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april 2017

The last part of the OSHA inspection applies to you only if your practice has been cited or fined for a problem. You have the right to contest any citations and/or fines levied by OSHA. The first step of this process is to request an “Informal Conference” with the manager/supervisor who sent you the citation letter. Your inspector will not be present at the Informal Conference. This meeting must be requested within the timeframe given in your citation letter, usually 15 days of receipt. There is a form included for this in your citation letter. The time set for the meeting can be one that is mutually agreed upon by you and OSHA. It can usually be conducted by phone and you can bring your TMC Representative as well as anyone else you want. Your employees have the right to attend this meeting if they wish so you must post the time and information on how to join the phone call. The Informal Conference is your chance to state your reasons for removing or reducing citations and/or fines. You can ask for this even if you don’t have any explanation other than “We’re sorry and we fixed it.” OSHA cannot increase the citations or fines and you do not get on a “black list.” You can usually get some reduction in fines just by asking. OSHA is authorized to reduce your fines by up to 35% just by you asking for it. You must ask for what you want and make your case for it. There are a lot of strategies that can be employed during this negotiation. You can ask for “Serious” violations to be moved to a “Non-Serious” status and the fine removed or greatly reduced. You can ask for several related citations to be bundled together into one citation with only one fine. You can request whole citations be dropped. Always keep in mind that you are negotiating with the government. This means you need to be pleasant and conciliatory. Remember, you are not the ultimate power broker in the room.

Demystifying OsHa inspectiOns part 5: yOur rigHt tO cOntest OsHa’s citatiOns anD fines

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HIPAA OSHA INFECTION CONTROL BUSINESS ASSOCIATES

Continued on page 2

in this issue

Demystifying OSHA Inspections Part 5: Your Right to Contest OSHA’s Citations and Fines PAGE 1 - 2

Emergency Action Plan (EAP): Evacuation Maps: To Map or Not To Map?PAGE 3 - 4

Investigating a Potential Breach PAGE 5

It’s your call PAGE 6

Sign-in sheet PAGE 7

If you do not accept the settlement you have only one last recourse. You can request a “Formal Hearing”. This meeting will be in person before an administrative judge in Raleigh. This step should only be taken if you believe OSHA has violated regulations or if you have a legal reason that you did not violate a regulation. You are allowed to bring a lawyer and your consultant. OSHA will have their lawyers there. Results are final.

Your best protection from OSHA citations is a strong and continuing OSHA program. You need to understand what is expected from your business. Your program should include policies, procedures, strong documentation, good records, current SDSs, annual review of safety devices for sharps and thorough training. TMC can help you in develop a strong program and in negotiating the steps of the inspection process.

Continued from page 1

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Demystifying OsHa inspectiOns part 5: yOur rigHt tO cOntest OsHa’s citatiOns anD fines

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You see them, but do you need them?

OSHA does not require facilities to have a printed map for evacuation in the case of an emergency; but other governmental agencies may. Check with your insurance carrier, fire marshal and state and local agencies that may require evacuation maps. But OSHA does have requirements for your Emergency Action Plan (EAP).

An EAP is required for any facility with 11 or more employees. OSHA allow facilities with 10 or fewer employees to communicate their EAP plan orally. Whether presented in writing or verbally, the EAP must have the following minimum elements as described in the OSHA standard 1910.39(c)(1)-(6).

• Procedures for reporting a fire or other emergency • Procedures for emergency evacuation, including type of

evacuation and exit route assignments• Procedures for employees who remain to operate critical

operations before they evacuate • Procedure to account for all employees after an evacuation• Procedures to be followed by employees performing rescue or

medical duties• The name or job title of every employee who may be contacted

by employees who need more information about the plan or an explanation of their duties under the plan

Evacuation maps serve as a great visual tool to communicate important information from your EAP plan.

So whether you are required or you choose to utilize an evacuation map, make it your best.

The best evacuation map is one that is studied before an emergency! Include a review of your EAP and evacuation map when you have your periodic safety meetings and as a part of your new hire orientation. Place a copy of your evacuation map in areas where an exit route is not immediately apparent or near emergency lighting. It is easy to become disoriented if you are in a new environment, panicked or in the dark. Place a copy of your evacuation map in your EAP.

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emergency actiOn plan (eap): evacuatiOn maps: tO map Or nOt tO map?

oShA: compliance Manuals, Facility Audit, and training

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emergency actiOn plan (eap): evacuatiOn maps: tO map Or nOt tO map?

