfort and protection for workers.

However, if a respirator is used improperly or not kept

clean, the respirator itself can become a hazard to the

worker. Sometimes, workers may wear respirators

to avoid exposures to hazards, even if the amount of

hazardous substance does not exceed the limits set by

OSHA standards. If your employer provides respirators

for your voluntary use, or if you provide your own

respirator, you need to take certain precautions to be

sure that the respirator itself does not present a hazard.

You should do the following:

1. Read and heed all instructions provided by the

manufacturer on use, maintenance, cleaning and care,

and warnings regarding the respirator’s limitations.

2. Choose respirators certified for use to protect against

the contaminant of concern. NIOSH, the National

Institute for Occupational Safety and Health of the U.S.

Department of Health and Human Services, certifies

respirators. A label or statement of certification should

appear on the respirator or respirator packaging. It will

tell you what the respirator is designed for and how

much it will protect you.

3. Do not wear your respirator into atmospheres

containing contaminants for which your respirator

is not designed to protect against. For example, a

respirator designed to filter dust particles will not

protect you against gases, vapors, or very small solid

particles of fumes or smoke.

4. Keep track of your respirator so that you do not

mistakenly use someone else’s respirator.

The undersigned has read and understands this procedure:

Printed Name:

Signature:

Date:


Prioritizing efforts to acquire and use equipment in the

following order:

■ NIOSH-certified equipment; then

■ Equipment certified in accordance with standards of

other countries or jurisdictions except the People’s

Republic of China, unless equipment certified in

accordance with standards of the People’s Republic

of China is manufactured by a NIOSH certificate

holder[6]; then

■ Equipment certified in accordance with standards of

the People’s Republic of China, the manufacturer of

which is not a NIOSH certificate holder[6]; then

■ Facemasks (e.g., medical masks, procedure masks).

[6] According to the National Institute for Occupational

Safety and Health (NIOSH), it has observed that

products from the People’s Republic of China may not

meet the requirements of the standards to which they

are certified and may not offer or sustain the protection

claimed as typically expected when using NIOSH-

approved N95 respirators. However, devices supplied by

current NIOSH approval holders producing respirators

under the standards authorized in the countries and/

or jurisdictions addressed in this memorandum are

expected to provide the protection indicated, given that

a proper fit is achieved.


NEW JERSEY

CORPORATE HEADQUARTERS

25B Vreeland Road, Suite 101

Florham Park, NJ 07932

Phone: 973.538.1110

NORTH CAROLINA

SOUTHEAST REGIONAL OFFICE

301 McCullough Drive, Suite 400

Charlotte, NC 28262

Phone: 704.233.7320

NEW YORK CITY

5 Penn Plaza, 23rd Floor

New York, NY, 10001

Phone: 917.830.2640

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