In addition to exit locations and routes, the map should indicate the location of safety tools for various types of emergency situations. Elements for a great evacuation map include:

tMC OshA COMpliAnCe

Continued from page 3

• Map legend• “You are here”• Exits/handicapped accessible exit locations• Exit routes with alternate routes• Fire extinguisher locations• Fire alarm locations• First aid material locations• Oxygen tank locations• PPE locations

• AED locations• Spill kit locations• Tornado/hurricane/earthquake/safe room locations• Security desk locations• Restroom locations• Roof accessibility• Emergency phones and contact number locations• Electrical panel locations• Specific safe meeting place for assembly after evacuation

Design your own evacuation map or find a professional to assist you. Map creating software is also an option. An evacuation map should be accurate, detailed and strategically posted to best protect you, your employees and patients.

Even if you are not required to have an evacuation map, having one could make the difference between danger and safety.

oShA: compliance Manuals, Facility Audit, and training

tMC hipAA COMpliAnCehiPAA: compliance Manuals, Facility Audit, and training

investigating a pOtential BreacH

A breach can happen in the best of compliance programs. While you can’t change what has already happened, you should discover why it happened and make changes to prevent it from happening again. Here’s how one client correctly handled their potential breach.

Soon after returning to work from the holidays the practice was visited by their Business Associate (BA) who handles their shredding. The bin for the bimonthly pickup was unusually empty. The practice swung into action.

They interviewed employees to see if someone knew what happened. An employee remembered the trash being picked up a few days before. She had not gotten them to sign in because she misinterpreted a recent memo about mail pickup.

The client called TMC to get advice and assistance. The BA was asked to verify that an additional pickup had not happened. A new bag in the shredding receptacle left by the earlier pickup had another shredding company’s logo. The BA contacted this other shredding company to see if they had picked up accidently. Both companies pitched in with the investigation.

The practice gathered information on whose information could have been breached. This included anything printed during the two-week period. They also interviewed employees to see if anyone threw out other papers during this time. (Remember if you can’t narrow down who was affected you have to notify ALL your patients.)

The practice realized that the business they shared a parking lot with had active cameras on the lot. They contacted the business who agreed to view the film for the time in question. The film showed the pickup.

The BA identified the truck as a third trash pickup company. The practice identified the new company as one they had a service contract with to pick up recycling. After contacting the third company the practice discovered that this company also handled shredding and the materials picked up had been handled correctly.

The practice documented all their investigative results.

• This was a security incident but not a breach due to the following exclusion in the law: 164.402 Definitions. (2) Breach excludes: (i) Any unintentional acquisition, access, or use of protected health information by a workforce member or person acting under the authority of a covered entity or a business associate, if such acquisition, access, or use was made in good faith and within the scope of authority and does not result in further use or disclosure in a manner not permitted under subpart E of this part.

• The misinterpreted memo was rewritten for better clarity and reviewed with the staff.

• Check In and Log In procedures were reviewed, updated and shared with the staff.

• The practice launched a new Risk Analysis with TMC and their IT company to identify any other potential areas of liability.

• Documentation on the security incident was concluded and filed.

This practice did all the right things. A good HIPAA program is reviewed and updated regularly. In the rush to determine if a breach happened many practices forget to look at why it happened and what they can do to prevent it from happening again.

A big Shout Out to this practice and their business partners who really pitched in to help.

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HIPAA OSHA INFECTION CONTROL BUSINESS ASSOCIATES5

it’s yOur CAll

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HIPAA OSHA INFECTION CONTROL BUSINESS ASSOCIATES

HIPAA Situation: An angry patient just came into the office because

his ex-wife received a call about his upcoming appointment. On review, you see that his ex-wife

is listed as authorized to receive calls, but the man tells you that all authorizations expire

within a year. Is this true?

6

OSHA Situation: How long has it been since you hired a new employee? Did you cover all the basics to get them started? Or did you have endless questions from your new employee about things you forgot?

VISIT OUR BLOG FOR THE ANSWERS

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april 2017

Demystifying OSHA Inspections Part 5: Your Right to Contest OSHA’s Citations and Fines PAGE 1 - 2

Emergency Action Plan (EAP): Evacuation Maps: To Map or Not To Map?PAGE 3 - 4

Investigating a Potential Breach PAGE 5

It’s your call PAGE 6

Sign-in sheet PAGE 7